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Section Heading Section Sub

The Current Status of Laparoscopic Radical Prostatectomy

a report by

Frederico R Romero Master’s Student, Federal University of Paraná

The most important objective of radical prostatectomy is to cure

To evaluate the current status of LRP, the most relevant studies were

prostate cancer by the complete surgical removal of the entire prostate

reviewed comparing laparoscopic with retropubic radical prostatectomy

and seminal vesicles, with the least morbidity and preserving urinary

with regard to peri-operative, functional and oncological outcomes.

continence and erectile function. Peri-operative Outcomes The traditional surgical approach in the treatment of prostate cancer has been open radical retropubic prostatectomy (RRP). Radical

Operating Time

prostatectomy as a curative treatment for prostate cancer was initially

Operating time is consistently longer for LRP compared with RRP.7,9–16

described by Hugh Hampton Young in 1905.1 In 1945, Millin et al.2

The mean operative time was 4.3 hours (range 2.4–6.7 hours) in LRP

reported on the retropubic approach to radical prostatectomy, which

and 2.9 hours (range 1.7–3.8 hours) in RRP. The longer operating time

has

worldwide,

with the laparoscopic technique may be explained by the fact that the

particularly after Walsh and Donker introduced the anatomical

lack of tactile sensation, limited instrumentation and focused view

concept of nerve-sparing radical prostatectomy in 1982.3

require a slower dissection.17,18 However, similar to what has been

subsequently

gained

widespread

application

observed with open surgery, a reduction in operating time can be Recently, rapid progression has occurred in urological surgical

expected for a laparoscopic series with increased experience along the

techniques towards minimally invasive treatment. Patients undergoing

learning curve.14,15

laparoscopic nephrectomy, nephroureterectomy and adrenalectomy have all enjoyed shorter hospitalisation periods, less post-operative

Blood Loss and Transfusion Rates

pain, speedier convalescence and improved cosmesis than patients

Blood loss is significantly lower in LRP than in RRP,7,12–15,19–22 with an

undergoing open surgery. In 1992, Schuessler et al. reported the first

average of 504.2cc (range 189–1,100cc) in the laparoscopic group, and

laparoscopic radical prostatectomy (LRP). Five years later, Schuessler

1,049.9cc (range 385–1,550cc) in the open group. Transfusion rates are

4

and colleagues concluded that, although feasible, this technique

usually lower in LRP.13,14,16,20 The mean transfusion rate was 13.2% (range

offered no major advantages over conventional retropubic surgery.5

0–63%) for LRP, and 28.8% (range 9–56%) for RRP.

However, since 1998 different groups have continuously improved the laparoscopic technique and have made this operation safe,

Pneumoperitoneum pressure on small venous vessels and meticulous

reproducible and teachable. Recently, further

comparative studies

haemostasis under magnification of the operative field – in particular

have been published, showing similar outcomes between laparoscopic

during dissection of the dorsal venous complex and lateral pedicles –

and open radical prostatectomy.

are the main factors affecting reduced bleeding and transfusion rates

6

7–36

during LRP.7,10,12–16,18–20,22,23 To be an acceptable treatment for prostate cancer, LRP has to demonstrate equivalent oncological and functional outcomes, have

Post-operative Pain and Analgesia

comparatively low peri-operative and long-term morbidity and be

LRP shows a lower intensity of early and late post-operative pain than RRP

reproducible by other groups.7,8

when using a visual analogue scale for post-operative pain assessment ranging from 0 (no pain) to 10 (excruciating pain).7,13,22 The pain scale at post-operative day one averaged 3.1 (range 1.7–4.5) in the LRP group,

Frederico R Romero is pursuing a Master’s degree in urology at the Federal University of Paraná, Brazil. His clinical interests concern endourology, larascopy and uro-oncology. He has authored or co-authored 35 articles in peer-reviewed journals, including Archivos Españoles de Urología, the British Journal of Urology, European Urology, the International Brazilian Journal of Urology, the Journal of Endourology, the Journal of Urology, Urologia Internationalis and Urology, as well as six book chapters related to laparoscopic surgery in urology. Between 2001 and 2005, he completed his residency in urology at Santa Casa Medical School, São Paulo, Brazil, followed by a fellowship in endourology and laparoscopy with Dr Louis R Kavoussi. Dr Romero graduated from the Federal University of Paraná, Brazil. E: frederico.romero@gmail.com

and 5.2 (range 2.6–7.8) in the RRP group. As assessed by pain medication requirements during hospitalisation postoperative pain is higher for RRP,14,22 but it has also been reported to be similar between LRP and RRP.11,19 This difference is partially explained because the lower mid-line incision associated with RRP may not be significantly more debilitating than the multiple incisions used for port entry during LRP,11,24 and urinary leakage into the peritoneum may be correlated with increased post-operative discomfort in the LRP group.15 Length of Hospitalisation Hospital stay is a difficult parameter to evaluate because it is affected by

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© TOUCH BRIEFINGS 2008


The Current Status of Laparoscopic Radical Prostatectomy

economic and social pressure in different geographical areas.10 In the US,

length of hospitalisation sensitivity analysis identified that equivalence in

the systematic application of specific clinical pathways shortened

cost could be achieved only if LRP was performed on an outpatient basis

hospitalisation after radical prostatectomy to fewer than three days.10,24

(less than one day length of stay).8,27 Another way to reduce expenditure

In Europe, hospital stay is longer because patient dismissal is based on

is to decrease equipment costs,8 especially disposable scissors and

complete patient recovery rather than hospitalisation costs.15

trocars.27 Complications certainly influence the total cost of any surgical

Comparative studies between LRP and RRP showed similar

or shorter

procedure. If the lower rates of complications with LRP prove to be

hospitalisation in patients undergoing laparoscopic treatment.10,11,15,16,25

reproducible,14,21,22 this may greatly narrow the cost differential between

The mean length of hospital stay was 2.2 days (range 1.7 to three days)

LRP and RRP.27

7,14,19

and 8.7 days (range seven to 12 days) for LRP in US and European studies, respectively. For RRP, the mean length of hospitalisation was 2.8

Taking into account the costs resulting from missed work during

days (range 2.4 to three days) in the US and 12.4 days (range 10–16 days)

convalescence, and that mean time to full recovery is 32 and 53 days

in Europe.

after LRP and RRP, respectively,14,19,22 a 21-day difference in return to work has a value to society that eliminates and even reverses the cost

Duration of Catheterisation

advantage of RRP.

Bladder catheterisation is shorter with LRP than with RRP.9,12,14,16,19,21,22 The mean catheterisation time was 7.6 days (range 5.8–14 days) after LRP, and

Functional Outcomes

14.1 days (range 7.8–22 days) after RRP. The significantly higher percentage of successful early catheter removal in the laparoscopic group

Urinary Continence

suggests a superiority of the quality of laparoscopic vesicourethral

Patient age, baseline incontinence, prior transurethral resection

anastomosis.13,18 The advantage of the laparoscopic anastomosis lies in the

of the prostate, surgical technique and surgeon experience are important

improved visualisation under magnification of the operating field.

risk factors for urinary continence after radical prostatectomy.26

13,18,26

Numerous refinements of the radical prostatectomy technique have Peri-operative Complications

significantly reduced the post-operative incidence of incontinence.

Unclear and non-standardised reporting makes the interpretation of

These refinements include pupoprostatic ligament sparing, meticulous

complication rates difficult.6 Several studies comparing LRP and RRP

bleeding control from the dorsal venous complex, delicate apical

showed similar medical and surgical complication rates,7,9,10,16,20 with an

dissection, preservation of the bladder neck, avoidance of coagulation in

average of 19% (range 5.1–37%) and 15% (range 8.3–20%),

the proximity of the neurovascular bundles and a watertight

respectively. Other studies showed that early and minor complications

urethrovesical anastomosis.9,12,26,28

occurred more frequently with RRP than with LRP,

14,21,22

but the spectrum

of the complications differed.14 In the laparoscopic group there were

Following radical prostatectomy, urinary continence rates can vary

more rectal injuries, urinary leakage and prolonged ileus compared with

significantly in relation to the different continence criteria applied and to

the open group.7,14 On the other hand, incidences of anastomotic

the modality of data collection.10 Defined as the use of no pads, diurnal

strictures, wound-related complications, lymphoceles and pulmonary

and nocturnal urinary continence rates are reported to be similar

embolism were higher after open surgery than laparoscopy.14,21,22

between LRP and RRP after 12 and 18 months of surgery.7,9,14,15,21,26,29 After LRP, the mean continence rate was 81.7% (range 60–91.7%) at 12

Short-term Convalescence

months, and 94.3% (range 92.8–95.8%) at 18 months. After RRP, the

Compared with patients undergoing RRP, patients undergoing LRP have

mean continence rate was 83.5% (range 66.7–92.9%), and 92.6%

a faster return to partial recovery – defined as independence with no

(range 92–93.2%) at 12 and 18 months, respectively.

need of assistance from others with routine daily tasks – and a faster return to full recovery – defined as complete physical strength with

Erectile Function

recovery to the pre-operative state.14,19,22 Partial and full recovery were

Patient age, baseline quality of erections, stability of relationships,

achieved after a mean of 13 days (range 12–14 days), and 32 days (range

cardiovascular co-morbidities, the degree of neurovascular bundle

27–39 days), respectively, for patients undergoing LRP, and 23 days

preservation achieved during surgery and the experience of the surgeon

(range 21–25 days) and 53 days (range 47–61 days), respectively, for

all contribute to the final potency status after radical prostatectomy.9,18,24

those undergoing RRP.

An objective evaluation of erectile function is difficult because of

19,22

heterogeneous definitions and methods of evaluation of sexual Costs

potency.28 Potency rates – defined as erections resulting in successful

RRP is significantly less expensive than LRP,

with most of the difference

sexual intercourse – are similar at 12 and 18 months after surgery.7,9,21

resulting from the higher surgical supply costs and operating room costs

After preservation of both neurovascular bundles, the potency rates after

in the LRP group.25 With the significantly shorter length of hospitalisation

12 months were 67.6% (range 53–79.5%) after LRP, and 57.4% (range

after LRP the room and board costs were lower, but this difference was

44–72.4%) after RRP.

8,25

not enough for LRP to make up the deficit from the surgical supply and operating room costs.25

Quality of Life Studies evaluating quality of life (QOL) using validated questionnaires

Refinements to the laparoscopic technique and improvements in available

found no differences in functional status, urological symptoms, physical

laparoscopic devices – potentially decreasing the operating time – would

comfort, psychological distress and social activity before and after surgery

allow a cost equivalency with RRP.8,25 A decrease in operating time by

for open and laparoscopic prostatectomy.26,30 Another study showed

159–174 minutes would make LRP costs equivalent to those of RRP.8,27 A

significantly higher QOL scores in the LRP group compared with RRP up

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Section Heading Section Sub to one year post-operatively.22 Patients receiving LRP also express a more

because of the slow-growing character of prostate cancer, disease

favourable attitude towards surgery than those undergoing RRP, and

recurrence may take more than 10 years to become clinically detectable.24

significantly more patients undergoing LRP would have chosen that therapy again compared with those undergoing RRP.18,30

Although data continue to mature for LRP series, the biochemical recurrence-free results appear similar to those reported in RRP. Salomon

Oncological Outcomes

et al. reported similar actuarial three-year recurrence-free rates of 84.1–86.2% for LRP and 75–89.3% for RRP (PSA <0.2ng/ml).16,23

Positive Surgical Margins

Park et al. calculated the five- and seven-year biochemical recurrence-

Positive surgical margins are defined as the presence of cancer at the

free probabilities using the multivariate Kattan post-operative

inked margin of resection on the prostatectomy specimen. The presence

nomogram and found no differences between LRP and RRP.34 Median

of positive surgical margins can be predictive of a higher risk of

biochemical recurrence-free probabilities for LRP after five and seven

biochemical, local and systemic progression.10,13,24,31–35 Significant risk

years were 97 and 96%, respectively, and for RRP were 96 and 95%,

factors for a positive surgical margin include pre-operative serum

respectively (PSA <0.4ng/ml).34

prostate-specific antigen (PSA), clinical and pathological stage, Gleason score, neurovascular bundle preservation and the experience of the

Conclusions

surgeon.18 LRP does not increase the risk of positive surgical margins

Radical prostatectomy is an effective treatment for localised

compared with RRP.6,7,10,14,16,25,20–23,26,32–34,36 The mean overall positive

prostate cancer. As LRP allows duplication of all surgical steps and

margin was 23.5% (range 7.8–50%) in LRP, and 25.1% (range

modifications performed during open radical prostatectomy, it is not

7.3–42%) in RRP.

surprising that the outcomes attained by RRP can be duplicated by the laparoscopic approach.

Biochemical Recurrence Rate The most important objective of radical prostatectomy is to cure prostate

Taking into account increased costs, longer operating times and a steep

cancer.24 The surrogate to disease-specific survival is the biochemical

learning curve, LRP provides similar intermediate and long-term

recurrence rate. An interpretation of results needs to consider the PSA cut-

functional and oncological results with decreased peri-operative

off used to define failure or recurrence. Different authors reported

morbidity. Numerous centres have reproduced these excellent outcomes

biochemical-free results with a PSA cut-off ranging from 0.1 to 0.4ng/ml

and LRP can currently be considered a reasonable alternative to RRP. The

and rising.6 The overwhelming majority of biochemical recurrences will

best choice for the treatment of prostate cancer should be based on the

become evident within the first five post-operative years.24 However,

experience of the surgeon and patient preference. ■

1. 2. 3. 4.

5.

6. 7.

8.

9.

10.

11.

12.

13.

14.

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EUROPEAN UROLOGICAL REVIEW


The Current Status of laparoscopic radical prostatectomy