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Keywords:

  • continence;
  • erectile function;
  • laparoscopy;
  • outcomes;
  • prostatectomy;
  • prostate cancer;
  • robotics

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To compare our experience of pure laparoscopic radical prostatectomy (LRP) with robot-assisted radical prostatectomy (RAP).

PATIENTS AND METHODS

The two techniques were compared retrospectively in 100 patients with localized prostate cancer who had LRP or RAP (50 each). Both groups were similar in age, serum prostate-specific antigen level, Gleason score and clinical stage. Their charts were reviewed, collating intraoperative data and early functional outcome.

RESULTS

The mean surgical time for LRP and RAP was 235 and 202 min (P > 0.05) and mean (95% confidence interval) blood loss 299 (40) and 206 (63) mL (P = 0.014), with no transfusions in either group. The positive margin rate did not differ significantly (14% LRP and 12% RAP) and there was no biochemical recurrence in either group. Early functional outcomes were similar.

CONCLUSIONS

Both LRP and RAP are technically demanding, but feasible, with the patient clearly benefiting. There were no major surgical differences between the techniques, but RAP is more costly.


Abbreviations
L(RP)

laparoscopic (radical prostatectomy)

RAP

robot-assisted prostatectomy

MSI

minimally invasive surgery

DVC

dorsal vein complex

IIEF-5

International Index of Erectile Function-5.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Laparoscopic surgery for localized prostate cancer is becoming standard in many institutions. Recently, laparoscopic technology (e.g. robots) and technique have advanced, resulting in significant progress in the development of minimally invasive surgery (MIS) for prostate cancer. The combination of lower postoperative morbidity, improved cosmesis, shorter convalescence and comparable oncological outcome has driven the demand for pure laparoscopic radical prostatectomy (LRP) compared to the open retropubic approach [1,2]. Consequently, various centres now regularly use LRP routinely for prostate cancer.

At our institution we have found this procedure to be technically reproducible, performing > 70 LRPs. These skills were transferred to perform robotic-assisted prostatectomies (RAP), now used in the USA and Europe, with early results still being reported [1,3,4]. The initial benefits are similar to LRP, except that it is more easily learned by surgeons trained in open techniques. We assessed the operative, pathological and functional outcomes from our unique experience of LRP and RAP.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

We retrospectively assessed LRP and RAP in the last 50 patients undergoing LRP and RAP (total 78 and 200, respectively); the LRP series was completed before the RAP series. Perioperative data with early oncological and basic functional results were recorded by chart review. The indications for surgery were identical to those for open retropubic RP. Patients were counselled about all possible treatments for prostate cancer [5].

Some patients had previous surgery (bilateral hernia mesh repair in two, appendicectomy in two and previous laparotomy in one). Two of these men required conversion to a transperitoneal approach (bilateral hernia mesh repair), as the extraperitoneal space could not be opened sufficiently for surgery.

All patients were positioned similarly; after general anaesthesia was established, an orogastric tube was placed. The supine position was adopted, with Trendelenburg tilt (15–20° for RAP and 30–40° for LRP), and the legs abducted to allow access for the robot and/or to the perineum. The arms were tucked beside the body and thoracic ‘X’ straps placed across the chest. After aseptic preparation and draping of the surgical field, a 16 F urethral catheter was inserted.

A balloon dilator was then placed through a 2-cm para-umbilical incision, under visual control, which developed the extraperitoneal space. Five ports (two robotic arms, one robotic camera port, two assistant ports) were required for the RAP and four ports for the LRP (two working ports, one camera, one assistant). The endopelvic fascia was dissected from the base to the apex of the prostate. The dorsal vein complex (DVC) was suture-ligated and the bladder neck dissected from the base of the prostate. The vas deferens and seminal vesicles were then dissected to the level of posterior Denonvilliers’ fascia. The vascular pedicles were bipolar cauterized, preserving the neurovascular bundles. The apical urethra and DVC were transected. Lymph nodes were sampled if the Gleason score was > 7 and/or the PSA level > 10 ng/mL, but in the 100 patients reviewed this was not required (Table 1). The vesico-urethral anastomosis was made using two continuous polyglactin sutures. The specimen was extracted through the para-umbilical incision in an entrapment bag, and a drain placed at the anastomosis.

Table 1.  Patient demographics, data before, during and after RP, and recovery of urinary continence after catheter removal
VariableLRPRAPP
  1. PIN, prostatic intraepithelial neoplasia.

Mean (95% CI):
age, years 61.8 (1.6) 59.6 (1.6) 0.06
PSA, ng/mL  6.0 (0.83)  7.3 (1.2) 0.06
Gleason grade  6 (0.14)  6 (0.15) 0.13
N with clinical stage
T1c 34 43
T2a 14  6
T2b  2  1
Mean (95% CI):
total operating time264 (38)277 (14)NS
surgical time, min235 (12)202 (38)NS
blood loss, mL299 (40)206 (63) 0.014
prostate weight, g 51 (4.1) 53 (5.3) 0.29
N with pathological stage:
T2a 13  8 
T2b 27 36 
T3a  7  6 
T3b  2 
PIN  1 
Preservation of neurovascular bundles, n
unilateral 10  1
bilateral 24 46
Total 34 47<0.001
none 16  3
Urinary continence, n
Immediate 10 23<0.001
<1 month 12 13NS
<2 months 14  4<0.001
<3 months 10  5<0.001
Still using liner for security  4  5NS
Overall continence rate, % 92 90NS

After surgery all patients were mobilized within 4 h of surgery, and generally discharged home within 23–48 h. The urethral catheter was routinely removed at 7 days after surgery.

One team of genitourinary pathologists analysed the pathological specimen, noting pathological stage, Gleason grade and surgical margin. All perioperative data, including age, preoperative PSA, clinical stage, Gleason grade, prostate weight, pathological variables (pathological Gleason grade, stage, margin status), blood loss, nerve-sparing and operating room times (total time including anaesthesia time, pre-docking/after undocking times, robot operating times) were recorded.

Early functional outcomes were assessed during the follow-up, including erectile function (interview and the International Index of Erectile Function-5, IIEF5, questionnaire). Spontaneous erections were documented at the consultations before surgery; the quality of the erections was not noted afterward, but IIEF-5 scores were recorded at 3 months. Continence was defined as being totally dry and using no pads, either for wetness or security. The time to total urinary continence was assessed by interview and examination (Valsalva manoeuvre and coughing with a full bladder). Data are expressed as the mean (95% CI) and compared using the paired t-test, with P < 0.05 taken to indicate statistical significance.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The demographics were similar in both groups (Table 1); the mean total operating-room time (including anaesthesia) and surgery time were similar (Table 1); the estimated blood loss differed but there were no blood transfusions in either group. Nerve sparing was less in LRP than RAP, but the mean specimen weights were similar.

There were four bladder neck contractures (one after LRP and three after RAP) treated by urethral dilatation, and two urinary leaks (one in each group) treated by prolonged catheterization (10 days). There were no other minor or major complications up to 30 days after surgery.

The pathological staging was comparable in the two groups (Table 1), with a mean Gleason grade of 6. The positive surgical margin rate was similar for both groups, at 14% (LRP) and 12% (RAP). There was no biochemical recurrence of prostate cancer in any of the 100 patients at a mean (range) of 5.3 (2–9) months after surgery.

Continence was verified by the absence of urinary leakage on Valsalva manoeuvre or coughing after catheter removal, at intervals (immediately, 4, 8, 12 and > 12 weeks). At 3 months after catheter removal, 46 patients (92%) in the LRP group and 45 (90%) in the RAP group were totally continent; the other patients were still using an underwear liner for security only (Table 1).

The assessment of erectile function after surgery was inconclusive as the data are immature. When interviewed, the LRP group had 22% spontaneous erections, with 36% requiring drug aid (sildenafil or tadalafil), with a mean IIEF-5 score of 37 (15); when interviewed, the RAP group reported spontaneous erections in 40%, with a further 46% requiring drug aid, and an IIEF-5 score of 34 (11).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

LRP aims to combine the advantages of open retropubic RP with those of minimally invasive surgery, to allow better intraoperative and functional outcomes. The LRP and RAP groups were comparable for patient and cancer demographics, and outcomes during and after surgery (Table 1). Limitations of the present study are the single-centre experience with relatively few patients and use of chart review, all increasing observer and comparison bias. Both groups had a higher prevalence of clinical stage T1c tumours, probably a result of patient selection over time. An important consideration was that the LRP series preceded the RAP series, and thus experience was gained in the laparoscopic anatomy required for these operations. To avoid any comparison bias caused by this factor (robotic set-up, team training, laparoscopic anatomy), we compared the last 50 patients in each group, allowing a comparison after gaining the experience, thereby minimizing the bias. Ultimately the goal was to show not only the ease of conversion from LRP to RAP, but also to compare the clinical outcomes, which should be similar with either technique.

The mean surgical times were no different between the groups; this is interesting, as the suturing aspects of this form of surgery are easier with the robotic arms in unskilled hands [6], but if already skilled in pure laparoscopy there should be no anticipated difference. The blood loss was less in the RAP group, with no blood transfusions in either group. This difference was not expected and may primarily be a result of the magnified, three-dimensional imaging of the robot, which allows the surgeon to perform more deliberate and accurate haemostatic manoeuvres.

The anatomical bilateral nerve-sparing dissection appeared to be easier during RAP than LRP, with a 92% preservation rate (Table 1). The comparable LRP group had a 48% bilateral nerve-preservation rate. The obvious bias is that patient selection may have improved, as suggested by the slightly higher incidence of T3 prostate cancers in the LRP group. The surgeon may also have been more confident with the margins of surgery as experience increased and the optics improved, and thus the RAP group benefited from the LRP experience.

There are usually complications during surgery; the objective of any improvement in a surgical procedure is that the morbidity is reduced and outcomes improved. There were some urinary leaks or bladder neck contractures in the present patients. The leaks may have occurred as a result of loose suturing, as our technique involves a continuous suture. However, as our technique of prostatectomy used an extraperitoneal approach with its obvious advantages [7], the leaks were localized. The contractures are difficult to explain, as there was good mucoso-mucosal apposition at the time of suturing, because of the excellent visualization afforded by MIS techniques. We can only suggest that a combination of overzealous diathermy at the bladder neck with over-tight suturing may have caused the problem, although we have no direct evidence for this.

The pathological/oncological outcome is an important measure of the effectiveness of a modified technique compared with the standard. The present two groups had comparable clinical staging, with most being biopsy-confirmed localized prostate cancer (T1c). The mean weights of the prostate specimens were similar, at 51–53 g, but this includes glands of 23–105 g. The positive surgical margins were similar in both groups, and lower than other reported in initial series [4,8].

Functional outcome is also an important benchmark for a newer procedure; the present results are early, but the outcomes are encouraging compared with open surgery. By 3 months, both groups had reached ≈ 90% total continence (Table 1); this high rate (with no use of pads) is promising. The mechanism for achieving this is probably a combination of preserving the length of the distal urethra and bladder neck urethra, and the neurovascular bundles and pubo-prostatic ligaments [9,10]. Also, accurate bipolar cautery and controlled dissection below the endopelvic fascia avoids nerve and muscle damage, which may be important in preserving the continence mechanism [11].

Assessing early erectile function for comparison with other series of RP is difficult, as the recovery of the neurovascular supply to the erectile tissue occurs 12–18 months after surgery [12]. Interestingly, in the RAP group nearly half the patients reported spontaneous erections, but the IIEF scores were not equally high; these data require further maturity before any meaningful comments can be made.

The present study highlights the feasibility of successful RP by either technique. The importance of this to the health-policy makers and providers cannot be over-emphasized. The use of MIS for the prostate allows patients to leave hospital within 1–2 days, and to return to their initial routine within a few weeks. Although this is difficult to measure from the present retrospective series, it is a reasonable assumption; we are planning long-term studies in this area. In contrast, open surgery, even in the best hands, may have a similar outcome to MIS in terms of hospital stay but the patients’ return to preoperative activity usually takes several weeks, in our experience. The important message from this is that as the incisions and overall trauma of surgery decrease, return to preoperative activity should logically take less time [13].

The overall cost affects two areas, i.e. the hospital and society. The latter is not easily measurable, but the cost of losing days from work/life affects everyone. In the present study we compared two minimally invasive procedures, which both provide a good recovery after surgery. If cost is measured as the clinical outcome alone, either technique is good, but financially RAP is a costly procedure.

Laparoscopically experienced surgeons with assistants generally untrained in laparoscopy undertook all the present surgery. The changes in the team added time and effort to the operations but this depiction of reality is important if these technologies are to be embraced. The laparoscopic skills allowed a smoother transition to RAP. Importantly, after our experience we suggest that surgeons should train appropriately and not simply take a 1–2 day course before attempting this demanding procedure. Indeed, the level of laparoscopic skills required to perform RAP has been underestimated [6], although there has been some attempt to address this [14], by groups who have laparoscopic experience available to them. If a surgeon wishes to use RAP, he or she should have appropriate laparoscopic experience available, or be a trained laparoscopist. The current disadvantage is the enormous cost of the robot- assisted approach compared with pure laparoscopy.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES