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ENDOUROLOGY
& LAPAROSCOPY
Transperitoneal
or extraperitoneal laparoscopic radical prostatectomy: does the approach
matter?
Eden CG, King D, Kooiman GG, Adams TH, Sullivan ME, Vass JA
From the Departments of Urology, North Hampshire Hospital, Basingstoke
and Frimley Park Hospital, United Kingdom
J Urol. 2004; 172 (6 Pt 1): 2218-23
- Purpose:
The greater accuracy of apical dissection and reconstruction in our
first 100 patients undergoing transperitoneal laparoscopic radical prostatectomy
(TLRP) was not matched by a proportionate increase in the rate of return
to normal continence compared with our prior open prostatectomy experience.
We postulated that greater bladder dysfunction due to the almost total
bladder dissection mandated by TLRP might be responsible and this might
be rectified by the adoption of laparoscopic radical prostatectomy using
an extraperitoneal approach (ELRP).
- Materials
and Methods: A total of 100 patients undergoing TLRP were compared
with 100 undergoing ELRP. The groups were subdivided into halves to
investigate the influence of any learning curve effect. All patients
had clinical stage T3aN0M0 or less prostate cancer and they were operated
on by a single surgeon.
-
Results:
Mean operative time (238.9 vs. 190.6 minutes), blood loss (310.5 vs.
201.5 ml), postoperative hospitalization (3.8 vs. 2.6 nights) and catheterization
duration (11.3 vs. 10.1 days) were significantly greater in the TLRP
group. After the first 50 cases were excluded in each group statistical
significance persisted only for operative time (218.3 vs. 184.2 minutes)
and hospitalization (3.5 vs. 2.5 nights). The pad-free rate was significantly
lower 3 months following ELRP (80% vs. 56%, p = 0.02). The overall 12-month
pad-free rate for TLRP and ELRP was 90% and 96%, respectively. The overall
12-month erection rate for TLRP and ELRP was 61% and 82%, respectively.
- Conclusions:
ELRP is superior to TLRP with respect to operative time, hospitalization
and early continence.
- Editorial
Comment
Since Guillonneau & Vallancien first described their successful
series of transperitoneal laparoscopic radical prostatectomy this procedure
disseminated world-wide.
Recently, few other centers developed the extraperitoneal technique
mimicking the open approach. Although the anatomical features are more
familiar to the surgeon the working operative space is more limited.
Conversely, the ELRP can be performed with the patient in supine position
and potentially decreases the incidence of ileus since the peritoneum
is not violated.
Important points discussed in this manuscript: 1) LRP should be taught
by a mentor/proctorship program, 2) Surgeons performing LRP must have
enough experience with radical prostatectomies anatomical variations
and its complications (more than 50 cases yearly), 3) According with
the authors bladder mobilization in the TLRP group affected patients
early urinary continence recovery compared to the ELRP. The authors
tried to remove other factors out of the equation, i.e.; learning curve,
prior obstructive problems and surgeries. The overall rate of positive
margins were the same revealing that the dissection was performed uniformly
in terms of technique but question remains if the last group of ELRP
patients with higher clinical stage prostate cancer and higher positive
margin rate had more incontinence than the rest. Certainly the observations
are intriguing and provoking but better delineation of the pathophysiology
is needed.
Dr.
Fernando J. Kim
Assistant Professor of Urology
University of Colorado Health Sciences Center
Denver, Colorado, USA
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