Laparoscopic Prostatectomy: Where Do We Stand?

Treatment Update

TREATMENT UPDATE Laparoscopic Prostatectomy: Where Do We Stand? Mesut Remzi, MD, Bob Djavan, MD, PhD Department of Urology, University of Vienna, Vienna, Austria Laparoscopic radical prostatectomy is an effective treatment for localized prostate cancer. This cost-intensive and technically demanding operation currently takes longer than the standard open procedures, but with increasing experience, it is eventually associated with lower costs and is nearly as fast. As more urologists gain such experience, the laparoscopic approach may challenge the standard approaches. [Rev Urol. 2002;4(1):12–16] © 2002 MedReviews, LLC Key words: Laparoscopy • Prostatectomy • Prostate cancer fter the introduction of radical prostatectomy for prostate cancer by Proust1 and Young2 at the beginning of the 20th century using the perineal approach, this technique became the standard for prostate cancer treatment. In 1945, Millin and colleagues proposed a retropubic approach for radical prostatectomy.3 Because of high intraoperative blood loss, low cure rates, and frequent incontinence and impotence, the retropubic approach fell out of favor with the advocates of urology in the 1960s and 1970s. In the early 1980s, Walsh introduced the nerve-sparing retropubic approach,4 and prostate-specific antigen (PSA) began to play a greater role in prostate cancer detection and staging.5,6 Use of the retropubic approach—allowing the simultaneous performance of a pelvic lymphadenectomy—increased.6 Nowadays the advocates of urologic laparoscopy are confronted with problems similar to those described for the retropubic approach. The acceptance of laparoscopy, in comparison, has been a much slower process, because this technique is considerably more demanding than open surgery. Therefore, urologists and patients have to be convinced of its benefits. At the beginning of the use of laparoscopic surgery in urology, varicocelectomy, pelvic lymphadenectomy, and nephrectomy were introduced. Nephrectomy has become the most commonly performed procedure.7 A S12 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY Laparoscopic Prostatectomy: Where Do We Stand? The advantages of laparoscopy over open surgery are reduced access trauma and, because of superior illumination and magnification with the video-assisted technique, better visualization of anatomic details. Several laparoscopic techniques have shown shorter hospitalization and convalescence, less perioperative pain, and improved cosmetic results.8-17 Laparoscopic surgery was first used to treat benign diseases. Since the mid1990s, laparoscopic approaches have been developed for malignant diseases. In 1997, Schuessler and colleagues presented the short-term experience of nine patients treated with laparoscopic radical retropubic prostatectomy.8 Since several recent studies8,13-15 have demonstrated the feasibility of laparoscopic radical prostatectomy, interest in this operation has increased enormously. The criteria for judging the benefits of laparoscopy for radical prostatectomy compared to the open approach are control of cancer, functional outcome, surgeons’ learning curves, and perioperative morbidity. The questions about laparoscopic prostatectomy nowadays are these: Can it challenge the open approach? What are the possible advantages of this technique? Does it have a steeper learning curve? Where do we stand now? Learning Curve As we know from many other indications for laparoscopic surgery, passing the so-called learning curve takes more than 20 cases.9 The learning curve can be defined as the improvement of surgical outcome (reduction of operation time, blood loss, and conversion and complication rates) as an increasing number of patients are treated using a laparoscopic technique. In some areas, eg, cholecystectomy and fundoplication, the laparoscopic approach has become the gold standard.9,10 We also know from these simpler techniques that surgical performance continues to improve after the plateau of the learning curve is passed and that functional results do not differ in patients at the beginning and at the end of the learning curve. In urology, laparoscopic nephrectomy showed clear advantages over the flank incision and therefore gained wide acceptance, to the point Two later rectal lesions could be handled laparoscopically.17 Abbou and coworkers reported operation times in their first 20 cases to have a median of 385 minutes. In 12 cases, no pelvic lymphadenectomy was performed; operation times were significantly shorter (P < .05) in the group that did not have pelvic lymphadenectomy (317 ± 89 minutes; range, 210-435 min) than in the group that had it (472 ± 124 minutes; range, 240-640 minutes). They Many institutions now use laparoscopic nephrectomy as the main approach for early-stage renal cell cancers. where many institutions now use laparoscopic nephrectomy as the main approach for early-stage renal cell cancers.12 As far as we know, just four groups have published their experience with 20 or more cases treated by laparoscopic prostatectomy.16-19 However, three of them have reported more than the 50 cases17,18,20 that are considered necessary to overcome the learning curve.18 Rassweiler and colleagues showed their experience on their first 60 cases.17 All the patients had a pelvic lymphadenectomy performed; the median operation time was 334 minutes (range, 235–500 minutes) overall, with a trend toward shorter operation times in the last cases. In 48% of the cases, blood transfusions were necessary (median 2.2 erythrocyte transfusions per patient; range, 2–11). The conversion rate was 6.6% (four patients); procedures in the first two patients had to be converted to open access because of major bleeding from Santorini’s plexus. The other two conversions were necessary because of periprostatic adhesions (No. 6) and a rectal lesion in a pT3 patient (No. 9). reported just two blood transfusions and no conversions.15,16 Van Velthoven and colleagues reported 22 laparoscopic prostatectomies. The operation time dropped from 570 to 240 minutes, and the conversion rate was 23% overall.18 The most experienced group, Guillonneau and Vallancien’s, reported on 210 laparoscopic prostatectomies.19 In 24% (n = 48), lymphadenectomy was performed. In the first 50 cases, the operation time was 267 ± 58 minutes; it decreased in the last 50 cases to 201 ± 42 minutes. The conversion rate was 12% for the first 50 operations; 2% of the next 50 surgeries had to be converted, and no conversions were necessary after that. Also, blood loss decreased from the first 50 to the last 50 cases from 514 ± 281 mL to 262 ± 151 mL. This group reported that the end of the learning curve appeared to be 50 procedures per operator. However, the procedure is being standardized and will therefore be teachable, and we can expect a faster learning curve for urologists who are taught it. In general, operation time, conversion rate, and blood transfusion rate VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 13 Laparoscopic Prostatectomy: Where Do We Stand? continued Table 1 Efficacy and Outcome of Laparoscopic Prostatectomy Abbou et al15,16,20 Guillonneau et al13,14,19,24 Rassweiler et al17 van Velthoven et al18 Number of patients 43 210 60 22 Number (%) of lymphadenectomies 8 (18.6) 48 (24) 60 (100) — Median age (y) 64.4 64 68 — Preoperative PSA level (ng/mL) (median ± SD [range]) 9.6 — 10.8 ± 6.7 (2–35) 26.8 ± — (1.4–75.5) 2.6 ± — (0.67–27.2) Median operation time (minutes) 338 ± — 235 ± 57 334 ± — range 240–570 Number of revisions 1 3 0 — Conversion rate (%) 0 3.3 6.6 23 Transfusion rate (%) 4.6 6.2 48 36 Complication rate (%) 13.9 4 — — Catheterization duration (d) 9.3 5.9 ± 2.8 Number (%) of positive margins 12 (27.8) 18 (15) 7±— 11 (18) — 5 (23) Lowest PSA (%) 100 94.7 — 90 Continence preserved (%) 60.4 72 95 — Sexual intercourse possible (%) 11 45 — — PSA, prostate-specific antigen. decrease with experience. As the Institute Mutualiste Montsouris in Paris showed for prostatectomy, operation times can become as short as open surgery times.14 Conversions and severe blood loss can be explained by lack of experience, so their rates can decrease to 0%. Efficacy and Outcome Results Of more interest than the learning curve itself are the efficacy and outcome of laparoscopic prostatectomy (Table 1). Of course, these have to be judged by the same criteria as those of the open approach. In any case, a reliable comparison of oncologic outcomes of different surgical techniques is possible only through randomized prospective studies, with stratification for clinical stage. Oncologic efficacy criteria are based on examination of the operative specimens and progression of PSA levels. Cancer found at the inked surgical margin in a radical prostatectomy 14 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY specimen implies that the tumor has not been completely resected and is an adverse prognostic sign. Paulson showed that 40% of patients with positive margins died from prostate cancer within 13.5 years, compared to 10% of those in whom the margin was negative.21 In a study by Epstein and associates, only the surgical margins and the Gleason grade of the prostate ual disease. The diagnostic value of an increasing PSA level after it has been undetectable is still unclear, but depending on what that level is, it can be a sign of prostate cancer progress or metastasis. The natural history of progression after PSA elevation following radical prostatectomy was described by Pound and colleagues.23 The actuarial metastasis- Laparoscopic operation times can become as short as open surgery times, and conversion and severe blood loss rates can decrease to 0%. cancer were independent prognostic factors when seminal vesicle invasion and lymph node metastases were excluded in a multivariate analysis of prognostic outcome.22 Measurement of PSA after prostatectomy has had a profound impact on the management of prostate cancer. A persistently elevated PSA value after prostatectomy is a sign of resid- free survival for 1997 men was 82% at 15 years after surgery. Fifteen percent (304) developed biochemical PSA elevation. Of these, 35% had metastatic disease after a median of 8 years from the time PSA elevation was detected. In survival analysis, time to biochemical progression (P < .001), Gleason score (P < .001), and PSA doubling time (P < .001) Laparoscopic Prostatectomy: Where Do We Stand? Table 2 Complications of Laparoscopic Radical Prostatectomy Major Complications Minor Complications Abbou et al Postoperative ileus . . . . . . . . . . . Vesicourethrocutaneous fistula . . Rectal injury (colostomy) . . . . . . Vesicourethral leakage (revision) . . . . . . . . 2 1 1 1 Lymphorrhea . . . . . . . . . . . . 2 Guillonneau et al13,14,19,24 Vesicourethral leakage (revision) Rectal injury . . . . . . . . . . . . . . . Ureteral injury . . . . . . . . . . . . . . Ileal peritonitis . . . . . . . . . . . . . . . . . . . . . 1 3 1 1 Epigastric artery injury . . . . . 2 Transient paralysis of obturator nerve . . . . . . . . . . 1 Transient urine leakage . . . . . 11 Rassweiler et al17 Anastomotic strictures . . . . . . . . . . 2 Pelvic hematoma . . . . . . . . . 7 Subileus . . . . . . . . . . . . . . . . 2 Transient urine leakage . . . . . 15 15,16,20 were predictive of the probability of and time to development of metastatic disease.23 Nevertheless, Guillonneau24 reported positive margins in 15.5% (pT2a, 10.6%; pT2b, 16%; pT3a, 33%; pT3b, 50%), Rassweiler and associates17 in 18.3% (pT2-3a, 7%; pT3b, 31%; pT4, 100%), and Abbou in 27.8% of specimens from laparoscopic prostatectomy.20 In 570 open radical suprapubic and 280 perineal prostatectomies, Jones and colleagues described posi- retropubic prostatectomy, 80% reported complete urinary control or occasional spotting only; 15% experienced grade II stress incontinence, and 3% total incontinence.28 Incontinence rates after prostatectomy are quite variable and depend on the definition of “continence." So far, early continence rates following laparoscopic radical prostatectomy are quite encouraging, particularly considering the short follow-up period. Using a very strict definition of continence Early continence rates following laparoscopic radical prostatectomy are quite encouraging. tive margins in 11% and in 13%, respectively.25 Ohori and coworkers reported positive margins in 16% of 478 open radical prostatectomy specimens.26 Fesseha and associates reported that, out of 590 patients, 217 (37%) had either positive surgical margins or extraprostatic extension.27 However, in two laparoscopic series, the PSA, after a mean follow-up of 4 months, was 0.1 ng/mL in 92%24 and in 95%17 of cases. Hautmann and colleagues showed that of all patients who were followed for 1 year or longer after open (“no protection against incontinence day or night"), Guillonneau’s, Abbou’s, and Rassweiler’s groups reported continence in 37%14 and 60.4%20 at 1 month, 68%17 at 3 months, 72%14 at 6 months, and 95%17 at 9 months postoperatively. In the series of Abbou and colleagues, 11% of all subjects were able to have sexual intercourse 1 month postoperatively and 45% of those who underwent the 81st through the 120th procedures were able to have an erection.14 Table 2 summarizes complications of laparoscopic radical prostatectomy. In all, five rectal injuries, one requiring colostomy; four cases of postoperative ileus; two vesicourethral leakages requiring revision; one vesicourethrocutaneous fistula; and one ureteral injury have been described as major complications so far. Future Aspects Now that the feasibility of laparoscopic radical prostatectomy has been shown and it has become a standard method for all patients with clinically localized prostate cancer,14 this approach has to be judged by the same oncologic and outcome results as the open approach. Laparoscopic radical prostatectomy is a technically demanding procedure with a long learning curve. The possible advantages of the magnification and better visualization achievable with the laparoscopic approach are better control of the nerve bundles and therefore better control of erectile dysfunction, and better visualization of the anatomy and therefore better urethrovesical anastomosis with less incontinence. The disadvantages are those of laparoscopy in general: decrease in tactile feedback and loss of three-dimensional depth perception. Early results showed the efficacy of the laparoscopic method as a com- VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 15 Laparoscopic Prostatectomy: Where Do We Stand? continued petitive approach in the treatment of prostate cancer but no clear advantages in the outcome of continence and erectile dysfunction at that time. This might be explained by the learning curve and the highly technical, demanding nature of the procedure. As described by all authors, a nerve-sparing laparoscopic radical prostatectomy was rare in the first reports.13-19,24 Guillonneau and associates started to spare the nerves after the 80th procedure.14 A new treatment modality for prostate cancer can succeed only if it has a superior outcome. The laparoscopic radical prostatectomy is a new method for the treatment of localized prostate cancer that is able to challenge the standard retropubic and perineal approaches. Urologists are still in the learning curve, and therefore there is insufficient data to allow comparison of this method with the older ones. At the moment, laparoscopic radical prostatectomy is an operation suited to centers with high experience levels and good infrastructures. Because of its long operation times, only training centers like universities and larger teaching hospitals are able to perform this cost-intensive and technically demanding operation during this time of learning. As the first results from Paris showed, laparoscopic prostatectomy can be cheaper than and nearly as fast as open surgery14 and therefore may become an operation with wider acceptance and use. Time will tell—as it did for other uses of laparoscopy in medicine—whether laparoscopic radical prostatectomy can last and be accepted as a useful and meaningful procedure in the treatment of localized prostate cancer. Conclusion Laparoscopic radical prostatectomy is not just feasible; it is a new, effective method for treatment of localized prostate cancer. The possible advantages of the magnification and better visualization permitted by the laparoscopic approach have to be proven by outcomes in terms of erectile dysfunction and incontinence. If the results are better than those of the open approach, it will be merely a matter of time until laparoscopic radical prostatectomy presents a serious challenge to the standard open approach. 12. 13. 14. 15. 16. 17. 18. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Proust R. Technique de la prostatectomie périnéale. Ass Franc Urol. 1901;5:361. Young HH. The early diagnosis and radical cure of carcinoma of the prostate: being a study of 40 cases and presentations of radical operation which was carried out in 4 cases. Johns Hopkins Hosp Bull. 1905;16:315. Millin T. Retropubic prostatectomy: a new extravesicle technique. Lancet. 1945;2:693. 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Current status and trends in laparoscopic antireflux surgery: results of a consensus meeting. Endoscopy. 1997;29:298–308. Remzi M, Lenglinger J, Erne B, et al. Einfluss der Lernphase auf Sicherheit und Effizienz der 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. laparoskopischen Fundoplicatio. Der Chirurg. 2001;72:261–265. Cadeddu JA, Ono Y, Cayman RV, et al. Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience. Urology. 1998;52:773-777. Guillonneau B, Cathelineau X, Barret E, et al. Laparoscopic radical prostatectomy: technical and early oncological assessment of 40 operations. Eur Urol. 1999;36:14-20. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience. J Urol. 2000;163:418-422. Abbou CC, Salomon L, Hoznek A, et al. Laparoscopic radical prostatectomy: preliminary results. Urology. 2000;55:630-634. Jacob F, Salomon L, Hoznek A, et al. Laparoscopic radical prostatectomy: preliminary results. Eur Urol. 2000;37:615-620. Rassweiler J, Sentker L, Seemann O, et al. Laparoskopische radikale Prostatektomie-Technik und erste Erfahrungen. Akt Urol. 2000;31:237-245. van Velthoven R, Peltier A, Hawaux E, Vandewalle JC. Transperitoneal laparoscopic anatomical radical prostatectomy: preliminary results [abstract]. J Urol. 2000;163(suppl):141. Guillonneau B, Chathelineau X, Barret E, et al. Morbidity of laparoscopic radical prostatectomy: evaluation after 210 procedures [abstract]. J Urol. 2000;163(suppl):140. Abbou CC, Antiphon P, Salomon L, et al. Laparoscopic radical prostatectomy—preliminary results. J Urol. 2000;163(suppl):141. Paulson DF. Impact of radical prostatectomy in the management of clinically localized disease. J Urol. 1994;152:1826-1830. Epstein JI, Pizov G, Walsh PC. Correlation of pathologic findings with progression following radical retropubic prostatectomy. Cancer. 1993;71:3582-3593. Pound CR, Partin AW, Eisenberger MA, et al. Natural history of progression after PSA elevation following radical prostatectomy. JAMA. 1999;281:1591-1592. Guillonneau B, Cathelineau X, Barret E, Vallancien G. Short-term oncological results of laparoscopic radical prostatectomy. Statement after 135 first procedures [abstract]. Eur Urol. 2000;37(suppl 2):386. Jones J, Gillitzer R, Melchio R, Fichtner J. Radical prostatectomy: rate of positive margins of perineal and suprapubic prostatectomy. Urologe A. 1999;38(suppl 1):22. Ohori M, Wheeler TM, Kattan MW, et al. Prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol. 1995;154:1818-1824. Fesseha T, Sakr W, Grignon D, et al. Prognostic implications of a positive apical margin in radical prostatectomy specimens. J Urol. 1997;158:2176-2179. Hautmann RE, Sauter TW, Wenderoth UK. Radical retropubic prostatectomy: morbidity and urinary continence in 418 consecutive cases. Urology. 1994;43(2 suppl):47-51. Main Points • The feasibility of laparoscopic radical prostatectomy has been shown, and it has become a standard method of treatment for clinically localized prostate cancer. • Laparoscopic radical prostatectomy is a technically demanding procedure with a long learning curve. • Experience with this procedure is still insufficient to make a valid comparison with open techniques. 16 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY