Neurovascular structure-adjacent frozen-section examination (NeuroSAFE) during robot-assisted radical prostatectomy shows better bilateral nerve preservation than standard RARP: a systematic review and meta-analysis

Background: The neurovascular structure-adjacent frozen-section examination (NeuroSAFE) technology provides real-time margin assessment during robot-assisted radical prostatectomy (RARP) through frozen pathology to optimize oncological safety and functional outcomes. This study compared the perioperative outcomes, pathological outcomes, and oncology outcomes of patients undergoing NeuroSAFE RARP versus standard RARP. Methods: In July 2025, a literature search and assessment were conducted through PubMed, Embase, and Web of Science. The search targeted studies comparing RARP with NeuroSAFE (intervention) versus standard RARP (control) in men with prostate cancer to evaluate perioperative, pathological, and oncological outcomes. Only prospective studies and randomized controlled trials are included in this meta-analysis. Perioperative (operating time, numbers with post-surgical adverse events, and numbers of surgeon-reported bilateral nerve-sparing), pathological [positive surgical margins (PSM)], and oncology [biochemical recurrence (BCR)] outcomes were analyzed using Review Manager software, with weighted mean difference for continuous variables and relative risk (RR) for dichotomous variables. Results: The results of 2186 patients were analyzed, and 1174 out of 2186 patients were treated with NeuroSAFE. In all studies, patients who underwent NeuroSAFE had a higher number of bilateral nerve-sparing surgeries than controls. In the NeuroSAFE cohort, a statistically significant increase in surgeon-reported bilateral nerve-sparing was observed [RR 1.37, 95% confidence interval (CI) 1.26–1.49, I 2 = 17%] and no difference in PSM (RR 0.99, 95% CI 0.86–1.12, I 2 = 61%). Similarly, NeuroSAFE led to no difference in BCR (RR 0.79, 95% CI 0.28–2.17, I 2 = 78%) and numbers with post-surgical adverse events (RR 1.12, 95% CI 0.6–2.09, I 2 = 0%). Conclusion: According to the current results, the NeuroSAFE method could increase the rate of bilateral nerve-sparing, without more PSM and BCR possibility, which means it may lead to a better functional outcome. This conclusion still needs more randomized clinical research data to verify.