Retzius Sparing Radical Prostatectomy Versus Robot-assisted Radical Prostatectomy: Which Technique Is More Beneficial for Prostate Cancer Patients (MASTER Study)? A Systematic Review and Meta-analysis

Context: Retzius sparing robot-assisted radical prostatectomy (RS-RARP) is increasingly being used, but results of pertinent studies on perioperative, functional, and oncological outcomes comparing the Retzius sparing approach with standard robot-assisted radical prostatectomy (RARP) remain inconsistent. Objective: To evaluate the effectiveness of RS-RARP compared with standard RARP, in terms of perioperative, functional, and oncological outcomes. Evidence acquisition: We performed a systematic search using multiple databases (PubMed, MEDLINE, EMBASE, and Cochrane Central) until March 2021. Only randomized controlled trials (RCTs) and prospective studies were eligible for study inclusion. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were respected. Studies were critically appraised for the risk of bias. Primary outcomes were continence/potency recovery, as well as positive surgical margin (PSM) rates. Secondary outcomes included total intra- and perioperative complication rates. Evidence synthesis: Four RCTs and six prospective observational studies were included in this systematic review. The meta-analysis revealed that PSM rates in <= pT2 tumors were statistically significantly higher, following RS-RARP as compared with RARP (risk ratio [RR] = 1.39; 95% confidence interval [CI] = [1.01-1.91]). PSM rates in >= pT3 tumors tended to be higher following RS-RARP (RR = 1.36; 95% CI = [0.74-2.50]), although statistical significance was not reached. Immediate continence recovery was higher and significantly advantageous for RS-RARP (RR = 1.81; 95% CI = [1.26-2.60]). Continence recovery also tended to be higher at 3 and 6 mo in the RS-RARP group (RR = 1.57; 95% CI = [0.693.58] and RR = 1.22; 95% CI = [0.89-1.66], respectively). The urinary continence recovery at 12 mo was similar in both groups (RR = 1.14; 95% CI = [0.98-1.32]). A meta-analysis of included studies showed no significant difference concerning the return of erectile function and major complication rates between RS-RARP and RARP (RR = 1.05; 95% CI = [0.76-1.45] and (RR = 0.79; 95% CI = [0.07-8.74], respectively). Conclusions: Available data suggest a statistically significant advantage in favor of RSRARP in terms of immediate urinary continence recovery. PSM rates in localized <= pT2 tumors are statistically significantly higher following RS-RARP. Potency and serious complication rates appear to be similar. Patient summary: Our meta-analysis of the current evidence shows a significant advantage for Retzius sparing robot-assisted radical prostatectomy (RS-RARP) over robot-assisted radical prostatectomy in terms of immediate urinary continence recovery, but positive cancer margins are higher following RS-RARP. There was no significant difference in the preservation of erectile function and overall postoperative complication rates between both the techniques. Crown Copyright (c) 2021 Published by Elsevier B.V. on behalf of European Association of Urology. All rights reserved.