Erectile dysfunction criteria of 131,350 patients after open, laparoscopic, and robotic radical prostatectomy.

PURPOSE: Comparing post-radical prostatectomy erectile function rates among different techniques has always been a challenge in urology. This difficulty is due to the heterogeneity of studies, mainly in relation to the type of erectile function classification criteria used. The aim is to apply a new evidence-gathering methodology, called reverse systematic review, to compare erectile function rates among retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robot-assisted radical prostatectomy, considering the diversity of classification criteria. METHODS: A search was carried out in eight databases between 2000 and 2020 through systematic review studies referring to retropubic radical prostatectomy, laparoscopic radical prostatectomy, or robot-assisted radical prostatectomy (80 systematic reviews). All references used in these systematic reviews were captured by referring to 910 papers in a global database called EVIDENCE. A total of 268 studies related to post-prostatectomy erectile function rates were selected for the final analysis, totaling 465 cohorts or reports referring to 131,350 patients. RESULTS: Note that, 119 (25.6%) reports for retropubic radical prostatectomy, 143 (30.7%) reports for laparoscopic radical prostatectomy, and 203 (43.7%) reports for robot-assisted radical prostatectomy were found. Mean overall erectile function rates, respectively for retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robot-assisted radical prostatectomy, were: 16%, 12%, and 35% at 1 month, 22%, 26%, and 42% in 3 months; 30%, 44%, and 54% at 6 months, 41%, 55%, and 59% at 12 months, and 58%, 52%, and 67% at more than 18 months. The most used erectile function criterion was Erection Sufficient for Intercourse (74.1%), followed by Sexual Health Inventory for Men > 21 (5.5%), and Sexual Health Inventory for Men > 16 (3.7%). Erection Sufficient for Intercourse showed the lowest discrepancy in erectile function rates in each period compared to the global average, for each technique, demonstrating less ability to influence the final results, favoring any of the techniques. CONCLUSIONS: The reverse systematic review demonstrated that the robot-assisted radical prostatectomy showed higher rates of erectile function recovery at all times analyzed (1->18 months), in relation to the retropubic radical prostatectomy and laparoscopic radical prostatectomy. The Erection Sufficient for Intercourse criterion was the most used in the literature and showed the lowest bias capable of influencing the results and favoring any of the techniques and might be the fairest option for future comparisons.

Radical Prostatectomy Technique Dispute: Analyzing Over 1.35 Million Surgeries in 20 Years of History.

Systematic reviews (SR) produce the best evidence comparing open (RRP), laparoscopic (LRP), and robotic (RARP) radical prostatectomy (RP). However, the hyperfiltration of evidence generates very specific scenarios that reduce the power of extrapolation. To compare RP evidence regarding demographics using a new methodology called reverse systematic review (RSR). Between 2000 and 2020, 8 databases were searched for SR studies on RRP, LRP, or RARP. All references were captured and analyzed over time in 80 SR. Total of 1724 reports (nr = 752, 43.7% for RARP; nr = 559, 32.4% for RRP; nr = 413, 23.9% for LRP) described 1,353,485 patients (881,719, 65.1% RRP; 366,006, 27.0% RARP; 105,760, 7.8% LRP). Patients/center/year was higher in RARP compared to LRP and RRP, median 50.0, 40.0, and 36.66, respectively, P < .001. Surgeons per study was lesser in RARP and LRP compared to RRP, median 2.0, 2.0, and 6.0, respectively, P < .001. Study duration and follow-up in years was shorter in RARP compared to LRP and RRP, median 2.6, 3.0, and 4.0, respectively, P < .001. Cumulative RARP reports predominate in North America (55.7%, nr = 468) and Asia (47.8%, nr =129), while LRP predominate in Europe (42.3%, nr =230) and RRP in Oceania (45.1%, nr = 23). After 2010 all continents began to accumulate more patients in the robotic approach. Potential biases related to shorter follow-up, greater volume centers, and surgeons were identified favoring the RARP. Analyzing the context of the available evidence is essential to compare techniques. Influenced by economic and scientific interests, robotic surgery was developed in centers with a higher volume of surgeries, characterizing potential biases when comparing techniques in the clinical shared decision.

Open, Laparoscopic, and Robot-Assisted Radical Prostatectomy Oncological Results: A Reverse Systematic Review.

Context: Systematic reviews (SR) have always been used as the best evidence to compare three radical prostatectomy (RP) techniques: retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic radical prostatectomy (RARP). Despite the superiority of minimally invasive surgery in relation to perioperative outcomes, the literature still cannot establish which technique is superior in relation to oncological outcomes. A new methodology called Reverse Systematic Review (RSR) was created to gather the best evidence in the literature based on a heterogeneous sample, allowing the comparison of oncological outcomes from a population point of view. Objective: To apply the RSR to compare RP techniques in relation to oncological outcomes: positive surgical margin (PSM) and biochemical recurrence rate (BCR). Evidence Acquisition: A search was carried out in eight databases between 2000 and 2020 through SR studies referring RRP, LRP, or RARP (80 SR). All references used in these SR were captured referring to 1724 reports. Preoperative and oncological outcomes were compared and correlated among RRP, LRP, and RARP. Evidence Synthesis: Five hundred fifty-nine (32.4%) reports for RRP, 413 (23.9%) for LRP, and 752 (43.7%) for RARP, and a total of 1,353,485 patients were found. Regarding PSM, 284 reports were collected for RRP, 324 for LRP, and 499 for RARP, with rates of 23.6%, 20.7%, and 19.2%, respectively, and only the RRP with statistical difference (p < 0.001). Using a nonlinear regression model, the BCR was correlated with follow-up time at 1, 2, 3, 5, 7, and 10 years: 10%, 15%, 18%, 20%, 23%, and 38% for RRP; 6%, 9%, 13%, 20%, 23%, and 10% for LRP; and 8%, 12%, 16%, 23%, 27%, and 19% for RARP. The absence of long-term work for RARP prevented more accurate projections of BCR. Conclusions: RSR proved to be effective in generating a population and heterogeneous sample capable of demonstrating better oncological results for minimally invasive surgery (LRP and RARP) compared to RRP. It demonstrated the maturity of temporal follow-up data for RRP and LRP and the impact of absence of late follow-up from RARP studies on the long-term rate of BCR. Patient Summary: After 20 years of coexistence of the three main radical prostatectomy techniques, the RSR was able to detect better results from minimally invasive surgery in relation to PSMs and long-term BCRs.

Sexual function criteria post laparoscopic radical prostatectomy: a reverse systematic review.

OBJECTIVE: To apply a new review methodology, called reverse systematic review (RSR), to assess how different classification criteria can influence erectile dysfunction rates in patients undergoing laparoscopic radical prostatectomy (LRP). METHODS: We used RSR from January 1, 2000, until December 31, 2020. The post-prostatectomy erectile dysfunction (PPED) rates were evaluated at 1, 3, 6, 12, and 18 months after surgery in different criteria selected as the most commonly used and divided into four groups: "Erection Sufficient for Intercourse (ESI)", "IIEF-5 > 17", "IIEF-5 > 22" and "Not Available". Temporal distribution of different criteria was analyzed to identify patterns throughout the "natural history" of LRP. RESULTS: 40 systematic reviews on LRP evaluated 81 cohorts and 21,618 patients on PPED. ESI was the predominant form of PPED evaluation (75.3%) followed by IIEF-5 > 22 (11.1%). Despite being a simpler criterion, ESI showed worse PPED rates at 1, 3, 6 and 12 months (8%, 27%, 43% and 51%) than IIEF-5 > 22 (14%, 26%, 45% and 58%). The studies were published between 2005 and 2015, but it was in 2010 that the ESI criterion was established as predominant in the literature, reducing the application of others. CONCLUSION: The RSR has proven effective in demonstrating how the PPED evaluation criteria behaved in the "natural history" of the LRP. It showed how a simple and easy-to-apply criterion, such as the ESI, was preferred by the authors, even showing worse PPED rates than other more complex.

Surgical Results and Complications for Open, Laparoscopic, and Robot-assisted Radical Prostatectomy: A Reverse Systematic Review.

Context: The advantages of minimally invasive surgery for radical prostatectomy (RP) have been demonstrated in a number of systematic reviews (SRs). However, the rigorous study selection process for SR means that a lot of information can be excluded, leading to a very specific clinical scenario that is often unrepresentative of real life. Our new reverse SR methodology generates a heterogeneous population database that covers a wide range of clinical scenarios. Objective: To compare perioperative surgical results and complications for open retropubic RP (RRP), laparoscopic RP (LRP), and robot-assisted RP (RARP) in a reverse SR. Evidence acquisition: Eight databases were searched for SRs on RRP, LRP, or RARP between 2000 and 2020 (80 SRs). All references used in these SRs were captured for analysis (1724 articles). Perioperative outcomes and complications were compared among the RRP, LRP, and RARP approaches. Evidence synthesis: We identified 559 (32.4%) reports on RRP, 413 (23.9%) on LRP, and 752 (43.7%) on RARP, involving 1 353 485 patients overall. RARP showed a significantly higher annual volume of surgery per surgeon (AVSS) in comparison to RRP and LRP (mean 64.29, 43.26, and 41.47, respectively), a higher percentage of low-risk patients (prostate-specific antigen <10 ng/ml, Gleason <7, stage

Development and application of Reverse Systematic Review on laparoscopic radical prostatectomy.

CONTEXT: Evidence-based medicine was widely used in the context of diverse surgical treatments through several systematic reviews (SR). Despite the high level of evidence from these reviews, the specificity of the analyzed outcomes makes it difficult to establish the state of maturity of the analyzed technique neglecting significant bias. OBJECTIVE: To describe a novel SR methodology based on a temporal population analysis in a Reverse Systematic Review utilizing the case of well-established laparoscopic radical prostatectomy (LRP). EVIDENCE ACQUISITION: A systematized search was performed in order to obtain the primary studies feeding SR for the composition of a complete database, covering clinical-surgical and bibliometric variables. Quantitative, qualitative, and temporal correlations of studies variables were performed to determine trends regarding results, geographic distribution and bibliometrics to delineate the development and trends of LRP between 2000 and 2017. EVIDENCE SYNTHESIS: Among a total of 353 SR found, 40 were included and provided 238 primary studies elected to the database composition. An accumulation of studies was found on the Europe-USA axis predominantly in 4 preeminent scientific journals, which scientifically influenced the profile of publications, mainly until 2011 when interest clearly migrates to robotic-assisted surgery reducing the influence of these centers in the development of LRP in an upfront reversal in the standard of publications with a clear shift between LRP and robotic-assisted surgery studies. Operative time, blood loss, and conversion to open surgery showed trend to reduction and only biochemical recurrence (among PENTAFECTA) positively correlated with the year of publication, all with stabilization throughout the period. CONCLUSION: The Reverse Systematic Review proved to be feasible and effective in demonstrating the evolution of a surgical technique, outlining its "Natural History," which is not captured in the standard SR. In addition, it allowed to identify the presence of scientific influencers and potential biases in the composition of the best evidence in the literature, as well as to trace the curves of development until its technical-scientific maturity. Further studies to test the reproducibility of this methodology may aid in the comparison of diverse surgical techniques. Patient summary: This temporal study analyzed the variables inherent to the publications and the patients in the primary studies of SRs that approached a specific surgical technique. The results demonstrated the scientific maturity of the technique and the vulnerability to scientific influencers in the history of its development.