Open versus Laparoscopic Radical Prostatectomy

Open versus Laparoscopic Radical Prostatectomy

european urology supplements 5 (2006) 377–384 available at journal homepage: Open versus Laparoscopic ...

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european urology supplements 5 (2006) 377–384

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Open versus Laparoscopic Radical Prostatectomy G. Janetschek a, F. Montorsi b,* a b

Department of Urology, Elisabethinen Hospital, Linz, Austria Department of Urology, Universita’ Vita Salute San Raffaele, Milan, Italy

Article info


Keywords: Laparoscopy Open surgery Prostate cancer Prostatectomy

Radical prostatectomy (RP) is a curative treatment for localized prostate cancer that involves removing the prostate and seminal vesicles. The primary goals of RP include ensuring oncologic control and maintaining the preoperative status of continence and potency. This report focuses on the outcomes and the keys to success for both open retropubic and laparoscopic RP. Both surgical volume and the surgeon are directly related to postoperative erectile function in men. The preoperative status of the patients is also of importance because it significantly affects postoperative functional outcomes. Surgical steps, which are keys to success following the open procedure, include incision of the endopelvic fascia, control of the Santorini plexus, and nervesparing procedures. Similarly, the key surgical steps of laparoscopic prostatectomy are described and a comparison between the transperitoneal and extraperitoneal route is made. Oncologic and functional outcomes observed following the two procedures are discussed. This report then briefly introduces the robotic surgical system and summarizes the related panel discussion. In conclusion, the difference between one surgeon’s performance and that of another seems to count for more than any difference between procedures. Whilst postoperative functional outcomes are hard to evaluate, they seem to be comparable following the two different approaches. # 2006 Published by Elsevier B.V. DOI of original article: 10.1016/j.eururo.2005.12.007 * Corresponding author. University Vita Salute San Raffaele, Department of Urology, Via Olgettina 60, 20132 Milan, Italy. Tel. +39 02 26437286; Fax: +39 02 26437298. E-mail address: [email protected] (F. Montorsi).



The first radical prostatectomy (RP) for cancer was performed by Billroth in 1869 [1] using the perineal approach and was followed by the retropubic approach introduced by Millin in 1945 [2]. Nearly four decades later, in 1982, Walsh and Donker [3] described the course of the

neurovascular bundles (NVBs) reaching the corpora cavernosa. This anatomic discovery led to the description of the so-called nerve-sparing procedure while completely excising the prostate [4]. This surgical technique allowed for the prevention of the functional consequences of RP, as such ensuring continence and potency in addition to good oncologic control.

1569-9056/$ – see front matter # 2006 Published by Elsevier B.V. doi:10.1016/j.eursup.2006.01.003


european urology supplements 5 (2006) 377–384

Laparoscopic prostatectomy has been progressively gaining popularity in the urologic literature, both with the extraperitoneal [5] and transperitoneal [6] approaches. To date, these procedures have not shown any advantage over conventional surgery in terms of oncologic control and postoperative functional results. However, due to the less invasive nature of laparoscopy it was assumed that better postoperative recovery and reduced morbidity would have been demonstrated [6].


Selecting the proper surgeon

It has been generally assumed that surgeons will appreciate and assimilate the principles of their mentors during the course of their training. Not only is it important for trainee surgeons to learn surgical procedures on site in highly specialized centers, but they also need to be willing to invest time and energy in a personal regime of continuous learning and improving techniques. A recent study [7] has suggested that both surgical volume, defined as the cumulative number of RPs performed by the surgeon, and the surgeon as a particular individual, are the two most important predicting factors directly related to postoperative erectile function (EF) recovery in men undergoing RP [7]. Even among those surgeons performing many RPs, the study noted significant variation in EF recovery, which might be ascribed to the complexity of the procedure. It is recognized that the successful outcome of a surgical procedure is not necessarily related to the numbers of these procedures that have been performed by a surgeon in the past.


Selecting the proper patient

When evaluating functional outcomes after RP, proper evaluation of the preoperative status of the patient is important. It is evident that only patients who are fully potent preoperatively can expect to achieve full restoration of spontaneous erection capacity following surgery. Consequently, patients who are older than 65 yr, those who have been taking phosphodiesterase-5 inhibitor medication prior to surgery, and patients with vascular comorbidities are at greater risk of developing postoperative erectile dysfunction (ED) following RP [8]. However, one should realize that the physician–patient interview is not always sufficient to objectively assess the preoperative potency status of patients. A recent study on 300 consecutive patients reporting full potency during the patient–

physician interview highlighted the fact that when the same patients were administered the International Index of Erectile Function (IIEF) questionnaire, 66% of them had some degree of ED [9].


Surgical procedures


Radical prostatectomy

It is generally accepted that open retropubic RP (RRP) is considered as the gold standard. However, it is important to realize that with the increasing understanding of the anatomy of the prostate, surgeons have been applying new approaches to the incision of the endopelvic fascia, control of the Santorini plexus (SP) and nerve-sparing procedures. A study by Costello et al. [10] has reported that although the major trunk of the NVBs runs posterolateral to the prostate, there are branches that course high lateral to the prostate. In addition, nerve fibers pierce the levator ani musculature and subsequently reach the corpora cavernosa. Given this, it appears to be very important for surgeons to use ligation sutures or clips to control the small vessels piercing the levator ani musculature while avoiding the use of cautery at all times. The SP surrounds the upper half of the striated urethral sphincter. Montorsi et al. [11] showed better control of the plexus by placing a superficial ligation suture (Fig. 1; 3-0 Monocryl on a SH needle). This suture is not aimed at ligating all branches of the SP but allows for the superficial veins to be pulled together to facilitate their subsequent division. The SP is divided and bleeding is controlled with a running suture on the distal and proximal trunk of the plexus (Fig. 2). The nerve-sparing procedure, developed by Walsh [4], has markedly improved potency rates, with studies reporting the recovery of EF in 16–76% of men with bilateral preservation of the NVBs, and 0–56% in those with unilateral NVB preservation. Although the exact anatomy of the pelvic plexus and the cavernosal nerves is still a matter of debate, recent studies have sought a better understanding of the distribution of the prostatic nerves. Detailed dissection of 12 fixed male cadavers revealed pronounced levator ani and anterior rectal components (Fig. 3) in the NVBs [10]. The neurovascular supply to the rectum was found to be generally localized in the posterior and posterolateral sections of the NVB, running within the leaves of Denonvilliers’ and pararectal fasciae. The levator ani neurovascular supply was in the lateral section of the NVB, descending along and within the lateral pelvic

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Fig. 3 – Anterior wall of the rectum is reflected inferiorly. The large rectal veins can be seen exiting the neurovascular bundles just proximal to the level of the prostatic apex, coursing posteriorly to drain the rectum. A capsular vessel and nerve of the prostate can be seen descending along the posterior aspect of the prostate in the midline.

Fig. 1 – Running suture to pull together the superficial vein branches of the Santorini plexus.

fascia. The cavernosal nerves and the prostatic neurovascular supply descend along the posterolateral surface of the prostate, with the prostatic neurovascular supply most anterior.

Fig. 2 – Division of the Santorini plexus.

One conclusion is that the NVB is more complicated than previously thought [10]. Powell et al. [12] specifically studied the neuroanatomy of the prostate using whole-mount preparations and found the highest innervation in the NVB and seminal vesicles (SVs), followed, respectively, by the peripheral and transition zone. Furthermore, it was observed that the posterior capsule was significantly more innervated compared to the anterior capsule ( p < 0.0001) [12]. This complex network of the pelvic plexus was seriously altered after benign prostatic hyperplasia, characterized by increased lateral and anterior nerve displacement [13]. Powell et al. [12] also noted that the caudal aspects of the pelvic plexus encased the SVs and that the cavernosal nerves were completely dispersed along the lateral aspect of the enlarged prostate, making it extremely difficult to dissect (Fig. 4). Recent studies suggest that motor and sensory components of the pelvic nerve may be affected by surgery, because both components are anatomically located in intimate contact with the SVs. SV-sparing RP (Fig. 5) is aimed at preserving the pelvic plexus and it has been proposed to improve postoperative continence and EF [14]. Koh et al. [15] and Zlotta et al. [16] defined the patient subpopulation who could be safely spared from SV excision during RP. According to these authors, resection of the SV might not be necessary for all patients undergoing RP, especially when prostate specific antigen levels are <10 ng/ml, biopsy Gleason score


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Fig. 4 – Cage-like embedding of the seminal vesicles (SVs) by the pelvic plexus. The caudal aspects of the pelvic plexus (red asterisks) encase the seminal vesicles. After benign prostatic hyperplasia has developed, the cavernosal nerves (green asterisks) are completely dispersed along the lateral aspect of the enlarged prostate (P). B = urinary bladder; U = right ureter.

<7, or when fewer than 50% of the prostatic biopsies show cancer involvement. It is important to leave a dry field at the end of the procedure because hematoma will result in fibrosis and delayed recovery of potency. To date a postoperative optimal outcome (potency, continence, and recurrence free) after radical prostatectomy can only be achieved in up to 53% after 48 mo [17].

Laparoscopic radical prostatectomy

Following the publication of laparoscopic RP (LRP) procedures, a number of teams have proven the feasibility of the transperitoneal and the extraperitoneal approaches for RP [18–21]. LRP is routinely performed with a descending technique, whereas open RP is usually performed with a retrograde technique. The main differences between the transperitoneal descending and extraperitoneal descending procedures are characterized by the mobilization of the SV and vas deferens, which are approached through the pouch of Douglas or bladder neck, respectively. However, surgeons now also approach the SV through the bladder neck when using the transperitoneal approach, resulting in a much faster and straightforward surgical procedure. Urologists have reported that at the level of the prostate, they have observed no significant differences in technique or outcome between the transperitoneal and extraperitoneal approaches [22]. Further, they observed no significant differences in terms of blood loss (360 ml vs. 375 ml, respectively), transfusion rate (4% vs. 3%, respectively), and major and minor complication rates (10% vs. 9%, respectively). The only significant difference was the operative time (transperitoneal, 173 min; extraperitoneal: 163 min; p = 0.003). However, when performing an extended pelvic lymph node dissection, the transperitoneal approach offers some advantages over the extraperitoneal approach, including better exposure and lower risk of lymphocele.

Fig. 5 – Seminal vesicle-sparing prostatectomy (B) versus non–seminal vesicle-sparing prostatectomy (A).

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The learning curve for radical prostatectomy

Although the RRP approach is considered to be the gold standard, it is often forgotten that this surgical approach is characterized by a very steep learning curve. A self-administered survey on localized ED and urinary dysfunction (UD) was completed in a population of 2415 men with prostate cancer treated with prostatectomy in the Province of Quebec between 1988 and 1996 [23]. The time between treatment and survey completion ranged from 17 mo to 8.5 yr. Twenty-five percent of the 2227 men without ED prior to surgery who underwent this RP reported erections of adequate firmness for intercourse following the procedure. The overall ED rate was 75%, but increased with age: 55% in men aged <60 yr to 85% in men 75 yr or older. The ED rate was significantly related to UD severity: 6.6% of the patients studied reported severe UD, quantified as urinary leakage exceeding 1 tablespoon. In line with the ED rate, UD was agedependent, ranging from 4% in men aged <60 yr to 10% in men 75 yr or older. Strictures were reported by 16.3% and were associated with a 2-fold increase in severe UD rate ( p < 0.001) [23]. These results are confirmed by other studies, although it should be mentioned that the literature provided divergent potency rates. In a study between 1990 and 1994 [24], 79% of the 398 men enrolled in the study reported unsatisfactory erection capacity, with 13.3% experiencing postoperative potency after unilateral nerve-sparing RP, and 31.9% experiencing postoperative potency after bilateral nervesparing RP [25]. These figures are in sharp contrast to the very good potency rates (86%) reported by Walsh et al. The reason for these divergent results may be explained by the lack of an objective method for measuring potency. However, the introduction of the IIEF provided investigators and patients with an easy-to-use questionnaire, although caution is needed when interpreting these results. Although the questionnaire is completed following a surgical procedure, it is very important to have access to the preoperative data for comparison to minimize patient bias. It is a well-known phenomenon that the responses recorded from patient-completed questionnaires differ significantly from those noted by the physicians concerned. In a study conducted between 1993 and 2002 in 19 hospitals in Austria over a follow-up period of 3.3 yr, the questionnaire reported an 80% postoperative ED rate (unpublished data). To evaluate levels of morbidity in correlation with the learning curve, the results from 1537


patients with regionally confined prostate cancer who underwent RP, the operations being performed by any one of 13 different surgeons (mean number of operations = 101.3) were examined. Following operation, 9.8% of patients reported late complications (usually anastomotic stricture [7.8%]). In terms of continence, 86.3% of patients found they were very dry and did not need any pads, whereas 4.7% presented with marked stress urinary incontinence. An assessment by a surgeon yielded only a slight influence on the rates of incontinence and stricture, but provided a great learning curve in terms of blood loss (from 1200 to 400 ml) and operation time (from 240 min to 125 min) [26]. Although the patient population for LRP was much smaller (n = 120), Guillonneau et al. [18] reported only 2.5% of patients experiencing major complications (rectal injury, anastomotic leak). 4.4.

Oncologic outcomes

To evaluate the oncologic outcomes, researchers looked at different parameters (positive margin rate, progression-free survival, and disease-specific survival). They observed no differences in positive margins when comparing open RP with LRP; both procedures may be considered equally effective [27]. Any definitive cure for prostate cancer needs long-term follow-up; thus at this point (in the shortterm) any data, especially concerning LRP, is immature. An evaluation of 1000 cases treated with LRP after a follow-up period of 3 yr revealed that the biochemical progression-free survival rate was 90.5% at 3 yr. According to the pathologic stage, the progression-free survival rate was 91.8% for pT2a, 88% for pT2b, 77% for pT3a, 44% for pT3b, and 50% for pT1-3. Of the patients, 94% with negative surgical margins and 80% with positive margins had progression-free survival ( p < 0.001) [28]. 4.5.

Functional outcomes

To evaluate the functional outcomes of various RP procedures, prospective studies at three different centers were performed, with one center having RRP expertise, one center having perineal RP (PRP) expertise, and one center having LRP expertise. Each center enrolled 50 consecutive patients, and the most experienced surgeon in each center performed the surgical procedure. Evaluation of the functional outcomes (continence and potency) took place preoperatively, 1 d after the removal of the catheter, and 1, 3, 6, 12, and 24 mo after the procedure using standardized questionnaires (the UCLA Prostate Cancer Index and IIEF-5). Because there appeared


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recommend intensive therapy, such as phosphodiesterase-5 inhibitors, to prevent fibrosis. The results indicate that following bilateral nerve-sparing RP, both RRP and laparoscopic procedures have comparable outcomes (Fig. 7). 4.6.

Fig. 6 – Urinary control after radical prostatectomy: comparison between the open and laparoscopic approach.

to be significant discrepancies between the learning curves of the three different surgeons (the open RP surgeons had performed >1000 surgeries compared to the 90–140 cases of the LRP surgeon), the study managers added a second group of laparoscopically treated patients (n = 260–310) to the analysis to overcome surgeon bias. With respect to urinary control, both RRP and PRP produced very good results (Fig. 6). Recovery was faster following RRP than it was following PRP. However, following PRP, patients reached preoperative scores after 3 mo and improved even further. Both laparoscopic groups scored less well than RRP, but this phenomenon could be ascribed to positioning on the learning curve (Fig. 6). The managers of the study said that the long-term results (after 2 yr) were comparable with the RRP results. With respect to potency, the preservation of EF is closely associated with careful surgery and the prevention of fibrosis. Given this, practitioners

Robotic surgical systems

The US Food and Drug Administration approved the first laparoscopic surgical robot system in 2000. One year later, Abbou et al. [29] reported the use of robotic-assisted laparoscopic surgery in urology. Since then, the number of centers using roboticassisted laparoscopy has increased exponentially across Europe. The introduction of the robot has added to the surgeon’s comfort and has allowed procedures to more closely emulate open surgery, offering great precision and control of hand movements, and providing excellent three-dimensional views when incising tissue and placing sutures. Ahlering et al. [30] compared the results of his previous 60 RRPs with 60 robot-assisted LRPs, after he passed the learning curve point of 45 cases. Overall, both groups had (apart from less blood loss and shorter hospital stays following robotic laparoscopic surgery) similar clinical outcomes, including operative times, pathologic stage of the tumours, positive margin rates, blood transfusion rates, and postoperative complication rates (Table 1). Probably the biggest advantage of robot-assisted laparoscopic surgery is the reduction in length of the laparoscopic learning curve, for both experienced open and young surgeons. In addition, this procedure may be very useful for studying the anatomy of, and imaging, the prostate during the procedure.

Table 1 – Robotic assisted LRP vs. RRP in 120 patients operated on at the University of California, Irvine [30] RRP (n = 60) Body mass index Operating time, h Positive margins, % Blood loss, ml Transfusion rate, % Hospital stay, d Catheterization time, days Complications Continence at 3 mo

Fig. 7 – Comparable outcomes for retropubic and laparoscopic radical prostatectomy with respect to potency rates.

27 3.6 12 418 1 2.2 9 10% 75%

Robotic-assisted LRP (n = 60) 26 3.9 10 103* 0 1.1* 7 6.7% 76%

RRP = retropubic radical prostatectomy; LRP = laparoscopic radical prostatectomy. * p < 0.05.

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Interactive voting and panel discussion

The majority of surgeons who attended the meeting mainly performed open retropubic (74%) prostatectomies; 43% of the participants were thinking of converting from open to laparoscopic surgery. Although discussions during the meeting revealed that participants thought there was no difference in quality of outcome between the procedures used, the reason why the proportion of those thinking of converting to laparoscopic surgery was so high because surgeons were experiencing increasing pressure more frequently to undertake less invasive surgery. This pressure had mainly come from patients who through the media had become aware of the current medical possibilities and who were interested in fast recovery and return to their preoperative status. Only 5% of the attendants had performed mainly PRP, but it was agreed during discussion that, depending on the preoperative status of the patient, this approach also might be a good solution. If a patient was impotent preoperatively, the perineal approach was very well suited for RP and even provided a good chance of preserving continence. It is difficult to speculate on the number of surgeries required for any one surgeon to progress along the learning curve. This figure will depend partly on the capacity of the individual surgeon, partly on the complexity of the particular method, and partly on the learning capacity of the institution concerned. In terms of the learning or teaching mechanism, a specialist center of expertise will move surgeons along the learning curve faster than will a center that is itself working on its expertise. The same phenomenon is true for the method, in that it takes some time for a surgeon to become familiar with the procedure, irrespective of his capacities. The process for a practitioner converting from open RP to LRP is different, even for surgeons who are skilled in open RP. Robot-assisted laparoscopy increases the rate of learning and thus movement along the learning curve, but provides little gain in cost effectiveness. This is because the robot is very expensive. However, the two procedures do not differ significantly in terms of quality of functional and oncologic outcome. The robot is equipped with a three-dimensional endoscope that facilitates the understanding of the anatomy of the prostate. Three-dimensional visualization enables practitioners continuously to monitor the constantly changing anatomic knowledge of the prostate.




Although each surgical procedure has its own advantages and disadvantages, it seems that the difference between surgeons is greater and more important than the difference between the procedures. This means that it is virtually impossible to make comparisons between different procedures as such. Several reports in the literature indicate that both the oncologic and functional outcomes are comparable, independent of what procedure is used, once the surgeon has moved along the learning curve. It is to be expected that technological improvements are likely to lead the further development of a new generation of robots and instruments.

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