This review concluded, based on data from observational studies, that robotic-assisted laparoscopic pyeloplasty and conventional laparoscopic pyeloplasty for uteropelvic junction obstruction appeared equivalent with respect to postoperative urinary leaks, hospital readmissions, success rates and operative time. Multicentre randomised controlled trials are required before one approach can be recommended over the other. These conclusions appear likely to be reliable.

To assess the impact of robotic-assisted laparoscopic pyeloplasty over conventional laparoscopic pyeloplasty for patients with uteropelvic junction obstruction, focusing on operative time, length of hospital stay, postoperative complications and success rate.

MEDLINE, EMBASE, LILACS and SciELO were searched for dates ranging 1992 to 2008 for publications in English, French, Spanish, Portuguese, Italian and German. Search terms were reported. Abstracts from American and European scientific meetings were also searched. In addition, the related articles function on PubMed was used, references of identified studies were checked, and experts were contacted.

Any clinical trial or observational study that compared robotic-assisted laparoscopic pyeloplasty with conventional laparoscopic pyeloplasty in the treatment of uteropelvic junction obstruction was eligible for inclusion in the review.

The outcomes of interest were operative time, length of hospital stay, postoperative complications and success rate.

The majority of included studies enrolled adults, two assessed procedures in children and one included a mixture of adult and paediatric patients. A minority of studies employed retrograde pyelography. Most studies used polyglycolic sutures. Half of included studies were based on single surgeon experience.

Two reviewers independently assessed the studies for inclusion in the review; disagreements were resolved through consensus.

Two reviewers independently assessed the studies for validity using a modified version of the Newcastle-Ottawa scale that assessed: selection, applicability and comparability of study groups; evaluation of outcomes; and adequacy of follow-up. Studies scoring fewer than 5 points were considered to be low quality; those scoring between 5 and 7 points to be high quality.

The authors extracted data to permit the calculation of odds ratios (OR) and risk differences (RD) for dichotomous outcomes or mean differences for continuous data, each with 95% confidence intervals. Authors were contacted for missing data.

The authors did not state how many reviewers performed the data extraction.

Pooled odds ratios and weighted mean differences (WMDs), with 95% confidence intervals, were calculated using a random-effects model. Statistical heterogeneity between studies was assessed using the χ² statistic. It appeared that I² statistics were also calculated.

A priori subgroup analyses were conducted to assess: the impact of adjusting for prior experience with conventional laparoscopic pyeloplasty; for which prior publication record was used as a proxy; for high versus low methodological quality; and for adult versus paediatric population.

Publication bias was assessed through visual inspection of funnel plots.

Eight studies were included in the review (n=326 patients); all studies were observational. Only one study had a prospective design, although two of the remainder declared prospective data collection. Mean follow-up time ranged from three to 46 months. Three studies were considered to be high quality, scoring 5 points; three studies scored 4 points and two scored 3 points.

Robotic-assisted laparoscopic pyeloplasty was associated with a statistically non-significantly shorter operation time compared to conventional laparoscopic pyeloplasty (WMD -10.4 minutes, 95% CI -24.6 to 3.00; seven studies), with statistically significant heterogeneity.

Hospital stays were statistically significantly shorter following robotic-assisted laparoscopic pyeloplasty than conventional laparoscopic pyeloplasty (WMD -0.5 days, 95% CI -0.6 to -0.4; five studies), although the clinical significance of this was unclear.

There was no statistically significant difference in complication rates between the procedures (OR 0.7, 95% CI 0.3 to 1.6; eight studies).

Success rates were similar for the two procedures (OR 1.3, 95% CI 0.5 to 3.5; eight studies).

Subgroup analysis showed that operative times were significantly shorter for robotic-assisted laparoscopic pyeloplasty in centres with low conventional laparoscopic pyeloplasty experience compared with centres with high experience (for which no significant difference was found between the two procedures); statistical heterogeneity in these subgroups remained high. No other significant differences were found in other subgroup analyses.

Results of funnel plot analyses were not reported.

Robotic-assisted laparoscopic pyeloplasty and conventional laparoscopic pyeloplasty appeared equivalent with respect to postoperative urinary leaks, hospital readmissions and success rates for patients with uteropelvic junction obstruction. The estimate of treatment effect for operative time using a random-effects model did not favour either procedure. Multicentre randomised controlled trials (RCTs) are required before one approach can be recommended over the other.

The review question and inclusion criteria were clear. The authors searched several relevant databases and other relevant sources for studies published in a range of European languages, reducing (but not eliminating) the risks of publication and language biases. The authors reported using methods designed to reduce reviewer bias and error in the selection of studies and the assessment of validity, but not in the extraction of data.

The validity assessment used a tool appropriate for observational studies. Meta-analysis was used appropriately. Pre-planned subgroup analyses were used to explore differences between the studies, in addition to an assessment of statistical heterogeneity.

The authors' conclusions reflected the results of the review and the level of evidence available; consequently they appear likely to be reliable.

Practice: The authors did not state any implications for practice.

Research: The authors stated that multicentre RCTs comparing robotic-assisted laparoscopic pyeloplasty and conventional laparoscopic pyeloplasty in patients with uteropelvic junction obstruction are required before one approach can be recommended over the other. They also stated that future cost analyses may prove useful in deciding between the procedures.

None.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.