LAPAROSCOPIC RADICAL PROSTATECTOMY: PRELIMINARY RESULTS C. C. ABBOU, L. SALOMON, A. HOZNEK, P. ANTIPHON, A. CICCO, F. SAINT, W. ALAME, J. BELLOT, AND D. K. CHOPIN
ABSTRACT Objectives. To evaluate our preliminary experience with laparoscopic radical prostatectomy. The indications for laparoscopy are currently being extended to complex oncologic procedures. Methods. Forty-three men underwent laparoscopic radical prostatectomy. We used five trocars. The surgical technique replicates the steps of traditional retropubic prostatectomy, except that the rectoprostatic cleavage plane is developed transperitoneally at the beginning of the procedure. In the first 10 patients, we performed the vesicourethral reconstruction with interrupted sutures; in the remaining 33 patients, we performed it with two hemicircumferential running sutures. The specimen was removed through the umbilical port site. Results. Once the developmental phase with the first 10 patients was concluded, the median operating time was 4.3 hours without pelvic lymphadenectomy, and the median postoperative bladder catheterization was 4 days. Two (4.7%) of 43 patients underwent transfusion. Twelve patients (27.9%) had positive surgical margins; all patients had a postoperative prostate-specific antigen level of less than 0.1 ng/mL at 1 month. Rectal injury occurred in 1 patient, requiring colostomy, and 4 patients had urethrovesical anastomotic leakages requiring surgical repair. One month postoperatively, 36 patients (84%) were fully continent (no leakage). Six patients had had erections, and four stated they had had sexual intercourse. Conclusions. Laparoscopic radical prostatectomy has evolved to a fully standardized and reproducible procedure. The short-term oncologic and functional efficacy rates are equivalent to those for open surgery. The operating time is reasonable once the learning curve is over, and postoperative morbidity is diminished. Because of the improved visual accuracy, permitting more precise dissection, this technique has the potential to become an important advancement in urologic surgery. UROLOGY 55: 630–634, 2000. © 2000, Elsevier Science Inc.
he goals in radical prostatectomy are oncologic control, continence, and eventually potency.1 New technologies, including laparoscopic surgery, must maintain these targets and improve quality of life and morbidity.2 The progress of laparoscopy permits us to extend the indications for its use to include complex oncologic and reconstructive surgery. This report covers our entire experience with laparoscopic radical prostatectomy (LRP) and aims to demonstrate its feasibility and reproducibility and the quality of its results. From the Service d’Urologie, Hoˆpital Henri Mondor, Cre´teil, France Reprint requests: Cle´ment-Claude Abbou, M.D., Service d’Urologie, Hoˆpital Henri Mondor, 51 Avenue du Mare´chal de Lattre de Tassigny, Cre´teil 94010, France Submitted: December 28, 1999, accepted (with revisions): January 18, 2000
© 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
MATERIAL AND METHODS PATIENTS From May 1998 to September 1999, 43 men underwent LRP for localized prostate cancer. Preoperative data are summarized in Table I. All patients underwent serum prostate-specific antigen (PSA) testing (Hybritech assay; normal less than 4 ng/mL). Sextant biopsies were performed in each patient to confirm malignancy. Patients with a PSA level less than 10 ng/mL and a Gleason score less than 7 did not undergo pelvic lymph node dissection. In the other patients (PSA 10 ng/mL or greater and/or Gleason score 7 or greater), pelvic lymph node dissection was performed, followed immediately by LRP, according to node status. The surgical specimens were analyzed according to the Stanford protocol.3 The specimen weight, tumor volume, pathologic stage, and surgical margin status were determined by the same pathologist, using the 1997 TNM classification.4 Continence and potency were evaluated with a self-administered questionnaire. Continence was defined as no leakage and potency as spontaneous erection allowing penetration without drug use. Preoperatively, all patients were continent, and 33 patients were potent. 0090-4295/00/$20.00 PII S0090-4295(00)00502-1
TABLE I. Patient characteristics
Age (yr) PSA (ng/mL) Gleason score
64.4 ⫾ 6.1 9.6 ⫾ 6.2 5.9 ⫾ 1.1
65.2 (47–73) 8 (2–30) 6 (4–8)
KEY: PSA ⫽ prostate-specific antigen.
FIGURE 1. Position of the trocars: (A) 12-mm trocar, (B) 5-mm trocar, (C) 12-mm trocar, (D) 5-mm trocar, and (E) 12-mm trocar.
SURGICAL TECHNIQUE The surgical technique has been previously described.5 The patient was placed in the dorsolithotomy position with slightly raised legs, allowing a digital rectal examination to be performed. Five trocars were inserted (Fig. 1). The first 12-mm trocar was placed with an open technique through a minilaparotomy just below the umbilicus. Insufflation was begun, and a 0° lens was placed. The secondary trocars were placed under visual control. The pouch of Douglas was incised horizontally at the posterior aspect of the prostate; the vasa deferentia were identified and dissected toward the prostate. The seminal vesicles were entirely exposed (Fig. 2a). Denonvilliers’ fascia was easily identified under the seminal vesicles and incised to expose the prerectal fatty tissue and to allow the rectoprostatic cleavage to be extended downward until the levator ani muscles were reached. To expose the anterior aspect of the bladder, the parietal peritoneum was opened 6 cm below the umbilicus, and the urachus and the two umbilical arteries were coagulated and divided. The pubic arch and the anterior aspect of the prostate were exposed. The endopelvic fasciae were incised on both sides toward the puboprostatic ligaments. The Santorini plexus was ligated twice with a Vicryl suture with a 26-mm needle (Fig. 2b). We prefer to divide the plexus later, after having opened the bladder neck. The bladder neck was identified with palpation with scissors that distinguish mobile bladder wall from solid prostatic substance (Fig. 2c). This permits one to develop the optimal prostatovesical plane and to open the bladder neck electively. Next, the balloon of the Foley catheter was then deflated and the catheter lifted, exposing the posterior aspect of the bladder neck, which was then opened. This provided access to the posterior dissection plane at the level of the seminal vesicles, which were pulled upward, and the vesical neck was circumferentially divided. The prostatic pedicles were divided near the prostate after systematic bipolar coagulation or clipping. The dorsal vein complex was UROLOGY 55 (5), 2000
sectioned between the two previously performed ligatures, and the apex was exposed and dissected. The urethra and the rectourethralis muscle was divided. A rectally inserted finger allowed better identification of the rectal wall. The prostatorectal dissection was pursued, and the pedicles were divided by clipping or bipolar (instead of monopolar) coagulation to avoid thermal and electrical injury. If preservation of neurovascular bundles was indicated, the division of the pedicles was performed close to the prostatic capsule. After the detachment of the prostate, the gland was put in an endobag until the end of the procedure. The bladder neck was inspected and trimmed, and the ureteral orifices were identified. The urethrovesical anastomosis was performed with interrupted sutures in the first 10 patients (group A) and with two (ie, posterior and anterior) hemicircumferential running sutures (group B, Fig. 2d) in the 33 following patients. For this, we used two needle drivers placed in trocar E and C (Fig. 1). Approximately 4 mm of tissue on each side is optimal. A Foley catheter was inserted into the bladder, and the anastomosis was checked for water tightness. We removed the prostate through the umbilical port site, which was enlarged to between 3 and 5 cm, depending on the size of the prostate. A small suction-drain was inserted and left in place for 48 hours.
RESULTS The patient characteristics of the 43 patients are described in Table I. The clinical stage was as follows: 1 T1a, 29 T1c, 12 T2a, and 1 T2b. Pelvic lymph node dissection was performed in 17 patients. In group A, the median operating time was 7 hours without lymphadenectomy (5 patients) and 8.6 hours with lymphadenectomy (5 patients). In group B, the median operating time was 4.3 hours in 21 patients without lymphadenectomy and 5.1 hours in the 12 patients with lymphadenectomy. The median duration of catheter drainage and the median hospital stay was 14 and 9 days, respectively, in group A and decreased to 4 and 5 days, respectively, in group B. No patient required conversion to open surgery. The pathologic results are given in Table II. The complications consisted of 2 cases of prolonged lymphatic drainage, 1 case of rectal injury sutured laparoscopically and treated by temporary colostomy, and four vesicourethral anastomotic leakages that were managed by open surgery in 3 patients and laparoscopically in 1 patient. One month after LRP, all patients received a selfrating questionnaire on micturition and potency. One month after surgery, 36 patients (84%) were fully continent. Of the remaining 7 patients (16%), 5 patients had only minor and occasional leakage during extreme stress; these patients did not wear any pads. The other 2 patients wore one pad daily for minor stress incontinence. Six patients reported normal, spontaneous erections 1 month postoperatively, and four were able to have sexual intercourse. After a mean follow-up of 6.3 ⫾ 4.8 months (range 1.1 to 16.8), the digital rectal exam631
FIGURE 2. (a) Dissection of the seminal vesicles and vasa deferentia, (b) ligature of the venous complex, (c) incision of the bladder neck, and (d) anterior hemicircumferential running suture.
TABLE II. Pathologic results Average
Weight (g) 58 ⫾ 24.2 52 (20–126) Gleason score 6.3 ⫾ 1 6 (4–10) Tumor volume (cc) 1.6 ⫾ 1.6 1.2 (0.01–7.9) Pathologic findings (n) Intracapsular (pT2) 38 (88) Capsular invasion (pT3a) 3 (6.9) Seminal vesicle, invasion 2 (5.1) (pT3b) Lymph node invasion 1 (2.5) Positive surgical margins 12 (27.7) Apex 8 Bladder neck 2 Apex and bladder neck 3 Numbers in parentheses are percentages, unless otherwise noted.
ination was normal in every patient. The serum PSA level was less than 0.1 ng/mL in all 43 patients. COMMENT The laparoscopic approach was introduced in our practice in 1998. In our first 10 patients, the 632
median operative time was 7 hours without and 8.6 hours with pelvic lymphadenectomy, similar to the experience of Schuessler et al.6 in 1991 and of Raboy et al.7 in 1997. After having standardized our technique, the median operative time decreased to 4.3 hours without and 5.1 hours with pelvic lymphadenectomy. These operative times are similar to a series of 65 patients reported in 1999,8 in which, however, 9% of the patients required conversion to open surgery. In our experience, the improved visibility permitted far more precise dissection than open surgery. Better visualization of the urethral sphincter and neurovascular bundles facilitated sparing of these structures, resulting in greater potential for continence and potency preservation after LRP. This is confirmed by our results regarding morbidity, hospital stay, duration of bladder catheterization, continence, and potency. Once the learning curve was completed, 50% of our patients left the hospital 5 days after surgery, without a bladder catheter. Four patients had sexual intercourse 1 month after the procedure. We experienced four urinomas, which necessitated a new vesicourethral anastomosis with open UROLOGY 55 (5), 2000
surgery in three. These four complications all occurred because of the disruption of the suture line. As the magnified view tends to make the suture superficial, care should be taken to include sufficient tissue in the suture lines. Furthermore, after transurethral resection of the prostate, the distance between the bladder neck and the ureteral orifices must be evaluated by flexible cystoscopy before LRP. The short-term oncologic results were similar to those of conventional procedures. We found positive surgical margins in 12 patients (27.9%). In a review of published reports, Wieder and Soloway9 reported that the overall rate of a positive surgical margin with radical prostatectomy is 28%. The risk of metastatic seeding after oncologic laparoscopic procedures is controversial. Oefelein et al.10 found positive cells in the operative field blood of 20 (91%) of 22 men undergoing open radical retropubic prostatectomy. However, the implications of these findings are unclear; therefore, we do not believe that LRP increases the risk of surgical field contamination. CONCLUSIONS LRP is now feasible by a urologist well trained in laparoscopy. The technique has been standardized and offers all the advantages of laparoscopic surgery in terms of postoperative quality of life. Shortterm cancer control was comparable to open surgery in the present preliminary series. Full continence appeared earlier. Even if preservation of potency cannot be fully evaluated based on these short-term data, we believe that the quality of surgery opens free scope for improvement of the results. REFERENCES 1. Walsh PC: The status of radical prostatectomy in the United States in 1993: where do we go from here? J Urol 152: 1816, 1994. 2. Gasman D, Saint F, Barthelemy Y, et al: A laparoscopic approach for adrenal and renal surgery. Urology 47: 801– 806, 1996. 3. Stamey TA, McNeal JE, Freiha FS, et al: Morphometric and clinical studies in 68 consecutive radical prostatectomies. J Urol 139: 1235–1241, 1988. 4. Sobin LH, and Witterkind C (Eds): TNM Classification of Malignant Tumors. New York, Wiley, 1997, pp 108 –180. 5. Abbou CC, Hoznek A, Salomon L, et al: Laparoscopic radical prostatectomy. Surg Tech Urol 12: 2–7, 1999. 6. Schuessler WW, Schulam PG, Clayman RV, et al: Laparoscopic radical prostatectomy: initial short-term experience. Urology 50: 854 – 857, 1997. 7. Raboy A, Ferzli G, and Albert P: Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 50: 849 – 853, 1997. 8. Guillonneau B, and Vallancien G: Laparoscopic radical prostatectomy: initial experience and preliminary assessment after 65 operations. Prostate 39: 71–75, 1999. UROLOGY 55 (5), 2000
9. Wieder JA, and Soloway MS: Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer. J Urol 160: 299 –315, 1998. 10. Oefelein MG, Kaul K, Herz B, et al: Molecular detection of prostate epithelial cells from the surgical field and peripheral circulation during radical prostatectomy. J Urol 155: 238 –242, 1996.
EDITORIAL COMMENT The authors are to be congratulated for their display of laparoscopic skills and their efforts at broadening the indications for minimally invasive surgery in urologic oncology. They have reported on 43 cases of LRP. The procedure time averaged 4.3 hours. The results included a 27.9% positive surgical margin rate, 84% of the patients were fully continent, and 14% of the patients reported spontaneous erections. These data are comparable to those recently reported by Guillonneau and Vallancien.1 In evaluating a new surgical procedure, both the feasibility and efficacy must be proved. Once this has been accomplished, the procedure must be compared to a standard to determine potential technical advantages and benefits to the patient. In 1997, Schuessler et al.2 summarized their initial experience with LRP. They found LRP to be feasible but that it offered no advantage over open surgery and was technically challenging and associated with long operative times, averaging 9.4 hours. The current revitalization of LRP is encouraging and demands a serious and honest evaluation. In the initial series of Schuessler et al., the greatest impediment was the reconstruction of the urethrovesical anastomosis and was the primary cause for excessive operative times. The methods outlined by Abbou and colleagues and Guillonneau and Vallancien,1 along with the advancements in laparoscopic suturing have improved urethrovesical reconstruction and significantly shortened the operative time. Is LRP a reasonable treatment option? The goals for surgery of prostate cancer are removal of the cancer, maintenance of continence, and preservation of potency. LRP appears to offer an acceptable cancer operation. Abbou and colleagues reported a 27.9% positive margin rate in this series of 43 patients. Guillonneau and Vallancien1 reported a 15% positive margin rate in a series of 120 patients. In a review of the incidence of positive surgical margins after open radical retropubic prostatectomy Wieder and Soloway3 found an incidence ranging from 5% to 23% for Stage T1a-T2a prostate cancer. Undoubtedly, as experience is gained, the positive margin rate will approach that of open surgery. Reported continence appears to be equivalent. Potency has yet to be formally addressed based on the operative techniques described, since there was minimal information regarding the identification and dissection of the neurovascular bundles. Interestingly, all investigators have reported patients who have preservation of potency after LRP. Therefore, as the technique evolves, dissection of the neurovascular bundles and maintanence of potency should occur. This report is encouraging and has overcome obstacles identified early in the experience with LRP. In 1997, LRP was feasible, and in 2000 it appears efficacious. Now LRP must be compared with the standard, open radical retropubic prostatectomy, evaluating both potential technical advantages and the relative morbidity. Open radical retropubic prostatectomy is routinely performed for localized prostate cancer, with excellent results and minimal morbidity. Therefore the bar set by open radical retropubic prostatectomy is no trivial challenge for LRP. 633