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Official Journal of the
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ISSN: 1983-991X
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| Original Article « PDF file » |
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Laparoscopic Radical Prostatectomy 10 years' experience
1 Mirandolino B. Mariano; 2 Marcos Vinícius Tefilli; 3 Gilvan Neiva Fonseca;4 Isidoro Henrique Goldraich
1 Member of the Brazilian Society of Urology. President of the Brazilian Society of Laparoscopic Surgery. President of the Latin American Association of Minimally Invasive Surgery; 2 M.D., Division of Urology of Hospital Mãe de Deus, Porto Alegre, RS. Fellow in Urological Oncology, Wayne State University, MI, USA; 3 M.D., Head of Urology of Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Goiás; 4 M.D., Hospital Moinhos de Vento.
ABSTRACT
Purpose: The authors assess the morbidity, functional results and oncologic follow-up of their personal series
of laparoscopic radical prostatectomies performed in a 10-year period.
Material and Methods: The data on 780
laparoscopic radical prostatectomies performed between September 1997 and December 2007 were stored in a personal
database. The following parameters are described and analyzed critically: operative time, blood transfusions, conversions,
length of hospital stay, complications, functional results of sexual potency and urinary continence, surgical margins and
oncologic follow-up. Results: Operative time averaged 125 minutes, with a mean bleeding volume of 335 ml and mean
hospital stay of 4.3 days. The rates of conversion to open surgery amounted to 1.36% and the overall complication rate
was 14.24%. The pathology analysis showed pT2 tumors in 82.60% and pT3 tumors in 17.39% of cases. The overall
margin positivity rate was 19.58%, with biochemical recurrence of 10.27% with a mean follow-up of 62.5 months.
Urinary continence and sexual potency yielded rates of 88% and 61%, respectively, 12 months after surgery.
Conclusions: Laparoscopic radical prostatectomy is a technically well-defined procedure that provides ideal oncologic and
functional results after proper training. Nowadays, it is our treatment of choice for patients with prostate cancer.
Key words: Prostate cancer. Radical prostatectomy. Laparoscopic surgery.
Bras. J. Video-Sur, 2009, v. 2, n. 4: 020-026
| Accepted after revision: April, 7, 2009. |
INTRODUCTION
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ven though no consensus exists on the best therapeutic approach to prostate cancer, radical prostatectomy is regarded as the treatment of choice by most urologists. Radical retropubic prostatectomy has been the gold standard treatment worldwide, allowing high rates of cancer control with low rates of incontinence and sexual dysfunction. Laparoscopy has been used as an alternative, combining the principles of anatomic radical prostatectomy with the advantages of minimally invasive surgery (1-6). In this report, the authors describe technical aspects and complications, as well as oncologic and functional results of laparoscopic radical prostatectomy (LRP) within a 10-year period.
MATERIAL AND METHODS
A total of 780 patients with clinically
localized prostate cancer were submitted to LRP by one of
the authors, between September 1997 and December 2007. The patients were recruited from the
authors' private practices or were referred to surgery by
other physicians. The data were stored and updated according to outpatient follow-up, and 50 patients
were excluded from the analysis due to loss to
follow-up and/or inappropriate records.
Postoperative assessments included clinical examination and the prostate-specific antigen
(PSA) test, which was requested every three months in
the first two years, every six months from the third to
the fifth years, and every year thereafter.
Radiological examination was requested, if clinically
indicated. Biochemical recurrence was defined as two
PSA measurements above 0.2 ng/mL.
Pathology data were obtained from pathology reports, and if necessary, the slides were
reviewed. The TNM 1997 was used for staging and the
Gleason score was employed for cell differentiation (7).
A positive surgical margin after radical
prostatectomy was defined as spread of the tumor to the
inked margin of the surgical specimen on
microscopic examination.
Data on sexual potency and urinary continence were obtained from outpatient
records. Urinary incontinence was regarded as the use of
any protection against urinary leakage, and
erectile dysfunction was defined as spontaneous
and permanent inability to achieve enough erection
for vaginal penetration.
1. Surgical technique
The patient is placed in dorsal recumbency, with his arms at the sides and his legs partially
spread apart and comfortably placed in the modified
lithotomy position. Safety devices are fastened to the table
at the level of the patient's shoulder. A two-way 20
Fr Foley catheter is inserted and fixated.
1.1 Transperitoneal access
The first trocar 11/12 mm is inserted at the level of the umbilical scar using the open
technique. The pneumoperitoneum is established and a
0-degree lens is used for inspection of the cavity and
placement of other trocars under direct visualization.
The additional trocars are placed in an inverted W configuration, with the vertex at the umbilical
level towards the lens.
Another two trocars measuring 11/12 mm are placed adjacent to and below the camera for
the working clamp and ultrasonic scalpel,
respectively. Another two trocars, measuring 6 mm, are
inserted laterally close to the anterior superior iliac spines
for aspiration and ancillary clamping. The surgical
steps are described in table 1.
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1.2 Preperitoneal access
The open access is obtained with a small 3-cm incision below the umbilical scar. The
anterior aponeurosis of the abdominal rectus muscle is
incised and dissected at midline, thus exposing the
posterior aponeurosis. The midline raphe is sectioned. The
virtual prepubic space can be created with a
digital maneuver or using specific balloons.
The first 11/12-mm trocar is inserted and the aponeurosis around it is sutured to avoid gas
leakage, thus establishing the working space. Then the
10-mm and 0-degree lens, used for inspection and placement of other trocars under direct
visualization, is inserted. Additional trocars are placed in
an inverted W configuration, similarly to the transperitoneal approach. The surgical steps
are described in table 2.
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RESULTS
A total of 730 patients with mean age of 64.6 years (42 to 76) and clinically localized disease
were selected for this review.
The transperitoneal approach, as described above, was used in 559 cases and the
preperitoneal approach was used in 171 cases.
Pelvic lymphadenectomy was indicated for patients
with Gleason score greater than 7 and/or PSA greater
than 10 ng/dl, being required in 76 cases (10.41%).
Operative time averaged 125 minutes (90 to 240), with a mean hospital stay of 4.3 days (1.5
to 20). When pelvic lymphadenectomy was
performed, operative time increased by 40 minutes.
The mean bleeding volume in the intraoperative period was 335 ml (50-1,150 ml),
with transfusion rates of 5.34% (39 cases). None of
these patients required reoperation.
The rates of conversion to the open technique amounted to 1.36% (10 cases), with an
overall complication rate of 14.24% (104 cases). The
data are summarized in table 3.
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The pathological assessment revealed pT2a tumors in 19.45% of cases (142 patients), pT2b
tumors in 63.15% of cases (461 patients), pT3a/b tumors
in 14.38% of cases (105 patients) and pT3c tumors
in 3.10% of cases (22 patients). The Gleason score
was distributed as follows: 2 to 4 in 3.97% (29 cases), 5
to 6 in 44.93% (328 cases), 7 in 46.02% (336 cases) 8
to 10 in 5.06% (37 cases). The mean overall margin positivity rate was 19.58% (143 cases): 7.69%
for pT2a (11 cases), 19.08% for pT2b (88 cases),
34.28% for pT3a/b (36 cases) and 36.36% for pT3c (8
cases). The positive surgical margins were located
as follows: in the apical region 49.65% (71 patients),
at the bladder neck 20.27% (29 patients) and in
the posterolateral region 30.06% (43 patients). Table
4 summarizes the data on surgical margins.
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In this series with a minimum follow-up of 5 months and maximum follow-up of 120 months
(mean of 62.5 months), the overall rate of
biochemical recurrence was 10.3% (75 patients).
Urinary continence had a rate of 87.94% (642 patients) 12 months after surgery, and sexual
potency yielded a rate of 60.95% (445 patients) in the
same period.
DISCUSSION
The mean intraoperative bleeding volume in the present series amounted to 300 ml with
transfusion rates up to 5%. The major bleeding in
radical prostatectomy, both in the open and
laparoscopic techniques, occurs while controlling the dorsal
venous complex and while ligating the lateral prostatic
pedicles. Laparoscopy offers increased magnification,
excellent illumination and tamponading effect of CO2,
which facilitates hemostasis and visualization. Safe
ligation of the dorsal vein complex is performed under
good anterior and lateral visualization of the venous
plexus and of its lower limit, close to the urethra. We
removed all of the preprostatic fat and approached
the endopelvic fascia with clear exposure of
puboprostatic ligaments and their lateral limits.
Puboprostatic ligaments were not sectioned and, additionally, we
used a metallic urethral sound for precise identification
of the urethra and its posterior mobilization, thus
allowing for the safe passage of two figure of eight 2-0
vycril sutures. The ligation of arterial lateral prostatic
pedicles can be safely obtained with the harmonic
scalpel, bipolar cautery, using clips or intracorporeal suture
at the surgeon's discretion, seeking not to use any
form of energy close to them (1-6,8,9-12).
Different types of complications have been reported in up to 35% of the cases, but most of
them have negligible clinical consequences (1-18).
Mortality has been around 0.5 to 1%, and has been related
to heart diseases or cases of pulmonary embolism.
All publications on LRP show a tendency towards
the reduction of postoperative complication rates,
from 25% to approximately 5% after the learning
curve has been achieved, and this was also observed in
the present series (3,5,6,10,12-17).
Rectal injuries are potential complications of radical prostatectomy, with rates between 0 and
9% being described in LRP series (15,18).
These injuries often occur at the end of the excision of the
prostate gland, or during the dissection of the lateral
pedicles or during the section of the rectourethralis
muscle adjacent to the prostatic apex. When these
injuries are observed in the intraoperative period, they
must be corrected through laparoscopy with primary
suture, and the suture must be "strengthened" with
omentum or preperitoneal fat. Most cases have a
favorable outcome with the primary suture and occasionally
with protective colostomy, if necessary, depending on
the extent of the injury and level of local
contamination. When these injuries are not identified in
the intraoperative period or when the primary suture
fails, a rectourethral fistula develops, a complication
that occurs in 15 to 25% of the times that a rectal injury
is sutured laparoscopically. The conservative management with derivative colostomy for up to
three months has been the initial approach in these
cases, provided that no sepsis is associated.
However, spontaneous closure is extremely rare and
most patients require surgical treatment. Abdominal
(either open or laparoscopic), perineal or
posterior transsphincteric approaches have been used to
correct these rectourethral fistulas, although no
agreement exists on the best therapeutic approach that should
be used. The closure of rectourinary fistulas in our
setting have been performed laparoscopically by the
abdominal approach, even though we recognize that
the sagittal transsphincteric approach is a good
alternative. In our patient population, we had four rectal
injuries, two of which were identified and sutured in
the intraoperative period, resolving uneventfully. One
of the injuries was detected when the catheter was removed, and it was treated with derivative
colostomy and corrected laparoscopically three
months afterwards. The other injury consisted of low
output fistula, which closed spontaneously with an
indwelling catheter.
Ureteral injuries yield rates of 0.5% in LRP, and predominantly occur in three situations: 1)
when we mistake the vas deferens for the ureter, 2) when
a previous transurethral resection was made, which prevents the proper visualization of ureteral
meatuses at the bladder neck; 3) when the ureter is
enveloped by urethrovesical anastomosis (2,5,10,12,15).
Treatment usually consists of laparoscopic
ureteral reimplantation. In our patient population, we had
three cases of ureteral injuries, one during the
intraoperative period, corrected with laparoscopic reimplantation,
and two cases in which the ureter was enveloped by
the anastomosis, whose correction consisted of
ureteral reimplantation in a reoperation.
Urethrovesical anastomosis is the most technically challenging step of the procedure.
Although laparoscopy provides ideal illumination and
increased magnification for the sutures, their accurate
placement depends on expertise in intracorporeal suturing,
which needs to be standardized. Separate stitches
or continuous suture can be used, but we have
preferred the latter, since it reduces the number of
knots, presumably facilitating the procedure. With regard
to complications related to laparoscopic
urethrovesical anastomosis, anastomotic leak has occurred in
around 10% of the cases, but it usually resolves
spontaneously with bladder drainage and maintenance of
the suprapubic drain. In our patient population, all
cases resolved spontaneously with bladder drainage
and maintenance of the drain. One case needed
drainage for up to three weeks, with maintenance of the
bladder catheter and of the suprapubic drain throughout
the period.
Conversion has averaged 2.4% (0 to 14%), and is predominantly required due to technical
reasons, such as bleeding, adhesions or excessive
operative time, without severe complications (15). According
to our experience, after the conversion of the first
10 cases, there were no other conversions to open surgery.
Urinary continence rates after open radical prostatectomy have ranged from 31% to 92%.
In most laparoscopic series, the rates of urinary
control at 3, 6 and 12 months have been around 58%,
68% and 82 to 91%, respectively (5,14,15). One
should recall that urinary continence rates are higher
and better in younger individuals and in those which
the neurovascular bundles were preserved. Some
authors have shown that patients achieve urinary control
earlier after LRP when compared to open retropubic
surgery (6,8). Using the experience gained in LRP,
some maneuvers have been developed in order to
improve urinary control rates. The so-called
"urethral stretching" can be performed and consists of
dissection of the urethra, proximal to the urinary
sphincteric region, allowing for suture with lesser tensile
strength without enveloping the pelvic musculature
and consequently the striated sphincter. In addition,
the preservation of the bladder neck in patients with
low risk for cancer may bring some benefit.
Rates of sexual function preservation range considerably from 11% to 85% in the reported
series of retropubic radical prostatectomies. Again,
sexual function recovery depends on age and on the preservation of neurovascular bundles. There
was gradual temporal recovery, according to
assessments at 3, 6, 12 and 18 months with rates of 38%,
54%, 73% and 86% in the best series. In reported laparoscopic series, the mean erectile function rate
is 59% in 6 months (3,5,12,13,15). Technically, laparoscopy can provide as ood results as those
of the open surgery in terms of preservation of
sexual potency. In addition to excellent anatomic
expertise, contributing factors include increased
magnification, excellent illumination and reduced local bleeding.
The control of lateral prostatic pedicles and vessels at
the apices of the seminal vesicles with clips or
manual suture, using cold scissors, has been of great
value, avoiding the use of thermal energy close to
the neurovascular bundle. In our recent cases, we
have used only cold scissors close to the seminal
vesicles and posterolateral neurovascular bundle, using
solely intracorporeal suture or polymer clips for hemostasis.
Margin positivity rates vary widely in the literature, from 5% to 45%, depending on the
tumor stage, tumor differentiation, technique used
and surgeon's expertise. Positive surgical margins
in retropubic radical prostatectomies yield rates of
16% to 28% for pT2 tumors, and up to 47% to 52%
for pT3 tumors. If we consider patients with
nonpalpable tumors diagnosed through abnormal PSA
levels, margin positivity rates can be as low as
8% (2,6,9,12,15).
In several LRP series, margin positivity rates have been quite similar to those described
for retropubic prostatectomies, depending basically on
the extent of the disease. The mean margin positivity
rates for pT1/pT2 tumors have ranged between 11%
and 26%, amounting on average to 4% for pT1/pT2a
and to 18% for pT2b. For advanced-stage tumors, the
rates increase to 33% to 39% for pT3a and to 81%
for pT3b. Positive surgical margins in LRP in most
series are located in the apical region (50 to 70%),
basal region (10%), posterolateral region (10 to 25%),
anterior region (5%) and multiple regions (5%) (2,6,9,12,15). In our patient population, we have
an overall margin positivity rate of 19.58%: 7.69%
for pT2a, 19.08% for pT2b, 34.5% for pT3a/b and
36,3% for pT3c. With regard to the location of
surgical margins, 49.7% of the cases showed apical
margins, 29.9% posterolateral margins and 20.3% bladder
neck margins.
Based on our experience, apical dissection is a crucial step in LRP since it plays an
important role in urinary continence (length of urethral
stump, quality of the anastomosis and sphincter
control), erectile dysfunction (injury to the
neurovascular bundle), surgical margins and risk of rectal injury.
We have observed that urethral transection at the end
of the procedure after total release of both
neurovascular bundles, as well as the preservation of the
bladder neck only in cases with safe clinical characteristics
of localized disease would be the two most
important factors for the reduction of positive margins. Ran
et al. demonstrated that good apical dissection
with section of puboprostatic ligaments and the nonpreservation of the bladder neck decreased
the margin positivity rate to 0% at the bladder neck
and from 12% to 6% at the apex (11). Although we
have an optimal margin positivity rate, our rate
of posterolateral margins is high, perhaps due to considerable concern with sexual potency and
its preservation, a fact that we have been
reconsidering in some situations.
The biochemical recurrence rates, have amounted to 11% for patients with clinically
localized disease and follow-up of 5 years, outperforming
the statistics of large series of retropubic
radical prostatectomies (2,6,9,11,12,15). If observed
more closely, the rates of biochemical recurrence in
LRP have been 8.6% (4 to 15.3%) for pT2 and 17.5%
(15 to 20.6%) for pT3 in periods of up to 5 years.
The disease-free survival rates have reached 92%
for pT2aN0; 88% for pT2bN0; 77% for pT3aN0; 44% for pT3bN0 and 50% for pT1-3N1. Open
radical prostatectomies have yielded biochemical control
rates of 88% to 93% for pT1-2N0, 75% for pT3aN0
and 47% for patients with invasion of seminal
vesicles. Our rate of biochemical control has averaged
10.3% with a mean follow-up of 62.5 months.
CONCLUSIONS
LRP is a standard procedure whose advantages include minimal disfiguration, shorter hospital stay, reduction in blood transfusion rates, lesser postoperative discomfort and quicker return to daily activities. With the additional development of materials, robotics breakthroughs, better qualification of surgeons, patients' preference and tendency towards detecting neoplasms at initial stages, laparoscopy may become the gold standard for radical prostatectomy in the near future.
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Correspondence address:
Mirandolino B. Mariano
Rua Costa 30/803/ Porto Alegre, RS
CEP: 90110-270
Tel: +55 (51) 3230-2730 Fax: +55 (51) 3231-7247
Email: mirandolino@terra.com.br