LAPAROSCOPIC RADICAL PROSTATECTOMY

LAPAROSCOPIC RADICAL PROSTATECTOMY

0022-5347/05/1734-1072/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION Vol. 173, 1072–1079, April 2005 Printed in U.S.A...

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0022-5347/05/1734-1072/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 173, 1072–1079, April 2005 Printed in U.S.A.

DOI: 10.1097/01.ju.0000154970.63147.90

LAPAROSCOPIC RADICAL PROSTATECTOMY EDOUARD J. TRABULSI

AND

BERTRAND GUILLONNEAU*

From the Section of Minimally Invasive Surgery, Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York

ABSTRACT

Purpose: After the pioneering period when only few teams were performing the procedure, the laparoscopic approach to radical prostatectomy has become widespread with several technical variations. A comprehensive review of the published literature on laparoscopic radical prostatectomy was performed to determine the current state of the art of this surgical innovation in terms of perioperative parameters, functional results and cancer control. Materials and Methods: English language, peer reviewed articles published before June 2004 concerning laparoscopic radical prostatectomy were found by MEDLINE query. All articles were analyzed and none were a priori excluded. Conclusions were drawn from series of 50 or more patients. Results: Laparoscopic radical prostatectomy is being performed at multiple centers worldwide using various surgical approaches and technologies. Analysis of perioperative parameters, including surgical blood loss, operative time, complications and convalescence, demonstrated low morbidity and showed a clear trend toward improvement with increased experience. The reported positive surgical margin rates were lower in more recent series. As measured by prostate specific antigen recurrence and disease-free intervals, oncological results and cancer control rates are difficult to ascertain in the immature series published to date. Functional results in terms of postoperative urinary and sexual function appear encouraging. Conclusions: Overall the current operative, oncological and functional results of laparoscopic radical prostatectomy appear to approximate those of open radical retropubic prostatectomy. These results justify the considerable interest of the urological community in laparoscopy, as evidenced by its widespread application. Nevertheless, longer followup and more mature data are needed definitively to establish laparoscopic radical prostatectomy as an alternative to the retropubic approach. KEY WORDS: prostate, prostatectomy, prostatic neoplasms, laparoscopy, robotics HISTORY

The first laparoscopic radical prostatectomy (LRP) was performed in 1997 by Schuessler et al.1 Since then, LRP has been reported widely and it has become increasingly important as a prostate cancer treatment. Two large early series originated in France2– 4 and LRP has since been described in large series (greater than 50 cases) from Germany,5, 6 Belgium,7 Japan,8 the United Kingdom,9 the United States10, 11 and Italy.12 Cumulatively well over 3000 procedures have been published worldwide using various techniques, surgical approaches, and surgical and robotic instruments. The evolution of LRP, surgical nuances and functional results are reviewed. THEORETICAL ADVANTAGES

The major impetus driving the development of minimally invasive techniques for prostate cancer has been patient satisfaction and quality of life (QOL). Shorter convalescence with a more rapid return to normal activity and shorter Foley catheter duration are attractive goals to be achieved by LRP. Cosmetic results, which are a common benefit of minimally invasive procedures in general, may be less of a concern in the generally older male population with prostate cancer. Additional potential benefits of LRP are decreased blood loss and magnification of the operative field. Most operative bleeding during radical prostatectomy is venous, which CO2

insufflation theoretically tamponades by increased intraabdominal pressure. The 10⫻ to 15⫻ magnification afforded by laparoscopy also allows more precise visualization of intraoperative details, which is particularly valuable for creating the vesicourethral anastomosis. The anastomosis, which is fashioned with a running suture or 8 to 12 interrupted sutures, is generally watertight immediately, allowing rapid removal of the Foley catheter. An area of concern with LRP is the lack of tactile sensation normally available during open prostatectomy. Tactile sensation has been advocated as a useful aid for the assessment of induration and palpable nodules, and delineation of the proximity or involvement of the neurovascular bundles by cancer. These concerns are balanced by the improved vision under magnification afforded by laparoscopy. TECHNIQUE

Evolution of techniques. The initial report of LRP by Schuessler et al was of 9 cases performed through an intraperitoneal approach in antegrade fashion.1 Average operative time was 9.4 hours and there were 3 complications, namely cholecystitis, thrombophlebitis associated with pulmonary embolism and small bowel hernia into a trocar site. Therefore, the experience was not conclusive and the group stated that, although laparoscopic radical prostatectomy was feasible, this approach offered no advantage over open surgery with regard to tumor removal, continence, potency, length of stay, convalescence and cosmetic result. Shortly thereafter a single case of laparoscopic radical prostatectomy through an extraperitoneal approach was reported.13 However, the largest initial series originated in

Submitted for publication April 6, 2004. * Correspondence: Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021 (e-mail: [email protected]). 1072

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France at Montsouris Institute in Paris and then at Henri Mondor Hospital in Cre´teil2– 4, 14 –18 with different conclusions. Retrospectively it appears that the French experiences were more successful because they involved a technique that mimicked more closely the retropubic approach commonly used in open radical retropubic prostatectomy (RRP). Particularly control of the prostatic pedicles was performed in the space of Retzius, not through the posterior approach through the pouch of Douglas. Additionally, the intracorporeal suturing technique was mastered and used efficiently to allow more accurate control of the dorsal venous complex (DVC) and creation of the vesicourethral anastomosis. More recently LRP using robotic assistance was described.19, 20 Intraperitoneal: According to the Montsouris technique, which was described after the report of Schuessler et al,1 the seminal vesicles are dissected first through the pouch of Douglas and the bladder is then dissected off of the anterior abdominal wall, allowing access to the space of Retzius.14 The endopelvic fascia is incised, exposing the lateral margins of the DVC distal and allowing placement of a suture ligature around the DVC for hemostasis. The bladder neck is incised and the previously dissected seminal vesicles are exposed. In select patients neurovascular bundle preservation is then performed from the base toward the apex, starting at the lateral pedicle of the prostate. Finally, the urethra is transected and urethrovesical anastomosis is performed. Extraperitoneal: The intraperitoneal approach to LRP has been criticized as creating the potential for several different complications. A risk of the intraperitoneal technique is unrecognized bowel injury away from the visual field. Intraperitoneal urine leakage or hematoma formation perioperatively with subsequent bowel dysfunction or ileus and delayed intra-abdominal adhesion formation have also been cited as potential negatives. These concerns led investigators to develop extraperitoneal (EP) approaches to LRP.7 Subsequent reports from Belgium7 and then from Germany21–23 demonstrated the feasibility of extraperitoneal approaches. At these 2 centers groups use an antegrade approach, starting at the bladder neck, dissecting the seminal vesicles and vasa deferentia through the bladder, and proceeding distal toward the prostate apex and dorsal venous complex. Besides the theoretical advantages noted the groups suggested that operating in the space of Retzius is more familiar to urologists experienced with open retropubic prostatectomy, which may improve the learning curve. The potential disadvantages of this approach are a more limited working space and less bladder mobilization, which can make the urethrovesical anastomosis more difficult and may place the anastomosis under increased tension. Finally, dissection of the seminal vesicles could be more difficult, theoretically leading to unrecognized trauma to the inferior hypogastric plexus and neurovascular bundles with functional consequences. Transperitoneal (TP) and extraperitoneal LRP were first analyzed by Hoznek et al.24 In this retrospective study the last 20 patients operated on through a transperitoneal LRP were compared with the first 20 undergoing extraperitoneal LRP. Operative time for extraperitoneal LRP was significantly shorter and resumption of a regular diet was significantly more rapid. The duration of catheterization and positive margin rates were similar in the 2 groups. However, more recently a retrospective study analyzing 100 consecutive extraperitoneal LRPs and 100 consecutive transperitoneal LRPs at Montsouris Institute showed no significant differences in operative, postoperative or pathological parameters between the 2 approaches, but rather highlighted the importance of individual surgeon training and experience for determining the optimal technique to use.25 Another retrospective study from Cre´teil examined the outcomes in 165 first patients operated on transperitoneally and then 165 operated on extraperitoneally.26 There were no differences in complication, convalescence or positive margin rates but there was a slightly shorter mean operative time in the extraperito-

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neal cohort, which could be explained by the learning curve and greater experience. There was also significantly higher blood loss and catheter duration in the extraperitoneal LRP cohort, of which the explanation is not easily attributable except for experience. Therefore, it would be reasonable to consider a history of abdominal surgery, prostate size and the intent to spare the neurovascular bundles to select the appropriate approach in a given patient. Robotic: The use of robotics in laparoscopy has been spurred by the commercial availability of master-slave robotic devices such as the daVinci surgical robot (Intuitive Surgical, Mountain View, California). The operating surgeon sits at a computer console separate from the operative field.27 The computer software damps the degree of movement by the operator, resulting in motion of the laparoscopic instruments that are further articulated, which afford extra planes of motion.20, 28 –31 Despite the lack of haptic feedback provided, it has been suggested that this combination of factors could lessen learning time and allow novice laparoscopists to complete these procedures.32 Use of the da Vinci robotic system has been reported with the transperitoneal and extraperitoneal approaches.33, 34 Analysis of the results of robotic LRP are often difficult to interpret since they are often dominated by the enthusiasm of the investigators rather than supported by data. Regarding radical prostatectomy, to our knowledge there are no data supporting a potential benefit in terms of cancer control or functional results of the laparoscopic approach with or without robotic assistance. The decrease in the learning curve with robotic assistance is equivocal and not convincing from a oncological point of view. Finally, most advantages (pain, blood loss and recovery time) are related to laparoscopy per se rather than to the assistance of a computer. The instruments are not yet comparable in term of quality with those used in laparoscopic surgery. Most groups authors described an important use of the hook with monopolar electric current, which has significant thermal and electrical spread, and can cause injury to adjacent structures, such as the neurovascular bundles. Finally, the cost of the use of robotic devices in prostate surgery is critical.35 Besides extra time for the preparation and set-up necessary to use the master-slave robot, the system requires a tremendous capital investment (purchase and maintenance) and functional cost since the laparoscopic instruments used by the master-slave robot have pre-programmed senescence, requiring new instruments after a defined number of procedures. Learning Curve: LRP is generally thought of as a technically demanding laparoscopic procedure with an extended learning curve. LRP can be learned during residency or fellowship training and other formats have been explored for the practicing urologist. Training laboratories with laparoscopic skills trainers and ex vivo models of the urethrovesical anastomosis have enabled urologists to improve their skills in a short period.36 On site mentoring by experienced laparoscopists has created successful LRP programs in the United States of America.34, 37 The question of the learning curve is relatively recent in the surgical field and it has certainly been scrutinized widely for the laparoscopic techniques. The minimum number of cases required for proficiency in LRP has been debated and there is no more accurate answer for laparoscopy than there is for the open retropubic approach. There is clear evidence that there is continued improvement in operative parameters, such as operative time, blood loss and the need for open conversion, even after the initial 50 operations.15 Subsequent reports from Montsouris demonstrated continued improvement in operative time even after 300 cases.38 There is not yet a consensus of what proficiency should be required before performing LRP independently and how safely this level can be achieved by a junior surgeon. Therefore, there is a clear lack of information regarding this topic but certainly de-

23

10

11

1.4 First ⫹ 0 second 219 pts None reported 7

12 First ⫹ 11 second 219 pts 4.5 30.1 First ⫹ 9.6 second 3.7 First ⫹ 0.5 219 pts second 219 pts 53% Autologous ⫹ 6 0 heterologous 1,100 First ⫹ 800 second 219 pts 376

Not reported Not reported 4.2 Not reported Not reported Not reported 150 Last 100 pts

TP 80 Milan

Rassweiler et al43 Gregori et al12

Heilbronn

438

TP

165 With node dissection in last 100 pts 135 Without node dissection 288 in First ⫹ 218 in second 219 pts 218 Robotic 250

26 70

Hara et al46, 79 Stolzenburg et al22 Menon et al11

Detroit

19 21 3.8 None reported 9 8.2 Not reported Not reported 0 0 3.80 1.40 850 350 453 155

1.40 1 10 3 449 313 274 245 70 100

Boston United Kingdom Kobe Leipzig

TP TP

200 550

Guillonneau et al17 Dahl et al10 Eden et al9

Montsouris

TP EP

23 8 140 1 Not reported Not reported

3.6 1.45 4.2 Last 350 pts

After catheter removal Not reported 4.2 2.4 5.3

0 9 14 34 0 1.5 2.4 0 14 4.8 Last 124 pts 12 5.5 Last 10 pts 2.5 6.1 Last 124 pts 8 7.5 Last 10 pts 0 0 0 2 0 3 2 13

600 Not reported 185 1,350 First 10 ⫹ 492 last 10 pts 380 345 240 Last 114 pts 265 317

EP TP TP EP in 42 pts, TP in 8 TP 1 134 125 50

0 Not reported 7.3 0 Not reported 583 564 TP 9

New York Cre´teil Berlin Brussels

Center References

San Antonio

% Conversion % Transfusion Mean EBL (ml) Mean Operative Time (mins) Surgical Approach

TABLE 1. Reported LRP series from centers worldwide

Mean Hospital Stay (days)

PERIOPERATIVE PARAMETERS

Operative time. Table 1 shows that average operative time has decreased substantially with increased experience. The average operative time at Montsouris, which is the center with the largest reported experience with LRP, decreased from more than 240 minutes in the first 100 cases to 170 minutes in the last 350.17 Similarly in Cre´teil average operative time was more than 8 hours in the first 20 cases and it decreased to 4 hours in the next 114.18 Other reports worldwide describe similar decreases in operative time after the initial experience. Pelvic lymphadenectomy, which at most centers is performed only in select patients at high risk, appeared to add 30 to 60 minutes to operative time in most series. Estimated blood loss. Average estimated blood loss (EBL) in reported LRP series varies widely (table 1). Because lower EBL represents an advantage of LRP over open RP with a reported mean EBL of 600 to 1,400 cc in various open RP series,42 this parameter requires careful examination. Average EBL in large series was 380 ml in 550 patients, decreasing to 290 ml in the last 350.17 In this series the overall transfusion rate was 5.3%, decreasing to 2.6% in the last 350 cases. Table 1 shows that average EBL at other centers worldwide is similar and only EBL data from Heilbronn were noticeably higher with an average EBL of 1,100 ml and a transfusion rate of 30% in their initial 219 patients, and 800 ml with a 9.6% transfusion rate in the last 219.43 The reason for this discrepancy is unclear and it may represent an argument for antegrade dissection of the prostate in laparoscopy since the technique used at this institution is mainly retrograde. Hospital stay and duration of catheterization. Hospital stay after LRP depends on cultural and societal factors unique to each center. In Europe patients are much more reluctant to leave the hospital with a catheter than in the United States, making this parameter meaningless as an indicator of convalescence. It more correctly represents a measure of the duration of urethral catheterization. Table 1 shows that the average duration of catheterization decreased in all series at an average of approximately 4 to 6 days, which is shorter than historical controls of open RRP. Early removal of the urinary catheter was examined with cystography by Nadu et al in 113 patients and no increases in the incontinence rates, anastomotic stricture or urinary extravasation were noted.44 After a period of enthusiasm when the urinary catheter were removed as early as postoperative day 3 there is now a trend toward routinely removing it between days 5 and 7 to decrease the risk of acute retention and recatheterization. Convalescence. Most series reported to date lack detailed data on convalescence and return to normal activities. In addition, few reports describe the degree and duration of postoperative pain and use of analgesics using validated questionnaires. In a small series from Johns Hopkins postoperative analgesic requirements and time to complete convalescence after LRP were significantly improved compared to open RRP.45 In a prospective study from Kobe, Japan

Schuessler et al1 Raboy et al13 Hoznek et al18 Turk et al5 Bollens et al7

Mean Catheter Duration (days)

% Rectal Injury

% Overall Complications

creased operative time cannot be the only end point of the learning curve. Analysis of open RRP series demonstrate improved positive surgical margin rates with increased surgical experience, which may be an more relevant end point for analyzing the learning curve for LRP.39 In 2 small studies comparing operative and pathological parameters between experienced and novice laparoscopists surgeon experience was associated with operative time, especially in obese patients,40 but it was not associated with positive surgical margin rates.41 However, the overall high positive margin rate in this series could explain this result, which contradicts the analysis of RRP.39

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LAPAROSCOPIC RADICAL PROSTATECTOMY

No. Pts

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LAPAROSCOPIC RADICAL PROSTATECTOMY

comparing open RRP and LRP the European Organization for the Research and Treatment of Cancer Prostate Cancer QOL questionnaire for general health related QOL was used to measure QOL differences before and 6 months after surgery.8, 46 The investigators found no significant differences between open RRP and LRP,8 although patients receiving LRP expressed a more favorable attitude toward surgery than those undergoing open RRP and significantly more undergoing LRP would have chosen that therapy again compared to those with open RRP. These data supports the concept that the benefits of the laparoscopic approach in this study would be more important in the immediate postoperative period. Cost. Cost comparisons between standard RRP and LRP have not been thoroughly examined. In an early report from Montsouris average costs were compared between RRP and LRP with LRP offering a cost advantage when operating room expenses and hospitalization costs were evaluated.15 However, in the United States cost analysis is hampered by the wide variety of instruments used and the variable use of reusable instruments. Cost analysis of robotic LRP is made more difficult by the large capital investment required for acquisition of the surgical robot, which must be factored into any cost analysis on a per case basis. Complications. Complication rates after LRP have varied significantly from 3.6% to 34% (table 1). Unclear and nonstandardized reporting makes interpretation of the reported complication rates difficult and the learning curve of LRP skews the results strongly. In a consecutive series of 567 patients operated on by LRP the overall complication rate was 17.1%, including major complications (3.7%) and minor complications (14.6%).38 Perioperative complications requiring reoperation occurred in 3.7% of the patients for a major complication (2.3%) or a minor complication (1.4%). Major complications requiring reoperation were bowel or rectal injury in 1% of cases, hemorrhage in 1% and ureteral injuries in 0.3%. Minor complications requiring intervention were epigastric artery injury in 0.5% of cases, wound dehiscence in 0.7% and persistent lymphatic drainage in 0.2%. Other rare minor complications were deep vein thrombosis in 0.3% of cases, paralytic ileus in 1%, vesicourethral anastomotic leakage in 0.2%, upper extremity neuropathy in 0.4% and obturator nerve neuropraxia in 0.2%. Conversion from LRP to open RRP occurred in 7 patients (1.2%), of whom all were among the first 70. There were no conversions in the last 500 patients. Similarly in the series from Cre´teil and Heilbronn the complication rate decreased significantly as experience increased from 23% to 3.2% and from 13.7% to 6.4%, respectively, between the initial and more recent reported experiences.18, 43 Rectal injury is a potential severe complication of radical prostatectomy, occurring in between 1% and 2% of cases.47 The location of the rectal injury is usually apical and the major risk factor for rectal injuries seems to be a nonnerve sparing procedure. Although rectal injury is a major complication when it is not recognized, the rate of rectal injuries seems to be similar to that of open RRP and, when recognized immediately, primary closure in 2 layers is associated with no adverse sequelae.47, 48 When it is unrecognized or insufficiently repaired, rectal injury can cause peritonitis between postoperative days 2 and 4 with the particular clinical and biological symptoms reported by Bishoff et al.49 This presentation requires reoperation and temporary colostomy. CANCER CONTROL

Since the introduction of modern anatomical open RRP in 1982 by Walsh and Donker,50 the reported 5 and 10-year prostate specific antigen (PSA) nonprogression rates after open RRP have been reported to be 77% to 80% and 54% to 75%, respectively.51–55 Because LRP has been performed only

in the past 6 years, long-term data on PSA nonprogression after LRP are unavailable. However, short-term oncological data after LRP are encouraging (table 2). In the initial oncological survey reported in 1999 definite or probable positive margins were found in 7 of 40 patients (17.5%), including 3 with positive findings only at the apex.3 In this initial series followup was too short to show any meaningful PSA nonprogression rate. In 2003 a subsequent series of 1,000 cases of LRP showed oncological results at a median followup of 12 months.56 The positive surgical margin rate was 19.2% overall and it varied with pathological stage from 6.9% in pT2a cases up to 32% in pT3b cases. Table 3 lists positive surgical margin rates for each clinical and pathological stage, and each Gleason score. This positive surgical margin rate compares favorably with the reported positive surgical margin rates in large open RRP series57–59 but no real comparison can be drawn since no prospective or randomized studies are available. Significant risk factors for a positive surgical margin were preoperative serum PSA, clinical stage, pathological stage and Gleason score. In this study neurovascular bundle preservation did not affect the rate of positive surgical margins or progression. In another retrospective study from Germany 3 consecutive cohorts of patient who underwent radical prostatectomy from 1999 to 2002 were analyzed.43 The cohorts consisted of 219 patients undergoing open RRP before routine LRP was performed, the initial 219 who underwent LRP during the learning curve (early) and the next 219 who underwent LRP (late). To maintain the accuracy of comparison the cohorts included only patients who underwent concurrent pelvic lymphadenectomy and 83 who underwent LRP without lymphadenectomy were excluded. As expected with stage migration, the percent of patients with organ confined (pT1/ T2) tumors was lowest in the RRP group (45.7% vs 55.3% vs 65.3% for open RRP vs early LRP vs late LRP) but not significantly different. The positive surgical margin rate also did not differ significantly in these 3 groups (table 2). At the relatively short median followup of 30 months the PSA nonprogression rate in the early LRP cohort was 86.8%. A similar study compared a matched cohort of 139 open RRP and 139 LRP cases of procedures done by 2 senior surgeons during 1994 to 1997.60 There was no significant difference between the open RRP and LRP groups regarding PSA (10.6 vs 10.4 ng/ml), age (64.3 vs 63.5 years), biopsy Gleason score (5.7 vs 5.8) or number of positive biopsy cores (2.3 vs 2.3). On final pathological analysis there were no significant differences between open RRP and LRP in the rate of positive lymph nodes, prostate weight or pathological stage except stage migration in favor of pT2 tumors. Additionally, there was no significant difference in final Gleason

TABLE 2. Open RP, early LRP and late LRP comparison from Heilbronn, Germany Open RP No. pts 219 Median mos fol67 (43–97) lowup (range) % pT1/T2 45.7 % Pos surgical 28.7 margins: pT2 6.3 pT2a 1.8 pT2b 15.2 pT3a 30.6 pT3b 52.4 pT4 100.0 % PSA relapse 17.4 % Overall survival 96.6 % Ca specific sur97.2 vival Adapted from Rassweiler et al.43

Early LRP

Late LRP

219 30 (13–45)

219 8 (1–13)

55.3 21.0 6.9 2.3 9.6 17.3 54.3 100.0 13.2 98.6 99.1

65.3 23.7 12.0 2.5 15.5 38.8 54.5 100 Not available Not available Not available

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LAPAROSCOPIC RADICAL PROSTATECTOMY

TABLE 3. Surgical margin status in 1,000 LRP cases from Montsouris Institute, Paris, France No. Surgical Margins (%) Pos Clinical stage: T1a T1b T1c T2a T2b Pathologic stage: pT2 pT2a pT2b pT3a pT3b pT1–3N1 All Gleason score:

p Value

Neg

⬍0.001 2 0 103 74 11

(33) (16) (14) (41)

4 (67) 3 (100) 557 (84) 230 (76) 16 (49)

120 (15.5) 14 (6.9) 106 (18) 43 (30) 25 (32) 4 (67) 192 (19.2)

655 (84.5) 189 (93.1) 466 (82) 99 (70) 52 (68) 2 (33) 808 (80.8)

⬍0.001

Not significant

2–4 0 4–6 72 7 95 8–10 25 Adapted from Guillonneau et

(15) (21) (30) al.56

4 (100) 391 (85) 356 (79) 57 (70)

score, although there was a trend toward a higher percent of high grade cancers (Gleason 8 to 9) in the open RRP group (8.6% vs 4.3%). The overall rate of positive surgical margins was significantly lower in the LRP group than in the matched open RRP group (13.7% vs 25.9%, p ⬍0.02). When examining organ confined cancers, the positive surgical margin rate in patients with pT2 disease was also significantly lower for LRP (10% vs 20.9%, p ⬍0.05). Interestingly apical positive surgical margins appeared to account for the differences with 2 to 3 times fewer positive apical surgical margins for LRP than open RRP, while there were no significant difference in positive surgical margins at other prostate sites. These results contradict the results of other studies. A retrospective study of patients with organ confined prostate cancer (pT2) treated with retropubic prostatectomy (116), radical perineal prostatectomy (86) or LRP (169) did not show any differences in the overall rate of positive surgical margins in the 3 groups.61 However, the location of positive surgical margins appeared different among the groups with the lowest apical positive margin rate for radical perineal prostatectomy, the lowest bladder neck positive margin rate

for LRP and the higher posterolateral positive margin rate for LRP, although these differences did not achieve statistical significance. In a followup study from the same institution changes in LRP technique, including wide resection of the bladder neck and division of the puboprostatic ligaments, decreased the positive surgical margin rate but these technical changes are unlikely to be the only explanation for this decrease.62 Attempts at neurovascular bundle preservation in select patients did not result in more positive surgical margins. In another retrospective case-control study 60 patients with LRP were analyzed for pathological efficacy and compared with 60 concurrent patients undergoing open RRP and with 60 undergoing open RRP, matched with those with LRP by clinical stage and biopsy Gleason grade.63 In this study the positive surgical margin rate of LRP was not significantly different from that in either open RRP group, and the incidence of isolated apical positive margins and multiple site, positive margins was lower in the LRP group. Therefore, the difficulty of decreasing the positive surgical margin rate is still a problem even with laparoscopic approaches, where better visualization may lead to more dramatic improvement. This raises the question, which is not yet solved, of the influence of the technique itself or of surgeon experience. To decrease this rate the role of frozen section analysis on a wedge of tissue from the posterolateral margin in the vicinity of the neurovascular bundle was analyzed.64 If frozen section analysis revealed positive surgical margins, complementary resection of the ipsilateral neurovascular bundle revealed residual tumor in a third of these cases and the overall positive surgical margin rate decreased from 26% to 8% in organ confined (pT2) tumors. This rate, which is still too high for a contemporary series, does not justify systematic frozen section analysis. FUNCTIONAL RESULTS

Urinary. Table 4 shows that the reported rates of urinary continence after LRP compare favorably with those in large series of open RRP, which has been reported to be 80% to 95%.65–70 While the definition of urinary continence varies among the reported series, the incidence of requiring no pads after LRP was 83% to 100% at 1 year. As demonstrated by the Cre´teil experience, progress along the learning curve appears to improve urinary results. In that series the rate of urinary continence, defined as no pad required at 1 year, improved from 78% to 90% in subsequent reports.71, 72 In a

TABLE 4. Oncological and functional data after LRP in series worldwide References Hoznek et al18

Center

No. Pts

% Pos Surgical Margin

% PSA Nonrecurrence (interval)

% Urinary Continence (followup)

Cre´teil

134

25

89.6 (11 mos)

86.2 (1 yr)

Cre´teil

235

Not available

Not available

90 No pad (1 yr)

Berlin

125

26.4

100 (6 mos)

Bollens et Rassweiler et al43

Brussels Heidelberg

50 438

22 Table 2

94 (3 mos) Table 2

Guillonneau et al17

Montsouris

550

16.7

pT2a 92.3 (36 mos), pT2b 86.3 (31 mos)

Guillonneau et al56 Dahl et al10

Montsouris Boston

1,000 70

Table 3 11.4

90.5 (3 yrs) Not reported

Eden et al9

United Kingdom Kobe

100

16

100 (3 mos)

Not available 85, 1 or Less pad (3 mos) 90 No pad (1 yr)

26

Not reported

100 (1 mo)

100 No pad (6 mos)

70

21

Not reported

90 No pad (6 mos)

Salomon et Turk et

al72

al5 al7

Hara et

al79

Stolzenburg et al22

Leipzig

92, 1 Pad or less (9 mos) 85 (6 mos) 90.3 (12 mos), 95.8 (18 mos) 82.3 No pad (12 mos)

% Potency in Previously Potent Pts With Nerve Sparing BNS 46 (intercourse without sildenafil) BNS 58.8 (spontaneous erections) Unilat or BNS 59 (with or without sildenafil) BNS 83 (with sildenafil) Not reported BNS 85 (spontaneous erections), 66 (intercourse) Not available Not reported BNS 62 (spontaneous erections) BNS 71 (spontaneous erections), 14 (intercourse) BNS 33 (intercourse with sildenafil)

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LAPAROSCOPIC RADICAL PROSTATECTOMY

prospective comparison of 70 patients with RRP and 230 with LRP there was no significant difference in continence at 1 year but patients undergoing LRP had an earlier return to continence.73 Sexual. Table 4 lists reported rates of recovery of potency in several series worldwide. The measurement of potency after surgery appears to be somewhat convoluted with groups at some centers reporting only the rate of spontaneous erection and others including sildenafil use as satisfactory for potency. Most reported series include potency data only in later cohorts of patients after the technique was mastered. Additionally, potency depends significantly on preoperative sexual function, patient age and the degree of neurovascular bundle preservation achieved during surgery, namely bilateral nerve sparing (BNS), unilateral nerve sparing or no nerve sparing. Followup is another important facet in the analysis of sexual function after prostate surgery since potency can return months or years after surgery. Table 4 shows that potency rates after LRP with BNS are 58% to 83%. NEW INNOVATIONS IN LAPAROSCOPIC PROSTATE SURGERY

As the technique of LRP and robotic prostatectomy has become standardized and widespread, groups at several centers have begun to use these techniques as salvage LRP and to perform sural nerve grafting during LRP. An early experience from France described LRP performed as salvage therapy in 7 patients.74 All had previously undergone radiotherapy (external beam radiation in 5 and brachytherapy in 2), and had increasing PSA with no evidence of clinical metastasis. The operative parameters were similar to those of standard LRP with a mean operative time of 190 minutes and an operative blood loss of 387 ml. The urethral catheter was left longer (an average of 13 days) because of concerns with healing in a previously irradiated field. There were no intraoperative complications or conversions to open surgery. Five of the 7 patients were continent (71%) and postoperative PSA at a mean followup of 11 months was less than 0.1 ng/ml in 5. Turk et al reported on 15 patients undergoing LRP in which 1 or 2 neurovascular bundles were resected for adequate cancer control.75 Building on the experience of sural nerve grafts during open RRP reported by others76, 77 Turk et al performed laparoscopic sural nerve interposition graft in all patients successfully without complications, including 10 bilateral and 5 unilateral procedures.77 Nerve graft added 30 to 60 minutes to total operative time (range 210 to 275 minutes). Final pathological evaluation revealed pT3 disease in 11 of 15 patients (pT3a in 5 and pT3b in 6 or 73%) and surgical margins were negative in 14 (93%). Additionally, Kaouk et al from Cleveland reported the use of the daVinci robotic system for sural nerve grafting during LRP.78 In the initial experience bilateral nerve resection was performed in 2 patients and unilateral resection was done in 1. The robotic system was used for the entire procedure in the first patient, and only for sural nerve graft interposition and urethrovesical anastomosis in the next 2. All procedures were performed successfully, demonstrating the feasibility of this procedure. Because these reports describe the initial experiences, no functional or oncological data are available and long-term followup with a greater number of patients is necessary to determine efficacy. CONCLUSIONS

Since its inception by Schuessler et al in the early 1990s,1 laparoscopic radical prostatectomy has gained tremendous popularity and widespread implementation at specialized centers worldwide. LRP represents a technically demanding laparoscopic procedure but it can be performed systematically with standard techniques. The role of robotics in LRP remains to be defined. The obvious advantages are shorter

convalescence and markedly lower operative blood loss with more rapid removal of the urinary catheter. Long-term functional and oncological results are not yet available but early reports of positive surgical margin rates and PSA recurrence rates after LRP are encouraging. Early quality of life results of postoperative urinary and sexual function appear similar to those in open surgical series. Further studies in prospective patient cohorts with validated quality of life instruments and longer followup should help patients and clinicians decide the role that LRP will occupy in the future. REFERENCES

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