Laparoscopic Radical Prostatectomy
A review article on the latest technical innovation in prostate cancer care.
by Arnon Krongrad, M.D.
Laparoscopic radical prostatectomy (LRP) is the latest technical innovation in prostate cancer care. First described almost 10 years ago, the technique of LRP has been made standard, reproducible, and efficient in the last 2 years. If measured by effect on treatment burden, the LRP is arguably the most profound technical innovation in years. For the surgeon, LRP offers improved visualization of the anatomy, virtually eliminates the physical and emotional toll of radical prostate surgery, reduces blood loss, and provides better preservation of anatomical structures. For the patient, the LRP virtually eliminates operative convalescence.
History of the LRP
The "delayed fuse" is a phenomenon of surgical innovation. (1) So it was with percutaneous nephrostomy, today a common technique that was first described in 1865 by Thomas Hillier, redescribed in 1955 by Willard Goodwin, then, after a 25-year dormancy, became widely disseminated. A similar thing happened with the LRP.
LRP was first described in an abstract in 1992. (2) At that time, only two cases had been completed and laparoscopic suturing was in its infancy. In 1996, Price et al. reported LRP in the dog (3) and Raboy et al. completed a clinical case of extraperitoneal LRP. (4) In 1997, Schuessler et al. formally published their experience of several years before. (5) In 1998, Guillonneau et al. published a series of 40 robotically-assisted, transperitoneal LRPs done by two surgeons over an eight-month period at the Institut Montsouris in Paris. (6) This report was followed by an update after 65 patients (7) and another update, in February 2000, after 120 patients. (8) A report of the first 240 LRPs done at the Institut Montsouris is in press, (9) as is a clinical series of 43 patients from the Hôpital Henri Mondor. (10) During this period, other groups began to adopt the LRP and have also now begun to report their experience at endourological meetings. Video tapes (11 , 12) have been published and post-graduate courses have been organized.(13 , 14) We have recently published a detailed technical monograph.(15)
LRP benefits from the introduction into the urological operating room of surgical robots. Already in use in other disciplines, robots today perform a range of surgical functions. In LRP, a voice-controlled AESOP robot is used to hold the laparoscope. Replacement of a human assistant with the robot permits a less crowded operating table and assured the operative team a steady and responsive view of the field Fig.1). In its essence, LRP is an amalgam of well-established open radical prostatectomy techniques. In its approach to the dorsal venous complex and neurovascular bundles, the laparoscopic approach resembles the retrograde Walsh technique. Unlike previous techniques, the modern LRP, as standardized at the Institut Montsouris, is done initially by a transperitoneal approach and is finished in the retropubic, extraperitoneal space.
- The urethro-vesical anastomosis
The anastomosis is made with interrupted stitches. The anastomosis is constructed with 3-0 resorbable suture on a curved needle. The two first sutures are placed at 5 and 7 o'clock, going inside?out on the urethra and outside-in on the bladder neck. These two sutures are tied inside the urethral lumen. Four other sutures are symmetrically placed at 4 and 8, then 2 and 10 o'clock, and tied outside the lumen. Two final stitches are placed at 1 and 11 o'clock, but not immediately tied. The Foley catheter is inserted and its correct position is checked. Then the 2 sutures can be safely tied without any risk of piercing the catheter.
- Incising the urethra
Because the dorsal vein has been ligated and the pedicles have been incised, there will be little bleeding when the dorsal vein complex is incised. This incision is made by first coagulating with bipolar forceps and then incising the complex. The dorsal vein complex is retracted anteriorly to expose the anterior urethral wall, which is incised. The back wall of the urethra is also incised with the laparoscopic cold knife. Gentle traction is applied to pull the prostate superiorly. The rectourethralis represents the final attachment of the prostate and is divided.
- Freeing the vasa, seminal vesicles, and Denonvillier's fascia
The first step is to free up the vasa, seminal vesicles, and Denonvillier's fascia. This is accomplished through a low peritoneal incision, which first exposes the vasa. Once the vasa are transected, the seminal vesicles are easily identified and freed from their attachments and vasculature. With the vasa transected and seminal vesicles freed and retracted anteriorly, the Denonvillier's fascia is tented and incised. This action exposes the plane behind the prostate, which can be easily extended inferiorly.
- Dissecting the bladder neck
To identify the bladder neck, the anterior prevesical fat is retracted superiorly, causing a faint outline of the prostato-vesical plane. As with open surgery, this plane is developed with sharp and blunt dissection. The surgeon identifies the urethra, incising the anterior wall to expose the Foley catheter. The catheter balloon is then deflated and the catheter is pulled up and into the abdomen to expose the lateral and posterior urethral walls, which are incised. The Foley catheter is removed, and the assistant exposes the posterior face of the bladder neck holding the posterior bladder mucosal incision.
- Dropping the bladder
The LRP moves from the peritoneum to the retropubic space of Retzius, from which the operation is completed. To permit access to the retropubic space, the bladder must be dropped. After distending the bladder with saline, its contours are easily identified and the peritoneum incised. The fatty areolar tissue around the bladder are then easily dissected, causing the bladder to drop posteriorly. The bladder is then emptied.
- Taking down the Dorsal Vein
After coagulation of superficial, dorsal prostatic veins, the fat over the Fascia of Zuckerkandl covering the prostate can be resected or swept aside. The endopelvic fascia is incised, exposing the levator ani muscles. In some cases, one may observe the "continence" nerves described by Steiner. The puboprostatic ligaments can be incised. The dorsal venous complex can then be ligated with a 2-0 resorbable suture passed with a curved needle from one side to the other. A backbleeding stitch can also be placed. The dorsal venous complex may be transected later.
- Completing the operation
An endoscopic bag is passed through a 10-mm port. The specimen is placed in the sac and removed. The abdominal pressure is lowered to 5 mm Hg to check for bleeding. A drain is passed to the pelvis and sutured to the skin. The remaining instruments and trocars are removed and the incisions are closed and dressed.
- Incising the prostatic pedicles and neurovascular bundles
Unlike in retrograde retropubic radical prostatectomy, in the antegrade laparoscopic operation, the pedicles are laid virtually bare before they are incised. To best expose them, the surgeon grasps the vas and seminal vesicle through the space between the prostate and the posterior bladder neck and pulls them up to expose the pedicle to be incised. After transection of the pedicles, the surgeon will find a flimsy tube of fat, nerves, and vessels containing the neurovascular bundles. To preserve the bundles, it is necessary to make a lateral incision in a thin, visceral fascia that laterally covers the peri-bundle fat. The neurovascular bundles are dissected from the base of the prostate to their the entrance into the pelvic muscular floor, posterolateral to the urethra.
Immediate surgical results
The most obvious difference between LRP and open radical prostatectomy is that with LRP there is no abdominal incision. This difference explains the most obvious tangible benefit of LRP: the virtually complete absence of pain. Anyone experienced with open radical prostatectomy has but to make rounds after LRP to instantly understand this benefit. The patients are fully awake, alert, physically active, and eating solid food within hours of the operation.
My own experience has been that, while the patients acknowledge some discomfort on waking from anesthesia, they do not take so much as a Tylenol after surgery. A common first complaint of my patients at post-operative rounds has been that they are hungry. With early post-operative feeding comes early removal of intravenous lines, increasing mobility, comfort, and the sense that all is well.
The elimination of incisions and incisional pain also lead indirectly to improved immediate post-operative function. The absence of incisional pain also means that parenteral analgesics and/or epidural analgesia are not used. The elimination of analgesics and epidural lines also leads to patients who are more alert, more active, and whose bowel function is better. Instead of a large dressing as with open surgery, I use 1-centimeter-diameter, sterile gauze dots after LRP. These "bandaids" leave patients and their families psychologically ready for discharge much faster than what one typically sees when the patient has a large dressing.
Any patient consenting to LRP must understand the risk of conversion to an open operation. Conversion can be necessary in the event of brisk bleeding, rectal or ureteral injury, problematic urethro-vesical anastomosis, and other events. Factors that can increase the risk of technical difficulty and conversion neoadjuvant androgen deprivation, radiation, previous transurethral resection of the prostate, and infection.
At the Institut Montsouris, the institution with the greatest experience in LRP, mean operative time is now 206 minutes. While the fastest LRP was done in two hours (personal communication, Guy Vallancien), generally speaking the LRP is today a slower operation than the equivalent open operation. One wonders what will happen as instrumentation is customized for this operation.
The mean blood loss with LRP is less than 300 cc, a clear improvement over typical open radical prostatectomy. This marked improvement is probably explained by finer movements, markedly improved visualization of the operative field, more precise coagulation, and the hemostatic pressure of CO2 at approximately 15 mm Hg.
In France, where the technique was fully developed and patients apparently do not easily cope with leg bags, mean patient stay is 3 days. I have discharged patients on the second day and believe that, with more experience and confidence, the hospital stays will drop further. It is on the third post-operative day that the catheter comes out, representing another improvement over the open radical prostatectomy in regards to hospital stay and catheter duration.
As calculated by Guillonneau and Vallancien, these differences translate to a marked reduction in cost, favoring the LRP by approximately $1,200 per case.
In the most recent report of 240 cases from the Institut Montsouris, mean pre-operative PSA was 10.8 ng/mL, mean Gleason score was 5.8, mean specimen weight was 54 grams, and 86% of the specimens were reported as pathological stage T2; the positive margin rate was 14%. In the recent series of 43 cases from the Hôpital Henri Mondor, the mean pre-operative PSA was 9.6 ng/mL, mean Gleason score was 5.9, mean specimen weight was 58 grams, and 88% of the specimens were reported as pathological stage T2; the positive margin rate was reported as 28%.
In the 240 Montsouris patients, approximately 6% of patients for whom PSA was available at least one month post-operatively had PSA greater than 0.1 ng/mL. In the 43 Henri Mondor patients, none had a measurable PSA.
Without direct comparisons and adjustment for relevant covariates, we will not know if there is a difference between laparoscopic and open radical prostatectomy in positive margin rates or measurable post-operative PSA. What we can say is that LRP is associated with positive margin rates and measurable post-operative PSA at rates falling in the same range reported for open radical prostatectomy.
In the Montsouris series, 45% of a subpopulation of 40 highly-selected patients had satisfactory erectile function. In the Mondor series, with one-month followup, 14% of the overall series had erectile function.
In the Mondor series of 43 patients, 84% of patients reported full continence at one month after surgery. In the Montsouris series, 127 patients had at least a 6-month followup, of whom 115 patients answered self-administered questionnaires on urinary continence; 83% of the responders reported full continence. At the Institut Montsouris, using the same investigative methods, the authors found a 73% continence rate at 12 months with patients who had had an open radical prostatectomy. The authors make the unquantified observation that, in comparison to their experience with open radical prostatectomy, the recovery of continence is much quicker.
Without direct comparisons and adjustment for relevant covariates, especially direct measurement of pre-operative function, we will not know if there is a difference between laparoscopic and open radical prostatectomy in rates of urinary continence and erectile function. What we can say is that LRP is associated with urinary continence and erectile function that are comparable and perhaps even better than what is seen with open radical prostatectomy.
LRP is a safe, feasible, standardized, reproducible, and teachable procedure. In a growing number of medical centers, the LRP is the radical prostatectomy of choice. Given what it offers patients, there is ample reason to believe that the LRP will replace the open, retropubic, radical prostatectomy.
- Bloom DA: Surgical innovation and the delayed fuse: a case study of percutaneous nephrostomy. AUA News, November/December, 1999.
- Schuessler WW, Kavoussi LR, Clayman RV, Vancaillie TH: Laparoscopic radical prostatectomy: initial case report. J Urol 147:246A, 1992.
- Price DT, Chari RS, Neighbors JD Jr, Eubanks S, Schuessler WW, Preminger GM: Laparoscopic radical prostatectomy in the canine model. J Laparoendoscop Surg 6:405?412, 1996.
- Raboy A, Ferzli G, Albert P: Initial experience with extraperitoneal endoscopic radical prostatectomy. Urology 50:849?854, 1997.
- Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR: Laparoscopic radical prostatectomy: initial short?term experience. Urology 50:854?858, 1997.
- Guillonneau B, Cathelineau X, Barret E, Rozet F, Vallancien G: Laparoscopic radical prostatectomy: early and early oncological assessment of 40 operations. Eur Urol 36: 14-20, 1999.
- Guillonneau B, Vallancien G: laparoscopic radical prostatectomy: initial experience and preliminary assessment after 65 operations. Prostate 39: 71-75, 1999.
- Guillonneau B, Vallancien G: Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 163:418-422, 2000 (The most serious and widely-available analysis of LRP now available, written by the team that standardized and popularized the technique).
- Bertrand Guillonneau, François Rozet, Eric Barret, Xavier Cathelineau and Guy Vallancien: Laparoscopic Radical Prostatectomy: assessment after 240 procedures. Urol Clin N Amer (2000 in press). (A wide ranging report of results, technical points, and general overview of the technique, by the group at Institut Montsouris. For anyone wishing to a single source of information, this is a good place to start).
- Abbou CC, Salomon L, Hoznek A, Antiphon P, Cicco A, Saint F, Alame W, Bellot J, Chopin DK: Laparoscopic radical prostatectomy: preliminary results. Urology 2000 (in press).
- Abbou CC, Hoznek A, Salomon L, Pollux C, Hafiani M, Antiphon P, Gasman D, Chopin D: Laparoscopic radical prostatectomy. Eur Urol Video J Volume 6, 1999.
- Guillonneau B, Rozet F, Cathelineau X, Barret E, Nunez U, Vallancien G: Laparoscopic radical prostatectomy: technical aspects. Eur Urol Video J Volume 6, 1999.
- Vallancien G, Guillonneau B: 2nd international course on laparoscopic radical prostatectomy. Post-graduate course. Institut Mutualiste Montsouris. Paris, France. June 29-30, 2000.
- Laparoscopic urologic oncology. Post-graduate course. Ralph V. Clayman and Chandru P. Sundaram. Washington University School of Medicine, St. Louis, MO, June 23-25, 2000.
- Guillonneau B, Krongrad A, Vallancien G: Laparoscopic radical prostatectomy. A technical monograph. Private publication, 2000. A highly-detailed description of the technical points of LRP, with color, intra-operative photographs. Available on request from firstname.lastname@example.org.