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:
[email protected]
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
2
© 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
EUROPEAN UROLOGICAL REVIEW
3
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
