Comparative effectiveness of robotic and laparoscopic radical prostatectomy: a GRADE-assessed systematic review and...

Robot-assisted radical prostatectomy (RARP) has rapidly supplanted conventional laparoscopic radical prostatectomy (LRP), despite the limited high-quality comparative evidence. This systematic review synthesizes randomized controlled trial data comparing RARP with LRP for localized prostate cancer, incorporating the GRADE certainty assessment and pre-planned geographic subgroup analyses. This systematic review and meta-analysis was prospectively registered in PROSPERO (CRD420251207193). We conducted a PRISMA-compliant systematic review of MEDLINE, Embase, Cochrane CENTRAL, Scopus, Web of Science, and ClinicalTrials.gov through October 2025 for randomized controlled trials comparing RARP with LRP (2D/3D) in men with localized or locally advanced prostate cancer. The primary outcomes were 12-month urinary continence and erectile function scores. Secondary outcomes included perioperative metrics, complications, and positive surgical margins. Random-effects meta-analyses estimated risk ratios (RR) and mean differences (MD) with 95% confidence intervals. The risk of bias was assessed using the Cochrane RoB 2 tool, and the certainty of evidence was evaluated using the GRADE methodology. Four randomized controlled trials (1095 participants) met the inclusion criteria, with 734 patients in the RARP group and 361 patients in the LRP group. Conventional LRP achieved significantly superior 12-month urinary continence compared to RARP (RR 1.12, 95% CI 1.03-1.22; p = 0.006; I²=0%; moderate-certainty evidence), equivalent to 66 additional continent patients per 1,000 treated. Erectile function recovery at 12 months significantly favored LRP (RR 1.39, 95% CI 1.09-1.76; p = 0.007; I²=0%; moderate-certainty evidence), representing 91 additional potent patients per 1,000 patients. Positive surgical margins did not differ significantly (RR 1.11, 95% CI 0.85-1.44; p = 0.45; low-certainty evidence), supporting equivalent oncological safety. Perioperative outcomes, including operative time (MD 4.18 min, 95% CI - 0.51 to 8.87; p = 0.08), estimated blood loss (MD - 26.24 mL, 95% CI - 98.68 to 46.21; p = 0.48; I²=91%), and overall complications (RR 0.94, 95% CI 0.52-1.68; p = 0.83) showed no significant differences. The geographic subgroup analysis suggested potential regional variation, but the tests for interaction were not significant. This randomized evidence synthesis demonstrates that conventional laparoscopic radical prostatectomy was associated with significantly better urinary continence and erectile function at 12 months compared with robot-assisted approaches, while maintaining comparable oncologic and perioperative outcomes. These findings suggest that surgeon expertise and institutional experience may be important determinants of patient outcomes, independent of the technology platform employed.