Robotic versus open radical Prostatectomy: comparing automobiles and carriages in 2024

Abstract

The second Randomized Clinical Trial (RCT) to date comparing robotic (RARP) versus open (RRP) radical prostatectomy, the So Paulo trial (1) highlights the challenges of randomization in a period where technological access is widespread in the US and Europe.The Brisbane Trial, published 8 years ago, stands as the first and only comparator in this context (2).As new scientific insights emerge from centers adopting robotic surgery, RARP is increasingly viewed as the gold standard in current technology.However, open surgery can provide comparable oncological control and late quality of life and remains prevalent in developing countries due to limited resources.While robotic surgery may offer slightly better early sexual and urinary function, these remain secondary outcomes in both RCTs conducted so far.In the hierarchy of evidence, systematic reviews and RCTs are deemed the most robust.To delineate the natural history of Radical Prostatectomy (RP), the Reverse Systematic Review (RSR) method, recently described by Moretti TBC and Reis LO, compiled a population-based database named EVIDENCE.This database amalgamates data from 910 studies across 80 Systematic Reviews (SR) on RRP, laparoscopic, and RARP, encompassing 1,353,485 patients (3-8).The clinical heterogeneity generated by RSR allows EVIDENCE to provide central tendency values for population samples with a narrow standard error of the mean, enhancing the precision of mean values relative to the population.This heterogeneity also increases the generalization and representativeness, serving as a practical reference for urologists in real-world settings, and enabling comparisons across the available RCT.Table-1 summarizes key outcomes comparing the EVIDENCE database (3-6), So Paulo Trial [1], and the Brisbane Trial [2] and presents a didactic graphic representation for the pentafecta results between open and robotic radical prostatectomy by different assays.Values are color-coded (significant difference -red for above, green for below -and yellow for non-significant difference).While it is noted that the EVIDENCE was able to predict the results of the RTC's, acting as a weighting factor for the averages through its representative heterogeneity of scenarios, the So Paulo Trial [1] tends to report higher values, while the Brisbane Trial [2] reports lower values compared to EVIDENCE, illustrating how different randomized studies can depict diverse scenarios that require careful comparison.Surgeon related variabilities might play a significant role in the disagreements illustrated in Table-1, even between So Paulo and Brisbane randomized controlled trials, considering the wide variability among surgeons