RADICAL PROSTATECTOMY: 10 YEARS EXPERIENCE
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B. MARIANO, MARCOS V. TEFILLI, GILVAN N. FONSECA, ISIDORO H. GOLDRAICH
Urology (MBM), Santa Casa de Misericordia de Porto Alegre, Section of
Urology (MBM, IHG), Hospital Moinhos de Vento, Porto Alegre, Section of
Urology (MVT), Hospital Mae de Deus, Porto Alegre, Rio Grande do Sul,
and Section of Urology (GNF), University Hospital, School of Medicine,
Federal University of Goias, Goias, Brazil
The authors assess the morbidity, functional results and oncologic follow-up
of a series of laparoscopic radical prostatectomies performed in over
a 10-year period.
Materials 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 critically analyzed: operative time, blood transfusions,
conversions, length of hospital stay, complications, functional results
of sexual potency and urinary continence, surgical margins and oncologic
Results: Operative time averaged 125 minutes,
with a mean bleeding volume of 335 mL and mean hospital stay of 4.3 days.
The rate of conversion to open surgery was 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 positive margin rate was 19.58%,
with a biochemical recurrence of 10.27% at 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 good oncologic and
functional results after proper training.
words: prostatic neoplams; prostatectomy; laparoscopic surgery;
Int Braz J Urol. 2009; 35: 565-72
there is no consensus 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 worldwide,
allowing for high rates of cancer control with low rates of incontinence
and sexual dysfunction. Laparoscopy has been used as an alternative procedure,
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.
MATERIALS AND METHODS
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 for surgery by other physicians. The data were stored
and updated according to outpatient follow-up retrospectively in a data
base. Fifty patients were excluded from the analysis due to loss to follow-up
and/or inadequate records.
The transperitoneal approach was used in 559 cases and the preperitoneal
approach was used in 171 cases. Technically, 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 metal 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, in order to avoid any form of energy close to the pedicles.
We also have used only cold scissors close to the seminal vesicles and
posterolateral neurovascular bundle, using only intracorporeal suture
or polymer clips for hemostasis.
Postoperative assessments included clinical examination and the prostate-specific
antigen (PSA) test, which was performed every three months in the first
two years, every six months from the third to the fifth years, and once
a 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 1997 TNM classification system was used
for staging and the Gleason score was employed for tumor grade (7). A
positive surgical margin after radical prostatectomy was defined as the
spread of the tumor to the inked margin of the surgical specimen on microscopic
examination. Pelvic lymphadenectomy was indicated for patients with Gleason
score greater than 7 and/or PSA greater than 10 ng/dL, which was required
in 76 cases (10.41%). In the present series, patients with positive lymph
nodes were excluded from radical surgery for cancer.
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 sufficient erection for vaginal penetration.
of 730 patients with mean age of 64.6 years (42 to 76, SD 4.09) and clinically
localized disease were selected for this review. The PSA ranged from 2.80
to 16 ng/mL, (mean of 6.15 ng/mL, SD 1.14). Data regarding demographics
are summarized in Table-1.
Operative time averaged 124.97 minutes (90 to 240, SD 20.11), with a mean
hospital stay of 4.30 days (1.5 to 20, SD 2.14). When pelvic lymphadenectomy
was performed, operative time increased by 40 minutes. The mean time of
urinary catheterization was eight days (7 a 18, SD 1.31).
The mean bleeding volume during the intraoperative period was 335 mL (50-1.150
mL, SD 79.99), with transfusion rates of 5.34% (39 cases). None of these
patients required reoperation.
The rate of conversion to the open technique was 1.36% (10 cases), with
an overall complication rate of 14.24% (104 cases). The data are summarized
The pathological assessment revealed pT2a/b tumors in 19.45% of cases
(142 patients), pT2c 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 positive margin rate was
19.58% (143 cases): 7.69% for pT2a/b (11 cases), 19.08% for pT2c (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-3 summarizes the data on surgical margins.
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). The mean time for neoplasm recurrence was 9 months.
Urinary continence had a rate of 87.94% (642 patients) 12 months after
surgery. Sexual potency yielded a rate of 60.95% (445 patients) in the
same period. In this group of patients who remained potent postoperatively,
bilateral preservation of the neurovascular bundle was performed in 77%
of the cases (343 patients), unilateral preservation in 19.5% of the cases
(87 patients), and the neurovascular bundles were not preserved in 3.3%
of the cases (15 patients) (Table-4).
intraoperative bleeding volume in the present series amounted to 300 mL
with transfusion rates up to 5%. 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
a tamponade 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 (1-6,8-12).
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 reported to be approximately from 0.5 to 1%, and has been
related to heart diseases or cases of pulmonary embolism. All reported
series on LRP show a tendency towards the reduction of postoperative complication
rates, from 25% to approximately 5% after the learning curve has been
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 while sectioning the
rectourethralis muscle adjacent to the prostatic apex. When these injuries
occur during the intraoperative period, they must be corrected by laparoscopy
with a 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.
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 transphincteric 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 transphincteric 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 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 occurs mainly 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 meatus at the bladder neck; 3) when the ureter
is enveloped by a 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, where 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, which subsequently facilitates the procedure.
With regard to complications related to laparoscopic urethrovesical anastomosis,
anastomotic leak occurs in approximately 10% of cases, but it usually
resolves spontaneously with bladder drainage and maintaining a suprapubic
drain. In our patient population, all cases resolved spontaneously with
bladder drainage and maintenance of the drain. One case required drainage
for up to three weeks, with maintenance of the bladder catheter and of
the suprapubic drain throughout the period.
The conversion rate is on average 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). In our experience,
after the first 10 cases requiring conversion, 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). It should be kept in mind that urinary continence rates are
higher and better in younger individuals and where the neurovascular bundles
were preserved. Some authors have shown that patients achieve urinary
control earlier after LRP 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, which permits suturing with less 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 be of some benefit.
Rates of sexual function preservation range considerably from 11% to 85%
in the reported series of retropubic radical prostatectomies. Our criteria
for the preservation of the neurovascular bundle are based on the parameters
of age, clinical staging, transoperative impression and preoperative function
parameters. Again, sexual function recovery depends on age and on the
preservation of neurovascular bundles. There was a gradual temporal recovery,
according to follow-up 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 was 59% at 6 months (3,5,12,13,15).
Technically, laparoscopy can provide as good 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 apex of the seminal vesicles with
clips or manual suture, using cold scissors, has been invaluable, avoiding
the use of thermal energy close to the neurovascular bundle.
Positive margin 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, positive margin rates can be as low as 8% (2,6,9,12,15).
In several LRP series, positive margin rates have been quite similar to
those described for retropubic prostatectomies, depending basically on
the extent of the disease. The mean positive margin rates for pT1/pT2
tumors have ranged between 11% and 26%, amounting on average to 4% for
pT1/pT2a/b and to 18% for pT2c. For advanced-stage tumors, the rates increase
from 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
had an overall positive margin rate of 19.58%: 7.69% for pT2a/b, 19.08%
for pT2c, 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 could be the two most important factors for the reduction
of positive margins. Ran et al. demonstrated that good apical dissection
with sectioning of puboprostatic ligaments and the nonpreservation of
the bladder neck decreased the positive margin rate to 0% at the bladder
neck and from 12% to 6% at the apex (11). Although we have an optimal
positive margin rate, our rate of posterolateral margins was high, perhaps
due to considerable concern with sexual potency and its preservation,
a fact that has been reconsidered 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 (2,6,9,11,12,15,19,20).
If observed more closely, the rates of biochemical recurrence in LRP were
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 pT2a/bN0;
88% for pT2cN0; 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 the seminal vesicles. Our rate of biochemical control has averaged
10.3% with a mean follow-up of 62.5 months.
radical prostatectomy is a technically well-defined procedure that provides
good oncologic and functional results after proper training. It is currently
our treatment of choice for prostate cancer patients.
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Accepted after revision:
June 9, 2009
Dr. Mirandolino Batista Mariano
Rua Costa, 30 / 803
Porto Alegre, RS, 90110-270, Brazil
Fax: + 55 51 3231-7247
deserve to be congratulated, not only for the large amount of cases that
were presented, but mostly due to the fact that they kept the data organized
for over the years, which is absolutely unusual in our medical community,
especially when the cases come from a private service, outside of an academic
environment, as in this case.
As every retrospective work, there are a few flaws that do not in any
way diminish the authors’ effort. The Gleason criterion has changed
over the years and the cases with Gleason 5 or less probably would not
resist a revision. It is also important to notice that different pathologists
examined the specimens, which could introduce an important bias to the
results. The evaluation of the erectile function was not done before the
operations, which complicates the interpretation of the apparently excellent
rates of erectile function preservation.
However, it is important to point out the positive aspects of the work.
The average operation time of 125 minutes is better than that of most
of the major serious studies that were published. The amount of blood
loss, in average 335 mL, and the conversion rate of 1.36%, indicate a
good and well established technique by the authors. The long period of
follow-up, of 62.5 months, gives credibility to the results and consistency
to the work.
This paper, which is the most important ever published in our medical
community about radical laparoscopic prostatectomy, comes at a good moment,
in which the first preliminary series of robot-assisted laparoscopic prostatectomy
are being carried out. The results of future years must necessarily be
compared to those of this excellent work, which I personally consider
the gold-standard of radical laparoscopic prostatectomy.
Lisias N. Castilho
Campinas, SP, Brazil