Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery

Table 1 Characteristics of original studies

Ref.	Country	Study design	Control group	No. of cases for urogenital outcomes	Study specifically examines urogenital outcomes
Hellan et al[34]	United States	Retrospective	No control group	39	No
Patriti et al[40]	Italy	RCT	Robot vs lap	29 rob vs 37 lap	No
Luca et al[6]	Italy	Prospective	No control group	74	Yes
Kim et al[31]	South Korea	Prospective	Robot vs lap	30 rob vs 39 lap	Yes
Park et al[39]	United States	Prospective	No control group	30	No
Leung et al[5]	Hong Kong	Prospective	No control group	33	Yes
Park et al[32]	South Korea	Retrospective	Robot vs lap	14 rob vs 15 lap	No
D'Annibale et al[33]	Italy	Retrospective	Robot vs lap	30 vs 30	No
Stănciulea et al[37]	Romania	Retrospective	No control group	78	No
Erguner et al[38]	Turkey	Prospective	Robot vs lap	27 rob vs 37 lap	No
Park et al[9]	South Korea	Retrospective	Robot vs lap	32 vs 32	Yes
Ozeki et al[18]	Japan	Prospective	Robot vs open	15 rob vs 22 open	Yes
Cho et al[35]	South Korea	Retrospective	Robot vs lap	278 vs 278	No
Alecu et al[36]	Romania	Retrospective	No control group	79	No
Morelli et al[30]	Italy	Retrospective	Robot vs lap	30 vs 30	Yes

These include: (1) the studies country of origin; (2) the study design (prospective, retrospective or randomised control trial); (3) the control group (if present) used to compare with the robotic rectal surgery, this was either laparoscopic or open rectal surgery cases; (4) the number of cases included in each study whose urogenital outcomes were evaluated; and (5) whether the study was specifically designed to investigate the urogenital outcomes of robotic surgery or not. RCT: Randomised control trial; Robot: Robotic; lap: Laparoscopic.

Table 2 Further characteristics of original studies

Ref.	Fully or hybrid robotic procedure	Functional scores applied	Follow up in months	No. of surgeons performing cases	SIGN score
Hellan et al[34]	Hybrid	No	Median f/u 13 mo	Not stated	+
Patriti et al[40]	Hybrid	No	Mean f/u 12 mo	Not stated	+
Luca et al[6]	Fully	Yes	1, 6, 12	2 surgeons	++
Kim et al[31]	Hybrid	Yes	1, 3, 6, 12	1 surgeon	++
Park et al[39]	Reverse hybrid	No	Not stated	Not stated	+
Leung et al[5]	Mixture	Yes	3	Not stated	++
Park et al[32]	Hybrid	Yes	3, 6, 12	1 surgeon	++
D'Annibale et al[33]	Fully	Yes	1, 12	1 surgeon	++
Stănciulea et al[37]	93% fully	Yes	Once b/n 6 and 12 mo	3 surgeons	+
Erguner et al[38]	Mixture	No	Not stated	Not stated	+
Park et al[9]	Hybrid	Yes	3, 6, 12	1 surgeon	++
Ozeki et al[18]	Fully	Yes	3, 6, 12	2 for robot cases	++
Cho et al[35]	Fully	No	1	3 surgeons did 97.1% cases	++
Alecu et al[36]	Hybrid	Yes	Not stated	Not stated	+
Morelli et al[30]	Not stated	Yes	1, 6, 12	1 surgeon	++

These include: (1) whether the surgeons used the hybrid or robotic approach for their study; (2) whether urogenital function was assessed by means of functional scores or not; (3) the follow up period during which data for urogenital outcomes was collected; (4) the number of surgeons performing the cases in each study; and (5) the studies SIGN score. f/u: Follow up; SIGN: Scottish Intercollegiate Guidelines Network.

Table 3 Original studies reporting male urological function

Ref.	Males assessed independently of females	Functional scores applied	Control group	No. of cases examining male urological function	Follow up in months	Outcome summary
Kim et al[31]	No	Yes	Robot vs lap	30 rob vs 39 lap	1, 3, 6, 12	Urological function recovered faster in robotic group (3 mo vs 6 mo) IPSS change from baseline lower in robotic group at 3 mo (P = 0.036) Mean voiding volume deterioration lower in 3 and 6 mo in robotic group (P = 0.007, P = 0.049) Similar outcomes at 12 mo in both groups
Park et al[9]	Yes	Yes	Robot vs lap	32 vs 32	3, 6, 12	IPSS scores elevated post-operatively in both groups At 12 mo IPSS change from baseline lower in robotic group but non-significant (P = 0.051)
Park et al[32]	Yes	Yes	Robot vs lap	14 rob vs 15 lap	3, 6, 12	Deterioration of IPSS scores in 3 mo which recovered by 6 mo in both groups
D'Annibale et al[33]	Yes	Yes	Robot vs lap	30 vs 30	1, 12	Deterioration of IPSS scores in 3 mo which recovered by 12 mo in both groups
Ozeki et al[18]	Yes	Yes	Robot vs open	15 rob vs 22 open	3, 6, 12	No statistical deterioration of IPSS scores in either group
Morelli et al[30]	Yes	Yes	Robot vs lap	Not available	1, 6, 12	Voiding and incontinence worse 1 mo in both groups, incontinence recovered by 6-12 mo in both groups
Leung et al[5]	Yes	Yes	No control group	33	3	No significant male urological function deterioration
Luca et al[6]	Yes	Yes	No control group	38	1, 6, 12	No significant male urological function deterioration
Stănciulea et al[37]	No	Yes	No control group	78	Once b/n 6 and 12	No deterioration in IPSS scores but no data presentation in results
Hellan et al[34]	No	No	No control group	39	median F/U 13 mo	One patient (2.56%) developed bladder dysfunction post operatively
Park et al[39]	No	No	No control group	30	Not stated	No patients developed bladder dysfunction post operatively
Cho et al[35]	No	No	Robot vs lap	278 vs 278	1	Voiding dysfunction rate higher in the laparoscopic group (4.3% lap vs 0.7% rob; P = 0.012)

The following study characteristics are described: (1) whether male patients were assessed independently of female patients or not, in studies that this was not the case data from male and female patients was combined; (2) whether functional scores were used to assess urogenital outcomes or not; (3) the control group used in the study if applicable; (4) the number of cases examining male urological function; (4) the follow up periods in months; and (5) a brief summary of the study’s findings regarding male urological function. Robot: Robotic; lap: Laparoscopic; f/u: Follow up; IPSS: International Prostatic Symptoms Score.

Table 4 Original studies reporting female urological function

Ref.	Females assessed independently of males	Functional scores applied	Control group	No. of cases examining female urological function	Follow up in months	Outcome summary
Morelli et al[30]	Yes	Yes	Robot vs lap	Not available	1, 6, 12	No difference between the pre- and post-operative scores in both groups
Luca et al[6]	Yes	Yes	No control group	36	1, 6, 12	Worse female urological function at 1 mo with full recovery by 12 mo in both groups
Kim et al[31]	No	Yes	Robot vs lap	30 rob vs 39 lap	1, 3, 6, 12	As in Table 3
Stănciulea et al[37]	No	Yes	No control group	78	Once b/n 6 and 12	As in Table 3
Hellan et al[34]	No	No	No control group	39	Median f/u 13 mo	As in Table 3
Park et al[39]	No	No	No control group	30	Not stated	As in Table 3
Cho et al[35]	No	No	Robot vs lap	278 vs 278	1	As in Table 3

This table describes the same study characteristics included in Table 3 but for female instead of male patients. Robot: Robotic; lap: Laparoscopic; f/u: Follow up.

Table 5 Original studies reporting male sexual function

Ref.	Males assessed independently of females	Functional scores applied	Control group	No. of cases examining male sexual function	Follow up in months	Outcome summary
Kim et al[31]	Yes	Yes	Robot vs lap	18 rob vs 20 lap	1, 3, 6, 12	Quicker recovery of male sexual function in robotic group (6 mo vs 12 mo) No difference in IIEF change from baseline between two groups at any stage Erectile function and libido deteriorated significantly more in lap group at 3 mo
Park et al[9]	Yes	Yes	Robot vs lap	20 vs 20	3, 6, 12	Quicker recovery of male sexual function in robotic group (6 mo vs 12 mo) IIEF deterioration significantly higher in lap group at 6 mo (P = 0.03)
Park et al[32]	Yes	Yes	Robot vs lap	14 rob vs 15 lap	3, 6, 12	Better male sexual function scores at 3 and 6 mo in robotic group No difference in IIEF change from baseline between two groups at any stage
D'Annibale et al[33]	Yes	Yes	Robot vs lap	18 rob vs 23 lap	1, 12	Erectile function restored 1 yr post-operatively in robotic group (P = 0.066) and partially in lap group (P = 0.048) No statistical comparison of IIEF change from baseline b/n 2 groups at any stage
Ozeki et al[18]	Yes	Yes	Robot vs open	15 rob vs 22 open	3, 6, 12	IIEF scores unchanged at 3, 6 and 12 mo in both groups
Morelli et al[30]	Yes	Yes	Robot vs lap	Not available	1, 6, 12	Quicker recovery of erectile and orgasmic function in robotic group (6 mo vs 12 mo) No difference in IIEF change from baseline between two groups at any stage
Leung et al[5]	Yes	Yes	No control group	15	3	No significant difference between post- and pre-operative IIEF scores
Luca et al[6]	Yes	Yes	No control group	38	1, 6, 12	Male sexual function scores decreased at 1 and 6 mo, recovered at 12 mo
Stănciulea et al[37]	Yes	Yes	No control group	31	Once b/n 6 and 12	No difference of pre- and post-op IIEF scores with exception of 3 patients (9.68%) with severe erectile dysfunction
Alecu et al[36]	No	Yes	No control group	79	Not stated	3 patients (3.79%) developed important sexual dysfunction. No mention of IIEF scores in results
Patriti et al[40]	Yes	No	Robot vs lap	11 rob vs 12 lap	Mean f/u 12 mo	No difference in the incidence of sexual dysfunction between the 2 groups
Erguner et al[38]	No	No	Robot vs lap	27 rob vs 37 lap	Not stated	No difference in the incidence of sexual dysfunction between the 2 groups
Cho et al[35]	No	No	Robot vs lap	278 vs 278	1	No difference in the incidence of sexual dysfunction between the 2 groups
Park et al[39]	Yes	No	No control group	16	Not stated	1 patient (6.25%) developed ejaculatory dysfunction, no patients developed erectile dysfunction

This table describes the same study characteristics included in Tables 3 and 4 but for studies assessing male sexual function. Robot: Robotic; lap: Laparoscopic; f/u: Follow up; IIEF: International Index of Erectile Function score.

Table 6 Original studies reporting female sexual function

Ref.	Females assessed independently of males	Functional scores applied	Control group	No. of cases examining female sexual function	Follow up in months	Outcome summary
Morelli et al[30]	Yes	Yes	Robot vs lap	not available	1, 6, 12	Female sexual function worse at 1 and 6 mo and restored by 12 mo, in both groups
Luca et al[6]	Yes	Yes	No control group	36	1, 6, 12	Female sexual function worse at 1 and 6 mo and restored by 12 mo
Stănciulea et al[37]	Yes	Yes	No control group	13	Once b/n 6 and 12	No difference between pre- and post-operative FSFI scores (but data not provided in results section)
Alecu et al[36]	No	Yes	No control group	79 pts	Not stated	As in Table 5
Erguner et al[38]	No	No	Robot vs lap	27 rob vs 37 lap	Not stated	As in Table 5
Cho et al[35]	No	No	Robot vs lap	278 vs 278	1	As in Table 5

This table describes the same study characteristics included in Tables 3-5 but for studies assessing female sexual function. Robot: Robotic; lap: Laparoscopic; FSFI: Female Sexual Function Index.