Extraperitoneal Standard Laparoscopic Radical Prostatectomy

Comments on the extraperitoneal approach for standard laparoscopic radical prostatectomy: what is gained and what is lost

Laparoscopic extraperitoneal radical prostatectomy (LERP) is considered the standard care treatment option for the management of localized and locally advanced prostatic cancer (PCa) in many institutes worldwide. In this work, the main advantages and disadvantages of LERP approach are reviewed with regard to its outcomes, the complication management, the learning curve, and the extend of pelvic lymph node dissection (PLND). It is concluded that LERP demonstrates comparable cancer control, urinary continence, and potency outcomes with the open and the robot-assisted radical prostatectomy, while offering advantages in complication management in comparison to the transperitoneal approach. Learning curve of LERP is considered long and stiff and significantly affects perioperative outcomes and morbidity, cancer control, and functional results. Thus, close mentoring especially in the beginning of the learning curve is advised. Finally, LERP still has a role in the limited or modified PLND offered in intermediate risk PCa patients.

[Extraperitoneal laparoscopic radical prostatectomy. First 50 cases in a middle sized hospital. Evaluation of the learning curve]

OBJECTIVE

Report our experience in the first 50 cases of laparoscopic radical prostatectomy performed in our Hospital. We describe the surgical technique and the modifications that we have applied. Time consumptions and technical difficulties are reviewed.

METHODS

From January 2005 to September 2006 we indicated 52 extraperitoneal laparoscopic radical prostatectomies. Two of them were done with the advice of a master and won't be included in our series. We followed the Brussels technique with some modifications.

RESULTS

We completed integrally by laparoscopy the 78% of the cases (39/50). The 11 converted cases were done within the 25 first ones. Mean operating time for the pure laparoscopic cases was 280 minutes. We divide surgery in six steps with the following mean times in minutes: Trocars placement (30), seminal vessels dissection (95), Santorini (25), specimen in endobag (55), anasthomosis (55) and final (15). After case 25, the results improve. The most challenging step was seminal vessels dissection. Transfusion rate has been 7%. The mean hospitalization time has been 4 days with a 30% of patients discharged 48 hours after surgery. Positive surgical margins were observed in 12%. Two of our patients presented major complications (4%).

CONCLUSIONS

Extraperitoneal laparoscopic radical prostatectomy is feasible in an institution like ours if it has the aim of invest a big effort, especially regarding operating time. The most demanding steps are the dissection of the vesicoprostatic plane and the anasthomosis. There is a clear progression after case 25.

A Direct Comparison of Robotic Assisted Versus Pure Laparoscopic Radical Prostatectomy: A Single Institution Experience

PURPOSE

We compared a single institution experience with radical prostatectomy using a pure laparoscopic technique vs a robotically assisted technique with regard to preoperative, intraoperative or postoperative parameters.

MATERIALS AND METHODS

From May 2003 to May 2005 we reviewed 133 consecutive patients who underwent extraperitoneal robot assisted radical prostatectomy and compared them to 133 match-paired patients treated with a pure extraperitoneal laparoscopic approach. The patients were matched for age, body mass index, previous abdominopelvic surgery, American Society of Anesthesiologists score, prostate specific antigen, pathological stage and Gleason score. Preoperative, perioperative and postoperative data, including complications and oncological results, were analyzed between the 2 groups.

RESULTS

The 2 groups were statistically similar with respect to age, body mass index, prostate specific antigen, Gleason score and clinical stage. No statistical differences were observed regarding operative time, estimated blood loss, hospital stay or bladder catheterization between the 2 groups. The transfusion rate was 3% and 9.8% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.03). Conversion from robotic assisted laparoscopic prostatectomy to laparoscopic radical prostatectomy was necessary in 4 cases. None of the laparoscopic radical prostatectomy cases required conversion to an open technique. The percentage of major complications was 6.0% vs 6.8%, respectively (p = 0.80). The overall positive margin rate was 15.8% vs 19.5% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.43).

CONCLUSIONS

We demonstrated that the laparoscopic extraperitoneal radical prostatectomy is equivalent to the robotic assisted laparoscopic prostatectomy in the hands of skilled laparoscopic urological surgeons at our institution with respect to operative time, operative blood loss, hospital stay, length of bladder catheterization and positive margin rate.

Approach to endoscopic extraperitoneal radical prostatectomy (EERPE): the impact of previous laparoscopic experience on the learning curve

Background

We report our approach regarding the technique of endoscopic extraperitoneal radical prostatectomy (EERPE) and analyze the learning curve of two surgeons after thorough technical training under expert monitoring. The purpose of this study was to investigate the influence of expert monitoring on the surgical outcome and whether previous laparoscopic experience influences the surgeon's learning curve.

Methods

EERPE was performed on 120 consecutive patients by two surgeons with different experience in laparoscopy. An analysis and comparison of their learning curve was made.

Results

Median operation time: 200 (110 – 415) minutes. Complications: no conversion, blood transfusion (1.7%), rectal injury (3.3%). Median catheterisation time: 6 (5 – 45) days. Histopathological data: 55% pT2, 45% pT3 with a positive surgical margin rate of 6.1% and 46%, respectively. After 12 months, 78% of the patients were continent, 22% used 1 or more pad. Potency rate with or without PDE-5-inhibitors was 66% with bilateral and 31% with unilateral nerve-sparing, respectively. Operation time was the only parameter to differ significantly between the two surgeons.

Conclusion

EERPE can be learned within a short teaching phase. Previous laparoscopic experience is reflected by shorter operation times, not by lower complication rates or superior early oncological data.

Robot-assisted versus pure laparoscopic radical prostatectomy

The aim of this study is to report the relative advantages and disadvantages of the radical prostatectomy with a laparoscopic (LRP) and a robotic (RALP) approach. A medline search was performed. Published data regarding perioperative parameters, complications, oncological results, functional results were analyzed. Shorter learning curves have been reported with the RALP. Intra-operative and post-operative outcomes appear to be comparable between the two approaches. The average time for LRP is 234 min (151-453) versus 182 min (141-250) for RALP. Estimated blood loss for the LRP averages 482 ml (185-850) versus 234 ml (75-500) for the RALP. Complication rates in single institution studies are similar. Long-term outcomes data on PSA progression is not yet available for LRP or RALP due to their relatively short existence. RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost. Intra-operative and post-operative outcomes appear to be similar. Longer follow-up data is necessary to compare oncological and functional outcomes.

Preliminary experience with extraperitoneal endoscopic radical prostatectomy through duplication of the open technique

OBJECTIVE

To describe surgical and functional results with extraperitoneal laparoscopic radical prostatectomy with duplication of the open technique, from the experience obtained in the treatment of 28 initial cases.

MATERIALS AND METHODS

In a 36-month period, we prospectively analyzed 28 patients diagnosed with localized prostate cancer undergoing extraperitoneal laparoscopic radical prostatectomy.

RESULTS

Mean surgical time was 280 min, with mean blood loss of 320 mL. As intraoperative complications, there were 2 rectal lesions repaired with laparoscopic suture in 2 planes. There was no conversion to open surgery. Median hospital stay was 3 days, with return to oral diet in the first post-operative day in patients. As post-operative complications, there were 3 cases of extraperitoneal urinary fistula. Two of these cases were resolved by maintaining a Foley catheter for 21 days, and the other one by late endoscopic reintervention for repositioning the catheter. Five out of 18 previously potent patients evolved with erectile dysfunction. The diagnosis of prostate cancer was confirmed in all patients, with focal positive margin occurring in 3 cases. During a mean follow-up of 18 months, 2 patients presented increased PSA, with no clinical evidence of disease.

CONCLUSION

Laparoscopic radical prostatectomy is a laborious and difficult procedure, with a long learning curve. Extraperitoneal access is feasible, and it is possible to practically duplicate the principles of open surgery. The present technique can possibly offer advantages in terms of decreased blood loss, preservation of erectile function and prevention of positive margins.

Urological robotic surgery: Preliminary experience with the Zeus system

AIM

We performed robotic or robotically-assisted laparoscopic surgery for urological diseases, and evaluated the ef ficacy and safety of this surgery.

METHODS

Between November 2003 and June 2004, we performed laparoscopic surgery with the Zeus system in eight cases. Three adrenalectomy cases of cortical adenoma presenting with Cushing syndrome and primary aldosteronism, and two cases of nephrectomy for renal cell carcinoma in dialyzed patients were performed solely with Zeus. In two cases of ureteral stenosis, Zeus was used for ureteral anastomosis after partial ureterectomy by manual laparoscopy. In one prostatectomy case, vesico-urethral anastomosis was performed with Zeus after extraperitoneal prostatectomy by manual laparoscopy.

RESULTS

All of the cases were successfully treated without any complications during or after operation. All patients were discharged from hospital within 12 days postoperatively. As for adrenalectomy, nephrectomy and pyeloplasty, this may be the fi rst report in Japan.

CONCLUSIONS

Our preliminary experiences suggest that such a robot system, which is being developed day by day, might become more beneficial in future in urological laparoscopic surgery.