Abstract
BACKGROUND: With the rapid development of laparoscopic and robot-assisted surgery, many technological innovations and improvements have emerged to optimize minimally invasive surgery and ensure minimal patient risk. Although AirSeal has been widely reported in the field of urology, its perioperative outcomes and safety in minimally invasive urological surgery remain unclear because of inconsistent levels of evidence. OBJECTIVES: The authors performed this meta-analysis to evaluate the perioperative outcomes and safety of the valveless insufflation system (VIS) in minimally invasive urological surgery compared with the conventional insufflation system (CIS). METHODS: The authors comprehensively searched PubMed, Web of Science, Cochrane Library, and Embase databases to identify eligible studies published up to January 2024. Review Manager software (version 5.3.0) was used for the statistical analysis. Eligible studies were randomized controlled trials (RCTs) or non-RCTs of minimally invasive urological surgery with VIS vs CIS. The study outcomes included perioperative outcomes and safety. The authors excluded publication types, including letters, reviews, case reports, and animal and pediatric studies. RESULTS: The authors finally identified five RCTs and eight non-RCTs in this meta-analysis. The meta- analysis indicated that the operative time was comparable between the groups ( P =0.57, I2 =91%). However, a VIS may increase blood loss ( P =0.0004, I2 =45%) and shorten hospital stays ( P <0.00001, I2 =90%). Due to the high heterogeneity of the results, the authors carefully evaluated all included studies and discovered that the studies by Bucur and Ferroni may be the sources of heterogeneity. When these two studies were excluded, heterogeneity was significantly reduced, and the operative time for VIS was significantly shorter than that for CIS ( P =0.0002). Adjusted blood loss showed no difference between the VIS and CIS groups ( P =0.10). In terms of safety, the pooled results revealed that the incidence of Clavien-Dindo III-IV complications in the VIS group was significantly lower than that in the CIS group ( P =0.02, I2 =0%). Moreover, VIS significantly reduced general pain ( P =0.02, I2 =15%) and shoulder pain ( P =0.001, I2 =0%) 12-24 h postoperatively. No significant differences were observed in total complications ( P =0.06, I2 =0%), blood transfusion ( P =0.14, I2 =0%), and subcutaneous emphysema ( P =0.96, I2 =63%) between the two groups. CONCLUSIONS: Our meta-analysis revealed additional perioperative advantages of the VIS in minimally invasive urological surgery. Moreover, VIS is superior to CIS owing to less severe complication rates, general pain, and shoulder pain.