Comparison of antegrade and retrograde laparoscopic radical prostatectomy techniques

Abstract

We evaluated the effect of antegrade and retrograde approaches on functional recovery and surgical outcomes of extraperitoneal laparoscopic radical prostatectomy (LRP). We analyzed 135 patients who underwent extraperitoneal LRP, with the retrograde technique performed on 42 (31%; Group 1) and the antegrade technique on 93 (69%; Group 2). Both groups were statistically similar with respect to age, clinical stage, preoperative prostate‐specific antigen (PSA) and American Society of Anesthesiologists (ASA) scores, prostate volume, and previous surgical history. Mean operative time was significantly longer in Group 1 (244 ± 18.3 vs. 203.3 ± 18.4 min, p < 0.001), whereas mean anastomosis times for both groups were similar (35.8 ± 7.2 vs. 34.7 ± 5.8 min, p = 0.155). Estimated blood loss and transfusion rates were significantly lower in Group 2. A significant difference was observed for both hospitalization (6.79 ± 3.3 vs. 5.46 ± 3.08 days, respectively; p = 0.026) and catheterization times (12.24 ± 2.1 vs. 11 ± 1.08 days, respectively; p = 0.001) for Group 2. The total complication rate was 47.6% in Group 1, and 11.8% in Group 2 (p < 0.01). Rates of positive surgical margins were 14.2% and 15% for Groups 1 and 2, respectively. At the 12‐month interval from operation, similar recoveries in urinary continence were obtained for both groups (81% in Group 1; 91% in Group 2). Upon comparison of the two LRP techniques, we found that both were effective; however, the latter resulted in lower minor complication rate, lower blood loss, shorter operation time, and shorter length of hospital stay.

Introduction

Radical prostatectomy is the first‐line treatment option for patients with clinically localized prostate cancer [1]. Over the last decade, laparoscopic radical prostatectomy (LRP) has become increasingly used in the surgical management of prostate cancer [[1], [2]]. Functional results of LRP have been at least comparable to those of open radical prostatectomy, but have the advantages of superior cosmesis, lower blood loss, and reduced morbidity [3].

Among the available LRP approaches are transperitoneal and extraperitoneal methods. Both techniques can be performed from the prostate apex to the base (retrograde or ascending technique) or from the base to the apex (antegrade or descending technique) [4]. Although many teams have published various series of transperitoneal or extraperitoneal laparoscopic prostatectomies, only one study comparing the functional and surgical outcomes of antegrade and retrograde LRP techniques has been reported [[3], [4], [5], [6]]. In this study, we evaluated the effect of antegrade and retrograde approaches on the functional recovery and surgical outcomes of extraperitoneal LRP technique.

Materials and methods

Patients

We analyzed 135 patients who underwent extraperitoneal LRP, with the retrograde technique performed on 42 patients (31%; Group 1) and antegrade technique performed on 93 (69%; (Group 2), as described below. The data were prospectively collected and retrospectively analyzed. The treatment method was chosen by taking into account patient preference after the advantages and disadvantages of the techniques had been discussed with the patients. Operation was performed by the same surgeon in the same institution. We included the cases that were performed after an experience of >50 cases for both techniques. The study protocol was approved by the institutional ethical board at Bakirkoy Hospital, and written informed consent was provided by all patients.

Indications for LRP were generally the same as those for open prostatectomy. Patients with clinical stage T1c‐2c prostate cancer with a life expectancy of >10 years were candidates for LRP. Preoperative, operative, and postoperative data were compared between the two techniques. These include data for age, preoperative prostate‐specific antigen (PSA), body mass index, previous history of abdominal surgery, patient American Society of Anesthesiologists (ASA) score, clinical stage, Gleason score, operative time, estimated blood loss, transfusion rate, length of hospital stay, bladder catheterization, and analgesic requirement, as well as histopathologic findings such as surgical margin status, TNM stage, and Gleason score. To categorize the complications, the recently updated Clavien classification system was used [7].

Surgical procedures

All retrograde and antegrade LRPs were performed through the Heilbronn technique and modified Brussels technique, respectively [[8], [9]]. The former technique includes an ascending part, with early division of the urethra and posterolateral dissection of the prostate, followed by incision of the bladder neck and dissection of the seminal vesicles and vas deferens [8]. In the Brussels technique, includes an descending part which is the first step is the dissection of the bladder neck. Then the vas deferens and seminal vesicles are dissected followed by ligation of the dorsal vein complex and division of the urethra. An interrupted figure “X” UV anastomosis was performed [9].

Regardless of the approach, pelvic lymphadenectomy was performed when the PSA level was >10 ng/mL or when the Gleason score was 7 or greater. Unilateral or bilateral nerve‐sparing procedure was performed in all potent patients with a PSA of <10 ng/mL and a Gleason score <7 and without any palpable nodule.

Follow up

Pre‐ and post‐operative evaluation of continence and potency for all patients was performed by using the pad test and the Sexual Health Inventory for Men questionnaire. Patients not requiring any pads or those who did require one pad for safety were defined as continent. The use of one to two pads daily and normal physical activity (such as walking) was defined as mild incontinence. Severely incontinent patients used more than two pads per day. Functional results were recorded at 3, 6, and 12 months after operation.

Statistical analysis

All analysis was performed by using SPSS version 15.0 (SPSS Inc., Chicago, IL). Numerical parameters between both groups were compared using Student's t test. The chi‐square test was used for comparison of descriptive data. Statistical significance was considered at p < 0.05.

Results

The mean age was 62.8 ± 6.2 years for patients in Group 1 and 63.5 ± 5.3 years in Group 2 (p = 0.212). Both groups were statistically similar with respect to age, clinical stage, preoperative PSA, ASA score, prostate volume, and previous abdominal/pelvic surgical history. The patient demographic characteristics for both groups are compared in Table 1.

Table 1.

Patient demographic characteristics.

	Retrograde technique (Group 1)	Antegrade technique (Group 2)	p
No. of patients (%)	42 (31%)	93 (69%)
Mean age (range in years)	62.8  ±  6.2 (47–74)	63.5  ±  5.3 (49–78)	0.212
BMI (kg/m2)	25.4  ±  1.47	27  ±  0.93	<0.001*
Preoperative PSA (ng/dL)	10.1  ±  5.5 (2.2–26)	9.8  ±  3.4 (2.3–23.2)	0.157
Biopsy Gleason score			0.526
2–6	25 (59.5%)	61 (65.2%)
7	17 (40.5%)	32 (34.8%)
8–10	—	—
Clinical stage			0.106
T1c	27 (64.3%)	60 (65.2%)
T2a	12 (28.6%)	25 (27.2%)
T2b‐c	3 (7.1%)	8 (7.6%)
Mean prostate volume (mL)	40.5  ±  22.4 (15–120)	41.2  ±  17.3 (12–90)	0.848
ASA			0.2
1	10 (23.8%)	11 (12%)
2	28 (66.7%)	74 (79.3%)
3	4 (9.5%)	8 (8.7%)
Prior abdominal/pelvic surgery	10 (23.8%)	12 (12.9%)	0.19

* Statistically significant at p  <  0.05.

ASA  =  American Society of Anesthesiologists Score; BMI  =  body mass index; PSA  =  prostate‐specific antigen.

Intraoperative and postoperative data are shown in Table 2. Mean operative time was significantly longer in Group 1 (244 ± 18.3 vs. 203.3 ± 18.4 min, p < 0.001), whereas mean anastomosis times were similar in both groups (35.8 ± 7.2 vs. 34.7 ± 5.8 min, p = 0.155). No statistical difference in terms of nerve‐sparing procedures or lymph node dissections performed was found between the two groups. Estimated blood loss and transfusion rates were significantly lower in Group 2 (p < 0.05 for both). Furthermore, a statistically significant difference was observed for both hospitalization (6.79 ± 3.3 vs. 5.46 ± 3.08 days, respectively; p = 0.026) and catheterization times (12.24 ± 2.1 vs. 11 ± 1.08 days, respectively; p = 0.001) for Group 2. The total complication rate was 47.6% in Group 1, and 11.8% in Group 2 (p < 0.01). We observed five grade III complications including bladder neck contracture and bladder injury requiring surgical repair. No death or grade IV complications according to the Clavien classification were noted in either group. The complications are summarized in Table 3.

Table 2.

Perioperative and postoperative data.

	Retrograde technique (Group 1)	Antegrade technique (Group 2)	p
Mean operation time (min)	244.02  ±  18.3	203.36  ±  18.4	<0.001*
Mean anastomosis time (min)	35.8  ±  7.28	34.17  ±  5.84	0.155
Estimated blood loss (mL)	527.14  ±  265.18	203.36  ±  18.41	<0.001*
Blood transfusion (%)	9 (21.4%)	3 (3.2%)	0.002*
Pelvic lymphadenectomy (%)	19 (45.2%)	43 (46.2%)	0.914
Nerve‐sparing procedure
Unilateral (%)	10 (23.8%)	33 (35.4%)	0.251
Bilateral (%)	6 (14.2%)	19 (20.4%)	0.523
Mean catheterization time (day)	12.24  ±  2.1	11  ±  1.08	0.001*
Mean hospitalization time (day)	6.79  ±  3.3	5.46  ±  3.08	0.026*

* Statistically significant at p  <  0.05.

Table 3.

Complication rates.

	Retrograde group	Antegrade group	Grade	p
Abdominal wall hematoma	2 (4.7%)	1 (1.1%)	I	1
Urinary tract infection	3 (4.7%)	3 (2.1%)	II	0.373
Bleeding requiring transfusion	9 (21.4%)	3 (3.2%)	II	*0.001
Anastomotic leak	1 (2.4%)	—	II	0.309
Acute urinary retention	2 (4.7%)	2 (2.1%)		0.587
Bladder neck contracture	2 (4.7%)	2 (2.1%)	III	0.587
Bladder injury	1 (2.4%)	—	III	0.309

* Statistically significant at p  <  0.05.

There was no statistical difference between the groups in terms of the pathological results. Of the 42 patients in Group 1, 37 patients (88%) had pathological localized disease (pT2) and five patients (12%) had pathological locally advanced disease (pT3). Of the 93 patients in Group 2, 81 patients (87%) had pT2 and 12 patients (13%) had pT3. Rates of positive surgical margins were 14.2% and 15% in Groups 1 and 2, respectively (p = 0.907). At the 12‐month interval from operation, similar recoveries in urinary continence were obtained in both groups (81% in Group 1; 91% in Group 2). There was no severe postoperative incontinence in the two groups at 1‐year follow‐up.

Discussion

Since the initial report on LRP by Schuessler et al. in 1992, the procedure has been adopted by several urologists and, as in open surgery, different modifications have been introduced [2]. Various series comparing the functional and surgical outcomes of transperitoneal and extraperitoneal techniques have been reported [[3], [4], [5], [6]]. Extraperitoneal LRP has been found to have similar oncological results, shorter or equal operation times, and some clinical advantages such as lower morbidity and easier learning curve as compared with the transperitoneal technique [[10], [11]].

The LRP technique can also be performed with the retrograde technique (from the prostate apex to the base) or antegrade technique (from the base to the apex). Although several studies on LRP are available, data comparing retrograde and antegrade LRP techniques are insufficient. Therefore, we evaluated the effect of both approaches to extraperitoneal LRP on the functional recovery and surgical outcomes. We did not observe a significant difference between retrograde and antegrade techniques in terms of major complications, anastomosis time, and positive margin rate; but operative time, blood loss, minor complication rate, length of hospital stay, and bladder catheterization time were statistically higher with the retrograde technique.

Ressweiler et al. explained the experience of the German Laparoscopic Working Group [[12], [13]]. They found statistically significant differences in operative time and blood loss, with the extraperitoneal antegrade technique having more favorable outcomes. Early control of the prostatic pedicles and late division of the deep venous complex are probably the main reasons of the minimal blood loss and the clear working field in the antegrade technique as compared with those of the retrograde approach. In the present study, the transfusion rate was also significantly higher in the retrograde technique.

In a recent study, Ko et al. evaluated the impact of antegrade and retrograde approaches on the functional recovery and positive surgical margin rates after robot‐assisted LRP [4]. Findings from this report indicate that the retrograde technique facilitates recovery of potency as compared with that attained with the antegrade technique, without compromising margin status. In another study, Sciarra et al. focused on the effect of antegrade and retrograde approaches on surgical margin status [14]. They showed that use of the antegrade technique for radical prostatectomy is associated with a lower incidence of positive surgical margin. However, the positive margin rates for the retrograde and antegrade approaches in our series for were 14% and 15%, respectively. Hence, we may conclude that long‐term pathological outcomes were similar in both groups.

Continence status is an important concern related to patients' quality of life after radical prostatectomy. In the present series, similar recoveries in urinary continence were obtained with the two groups (81% in Group 1; 91% in Group 2) at the 12‐month interval from operation. Similar results were reported by Ficarra and colleagues in a systematic review [15]. They found comparable postoperative continence following different radical prostatectomy approaches.

The present study has some limitations in terms of the relatively small number of patients and the inadequate long‐term follow‐up data for evaluating survival rate, clinical recurrence, or biochemical recurrence. Therefore, our findings must be confirmed by large prospective randomized trials. Despite all of these limitations, we believe that our results will bring a new perspective to the selection of LRP techniques.

Conclusions

When retrograde and antegrade LRP techniques were compared, both methods were found to be effective; however, antegrade approach provided a lower rate of minor complications, less blood loss, shorter operation time, and shorter length of hospital stay.