Perioperative neurocognitive outcomes after robot-assisted pelvic surgery: a systematic review and meta-analysis of reported proportions, comparative risk and prognostic factors

Delirium and cognitive decline may complicate recovery after robot-assisted pelvic surgery, but their frequency and relationship to positioning remain uncertain. We assessed reported proportions, comparative surgical risk and prognostic factors. PubMed, CENTRAL, Scopus, Web of Science, Google Scholar, ClinicalTrials.gov and WHO ICTRP were searched through 4 August 2026. Eligible adult robotic pelvic studies reported objective cognitive testing or delirium. Two reviewers performed original screening, extraction and question-specific bias appraisal. Post hoc logit random-effects meta-analyses summarized prospective cohorts using restricted maximum likelihood and modified Hartung-Knapp intervals in R. Twenty-six reports represented 25 studies. Five cognitive cohorts (356 participants) yielded 29.0% (95% confidence interval [CI] 20.2-39.8%); excluding Beck yielded 31.8% (20.7-45.4%). Three delirium cohorts (245 participants) yielded a descriptive model summary of 10.3% (2.2-37.0%). Individual delirium proportions were 8/82 (9.8%; exact 95% CI 4.3-18.3%), 4/80 (5.0%; 1.4-12.3%) and 14/83 (16.9%; 9.5-26.7%). The approximate 95% prediction interval from the delirium meta-analysis was very wide (<0.1-99.8%). The same-procedure prostatectomy comparison yielded an unadjusted risk ratio of 1.06 (0.73-1.55) for early cognitive decline. Comparative evidence was of low or very low certainty. Definitions, surveillance and selection limited interpretation; Trendelenburg-duration findings were inconsistent. These proportions describe selected study-defined outcomes. They do not establish attributable robotic or positioning risk, a safe exposure threshold, or benefit from horizontal breaks. Standardized prospective measurement is needed.