Open versus laparoscopic radical prostatectomy: Part I
Laurent Salomon, Service d’Urologie, Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
Radical prostatectomy (RP) is a curative treatment for localized prostate cancer, which consists of removing the prostate and seminal vesicles, after bilateral ilio-obturator node dissection. The aims of RP are to ensure oncological control, to preserve continence and sexual potency (when possible) and to minimize morbidity .
The first RP for cancer was done by Young in 1905, using the perineal approach . In 1945, Millin described the retropubic approach to the prostate . It was nearly four decades later, in 1983, that Walsh described a retropubic RP technique which preserved the erector nerves . This method was based on a precise anatomical study of the urinary sphincter and neurovascular bundles, by which the erector nerves transit, showing their relation to the prostate and the urethra. Their preservation can prevent the functional consequences of RP, i.e. incontinence and possibly impotence, while ensuring good oncological control .
RP by the retropubic approach became the reference technique. Experience with this approach refined the surgical indications according to the clinical stage, the preoperative PSA level and the results of prostatic biopsy, leading to renewed interest in the perineal approach. Indeed, the main disadvantage of the perineal approach is that node dissection and RP cannot both be done via a single incision. Some authors recommended laparoscopic node dissection followed by perineal RP [6–8].
It has now been shown that node dissection is not necessary for patients with PSA values of < 10 ng/mL and a Gleason score of < 7 on positive prostatic biopsy specimens, as the risk of node involvement is minimal [9,10]. Moreover, the absence of node dissection did not affect the long-term oncological outcome . Node dissection no longer being obligatory, the perineal approach became a reasonable alternative to the retropubic approach for RP. The main advantages of the perineal approach are urethrovesical anastomosis under visual control, less blood loss (and lower transfusion requirements), and a shorter hospital stay [7,8,12–18]. In addition, Mokulis and Thompson  showed that young surgeons learnt the perineal more rapidly than the retropubic approach. However, the perineal has not become as popular as the retropubic approach, even though 16 centres in North America (USA and Canada) and nine in Europe have reported their experience during the last 5 years .
Compared with conventional open surgery, laparoscopic surgery results in less postoperative pain, a shorter hospital stay, and more rapid resumption of normal activities [21–23]. However, it remains controversial, because of the longer operating time, the relatively high morbidity early in the initial experience and the potential risk of cancer cell dissemination during tumour excision.
Ilio-obturator node dissection was one of the first laparoscopic operations in urological practice; its less invasive nature and efficacy were recognized in the extension and evaluation of localized prostate cancer [24,25]. The advent of laparoscopy in urology goes back to the first extensive nephrectomy by Clayman and to the first simple nephrectomy by Ferry in 1991 [26–28]. These reports showed that laparoscopy could be used for more complex procedures.
The use of laparoscopy for RP occurred in stages; laparoscopic node dissection was combined either with RP (to assess extension more precisely before RP), or, as noted, with perineal prostatectomy (during the same operation). Kavoussi et al. then described how, during laparoscopic node dissection before perineal RP, they were also able to dissect the seminal vesicles. The use of laparoscopy facilitated the approach to the seminal vesicles, which was difficult during open surgery, in which transperitoneal, transvesical, paravesical, retrovesical and transcoccygeal approaches to the seminal vesicle were used.
In 1996, Price et al. described laparoscopic RP in a canine model, in 1997, Raboy et al. reported the first RP by the extraperitoneal approach and Schuessler et al. described experience with nine laparoscopic RPs by the transperitoneal approach. Although Raboy et al. were satisfied with their results, Schuessler et al. considered that this technique offered no major advantages over conventional surgery in terms of oncological control, functional results (continence and erectile function), hospital stay, convalescence, or aesthetic results. Nevertheless, Schuessler et al. predicted that the results would improve with technical progress (especially better instrumentation) and greater experience.
In 1998, using Gaston's technique, Guillonneau et al. described 28 laparoscopic RPs initially, followed by a series of > 800 cases [34–40]. During this period, Abbou et al. were also developing laparoscopic RP. This approach gradually became more widespread and, in 2001, more than 1200 RPs had been reported, mainly by European centres [42–51].
The reference technique is retropubic RP described by Walsh et al. in 1983 , and this widely used technique will not be described in detail. However, the main improvement consisted of better control of Santorini's plexus, aimed at reducing blood loss [52,53] and that this technique, even in the experienced hands of Walsh et al., continues to develop, driven especially by attempts to obtain earlier postoperative continence . Similarly, the perineal approach is now well known [55–57].
The laparoscopic RP technique used by the Montsouris team is well standardized . Five trocars are used (three 5 mm, two 10 mm), one in the umbilicus and the others in the iliac fossae. The patient is placed in the Trendelenburg position. Pneumoperitoneum is induced with a Veress needle and maintained at 12 mmHg. The different steps of the operation are:
- • dissection of the seminal vesicles, via a direct approach, after incising the peritoneum above Douglas’ sac;
- • creation of a space between the rectum and prostate by pushing back Denonvilliers’ aponeurosis;
- • release of the bladder to approach the space of Retzius;
- • dissection of the lateral aspects of the prostate by incising the pelvic aponeurosis on each side;
- • separation of the prostate from the bladder, by close dissection of the bladder neck;
- • control of the vessels in the space of Retzius by endocorporeal ligature with resorbable thread;
- • control of the neurovascular bundles by dissecting as close as possible to the prostate, taking care not to penetrate the capsule;
- • urethrovesical suturing by discontinuous endocorporeal sutures, checking the correct installation of the Foley catheter;
- • removal of the prostate, in a bag, through one of the trocar ports;
- • installation of an aspiration drain and closure of the two 10-mm trocar ports;
- • if ilio-obturator node dissection is necessary, it is done at the beginning the operation, by the same transperitoneal approach.
The technique used in Créteil is also well standardized [59–61]. The differences with the Montsouris approach concern the way in which the neurovascular bundles are dissected from the prostatic vascular pedicles to the urethra; these bundles are strictly dissected, avoiding the use of mono or bipolar electrocautery, to reduce the risk of thermal injury. Haemostasis is ensured by clamping the vessels that run from the bundles to the prostate. The urethrovesical anastomosis is made using continuous sutures .
This technique also differs from the approach of Rassweiler et al.[46,62], in which, using the transperitoneal approach, the apex is dissected first and the seminal vesicles last, as during an exclusively retrograde retropubic RP.
In the same year that Schuessler et al. described laparoscopic RP by the transperitoneal approach, Raboy et al. described RP by the extraperitoneal approach. Few teams now use this latter approach, which reproduces retropubic RP with both antegrade and retrograde dissection (although Dubernard et al. used an exclusively retrograde dissection) [45,48,64].
Interestingly three of these teams have replaced the transperitoneal laparoscopic approach by an exclusively extraperitoneal laparoscopic approach [45,48,64], for several reasons. First, the extraperitoneal approach avoids abdominal complications (gastrointestinal wounds, urine leakage into the peritoneum from the anastomosis, postoperative ileus, pain from pneumoperitoneum, and intestinal occlusion by incarceration of small ileal loops anteriorly to the bladder). It also permits adjuvant radiotherapy, sparing the gastrointestinal tract, and avoids tumour cell dissemination in the peritoneal cavity. In addition, the Trendelenburg position is unnecessary. More simply, why transform an initially extraperitoneal approach into a transperitoneal approach on the pretext of changing technique? If laparo-conversion is necessary, the surgeon finds him or herself in the well-known situation of retropubic RP [45,48,49,63]. It has also been shown that the creation of the working space and the lack of initial dissection of the seminal vesicles does not lengthen the operation (and may even shorten it) . Finally, normal feeding can resume more rapidly .
Anaesthetic and surgical techniques have improved markedly since the first perineal RP by Young in 1902 and the first retropubic RP described by Walsh et al. in 1983 [2,4]. It is difficult to compare the results of different surgical techniques, because of differences in the surgeons’ experience, patient selection criteria, and the way in which complications and outcome (especially functional results) are evaluated. The three surgical approaches have not been compared in prospective randomized studies. When comparing published data it must be remembered that the results of laparoscopic RP involve patients operated on after 1998, who benefited from surgical and anaesthetic experience accumulated over 20 years of retropubic and perineal RP.
On analysing the results of 101 604 RPs undertaken in the USA between 1991 and 1994, including 93 986 by the retropubic and 7618 by the perineal approach, Lu-Yao et al. found that complications were more frequent than reported previously; thus, 71.2% of patients had no complications (88.3% had no serious complications) after retropubic surgery, compared with 75% (89.8%) after perineal surgery. The retropubic approach was associated with more cardiorespiratory but fewer surgical complications. Rectal injury was more frequent with the perineal approach (1.73% vs 0.68%, P < 0.001). Re-admission rates within 90 days after surgery were similar with the two approaches (8.5% with the retropubic and 8.7% with the perineal) but the reasons for hospitalization were different; the retropubic approach was associated with more cases of urinary retention, urethral stenosis and medical complications (thrombophlebitis of the lower limbs and pulmonary embolism), while the perineal approach was associated with a higher risk of infection, haemorrhage and haematoma, and rectal wounds necessitating colostomy.
The morbidity of RP is linked not only to the technique but also to comorbidity (especially among patients with an American Society of Anesthesiologist score of 3) and to blood loss . Rectal injury occurs during 1.4–2.4% of laparoscopic procedures, gastrointestinal lesions in 0.8–0.93% of transperitoneal procedures, ureteric wounds in 0.7–0.8%, and epigastric artery damage in 0.5–2.9%[43–46,67]. Currently, the mortality rate is close to zero, whatever the technique, all deaths being of cardiorespiratory origin [68–71].
All comparative studies show that the perineal approach is associated with less blood loss and a lower transfusion rate than the retropubic approach [7,8,12–18]. It is difficult to estimate blood loss during RP, as urine and blood are mixed in the aspirate. Blood loss during the retropubic approach is highly variable, with a mean of up to > 1500 mL ; however, through improved control of the plexus of Santorini, blood loss can be reduced to < 400 mL [52,53]. The most reproducible way of estimating blood loss is in terms of the proportion of transfused patients, although it some centres practice autologous blood collection before RP, with systematic reinfusion.
In a review article, Dillioglugil et al. reported that 29% of patients were transfused after retropubic RP. In a recent American series of 1000 RP, Lepor et al. found that 9% of patients received allogenic red cell concentrates, while 0.5% of patients were transfused in a recent European series of 350 cases .
With the perineal approach, the proportion of transfused patients was 5–11%, but this rate declines to < 5% as experience accrues; Weldon et al. and others reported that only 1% of patients received allogenic transfusions [57,75].
While the proportion of patients transfused after laparoscopic surgery is relatively low (2.8–3%) [40,60], Rassweiler et al. reported a rate of 31% and a mean of 2.4 red cell concentrates per patient after a purely retrograde approach.
The laparoscopic approach offers the same advantage as the perineal approach, i.e. less blood loss and fewer transfused patients, relative to the retropubic approach. This is because of the venous compression provoked by gas pressure and to the excellent view, permitting meticulous haemostasis. The absence of bleeding during laparoscopic surgery is not simply a consequence of this technique, but is crucial, as blood reduces the operative field and hinders colour vision. The use of an aspirator reduces intra-abdominal pressure and can halt the operation; this is not the case during open surgery.
RECTAL AND URETERIC DAMAGE
The frequency of rectal and ureteric injury is similar whatever the open surgical approach. The rate of rectal injury was 6% in the series of Brehmer et al., in which the prostate was more widely excised. Rectal wounds do not always require conversion to open surgery but can be repaired laparoscopically [76,77].
Some complications are more specific to the surgical approach, and especially to the perineal approach (hypoesthesia of the lower limbs caused by hip hyperflexion, rectourethral fistulae and pelvic cellulitis) . Overall, complications occur in 8.4–18% of open and 4–17% of laparoscopic procedures (Table 1) [43,45,46,49,57,63,65,67,68,72,74,75,79].
Table 1. Complications of RP, vesico-urethral anastomosis and catheterization during RP, according to the surgical approach
|||1 000||R||13.5||12|| 11||–||4.6|
|||1 870||R|| 8|| 9||–||–||3.8|
|||1 000||R||18|| 9.7|| 7–21||–||1|
|||220||P||18|| 4||–|| 2||1|
|||250||P|| 6.4|| 3||14||–||3|
|||200||P|| 7|| 2|| 2–7|| 8||5|
|||180||T|| 7.3||31|| 7||17.2||3.3|
|||134||T||12|| 2|| 4.8||15.1||1.4|
|||567||T||17.1|| 4.9|| 5.8||10||0.3|
|||50||E|| 4||13|| 7|| 4||–|
|||68||E|| 6|| 1||–|| 3.3||4.4|
|||70||E||12|| 1.4|| 8.2||–||–|
CATHETERIZATION AND URETHROVESICAL ANASTOMOSIS
Stenosis of the urethrovesical anastomosis occurs in 1–5% of patients after open and 1.6–3.3% after laparoscopic surgery; the corresponding rates of anastomotic leakage are 0.3–8.6% and 4–17.2% (Table 1). Once again, these values must be interpreted with care; it is too early to know the precise rate of ureteric stenosis after laparoscopic RP (cystography is not used routinely before catheter removal after open surgery).
Creating the vesico-urethral anastomosis under visual control during laparoscopic surgery, with continuous or interrupted sutures, allows the catheter to be withdrawn early . This approach was subsequently used during open surgery. Little et al. withdrew the catheter on day 5 after retropubic RP, after cystographic control on the third or fourth day; in 82% of cases the catheter was withdrawn without urinary retention. Souto et al. withdrew the catheter after cystographic control, 4 or 5 days after retropubic RP, in 30 of 45 patients free of anastomotic leakage. Urinary retention necessitating re-catheterization occurred in 6.7% of cases, and 3.3% of patients had anastomotic leakage. Lepor et al. withdrew the catheter after cystographic control 7 days after RP; 135 (75%) of 184 cystograms showed no anastomotic leakage and in 97% of these the catheter was withdrawn, with 15% of patients developing urinary retention. Brehmer et al. used cystography in the last 50 cases in their series of 200 perineal RP, authorising catheter withdrawal at 2–7 days after RP in 82% of cases. Finally, Koch et al. showed that the catheter could be withdrawn 3–4 days after surgery when cystography showed no anastomotic leakage.
The bladder catheter, which limits physical activity and is one of the most troublesome aspects for the patient , can therefore be withdrawn earlier than 14–21 days, which is the period usually considered necessary for the urinary epithelium to heal. Earlier catheter withdrawal after laparoscopic surgery has led users of the open approach (especially the retropubic) to do the same [68,83].
In the USA the hospital stay for retropubic and perineal RP is 2–3 days , and sometimes as short as 1 day , compared with 5–7 days in European series of laparoscopic RP . Differences in the American and European healthcare systems probably account for these differences. In their initial series of 40 laparoscopic RPs , Gill's American team reported a mean hospital stay of 1.6 days, which is remarkably short.
The hospital stay represents an important part of the cost of RP and is influenced by several factors, e.g. age, resumption of feeding, use of peridural anaesthesia and postoperative analgesia . The length of stay and related costs can be reduced by standardized patient care [87–91]. The hospital and healthcare system are important in this cost assessment. For treating prostate cancer laparoscopy is less costly than open surgery for ilio-obturator node dissection . Guillonneau and Vallancien  showed that, in France, laparoscopic RP was less costly than the retropubic approach, mainly because the hospital stay was shorter. In the USA, where the cost of using the operating room depends on the length of the operation, and where hospitalization after open surgery lasts 2–3 days, it is not certain that laparoscopy would be more economical . However, the patient can resume normal activities sooner after laparoscopic than open surgery, and the cost saving for society in terms of earlier return to work has not been assessed . However, most patients undergoing prostate surgery are retired.
Since the original reports, laparoscopic RP has gained wide popularity. The techniques appear in some instances more time-consuming than open RP, at least when gaining early experience, but blood loss, hospital stay, and early and late surgical complication rates are reportedly comparable with those of open surgery. In some series the laparoscopic technique even leads to better results.