Modified apical dissection during robot-assisted laparoscopic radical prostatectomy: a systematic review and meta-analysis

Robot-assisted laparoscopic radical prostatectomy (RALP) has improved patient recovery, but achieving optimal functional outcomes remains a challenge, especially early urinary continence. The Modified Apical Dissection (MAD) technique has been suggested to improve early continence compared to conventional RALP. A comprehensive search of PubMed, Embase, and Cochrane Central databases was conducted to identify studies on MAD from inception to March 2024. The risk of bias was evaluated using the ROBINS-I tool. Primary outcomes assessed included urinary continence, positive surgical margin rate, biochemical recurrence rates, and complication rates. Out of 789 studies screened initially, we selected 8 studies that met our inclusion criteria. Our analysis showed that patients who underwent the MAD technique had a significantly higher likelihood of achieving early urinary continence compared to those undergoing conventional RALP at the initial follow-up (Odds Ratio [OR] = 4.0, 95% CI = 1.87-8.57). This advantage continued at 1 month (OR = 5.44, 95% CI = 2.98-9.92), 3 months (OR = 5.36, 95% CI = 2.26-12.71), and 6 months (OR = 5.18, 95% CI = 1.51-17.75), though no significant difference was noted at 12 months. There were no significant differences in positive surgical margin rate or biochemical recurrence rate between MAD and conventional RALP. The overall complication rate was 10.9% (95% CI = 8.10-14.06), with most complications being classified as minor (Clavien-Dindo I-II). In summary, our meta-analysis suggests that the MAD technique may lead to earlier recovery of urinary continence without compromising oncologic outcomes in patients undergoing RALP. While there are published studies on the outcomes of MAD, only a few have the appropriate design with a comparison group needed for meta-analysis and discussing various endpoints. More randomized controlled trials are necessary, but the current literature still lacks retrospective studies with comparison groups.