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Minimally invasive (laparoscopic) radical prostatectomy (LRP)

Posted Sep 17 2008 1:46pm

Some History

The first laparoscopic radical prostatectomy (LRP) — based on techniques developed for minimally invasive gall bladder surgery (cholecystectomy) and knee and other joint surgery (arthroscopic surgery) — was carried out at Southeast Baptist Hospital in San Antonio, Texas, in 1991. However, attempting nine procedures between 1991 and 1995, Schuessler et al. determined that LRP was

feasible but currently offers no advantage over open surgery with regard to tumor removal, continence, potency, length of stay, convalescence, and cosmetic result.

In 1997, a small group of French physicians, under the leadership of Guy Vallancien and Bertrand Guillonneau made a second attempt to develop a laparoscopic method to carry out radical prostatectomy, and rapidly demonstrated the potential of this technique.

Since the introduction of LRP, the procedure has divided into two “camps”: the “non-robotic” procedure and the “robotic” procedure. For an explanation of the distinctions, see the section ” Who needs a robot — and why?

In the USA, an unknown number of “non-robotic” LRPs together with about 50,000 robot-assisted LRPs were carried out 2007 (see Box and Ahlering ). Thus, for a increasing number of urologists (and their patients), LRP is now the “hot” treatment option for management of early stage prostate cancer. This also means that the majority of urologists using this technique are still on their “learning curve.”

The Basics

The modern LRP is an adaptation of Walsh’s open “anatomic” radical retropubic prostatectomy. The key difference is that ― instead of having to make a relatively large incision in the lower abdomen, and operate through an “open hole,” the surgeon operates using minituarized videocameras and surgical equipment inserted into the abdominal cavity through very small incisions (”ports”). At the end of the operation, one of these incisions is enlarged just enough for the surgeon to remove the entire prostate, contained in a small plastic bag.

The following points are critical to understanding what will happen during and immediately after any laparoscopic radical prostatectomy:

  • Like other forms of prostatectomy, the procedure is carried out in a hospital under general, spinal, or epidural anesthesia.
  • Your surgeon will make five small “ports” in the lower part of your abdomen. They will be used by the surgeon and his assistant for two videocameras and various surgical tools.
  • As for a normal radical retropubic prostatectomy, the operation will include the removal of the entire prostate, the associated seminal vesicles, and (perhaps, if necessary) some of the pelvic lymph nodes to see whether cancer has spread into these nodes.
  • After removal of the relevant organs, the surgeon will reconnect your urethra to your bladder so that urinary function is restored.
  • All patients will initially require a urinary catheter (a tube that runs up through your penis into your bladder), which facilitates healing in the correct anatomical position.

This operation may take anything from about 90 minutes to 4 hours depending on things like prostate shape and size, patient size, need for lymph node removal, and the skill and experience of the surgeon.

The patient may be able to leave the hospital the same day or may need to stay in the hospital overnight, just to make sure there are no significant complications. The post-surgical recovery period is also brief, with patients commonly able to resume much of their normal routine within 3 to 5 days (although they will likely still need to have the urinary catheter in place for a longer period).

The Details

The laparoscopic technique has been described in detail by Guilloneau, Krongrad, and Vallencien. We therefore refer the interested reader to their original publication:

Please appreciate that this publication was prepared primarily for the education of other surgeons, but it is not difficult for an informed layman (or laywoman) to read and understand.

There are also many, many online video presentations demonstrating LRP, which can be seen on YouTube. Most of these are focused on the robotic as opposed to the non-robotic technique.

Once again, as with other forms of radical prostatectomy, from the patient’s point of view the technical details of the surgery are not really of any great significance. It is the outcome that is of importance. And the outcome is primarily dependent on the skill and experience of the surgeon, not on the equipment he or she is using.

For patients, The Krongrad Institute offers specific answers to over 30 questions about LRP on its web site.

We have addressed the relative merits of robot-assisted and non-robot-assisted LRP on another page. However, we will say this again here for emphasis: From the patient’s viewpoint it is the outcome that is  important, and the outcome is primarily dependent on the skill and experience of the surgeon, not on the equipment he or she is using.

Who Is an Appropriate Patient for This Procedure?

Any patient who is believed to have early stage (localized) prostate cancer, i.e., prostate cancer that is confined within the prostate, is theoretically an appropriate candidate for LRP. Such patients would normally have clinical stage T1N0M0 or T2N0M0 prostate cancer. This description of an “appropriate” patient for LRP is exactly the same as the description of an “appropriate” patient for RRP and RPP.

The Results You Can Reasonably Expect

All the available data now suggest that, when carried out by skilled and experienced surgeons (with or without the use of “robotic” assistance), LRP has similar long-term outcomes to those achieved using open radical retropubic and open radical perineal prostatectomy. The key differences for the patient relate to short-term issues such as post-surgical recovery time (much shorter), blood loss during surgery (minimal), and post-surgical pain (usually minimal).

A question that almost all patients want an answer to is, “What happens if you decide you can’t do the operation using laparoscopy after you have started?” As far as The “New” Prostate Cancer InfoLink is able to tell, the need to convert an operation from LRP into an open procedure is rare. Since 1997, Krongrad has completed over 1,000 LRPs, and only one of those operations was converted to an open RRP.

A very small number of surgeons have been doing the operation this way for 10 years, and those surgeons will all admit that their first 200 or so procedures were part of their “learning curve.” In other words, they do the operation technically better today than they did it when they first started.

The earliest long-term follow-up data on LRP were published in 2001 by Guillonneau et al. on the French group’s first 350 patients. As of December 2006, this group had carried out 3,061 LRPs, but long-term follow-up on these patients is not yet available. The “key learnings” from their initial 350 patients are still instructive today, however, because the majority of surgeons using LRP are somewhere along in their first 350 cases:

  • No deaths were observed in this series, and conversion from laparoscopic to an “open” procedure was required in only seven cases (all occurring among the first 70 patients).
  • The mean operating time for all 350 patients was about 3.5 hours, including the lymphadenectomy phase that was considered necessary in 21.4 percent of patients.
  • The mean operating time was just over 3 hours for the last 200 patients.
  • The mean intraoperative blood loss averaged 354 mL.
  • The overall transfusion rate was 5.7 percent, and 2.8 percent in the last 250 patients.
  • Intraoperative complications were reported in 14 patients (4 percent), and the reoperation rate was 3.7 percent.
  • The average postoperative bladder catheterization time was 5.8 days, and the catheter could be removed before the fifth day in 41 percent of patients.
  • By pathologic stage, the positive surgical margin rate was 3.6 percent for pT2a specimens (3 patients), 14 percent for pT2b specimens (29 patients), 33 percent for pT3a specimens (12 patients), and 43.5 percent for pT3b specimens (10 patients).
  • In the first 75 patients with pT2N0/Nx negative-margin specimens and a follow-up of >12 months, the PSA concentration was <0.2 ng/mL in 92 percent of patients.
  • The continence rate (no protection necessary either during the day or at night) among the first 133 patients was 85.5 percent and the postoperative erection rate was 59 percent among 22 selected consecutive patients.

There are two messages to the patient:

  • First, truly localized disease can be treated by minimally invasive LRP with a high degree of confidence that all cancer will be removed if the cancer really is organ-confined at the time of surgery (as is true with open prostatectomies). Again, however, until the operation is completed, the surgeon simply has no way to tell whether the tumor really is organ-confined.
  • Second, until the surgeon has done somewhere around 200 procedures (regardless of his/her prior experience with other forms of prostatectomy), he or she is still on the steep part of the learning curve.

A variety of tools, including the Partin tables, the Han tables, and the Kattan nomograms are available to help doctors and their patients project estimates of pathological stage and likely clinical outcome as determined from open radical retropubic prostatectomy data, based on pre-surgical data (the patient’s PSA, clinical stage, and biopsy-based Gleason score), post-surgical data (the patient’s pathological stage and pathology-based Gleason score), and other factors. These “prognostic tools” are discussed in detail elsewhere.

The Adverse Effects of Treatment

LRP comes with the same series of common (but usually manageable) short-term side effects as RRP and RPP, a risk for some significant and problematic long-term side effects, and a risk for some serious short-term risks, as follows:

The common, short-term side effects — Immediately following surgery almost every patient has at least some degree of two short-term problems. He has little to no control over his bladder, and he will have lost the ability to have an erection (even if he has the nerve-sparing procedure).

Assuming that the operation has been successfully carried out, and there are no unexpected complications, a high level of urinary control will commonly start to return within days or weeks. (It is true that some men are continent immediately but they compose a decidedly small proportion of patients.)

The vast majority of patients treated with LRP should regain a high level of continence within a few weeks. However, nearly all men will find that they don’t have quite the same degree of urinary control as they may have had prior to their surgery. Even 5 or 10 years after surgery, some men may worry about minor leakage on sudden movement or when lifting a heavy weight. For most men this is a minor irritation as opposed to a serious problem.

Recovery of erectile function normally takes longer. The neurovascular bundles (even when preserved) are always affected to some degree by the surgical procedure. (You can think of this in terms of them being badly bruised by the procedure.) Some men find that they recover a degree of erectile function within a few weeks. For others it may take 18 months to 2 years. The overall likelihood of recovery of erectile function is dependent on many factors, not just on anatomical preservation of the neurovascular bundles. These factors include age, baseline function, obesity, smoking history, other illnesses (e.g., diabetes, depression, and fatigue), and more. Radical prostatectomy is not an operation designed to improve erectile performance for men! The use of products like sildenafil (Viagra/Pfizer) or taldalifil (Cialis/Lilly) can assist with both the return of erectile function and the quality of performance once function has returned.

Problems with bowel movements appear to be minor to nonexistent in men undergoing LRP.

Significant, longer-term problems — For a relatively small percentage of men (particularly in the hands of the most skilled and experienced surgical teams), long-term incontinence and perceived failure to achieve the return of erectile function may become major issues. And if both neurovascular bundles have to be removed, then normal erectile function is very rarely going to return (although it is known to happen). There are ways to address both of these problems, but they require the understanding and the cooperation of both partners. For many men, loss of erectile function can be emotionally and psychologically disturbing and, in combination with the diagnosis of cancer and other life stressors, can lead to clinical depression.

Similarly, some men may never regain a normal level of urinary continence; and we do not understand why this happens. Again, there are ways to manage such problems, sometimes requiring additional surgery or other interventions. However, as with loss of erectile function, loss of bladder control can lead to depression as a consequence of the loss of control over an important, normal function.

The third longer term issue that occurs with some frequency is a slowly (or sometimes rapidly) increasing difficulty with urination. Most commonly this is a result of what is known as a “bladder neck contracture.” When your urethra is reconnected to your bladder, there may be regrowth of tissue as the surgical join recovers. This may result in the new tissue gradually blocking the urethral passage, and making it difficult or impossible to urinate. Various surgical means are available to resolve this problem in the short term and the longer term. For the vast majority of men who experience this problem, it may be temporarily worrisome but is relatively easily solved.

The serious short-term risks — Even a laparoscopic retropubic prostatectomy is a serious and invasive surgical procedure. As with all such procedures, there are risks related to anesthesia and the normal complications of surgery. However, the number of deaths associated with laparoscopic radical prostatectomy has been vanishingly small since the introduction of this technique, and has occurred only in the most unusual circumstances. (Please understand that it is never zero for any invasive surgical procedure.)

The risk of serious blood loss associated with laparoscopic radical prostatectomy is even less of a problem than it is with the radical perineal procedure.

Please understand that this is not, nor is it intended to be, a complete list of every possible risk associated with minimally invasive (laparoscopic) radical retropubic prostatectomy. If you decide to work with a surgeon who intends to use this procedure, you should be sure to review all relevant adverse events that may occur — including infertility, infection, injury to other organs, pain, and recurrence — with that surgeon prior to your operation, and you will certainly be asked to sign a relevant consent form prior to surgery.

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