Intraperitoneal effects of extraperitoneal laparoscopic radical prostatectomy

Comparison of Perioperative, Functional, and Oncological Outcomes of Transperitoneal and Extraperitoneal Laparoscopic Radical Prostatectomy

Purpose

This study aimed to compare the oncological, functional, and perioperative outcomes of localized and locally advanced prostate cancer treated with intraperitoneal or extraperitoneal laparoscopic radical prostatectomy (LRP).

Methods

From April, 2008, through December, 2020, 266 patients underwent laparoscopic radical prostatectomy, 168 cases with an extraperitoneal approach (E-LRP) and 98 cases using a transperitoneal approach (T-LRP). The clinical, perioperative, functional, and oncological outcomes were collected and compared between these groups. At the 3-, 12- and 24-monthfollow-ups, the functional outcomes tested were urinary function (urinary domain of EPIC) and sexual function (sexual domain of EPIC). The oncological outcomes of biochemical recurrence, biochemical recurrence-free survival, and positive surgical margin status were evaluated. Univariable and multivariable Cox regression analyses were used to identify factors predictive for biochemical recurrence. All statistical analyses used the R program.

Results

The patient characteristics were similar between the E-LRP and T-LRP groups except for higher prostatic-specific antigen (PSA) in the T-LRP group. The T-LRP had lower overall operative time (222.5 min vs. 290 min, p 0.001), decreased blood loss (400 ml vs. 800 ml, p < 0.001), and shorter hospital stays (4 days vs. 7 days, p < 0.001) compared to the E-LRP. Early sexual intercourse with penetration at 3 months was higher in the T-LRP group (36.7% vs. 15.5%, p 0.001). Urinary continence (no pads) was not different between the T-LRP and E-LRP groups at 3 and 24 months after surgery but higher in the E-LRP group at 12 months (1% vs. 3%; p=0.419, 85.1 vs. 83.7%; p=0.889, 47.4% vs. 34.6%; p=0.028, respectively). The EPIC questionnaire was used to assess functional outcomes at 3, 12, and 24 months after surgery and found that urinary function was significantly higher in the T-LRP group at 3 and 12 months (p < 0.001) but did not show a difference at 24 months (p=0.734), and sexual function scores were higher in the T-LRP group at 12 and 24 months (p=0.001). The positive surgical margin rate was higher in the E-LRP (38.7% vs. 21.4%; p=0.006). The BCR rate was not different between the groups (36.3% in the E-LRP group and 27.6% in the E-LRP group; p=0.184).

Conclusion

Transperitoneal laparoscopic radical prostatectomy (T-LRP) was found to be superior to extraperitoneal radical prostatectomy (E-LRP) in perioperative outcomes such as decreased operative time, decreased blood loss, shorter hospital stay, lower positive surgical margin, and improved early sexual intercourse and sexual function. The urinary functional outcome was better in the T-LRP group at 3 and 12 months. These findings support the use of transperitoneal laparoscopic radical prostatectomy, as our study patients exhibited significant benefits from this procedure.

Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP® robotic platform

BACKGROUND

The aim of this study was to evaluate perioperative factors associated with opioid-free management after robotic radical prostatectomy in a single institution.

METHODS

From January 2019 to January 2020, data from patients who underwent robotic radical prostatectomy was retrospectively entered in a preapproved IRB database. Data were analyzed according to the postoperative opioid administration in hospital and/or after discharge. Robotic radical prostatectomy was performed using either the standard multi-port Da Vinci Si robotic platform with a transperitoneal approach (MP-RALP) or the novel DaVinci SP^® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) with an extraperitoneal approach (SP-EPP). Patients undergoing minimally invasive surgery were included in the "enhanced recovery after surgery" (ERAS) protocol regardless of the surgery approach.

RESULTS

During the study period, 210 patients matched the selection criteria. Of those, 158(75%) patients received opioids during the hospital stay or after discharge and 52(25%) patients never received opioids. SP-EPP surgical approach and shorter LOS were predictors of never receiving opioids (Odds Ratio [OR]=4.97, (95% CI 1.81-14.77, P=0.002 and OR=0.56, CI 95% 0.35-0.86, P=0.011, respectively). SP-EPP surgical approach was increasing the odds of remaining opioid free whether in-hospital or after discharge (OR= 11.97, 95% CI 4.8-32, P<0.0001 and OR=11.6, 95% CI 4.6-31, P<0.0001, respectively). Finally, a high BMI increased the odds of receiving opioid in hospital or after discharge (OR=0.89, 95% CI 0.82-0.96, P=0.003 and OR=0.89, 95% CI 0.82-0.96, P=0.002, respectively).

CONCLUSIONS

In this series, after robotic radical prostatectomy the use of a less invasive approach (SP-EPP), a shorter LOS and a lower BMI, were predictive of opioid-free status.

Transperitoneal versus extraperitoneal approach in laparoscopic radical prostatectomy: A meta-analysis

BACKGROUND

To compare the transperitoneal approach with extraperitoneal approach in laparoscopic radical prostatectomy (LRP) (including pure and robotic-assisted LRP) using meta-analytic techniques.

METHODS

Medline (PubMed), Embase, Ovid, CMB, and Cochrane databases were searched for studies that compared the transperitoneal and extraperitoneal approaches in LRP from January 2000 to January 2017. Outcomes included were operative time, operative bloods joss (milliliters), rate of transfusion, rate of open conversion, rate of intraoperative complications, rate of postoperative complications, and time of postoperative catheterization.

RESULTS

Thirteen studies including 1674 patients were selected for the meta-analysis. 850 (50.8%) cases had undergone transperitoneal LRP (TLRP) and 824 (49.2%) cases had undergone the extraperitoneal LRP (ELRP). Comparison of operative time between the TLRP group and the ELRP group showed no significant differences (weighted mean difference [WMD] = 21.21,95%CI = -1.16-43.57, P = .06). No significant differences were observed in blood loss (WMD = -6.04, 95%CI = -43.38-31.29, P = .75) and the rate of transfusion (odds ratio [OR] = 1.03, 95%CI = 0.55-1.96, P = .92) between the 2 groups. No significant differences were observed for the rate of intraoperative complications (OR = 1.25, 95%CI = 0.57-2.21, P = .75) and the rate of open conversion (OR = 1.12, 95%CI = 0.32-4.97, P = .75). Significant differences were observed in the TLRP group compared with the ELRP group (OR = 1.69, 95%CI: 1.23-2.32, P = .001) regarding the rate of postoperative complications.

CONCLUSIONS

Our meta-analysis findings revealed that the TLRP group showed no significant differences in most important indicators compared with ELRP. Moreover, TLRP showed higher rate of postoperative complications compared with ELRP.

Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis

Objectives

To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP).

Methods

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be ≥6 months.

Results

In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of −0.30 days (95% confidence interval [CI] −0.35, −0.24) for the laparoscopic group and 1.09 days (95% CI −1.47, −0.70) for the robotic group (P < 0.001). Early continence rates favoured the E-RP group, although this was statistically significant only in the laparoscopic group (odds ratio [OR] 2.52, 95% CI 1.72, 3.70; P < 0.001). There was no statistically significant difference between the E-RP and T-RP cohorts for 12-month continence rates for both the laparoscopic (OR 1.55, 95% CI 0.89, 2.69; P = 0.12) and robotic groups (OR 3.03, 95% CI 0.54, 16.85; P = 0.21). The overall complication and ileus rates were significantly lower in the E-RP cohort for both the laparoscopic and robotic groups. The symptomatic lymphocele rate favoured the T-RP cohort, although this was statistically significant only in the laparoscopic group (OR 8.69, 95% CI 1.60, 47.17; P = 0.01).

Conclusion

This review suggests that the extraperitoneal approach is associated with a shorter hospital stay, lower overall complication rate, and earlier return to continence when compared to the transperitoneal approach. The transperitoneal approach has a lower lymphocele rate.

Open, laparoscopic and robotic radical prostatectomy: optimizing the surgical approach

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery.