Japanese experience with radical prostatectomy

LAPAROSCOPIC RADICAL PROSTATECTOMY

PURPOSE

After the pioneering period when only few teams were performing the procedure, the laparoscopic approach to radical prostatectomy has become widespread with several technical variations. A comprehensive review of the published literature on laparoscopic radical prostatectomy was performed to determine the current state of the art of this surgical innovation in terms of perioperative parameters, functional results and cancer control.

MATERIALS AND METHODS

English language, peer reviewed articles published before June 2004 concerning laparoscopic radical prostatectomy were found by MEDLINE query. All articles were analyzed and none were a priori excluded. Conclusions were drawn from series of 50 or more patients.

RESULTS

Laparoscopic radical prostatectomy is being performed at multiple centers worldwide using various surgical approaches and technologies. Analysis of perioperative parameters, including surgical blood loss, operative time, complications and convalescence, demonstrated low morbidity and showed a clear trend toward improvement with increased experience. The reported positive surgical margin rates were lower in more recent series. As measured by prostate specific antigen recurrence and disease-free intervals, oncological results and cancer control rates are difficult to ascertain in the immature series published to date. Functional results in terms of postoperative urinary and sexual function appear encouraging.

CONCLUSIONS

Overall the current operative, oncological and functional results of laparoscopic radical prostatectomy appear to approximate those of open radical retropubic prostatectomy. These results justify the considerable interest of the urological community in laparoscopy, as evidenced by its widespread application. Nevertheless, longer followup and more mature data are needed definitively to establish laparoscopic radical prostatectomy as an alternative to the retropubic approach.

Assessment of surgical technique and perioperative morbidity associated with extraperitoneal versus transperitoneal laparoscopic radical prostatectomy

OBJECTIVES

To compare the perioperative morbidity and surgical technique of the two main variants of laparoscopic radical prostatectomy: the more often used transperitoneal approach with primary dissection of the plane posterior to the seminal vesicles (TP-LRP) and a purely extraperitoneal approach (EP-LRP).

METHODS

Our initial 20 consecutive patients who underwent EP-LRP and the last 20 consecutive patients who underwent TP-LRP were included in this retrospective study. The two groups were well matched for age, American Society of Anesthesiologists score, body mass index, prostate-specific antigen level, and Gleason score. The mean time for completion of the individual laparoscopic steps was assessed for both approaches.

RESULTS

With EP-LRP, the mean operative time was shorter (169.6 minutes versus 224.2 minutes, P <0.001) and patients resumed a full diet earlier (mean 1.6 days versus 2.6 days, P = 0.002). The mean total dose and duration of morphine administration were higher in the TP-LRP group, but the difference was not statistically significant (6.0 mg versus 12.8 mg and 0.5 day versus 0.9 day, respectively). The catheter time was nearly identical in the two groups (mean 5.3 days with TP-LRP and 4.2 days with EP-LRP). The incidence of positive margins was not affected by the surgical approach.

CONCLUSIONS

These preliminary results suggest that the initial posterior dissection associated with TP-LRP is less efficacious than direct access of the prevesical space during EP-LRP. Measures of perioperative morbidity were at least equivalent, if not superior, for the EP-LRP technique. These findings, together with the significant decrease in operative time with EP-LRP, appear sufficiently important to abandon the transperitoneal technique.