Peritoneal flaps for the prevention of lymphoceles after robot-assisted radical prostatectomy-a systematic review and IPD-meta-analysis of randomized controlled trials

Lymphoceles (LCs) are one of the most common complications after robot-assisted radical prostatectomy (RARP). Peritoneal flaps (PF) have shown to possibly decrease the incidence of LCs. This individual patient data meta-analysis (IPD-MA) investigates the efficacy of PF on rates of symptomatic lymphoceles (sLCs) requiring intervention, sLCs, overall lymphoceles and perioperative complications. We conducted a prespecified systematic review and IPD-MA (PROSPERO CRD42024519284). A database search via Medline, Web of Science, Embase, Central, ClinicalTrials.gov and the International Clinical Trials Registry Platform was performed up to December 2023. Six randomized controlled trials (RCTs) comparing PF vs. no PF during RARP with PLND were included and five RCTs provided IPD. MA was conducted using a random-effects model (two-stage model). PF significantly reduced sLCs requiring intervention as well as the rates of sLCs and overall lymphoceles. Additionally, PF significantly reduced overall complications, most likely driven by fewer lymphoceles and associated interventions. Furthermore, BMI and the presence of lymphoceles at discharge were identified as risk factors for sLCs. Subgroup analyses suggested that the protective effect of PF diminishes with increasing BMI, indicating limited benefit in patients with severe obesity. The creation of PF after RARP significantly reduces sLCs without affecting the complication rate or meaningfully prolonging operative time. LCs at the time of discharge represent significant risk factors for occurrence of sLCs, indicating a possibility for closer observation for this subgroup. With the evidence provided by this IPD-MA, creation of PF should be the new standard of care to reduce LC-related morbidity.