GKT School of Medical Education, King's College London, Guy's Campus, London, UK.
Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
BJU Int. 2018 Aug;122(2):181-194. doi: 10.1111/bju.14170. Epub 2018 Mar 25.
To analyse the current difference between dismembered robot-assisted pyeloplasty (RAP) and laparoscopic pyeloplasty (LP) in the treatment of pelvi-ureteric junction (PUJ) obstruction as of 26 June 2017, focusing on operating time, length of hospital stay, complication rate, and success rate.
We searched PubMed, Medline and Embase databases, consulted experts, reviewed reference lists, used the 'related articles' PubMed feature, and reviewed scientific meeting abstracts for eligible articles published between 1993 and 26 June 2017. A modified Newcastle-Ottawa scale was used to assess study quality. Subgroup analyses were performed regarding patient age, single or multisurgeon experience, presence of complex renal anatomy, study quality, Clavien-Dindo grades, and length of follow-up.
From 4101 identified articles, 17 studies meeting our eligibility criteria were included for data extraction. All were observational studies, with 10 deemed to be of low quality. Meta-analysis showed that RAP resulted in a 27-min shorter operating time (weighted mean difference [WMD] -26.71 min, 95% confidence interval [CI] -44.42 to -9.00; P = 0.003) and a 1.2-day shorter length of hospital stay (WMD -1.21 days, 95% CI -1.84 to -0.57; P = 0.003). The quality of evidence for these outcomes was rated as very low. Significant heterogeneity was found when analysing operating time (P < 0.001) and length of hospital stay (P < 0.001), which could not be fully explained through subgroup analyses. We also identified other potentially significant sources of bias for which we could not adjust our analysis. RAP was also associated with a lower complication rate (odds ratio [OR] 0.56, 95% CI 0.37 to 0.84; P = 0.005) and higher success rate (OR 2.76, 95% CI 1.30 to 5.88; P = 0.008); however, whether statistical advantages for these two outcomes translated into clinically significant advantages was unclear. The quality of evidence for these outcomes was rated as low.
For patients with PUJ obstruction, our meta-analyses show that RAP is advantageous concerning operating time, length of hospital stay, complication rate and success rate. Our conclusions, however, are weakened by poor quality of evidence and significant study heterogeneity. In addition, whether the statistical significance observed in the present meta-analysis translates into clinical significance is an important question. Further high-quality studies, particularly randomized controlled trials, are necessary to strengthen conclusions.
分析截至 2017 年 6 月 26 日，分体机器人辅助肾盂成形术（RAP）与腹腔镜肾盂成形术（LP）治疗肾盂输尿管连接部（PUJ）梗阻的当前差异，重点关注手术时间、住院时间、并发症发生率和成功率。
我们检索了 PubMed、Medline 和 Embase 数据库，咨询了专家，查阅了参考文献列表，使用了 PubMed 的“相关文章”功能，并查阅了 2017 年 6 月 26 日之前发表的科学会议摘要中符合条件的文章。使用改良的 Newcastle-Ottawa 量表评估研究质量。针对患者年龄、单名或多名外科医生经验、复杂肾解剖结构、研究质量、Clavien-Dindo 分级和随访时间进行了亚组分析。
从 4101 篇鉴定的文章中，纳入了 17 项符合我们纳入标准的研究进行数据提取。所有研究均为观察性研究，其中 10 项被认为质量较低。Meta 分析显示，RAP 手术时间缩短 27 分钟（加权均数差值 [WMD] -26.71 分钟，95%置信区间 [CI] -44.42 至 -9.00；P = 0.003），住院时间缩短 1.2 天（WMD -1.21 天，95% CI -1.84 至 -0.57；P = 0.003）。这些结局的证据质量被评为极低。在分析手术时间（P < 0.001）和住院时间（P < 0.001）时，存在显著的异质性，这些异质性不能通过亚组分析完全解释。我们还发现了其他可能导致偏倚的潜在重要来源，但无法在分析中进行调整。RAP 还与较低的并发症发生率（比值比 [OR] 0.56，95% CI 0.37 至 0.84；P = 0.005）和更高的成功率（OR 2.76，95% CI 1.30 至 5.88；P = 0.008）相关；然而，这些两个结局的统计学优势是否转化为临床意义尚不清楚。这些结局的证据质量被评为低。
对于 PUJ 梗阻患者，我们的荟萃分析显示，RAP 在手术时间、住院时间、并发症发生率和成功率方面具有优势。但是，由于证据质量差和研究存在显著异质性，我们的结论被削弱了。此外，本荟萃分析中观察到的统计学意义是否转化为临床意义是一个重要问题。需要进一步进行高质量的研究，特别是随机对照试验，以加强结论。
