Surgical architecture and component identifiability in robot-assisted radical prostatectomy: a systematic review and network meta-analysis

Robot-assisted radical prostatectomy (RARP) combines preservation, reconstruction, and support maneuvers within named surgical packages, making component attribution difficult. To determine whether comparative evidence can identify independent surgical-component effects on strict early perfect continence while preserving oncological context. Comparative RARP studies were synthesized within a prespecified surgical-architecture framework. The primary outcome was perfect continence (0 pads/day) at 10–14 weeks. All prespecified bibliographic databases and registries were rerun through 26 September 2026. Randomized evidence underwent pairwise and network meta-analysis; component estimates were interpreted only after a prespecified structural-identifiability gate. Forty-eight reports representing 48 nonoverlapping study families, 98 arms, and 6,665 arm-level participants were included. Six randomized families provided exact strict 3-month events and formed three disconnected subnetworks; four families formed the largest connected network. In that four-family network, risk ratios versus standard RARP were 1.07 (95% confidence interval [CI] 0.65–1.78) for posterior reconstruction (PR), 2.94 (0.92–9.33) for PR plus anterior reconstruction/suspension, and 1.49 (0.63–3.52) for PR plus sling. PR was the only component meeting the prespecified structural gate; this denotes evidence structure, not a precise or validated independent causal effect. Descriptive positive surgical margin estimates were sparse (PR 0.96 [0.50–1.86]; PR plus anterior reconstruction/suspension 1.74 [0.57–5.25]). Confidence in all primary network comparisons was very low. The literature is broad at the level of named RARP techniques but insufficiently connected and replicated to isolate most component-specific effects. Package-level signals should not be reassigned to individual maneuvers unless those components vary independently across replicated comparisons. Future trials should report exact time-specific continence outcomes, explicit arm-level technical details, and replicated component contrasts.