No RCTs were found. Thirty comparative studies (n=5,144) were included. Twenty-one studies (n=3,996) compared laparoscopic with open radical prostatectomy and 9 studies (n=1,148) compared the different types of laparoscopic prostatectomy.
Most of the included studies used historical controls, but in most studies the treatment groups appeared to be similar at baseline. The studies did not use standardised outcomes for continence or potency. There was insufficient follow-up to adequately assess recurrence and survival. The duration of follow-up differed for laparoscopic and open surgical procedures.
Open versus laparoscopic surgery.
Conversion to open radical prostatectomy was reported in 20 studies. The median conversion rate was 0% (range: 0 to 20% in 12 studies). Reasons for conversion were rarely reported.
There appeared to be few differences in safety outcomes between open and laparoscopic procedures, but laparoscopic procedures were associated with lower blood loss and lower rates of transfusion.
Five studies found that the estimated blood loss was higher for RRP than for TLRP. One of 2 studies comparing EERP with RRP found significantly higher blood loss with RRP; the other study found no difference between procedures. All 3 studies comparing RALRP with RRP found higher blood loss with RPP
All 5 studies comparing TLRP with RRP found increased transfusion rates with RRP. One study found significantly more transfusions with RRP compared with EERP. Two of 3 studies comparing RALRP and RRP found more transfusion with RRP (one significantly more); the other study found no difference between procedures.
Laparoscopic procedures were associated with longer operating times than open prostatectomy: all 7 studies comparing TLRP with RRP and all 3 studies comparing EERP with RRP found lower mean operating times with RRP. However, laparoscopic procedures were also associated with a shorter length of stay and duration of catheterisation.
Seven of the 8 studies comparing TLRP with RRP found shorter hospital stays for TLRP; the remaining study found no difference between TLRP and RRP. One study comparing EERP with RRP and 3 studies comparing RALRP with RRP found significantly longer stays with RRP. All 5 studies comparing TLRP with RRP found shorter duration of catheterisation with TLRP. Two of 3 studies comparing EERP with RRP found significantly shorter duration of catheterisation with EERP. Two of 3 studies comparing RALRP with RRP found significantly shorter duration of catheterisation with RALRP.
Results on the use of analgesia varied between studies.
Positive margin rates of laparoscopic and open prostatectomy appeared similar.
Recurrence-free survival was poorly reported but appeared similar between laparoscopic and open prostatectomy.
Continence and potency were poorly reported. The findings suggested that continence may recover more quickly after laparoscopic surgery, whilst potency may recover more quickly after RRP than open prostatectomy.
The 2 studies compared TLRP with RRP found mixed results for continence. The only study comparing EERP with RRP found no important difference between procedures. One of 2 studies comparing RALRP with RRP found markedly faster recovery of continence up to 6 months after RALRP.
One of 2 studies comparing RALRP with RRP found higher rates of erection and intercourse return at 12 months after RALRP.
Quality of life was similar between TLRP and RPP in the 2 studies reporting this outcome.
Comparisons of laparoscopic procedures.
There were no important differences between the laparoscopic procedures.
Learning curve (6 studies).
Studies showed more conversions to open procedures for early compared with later experience (2 studies), a tendency for blood loss to decrease with experience (2 studies), a reduction in transfusions with experience (3 studies), and shorter operating time with experience (4 studies). Length of stay (2 studies), catheterisation (2 studies), positive margin rates (2 of 4 studies), and continence rates at 6 and 12 months (2 studies) did not seem to alter with experience. One study found that increasing experience was associated with faster recovery of potency after EERP.