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In the UK, over 4000 patients undergo radical prostatectomy for early prostate cancer each year. The procedure is technically challenging and there is ample evidence that outcomes are influenced by the experience of the operating surgeon. At the same time, patients are becoming more aware both of the variety of techniques used to treat prostate cancer and the different surgical approaches.
The following papers attest to the fact that, in experienced hands, there is little to choose between the outcomes of open versus laparoscopic prostatectomy both in terms of cancer control and functional results. The issues, therefore, are the increased cost of the laparoscopic approach versus the likely patient preference for minimally-invasive surgery. Is radical prostatectomy an operation for which, given the clinical equivalence of the procedures, the NHS should consider funding only the cheaper option or at least expect a patient contribution if he opts for a more-expensive procedure?
1The Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading, UK
✉
Correspondence to PR Malone, Consultant Urological Surgeon, The Harold Hopkins Department of Urology, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK E: Peter.Malone@royalberkshire.nhs.uk
With the introduction of the nerve-sparing radical prostatectomy in the 1980s, Walsh and colleagues1 revolutionised the treatment of localised prostate cancer. Despite the challenge of new technologies, such as brachytherapy, it has stood the test of time. At first the concept of a laparoscopic approach is appealing, appearing to combine the advantages of surgical removal of the cancer with a ‘minimally invasive’ procedure; the best of both worlds. However, the question is – does it deliver? The authors have compared the two techniques in terms of the major complications of this operation.
Complications of open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP)
Failure of surgery to eradicate the cancer
The most important aspect of radical surgery for prostate cancer is to provide a cure for the disease. Owing to the indolent nature of prostate cancer, it will still be many years before the true outcome of LRP will be known. Positive surgical margins are recognised as being an independent prognostic indicator for biochemical recurrence. There appears to be little difference in overall margin positivity rates between LRP and ORP.2 Nevertheless, there is evidence that, when stratified by clinical stage, ORP has lower margin positivity rates in pT2 disease.3
Continence
Incontinence is one of the most distressing side-effects of surgery, although fortunately most men recover well. Variations in definitions of continence make comparison between studies difficult. More recently, quality of life assessment tools have been used and these show excellent continence rates at 1 year for both LRP4 and ORP.5 There is nothing in the literature to suggest that equally expert surgeons differ in their abilities to achieve continence in their patients.
Potency
With increasing numbers of sexually active patients undergoing radical prostatectomies, potency rates have become increasingly important. In the majority of studies reported in the literature, retrospective reviews with variable definitions are used to assess potency. Increased magnification and better visualisation of the neurovascular bundles in LRP might be expected to provide a better outcome but this may be offset by the use of diathermy to achieve haemostasis. In the end, head-to-head studies show similar potency rates at 1 year.6 It appears, therefore, that despite the theoretical advantage of LRP, no clinical benefit has been shown. All of these studies have compared the results of nerve-sparing operations. Whereas this is the standard operation with ORP, it is a technically difficult and long procedure to do laparoscopically, so many inexperienced surgeons choose to sacrifice the neurovascular bundles particularly in the early stages of their learning curve. Potency rates are nearly always quoted in terms of the percentage of patients in whom a nerve-sparing operation was performed rather than the overall rates.
Blood loss
The effect of the pneumoperitoneum in LRP means that it is generally accepted that there is less intra-operative blood loss compared to ORP;2 however, it is not clear that, amongst experts, there is a difference in blood transfusion rates.3 If this is so, then the implication is that bleeding takes place postoperatively in LRP compared to peri-operatively in ORP rendering the patient more at risk of haematoma formation with all its inherent complications. The rate of transfusion does not appear to be clinically significant.
Postoperative pain and hospital stay
In a review of studies looking at postoperative pain levels, surprisingly there appeared to be no difference in pain levels between ORP and LRP.7 This suggests that the difference in postoperative pain in other operations may not be so apparent with the lower midline incision used in ORP. The duration of a patient's stay in hospital is partly dependent on the surgery and partly dependent on other factors, such as patient and surgeon preference and timing of removal of the catheter. LRP advocates claim that the direct visualisation of the vesico-urethral anastomosis enables a more water-tight anastomosis and, therefore, enables earlier removal of the catheter. In fact, retention rates after early removal on day 3 are unacceptably high in both LRP and ORP;8,9 thus, most surgeons prefer to wait a week before trial without catheter. Because laparoscopic surgeons frequently favour a trans-peritoneal approach, particularly if inexperienced, when there is an anastomotic leak, it renders the patient at significant risk from urinary peritonitis.10
Injury to other structures
In a recent systematic review of studies comparing ORP to LRP,2 21 studies were identified that gave head-to-head comparisons. The conversion rate ranged from 0–14% (median 2%) in 12 studies. In these, there appeared to be a slightly higher rate of ureteric injury in the LRP group in 6 studies. Rectal injury appears to be a particular problem in LRP with rates of 1–2% recorded in large series compared to rates of less than 1% in ORPs.3 In addition, rectal injury appears to be more apparent intra-operatively in ORP than in LRP and, therefore, more likely to be repaired at the time of surgery obviating the requirement for colostomy.
Learning curve
A number of studies have made note of a significant learning curve required for LRP.2 Conversion rate, complications, blood loss and transfusion rates all improved with experience, though no standard number of operations was identified. Although operative time for LRP does decrease with experience,2 it is accepted that the nature of laparoscopic surgery means that it will take longer to perform. Eden et al.10 reported, as have others, a maximum operating time of 10 h in the early stages of his learning curve. Anyone who is on the operating table for 10 hours runs a significant risk.
Cost
The factors that need to be taken into account when considering cost analysis reflect not only the equipment and theatre consumables used, but also the effect of a longer hospital stay, prolonged operative duration and personnel cost. Those studies available clearly demonstrate reduced costs for ORP over LRP.11,12 The main discrepancy in costs arises from the increased cost of laparoscopic consumables over open surgery consumables and the longer operative time.
Discussion
Despite the interest in LRP, it has still to prove itself. There is no evidence to show that LRP has a better oncological outcome than ORP; in fact, some evidence showing that ORP is better in pT2 disease. Despite the supposed benefits of magnification helping to preserve the neurovascular bundles and thus potency and continence, no clinical improvement has been demonstrated. Although the results of bilateral nerve sparing LRP are comparable to ORP, the nerve bundles are preserved in fewer LRP than ORP. There is reduced intra-operative blood loss in LRP; however, this has yet to be shown to be of any clinical significance, and the effect of removing the pneumoperitoneum has not yet been established. The cause for the reported reduced hospital stay for LRP is uncertain as other local factors may dictate patient discharge. ORP is performed much more quickly than, and as safely as LRP, with no increase in postoperative pain and at a reduced cost. In addition, it does not carry the steep learning curve that is widely recognised as existing with LRP.
Conclusions
Expert surgeons in either ORP or LRP provide excellent outcomes. However, there is no demonstrable benefit of LRP over ORP and significant problems with training and costs. It is disingenuous for laparoscopic surgeons to imply any advantage of laparoscopic over open surgery save for the loss of the scar, and this has to be traded for the increased risk of intra-operative complications particularly early on in the learning curve. There can be little doubt that an experienced open surgeon will give better results than an inexperienced laparoscopic surgeon. The long road to experience in laparoscopic surgery, in all but the most expert hands and in the absence of a robust mentoring system in the UK, will leave many casualties en route.
References
1.Eggleston JC, Walsh PC. Radical prostatectomy with preservation of sexual function: pathological findings in the first 100 cases. J Urol. 1985;134:1146–8. doi: 10.1016/s0022-5347(17)47661-0. [DOI] [PubMed] [Google Scholar]
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To a large extent, the argument as to whether laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP) is better is a false one. The outcome of any operation is dependent on two factors: (i) the characteristics of the disease being operated on; and (ii) the surgeon, especially his or her experience and currency. Patients, armed with their internet search, usually ask the wrong question, namely: ‘what is the best technique for my prostate cancer to be removed?’, rather than focusing on the more important question of ‘who should do my operation?’ Although the relationship between surgical volume and outcome is now well-established for complex operations, including radical prostatectomy,1 it is easy to understand why some surgeons are reluctant to emphasise this link when counselling patients if one considers that 10% of radical prostatectomies performed in the UK in 2004 were done by surgeons who did ≤ 5 cases during that year and 65% were done by surgeons doing ≤ 20 cases a year.2 There is no better example of an operation in which subtle changes in surgical technique result in large differences in outcome, especially for potency and continence, than radical prostatectomy. Little surprise then that lower-volume UK surgeons struggle to match the major endpoints of success of radical prostatectomy, such as positive surgical margin rates,3 achieved in higher-volume North American centres.
Division of dorsal vein complex at laparoscopic prostatectomy.
The following comparison between LRP and ORP assumes that the technique is performed by surgeons of equal experience and skill. The figures already presented suggest that, for some patients sitting opposite their surgeon to discuss the proposed treatment of their localised prostate cancer, this assumption is likely to be invalid. Robotic radical prostatectomy will not be considered further as it is not truly a laparoscopic technique (in reality, it precludes the acquisition of laparoscopic skills) and as its literature is tainted by irreproducible results, such as 96% postoperative potency rates,4 which belong more properly in the realm of science fiction rather than science fact.
Aside from any theoretical advantage to the patient, laparoscopy provides the pelvic surgeon with a much better view of the target organ thanks to markedly reduced venous bleeding and variable magnification. The literature suggests that one can progressively overcome the theoretical disadvantages of laparoscopy with increasing experience: 2-D vision and the different perspective to ORP and LRP suturing. It is these difficulties which make the learning curve for LRP long and steep, which translates into patient morbidity. The literature shows precisely this trend: early series with small patient numbers and short follow-up can (and have) produced terrible results whereas large series with more mature follow-up show that the results of LRP are at least as good as the best reported results of open surgery (Table 1) when performed by experts.2,5–8 No surprise then that the UK National Institute for Clinical Excellence and Health recently reversed its negative guidance on LRP issued in October 2003 (which was based on a literature search performed in 2002). If, and when, an expert laparoscopic surgeon is able to match the best results of ORP, the argument then hinges around the weight a patients attached to the generic advantages of laparoscopic surgery and reduced bleeding. Experience with laparoscopic cholecystectomy during the past two decades suggests only one likely outcome.
Emerging evidence from high-volume centres suggests that LRP might offer a further advantage for obese patients (BMI ≥ 30 kg/m2), in whom open pelvic surgery is notoriously difficult, with the added morbidity that difficult surgery often precedes. A study of 532 patients undergoing LRP by our group has found that, although the operating time was 15 min longer for obese patients, all other parameters, including blood loss, hospital stay and complications, were comparable in the two groups.9 This contrasts with the literature on ORP in which Chang and colleagues reported a significantly greater blood loss and transfusion requirement in the obese patients in their series of 436 patients.10
A further study of 600 patients by our group concluded that prior transurethral prostatectomy or bladder neck incision did not affect medium-term outcomes following LRP,11 in contrast to the ORP literature in which Tomschi found that the risk of bladder neck stenosis was double (26% versus 13%) following TURP in a series of 239 patients.12 We postulated that the more reliable tissue apposition at the anastomosis achieved by LRP is responsible for lowering this risk to base-line levels, even when a large bladder neck repair has been undertaken, such as that mandated following TURP.
No patients have been excluded from LRP in favour of ORP in the last 700 LRP cases we have performed so far. Conversely, we have operated on 4 patients in the past 9 months who have been refused open surgery for a variety of reasons: morbid obesity (BMI = 44 kg/m2); prior proctocolectomy and formation of faecal ileal reservoir; prior laparoscopic extraperitoneal bilateral mesh inguinal hernia repair; and prior Millin's prostatectomy.
Conclusions
In expert hands, LRP is capable of matching the best results of ORP and may be the approach of choice in certain high-risk patient groups. The generic advantages of laparoscopy and reduced bleeding are likely to persuade most patients to opt for LRP. However, the advantages of a laparoscopic approach are likely to be dwarfed by the influence on results of surgical expertise and currency on results.
References
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