Comparative Outcomes of Robot-Assisted vs Traditional Laparoscopic Ureteral Reimplantation for Lower Ureteral Stenosis: A Single Center Study

Introduction

Lower ureteral stenosis is usually caused by non-iatrogenic factors (including congenital ureteral orifice stenosis, stones, and inflammation) and iatrogenic factors (including gynecological/obstetric surgery and urological surgery). The treatment of lower ureteral stenosis caused by various reasons is diverse, and the effect of general drug treatment is poor. Surgery is an effective method for the treatment of lower ureteral stenosis. Ureterovesical reimplantation is a reliable choice when the therapeutic effect of ureteral stent implantation, balloon dilatation, and ureterotomy is poor [1]. Open ureteral reimplantation (OUR) is considered the “gold standard” of lower ureteral stenosis surgery [1], but its application is limited by large incision, postoperative hematuria, long hospital stay, and slow recovery. With the rapid development of laparoscopic surgery technology and equipment in urology, it is possible for minimally invasive technology to replace open surgery [2,3]. Compared with OUR, laparoscopic ureteral reimplantation (LUR) has the advantages of smaller incision, fewer adverse effects, shorter hospital stay, and faster recovery [2]. However, in the narrow space of the pelvic cavity, the laparoscopic straight rod instrument used for OUR and LUR has poor flexibility, limited magnification, and difficult operation of tissue separation and ureterovesical anastomosis.

The emergence of a robotic surgery system makes up for the above shortcomings of OUR and LUR [3]. It has the advantages of 3D enlarged field of vision, flexible rotation, and filtering function, which can effectively overcome the above shortcomings of traditional laparoscopic surgery. Therefore, robot-assisted laparoscopic ureteral bladder reimplantation (RALUR) has good clinical effectiveness [3] and high safety. At present, the methods of LUR mainly include cross triangle tunnel ureterovesical reimplantation (Cohen), the Politano-Leadbette method, the Lich-Gregoir method, and the Boari technique. Although the anti-reflux effect is satisfactory [4], the above operations are relatively complex, time-consuming, and require high technical requirements for the operator. The clinical application of external bladder nipple ureteral replantation has proven that the effect is satisfactory [5]. Therefore, this retrospective study from a single center aimed to compare clinical outcomes (efficacy, advantages, and disadvantages of the method) between RALUR and standard LUR in treating 34 patients with lower ureteral stenosis in the Department of Urology of our hospital from January 2019 to January 2023, so as to provide more reference for clinical practice.

Material and Methods

ETHICAL STATEMENT:

This study has been approved by the Ethical Committee of Guigang People’s Hospital ELW-2024-026-01. All patients involved in this study have provided written informed consent and approved this study. This study was performed in accordance with the Helsinki Declaration of 1975, as revised in 2013.

PATIENTS:

This study collected clinical data for 34 patients who underwent RALUR and LUR in the Urology Department of our hospital from January 2019 to January 2023. The patients were randomly divided into a combination of RALUR and LUR groups.

INCLUSION AND EXCLUSION CRITERIA:

Inclusion criteria included: 1) patient age greater than 18 years; 2) thorough imaging-based examination, such as urological ultrasound, intravenous urography, or computed tomography urography (CTU), excretory cystourethrography, or retrograde ureterography; 3) preoperative diagnosis confirmed to be lower ureteral stenosis, with a length of 10–20 mm; 4) failure or relapse after balloon dilation, ureterotomy, or ureteral stent placement, followed by the decision to undergo ureteral bladder replantation surgery.

Exclusion criteria included: 1) comorbidity with severe diseases of important organ systems such as heart, lung, and brain, including third-degree atrioventricular block, heart failure, severe pneumonia, pulmonary embolism, acute cerebral infarction, cerebral hemorrhage, and other diseases; 2) coagulation disorders; 3) other urinary system diseases, such as narrowing of the renal pelvis ureteral junction, multiple ureteral strictures, bladder ureteral reflux, duplicate kidney ureters, ureteral stones, and urothelial tumors; 4) other cases that require simultaneous surgery, such as inguinal hernia repair surgery, and radical cervical cancer surgery; 5) patients with transplant history; 6) the ureteral stenosis was caused by malignancy; 7) cases with incomplete clinical data or inability to return to the hospital for follow-up on time.

PREOPERATIVE PREPARATION:

Patients were administered admission examinations, including blood routine, urine routine, coagulation function, liver and kidney function, electrocardiogram, and chest X-ray. Patients with urinary tract infections received a sufficient course of antibiotic treatment. Patients underwent urological ultrasound examination to determine the separation of the renal pelvis and ureter. According to the specific situation, intravenous pyelography (IVP), CTU, or magnetic resonance urography were performed to understand the morphology, structure, and pathological relationship of the renal collecting system, ureter, and bladder. If necessary, retrograde ureterography and ureteroscopy were performed to locate the local lesion. Dynamic renal SPECT/CT imaging was used to determine the glomerular filtration rate (GFR) value of the affected kidney.

Preoperative preparation: A prophylactic antibiotic was administered half an hour before surgery. An indwelling urinary catheter was placed. The surgeons conducting the operations for the patients in the 2 groups were the same chief physician and assistant.

Anesthesia method and position: Both types of operations were performed under general anesthesia with tracheal intubation, in a supine position with the head and feet at a high position of 30 degrees.

RALUR SURGERY:

The RALUR group underwent surgery that employed the Da Vinci robot-assisted laparoscopic nipple ureteral bladder reimplantation platform (Figure 1). A 10 mm camera port was placed at the umbilicus using the Hasson technique, and the pneumoperitoneum was established. An 8-mm trocar (point a) was placed, and the observation lens was positioned to observe the intraperitoneal environment. Another trocar was placed under direct vision, and an 8-mm trocar (point b, point c) was placed at about 80 mm next to the left and right rectus abdominis at point a. A 10-mm trocar was inserted into the right anterior superior iliac spine at 30 mm (D) as the auxiliary hole. The trocar at point a was connected to arm 3 as the lens arm, the trocar at point b was connected to arm 2 to insert Maryland bipolar forceps, and the trocar at point c was connected to arm 4 to insert unipolar surgical scissors. The retroperitoneum was cut at the level of the iliac vessels, the ureter was found to be “straddling” the vessel here, and the expanded ureter was released downward to the bladder junction (the round ligament, broad ligament, and uterine artery were not cut in women, and the vas deferens was not cut in men). The cuts in the bladder area were closed as much as possible, and the ureter was sutured with 2-0 absorbable suture and cut transversely. The ureteral stump was cut longitudinally for about 5 mm, and the ureteral wall was sutured intermittently with 5-0 absorbable suture to form a papillary shape of about 10 mm. About 200 ml of water was injected into the bladder, and about 30 mm of the whole bladder layer was cut at the bottom of the affected bladder to avoid ureteral torsion and angulation. Under conditions of no tension, the nipple end of the ureter was dragged into the bladder for about 10 mm, and the F7 double-J tube was placed into the ureter through a trocar. The full-thickness bladder and the outer wall of the ureter were sutured intermittently with 3-0 absorbable suture. The bladder incision was sutured and closed. About 200 ml of water was injected into the bladder through the catheter, while carefully checking whether there was leakage at the anastomosis of the ureterovesical reimplantation and checking whether there was bleeding in the wound. An indwelling drainage tube was then placed, and finally the retroperitoneum and abdominal incision were closed.

LUR SURGERY:

For the LUR group, the technique of laparoscopic nipple ureteral reimplantation was carried out. A 10-mm camera port was placed at the umbilicus using the Hasson technique, and the pneumoperitoneum was established. A 10-mm trocar was placed (point a), inserting the laparoscope to observe the interior of the abdominal cavity. Other trocars were placed under direct vision. The 10-mm trocars (points b and c) were placed at about 80 mm next to the left and right rectus abdominis muscles of point a, and a 5-mm trocar was placed 30 mm from the right anterior superior iliac spine at point d, as the auxiliary hole. The retroperitoneum was cut at the level of the iliac vessels, the ureter was found to be “straddling” the vessel here, and the expanded ureter was released downward to the bladder junction. (In this group, to expose the surgical field, in women, part of the broad ligament was cut while trying to avoid damaging the uterine artery; in men, the vas deferens was cut as appropriate.) The urinary catheter was also removed. The other steps were the same as in the RALUR group.

OBSERVATION INDICES:

The indices of patients in the 2 groups were observed and compared in this study, including the operative time (from skin incision to the end of skin suture), postoperative hemoglobin decline (the difference between preoperative and postoperative final measurement before discharge), drainage tube removal time (drainage volume <10 ml per day can be removed), pain according to the visual analogue scale (VAS), postoperative hospital stay (discharge criteria: stable vital signs, normal diet, getting out of bed activity, self-urination after removal of urinary catheter), hospitalization expenses, postoperative complications (urinary leakage, stenosis, reflux, repeated urinary tract infection), postoperative 6-month follow-up data (degree of separation of the renal pelvis, degree of ureteral dilation, and GFR).

FOLLOW-UP:

The patients in the RALUR group and LUR group were followed up for 6 months after the operation. Six months after surgery, both groups of patients underwent urinary ultrasound, excretory cystourethrography, CTU, and radionuclide renography to measure the GFR of the affected kidney.

STATISTICAL METHODS:

This study used SPSS18.0 statistical software for data analysis. The measurement data were expressed as mean±standard deviation (mean±SD). The t-test was used for inter-group comparison, and paired t-test was used for intra-group comparison before and after operation. The measurement data of non-normal distribution were represented by M (Q1, Q3), and the Mann-Whitney U test was used for comparison between groups. The Fisher exact test was used to compare the quantitative data, with P<0.05 deemed to be statistically significant.

Results

GENERAL CHARACTERISTICS OF PATIENTS:

A total of 34 patients (34 sides) were included in this study. Patients were divided into the RALUR group and the LUR group according to the surgical method. The RALUR group included 14 patients (8 on the left side and 6 on the right side), 6 male and 8 female, aged 22–68 years (mean of 46.21±12.80). There were 10 patients with a history of surgery, including 2 cases of lower ureteral stone lithotripsy, 1 case of extracorporeal shock wave lithotripsy, 1 case of lower ureteral stenosis incision, 1 case of ureteral bladder replantation, 3 cases of cervical cancer radical surgery, 1 case of cesarean section, and 1 case of rectal cancer radical surgery. The LUR group included 20 patients (12 on the left side and 8 on the right side), 9 male and 11 female, aged 20–66 years (mean of 46.35±11.52 years). There were 15 cases with a history of surgery, including 4 cases of ureteral calculi, 2 cases of extracorporeal shock wave lithotripsy, 2 cases of ureteral stenosis incision, 1 case of partial cystectomy, 1 case of pelvic mass resection, 3 cases of cervical cancer radical resection, 1 case of endometrial cancer radical resection, and 1 case of rectal cancer radical resection. Comparing the general characteristics of patients in the 2 groups, including preoperative degree of renal pelvis separation, degree of ureteral dilation, and the GFR for the affected side, there were no significant differences (Table 1, P>0.05).

No conversion to open surgery occurred in the above 2 groups. The double-J tube was replaced 6 weeks after operation and removed 3 months later.

OPERATION-RELATED CONDITIONS AND HOSPITALIZATION EXPENSES:

The operation time, postoperative hemoglobin decline, postoperative drainage tube removal time, and postoperative hospital stay of patients in the RALUR group were significantly shorter than those in the LUR group (Table 2, P<0.05). However, the total hospitalization cost of the RALUR group was significantly higher than that of the LUR group (Table 2, P<0.05). There was no statistically significant difference in the postoperative VAS scores between the 2 groups (Table 2, P>0.05).

POSTOPERATIVE COMPLICATIONS:

The incidence of complications in the RALUR group was 28.6% (4/14) (Table 3). One patient showed gradual aggravation of renal hydronephrosis on follow-up ultrasound after removing the double-J tube. Ureteroscopy revealed stenosis at the anastomotic site, and an F7 double-J tube was re-retained for 1 month before removal. There was no increase in renal hydronephrosis on follow-up ultrasound. One case of reflux disappeared after drug treatment and infection prevention. Two cases of recurrent urinary tract infections were treated with oral antibiotics, and the urine routine returned to normal. No urine leakage or retention occurred in patients in the RALUR group.

The incidence of complications in the LUR group was 30.0% (6/20) (Table 3). One patient experienced urinary leakage, which self-closed with enhanced nutrition and prolonged indwelling catheter time. For 2 patients, follow-up with ultrasound after the removal of the double-J tube revealed that renal hydronephrosis was gradually worsening. Ureteroscopy revealed stenosis at the anastomotic site, and F7 double-J tubes were re-retained. One patient showed no progression in renal hydronephrosis during follow-up ultrasound, while the other gradually worsened. Ureteroscopy was performed to expand the body and double-J tubes were retained. One case of reflux disappeared after drug treatment and infection prevention. Two cases of recurrent urinary tract infections were treated with oral antibiotics, and the urine routine returned to normal. No urinary retention occurred.

In total, there were no cases requiring a second ureteral bladder replantation in either group. There was no statistically significant difference in complications between patients in the 2 groups (Table 3, P=1.00).

URINE REFLUX IN PATIENTS:

Both groups of patients were followed up for 6 months after surgery. Six months postoperation, urinary tract ultrasound, excretory cystourethrography, and CTU were performed to observe the urine reflux. Comparing these results with the CTU image pre-operation (narrow left lower ureter, dilated and tortuous upper ureter with hydronephrosis) (Figure 2A), the CTU re-examination 6 months postoperation showed that the left ureter drainage was smooth and there was no hydronephrosis in the upper urinary tract (Figure 2B). Meanwhile, the cystography result showed no urine reflux to the upper urinary tract 6 months postoperation (Figure 2C).

COMPARISON OF DEGREE OF RENAL PELVIS SEPARATION, DEGREE OF URETERAL DILATION, AND GFR BETWEEN THE 2 GROUPS:

Furthermore, nephrography was also performed to measure the renal GFR on the affected side 6 months postoperation. After 6 months of operation in the RALUR group, the degree of renal pelvis separation and ureteral dilation distance on the affected side were significantly reduced compared with their pre-operation values, and the GFR of the affected side kidney was significantly improved compared with the pre-operation GFR (Table 4, all P<0.001). The degree of renal pelvis separation and ureteral dilation on the affected side were significantly reduced in the LUR group 6 months after surgery, compared with before surgery, and the GFR of the affected-side kidney was significantly improved compared with the pre-surgery GFR (Table 5, all P<0.001). The degree of renal pelvis separation of the RALUR group was significantly greater than that of the LUR group (Table 6, P=0.030). However, there was no significant difference between the RALUR group and the LUR group in terms of the difference in degree of ureteral dilation and the difference in GFR of the affected kidney (Table 6, both P>0.05).

Discussion

The present findings showed that operation time and postoperative hemoglobin decline were less, postoperative drainage tube removal time and postoperative hospital stay were shorter, and total hospitalization cost was higher in the RALUR group compared with the LUR group. Renal pelvis separation distance and degree of ureteral dilation of the affected side were reduced in the RALUR group at 6 months postoperation, and GFR was improved. In the LUR group, degree of renal pelvis separation and ureteral dilation were reduced 6 months postoperation. The change in degree of renal pelvis separation in the RALUR group was greater than in the LUR group.

Lower ureteral stenosis refers to the obstruction of the lower ureter caused by various reasons, which blocks urine flow down to the bladder and causes the urine to accumulate in the ureter, renal pelvis, and calices above the obstruction [6]. There are many reasons for the disease, mainly non-iatrogenic factors such as congenital ureteral orifice stenosis, stones, inflammation, and iatrogenic factors such as gynecological and obstetric surgery, and urological surgery. The incidence of ureteral injury caused by gynecological surgery is 0.3–2.5%, accounting for 64–82% of iatrogenic ureteral injury [7], and the incidence of ureteral injury during stone surgery is 0.5–10.0% [7]. Long-term ureteral stenosis will lead to upper urinary tract hydronephrosis, secondary stones, and infection, which will cause renal function damage and even uremia. Therefore, timely intervention should be carried out to relieve obstruction, relieve symptoms, and prevent complications. Surgical treatment is the main treatment for lower ureteral stenosis. At present, various minimally invasive surgical techniques play a leading role in the treatment of lower ureteral stenosis. Ureterovesical reimplantation is still a reliable surgical method in the case of failure of the above treatment.

Although OUR is the criterion standard for surgical correction and has a precise curative effect, OUR has the disadvantages of large trauma and slow recovery. Lakshmanan et al [8] reported the first case of LUR in 2000. With the development of technology, the traditional LUR has achieved the same surgical effect as open surgery [9]. At the same time, because of its small incision, less discomfort, short hospital stay, fast recovery, and other characteristics, laparoscopic surgery is popular in the application of ureterovesical reimplantation. However, traditional laparoscopy has low magnification of the visual field, limited scope of instrument operation, and low flexibility. For patients with a history of previous surgery, pelvic or ureteral stenosis can be accompanied by severe peripheral adhesion and unclear boundaries. It is very difficult to separate the ureter by traditional laparoscopy, which can also do great damage to small blood vessels and adjacent tissues, leading to more bleeding during the operation. Compared with traditional open surgery and traditional laparoscopic surgery, Da Vinci robot-assisted laparoscopic surgery has obvious advantages, such as less bleeding. Peters et al [10] reported the world’s first Da Vinci RALUR in 2004 and achieved good results.

RALUR has the advantages of less bleeding, shorter operation time, and shorter postoperative hospital stay. The robot system can distinguish clearly, clamp flexibly, avoid vibration and traction injury, precisely release the ureter, significantly reduce the damage to surrounding tissues, reduce wound bleeding, prevent small blood vessels from coagulation, and quickly stop the bleeding from cutting-induced wounds. For patients with previous pelvic surgery history, the robot system has the advantages of flexible separation of adhesive tissues and organs, avoiding accidental injury to important nerves and blood vessels, and less bleeding. In the present study, the degree of postoperative hemoglobin decline in the RALUR group (7.21±2.39 g/L) was significantly less than that in the LUR group (10.12±3.07 g/L), similar to that reported abroad [11]. Actually, 1 gram of hemoglobin is approximately equivalent to 40 ml of blood. Therefore, about 280–400 ml of blood was lost in patients in the RALUR group and LUR group. Using RALUR, it is easier to find the ureter than when using LUR. The robot system can achieve fine separation and rapid and accurate suture, significantly reducing the operation time. The operation time in the RALUR group (201.50±41.25 min) was significantly less than that in the LUR group (241.50±53.56 min). Zhang et al [12] reported that in the reconstruction of ureteral stenosis, the operation time and suture time of patients with RALUR were significantly less than those with LUR, suggesting that the robot can effectively reduce the operation time and difficulty compared with traditional laparoscopy. However, there are also reports that robotic surgery takes more time than traditional laparoscopy [11] or open surgery [13], so there are some disputes about the time consumption of robotic surgery.

Robot-assisted surgery can reduce intraoperative bleeding and provide more anatomical precision, greater flexibility, more accurate sutures, and shorter operation time. The presence of pneumoperitoneum and duration of anesthesia during the operation is shorter, which is conducive to the recovery of gastrointestinal function after the operation [14]. A previous study [15] found that, compared with open surgery, minimally invasive surgery has less postoperative pain and less demand for narcotic analgesics. However, there was no significant difference in the postoperative VAS score between the 2 groups in our study, which may be related to the subjectivity of the score, the similar length of the abdominal wall wound in the 2 groups, and the time or dose of intraoperative anesthesia. The drainage tube removal time in the RALUR group was significantly shorter than that in the LUR group (P<0.001). There was no urinary leakage after the operation, the wound in the pelvic cavity was small, the hemostatic effect was good, the exudation was lower, and the indwelling time of the drainage tube was shorter. The above favorable factors allowed the patients in the RALUR group to be discharged earlier. In addition, the postoperative hospital stay in the RALUR group was significantly shorter than that in the laparoscopic group (P=0.017). Deng’s research [16] found that RALUR can reduce the length of hospital stay compared with open surgery. Rappaport et al [17] also reported that the average length of hospital stay (2 days) in the RALUR group was significantly shorter than that in the LUR group (5 days). Compared with LUR, RALUR has the following advantages: 1) It can achieve “low anastomosis” close to the opening of the ureter, and it can also easily sew out the ureter “nipple”. 1) It can avoid important blood vessels, ligaments, uterus and ovary in women, and vas deferens in men, during ureter replantation [13], reducing the risk of damage to surrounding organs after operation. 1) It can reduce hand tremor which could cause injury to the ureter and peripheral blood vessels. 1) With the assistance of the Da Vinci robot, the bladder muscle flap can be easily removed and sutured with the ureter end. 1) It can minimize fatigue and better maintain mental focus.

Robot surgical systems also have some shortcomings. On the one hand, the lack of tactile feedback may cause tissue fragmentation when clamping tissues, especially the ureter at the anastomosis, and may cause suture breakage or a loose knot when needle-suturing the anastomosis. In addition, the high cost of this type of surgery makes it difficult to promote the use of robotic laparoscopic surgery technology in most hospitals [13].

Studies [18,19] have shown that the incidence of complications after ureterovesical reimplantation is 2–12%. There was no significant difference in the total incidence of complications between the RALUR group and the LUR group. Anastomotic leakage after ureterovesical reimplantation is one of the common early complications [20]. Urine leaks out and accumulates in the pelvic cavity and abdominal cavity, causing abdominal infection. There are many reasons for anastomotic leakage after ureterovesical reimplantation, including the patient’s personal situation, surgical methods, and perioperative intervention [21]. In the present study, a single case of anastomotic leakage occurred in the LUR group after operation. The patient had a history of pelvic surgery before this operation. During the operation, the adhesion around the ureteral stenosis was serious, resulting in insufficient free length of ureter. It was considered that the anastomotic tension was too great. If anastomotic tension is found during the operation, the anastomotic stoma should be specially reinforced and sutured to achieve the purpose of reducing tension. In addition, it is important to keep the drainage of the ureteral stent unobstructed after operation to prevent urinary leakage. Early after ureteral replantation, if on the affected side of the lumbar distension, pain or even fever occurs after the removal of the ureteral stent, ureteral anastomotic obstruction and infection should be considered and should be actively treated in a timely manner. Abol Enein et al [22] believed that the serous membrane of the ureter is the basis for the formation of adhesive tissue. When the outer layer of the ureter is not completely covered by mucosa, inflammatory reactions and adhesion will occur on the ureteral wall, which will eventually lead to ureteral stenosis. In the present study, ureteral end splitting and eversion of 5–10 mm reduced the exposure of the ureteral serous membrane to urine, shortening the healing time of the anastomotic mucosa in the bladder, and reduced the possibility of scar stenosis and annular stenosis. In the RALUR group, even if there was a single case of stenosis and obstruction, the degree was mild, and the hydronephrosis was not aggravated and was in fact asymptomatic after re-indwelling the ureteral stent. However, in the LUR group, there were cases with severe stenosis and stenosis expansion, which indirectly reflected that the robot was better than laparoscopy in preserving the blood supply of the ureteral anastomosis. Although vesicoureteral reimplantation is the main treatment for ureteral outlet diseases such as lower ureteral stenosis and vesicoureteral reflux, ureteral reflux can still occur after operation. In the present study, both the LUR group and the RALUR group included complications due to postoperative reflux. One patient in each group had grade II and grade I reflux, respectively. After anticholinergic treatment, the re-examination showed that the nipple method had good anti-reflux effect. However, high-level reflux is a risk factor for the recurrence of urinary tract infection, so regular follow-up of urine routine, renal function, and urinary ultrasound should be performed after the operation. If the hydronephrosis caused by reflux persists or worsens, secondary reimplantation surgery should be performed when necessary to avoid serious renal injury. Repeated urinary tract infections in the patients in the present study are likely to be related to long-term indwelling of ureteral stents. It is worth reflecting on whether the time for pulling out the double-J tube should be shortened to 4–6 weeks as described in other literature [23], to reduce the incidence of recurrent urinary tract infection after operation.

The patients in the present study were followed up for 6 months postoperation. The degree of renal pelvis separation, degree of ureteral dilation, and renal function of the affected side in the RALUR group and the LUR group were both improved. The difference in preoperative and postoperative degree of renal pelvis separation in the RALUR group was significantly greater than that in the LUR group, indicating that the robot operation has a greater and more significant effect on the relief of hydronephrosis. This may be related to less distance from the lower ureter, a smaller wound and less postoperative adhesion, good blood supply protection, strong postoperative peristalsis, low position of ureteral bladder anastomosis, and low postoperative stenosis or reflux.

The present study also showed some limitations. First, this study is a retrospective study, and the number of cases is relatively small. The experimental results may be biased due to some factors, such as patients who are expected to have difficulty in surgery preferring to use robots, and poorer patients preferring to use laparoscopy. Second, the research observation index is limited. Third, the short follow-up time may lead to errors in the statistical results regarding postoperative complications. We hope to have more reports of similar studies, and to carry out long-term postoperative follow-up studies and prospective studies to compare the clinical characteristics of RALUR and LUR. At the same time, it is also hoped that the cost of robotic surgery will decrease, so that people will have a higher acceptance, and more hospitals will carry out robotic surgery. Fourth, the confidence intervals were not included and the potential need for adjustments for multiple comparisons have not been discussed, both of which could enhance the robustness of the findings. In future research, we would reduce and avoid bias by extending follow-up time and expanding the sample size. At the same time, China’s case resources should be utilized to conduct prospective, multicenter, and large-scale clinical studies, further elucidating the clinical advantages and limitations of the Da Vinci surgical robot in this procedure.

Conclusions

Compared with LUR, RALUR has the advantages of less bleeding, shorter operation time, high safety, shorter postoperative hospital stay, faster recovery, fewer perioperative complications, and a precise curative effect. However, the treatment cost of RALUR is significantly higher than that of traditional laparoscopic surgery. This study serves to provide an effective practical basis for the clinical application of RALUR technology, which could improve the clinical outcomes of patients.