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Laparoscopic Radical Prostatectomy - Mark Wright

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06/09/2006

Introduction

    At the time of writing this chapter over 500 Laparoscopic Radical Prostatectomies (LRPP) have been performed in the United Kingdom. With the increasing numbers of surgeons performing the procedure this chapter looks to review the technique, and critique the published results and functional outcomes.

History

    The first attempt to perform laparoscopic prostatectomy was presented by Schussler et al. at the American Urological Association meeting in 1992. In 1997 the same group published their experience of nine cases (1). They concluded that initial operations appeared to have little advantage over open surgery primarily due to the long operation times (mean 9.4 hours).
    In 1998 Vallancien and Guilloneau refined and standardized the procedure using a transperitoneal approach to the seminal vesicles and ampullae and intra-corporeal suturing (2). In the same year the first extra peritoneal LRPP was described by Ralboy et al.(3). Over 3000 cases have been subsequently recorded in the world literature.

Indications


    
Patients with clinically organ confined prostate cancer in males with a greater than 10 year life expectancy. As in open surgery coagulopathies are a contra-indication, however, there are no other absolute contra-indications to a LRPP. Patients who have previously undergone trans-urethral prostate surgery, or laparoscopic hernia (mesh) repair, or who are on anti-androgen medication should be approached with caution.

Equipment

    Table 1 lists the equipment recommended as a basic armamentarium for pelvic laparoscopic surgery:

Table 1: Laparoscopic equipment.

Re-useable

Single- use

Laparoscopic Pledgets

*

Johann Forceps x2

*

Needle holders x2

*

Laparoscopic J Hook

*

Maryland Forceps

*

Suction Irrigation device

*

Bipolar Forceps

*

Weck clip applicator

*

Urethral Sound

*

Laparoscopic Scissors

*


 

Patient preparation


    
Patients are anaesthetized with a general anaesthesia and muscle relaxant. Intravenous cephalosporin is administered on induction and an arterial line is placed to monitor blood pH (4). The patient is placed in a supine position on the operating table with 10-20 degrees of Trendelenberg. The abdominal wall is shaved from the costal margins to the symphysis pubis and the skin is prepped with an iodine-based disinfectant. Once draped a 20 Foley catheter is inserted per urethra and 20cc of water inserted into the catheter balloon. The catheter is placed on free drainage.

Operative steps:


A. Extra-Peritoneal Laparoscopic Radical Prostatectomy

  • Introduction of primary port.

A 10mm incision is made just inferior to the umbilicus and the anterior rectus sheath is incised using MacIndoe scissors. The anterior sheath is then retracted vertically using a 5mm retractor.

  • Creation of cave of Retzius.

A 10mm diameter inflatable balloon port (Tyco XB2 Endoview) is inserted through the incision in the anterior rectus sheath and passed caudally until the symphysis pubis can be palpated. A zero degree laparoscope is then passed into the port and the balloon is inflated with a hand pump. Approximately 400cc of air is insufflated until the following landmarks can be identified:

  1. Left and Right inferior epigastric arteries
  2. pubic arch and symphysis
  3. external iliac vessel pulsation
  4. internal inguinal rings are checked for any signs of herniation.

The balloon is then deflated and the preperitoneal space is checked for haemorrhage.

  • Port placement.

The placements of ports are very much operator dependent, however the following points need to be considered:

  1. with only one assistant only three ports are required – two for the surgeon and one for the free hand of the assistant for traction and suction.
  2. if an additional assistant is used or robotic camera holder employed, four ports can be utilized.
  3. a minimum of one 10mm port is required to allow introduction of sutures for intra-corporeal stitching. Two 10mm ports allow more flexibility.
  4. if the surgeon’s operating ports are placed either side of the primary camera port, this allows easier triangulation, but is less ergonomic. The alternative is to have the two operating ports to the left of the camera.

All ports should be inserted under endoscopic vision angled down towards the prostate. Structures to be avoided during placement include the inferior epigastric arteries, iliac veins, bladder and peritoneum.

  • Pelvic Lymphadenectomy

A bilateral lymphadenectomy is conducted removing lymphatic tissue in the area bounded by the pubic bone, external iliac vein and obturator nerve.  The lymphatic channels are sealed using 5mm titanium ligaclips to prevent a post-operative lymphocele.

  • Endopelvic fascia incision.

The prostate is retracted medially using a laparoscopic pledget, thus placing the endopelvic fascia under tension. A 1mm puncture is made in the fascia using a monopolar hook and then a linear incision is made in the endopelvic fascia from the vesico-prostatic junction to the edge of the pubo-prostatic ligaments using cold scissors. The lateral edge of the dorsal venous complex is then defined using a lap pledget. This process is repeated on the contralateral side.

  • Dorsal venous complex ligation.

The prostate is retracted inferiorly and a 1 Polysorb suture cut to 20cm is mounted in a needle holder in a plane parallel to the pubic arch. The needle is then rotated between the DVC and urethral wall and withdrawn at the contralateral side of the apex. A surgeon’s knot tied intracorporeally is then used to secure the DVC and pubo-prostatic ligaments. A helpful technique to facilitate this manoeuvre includes replacing the catheter with the urethral sound so that the prostate can be moved from side to side to facilitate the entry point of the needle and pick-up.

A further suture is then placed at the level of the anterior bladder neck to prevent back-bleeding from the superficial vesical veins.

  • Anterior bladder neck dissection.

The pre-prostatic veins are divided between the sutures with cold scissors and a lateral release performed bilaterally to allow the NVBs to fall posteriorly. The anterior neck is then identified by gentle to-and-fro traction on the urethral catheter. A combination of sharp and blunt dissection is then used to delineate the anterior and lateral walls of the bladder neck. Extra care on the lateral aspect of the anterior bladder neck will help prevent ureteric damage at the next step of the procedure.

The urethra is then incised anteriorly, the catheter balloon deflated and the catheter is grasped with a Johann forceps and used to retract the prostate superiorly by the assistant.

  • Posterior bladder neck dissection.

The posterior bladder neck is easily visualized with the prostate retracted and is then assessed for the presence of a median lobe and the exact location of the ureteric orifices. A horizontal incision is then made at the proposed line of trans-section. As this incision is developed, the posterior edge of the bladder neck is grasped in the midline with a Johann forceps and retracted anteriorly. The posterior bladder wall is then peeled off the prostate with a combination of sharp and blunt dissection. Care must be taken not to button-hole the posterior wall of the bladder. The anterior layer of Denonvillier’s fascia is then identified as a midline raphe and incised horizontally.

  • Dissection of ampullae

Incision of the mid-line raphe allows access to the paired ampullae which are grasped and retracted cranially. The vasa deferentia are dissected free of their investing tissue and ligated with locking nylon clips. These are then divided with cold scissors.

  • Dissection of seminal vesicles.

The freed ampullae are then grasped and retracted anteriorly. This allows access laterally to the seminal vesicles. Whilst it is safe to perform the circumferential dissection with bipolar diathermy, the tips of the vesicles lie very close to the NVBs and it is important not to use any thermal or electrical energy in this region. The artery is therefore ligated with locking nylon clips.

  • Lateral Pedicles

Both seminal vesicles are then grasped and retracted anteriorly. The urethral sound is re-inserted and the prostate angled laterally. This places the lateral pedicle under tension and allows accurate vision of the NVB. If a nerve-sparing procedure is to be carried out, then each feeding vessel to the prostate is individually clipped and divided and all forms of thermal energy are avoided. This process is repeated on the contralateral side.

  • Apical Dissection

The prostate is then retracted posteriorly placing it under tension. Cold scissors are then used to dissect the apex of the prostate free taking care to preserve the external-urethral sphincter mechanism and the NVBs that pass just lateral to the sphincter complex.

  • Transection of urethra.

The anterior urethra is transsected just distal to the apex of the prostate and the urethral sound advanced. The urethral is then elevated anteriorly and the posterior wall and recto-urethralis divided. The specimen is then placed in an entrapment bag.

  • Vesico-urethral anastomosis

Two 3/0 laparoscopic sutures (EV-23 17mm needle) are then tied together and introduced via one of the 10mm ports. Van Velthoven described a technique of a continuous Vesico-urethral anastomosis that, once mastered results in a tension-free, water-tight anastomosis that takes 30 minutes to complete (5). This technique is endorsed by the author.

  • Specimen removal.

An 18F silicon catheter is inserted and the anastomosis is checked for integrity by filling the bladder with 250cc of warm saline. The specimen is delivered via the camera (sub umbilical) port.


B.Transperitoneal Laparoscopic Radical Prostatectomy.

The steps for this procedure are almost identical, save for the initial dissection that involves a peritoneal incision over the seminal vesicles and a further incision through the median umbilical ligament to gain entry into the Cave of Retzius.

Complications

No intra-operative mortalities have been reported in the literature (July 2005). Conversion rates to open surgery vary between 0.3%-2.4% but are higher in the first 50 cases (6-9). The commonest cause for conversion is uncontrollable haemorrhage.

Rectal injury, as in ORPP, is rare (1.4%-2.4%) in LRPP and usually occurs at the apex of the prostate in non-nerve sparing procedures (6). The important management point is to recognize the injury at the time of surgery and repair the defect with two layers of interrupted sutures (10). Prolonged catheterization (14 days) is recommended.

Ureteric injury (0.8%) most commonly occurs during posterior bladder neck dissection when a median lobe is present. Injury, in this scenario, can be avoided by careful lateral dissection of the bladder neck and making a sharp horizontal incision in the posterior urethral urothelium overlying the median lobe. The posterior wall is then retracted anteriorly using a Johann forceps and the bladder is peeled off the prostate until the posterior median raphe is identified. The ureteric orifices should then be checked with the laparoscope.

Other complications include inferior epigastric artery and iliac vein damage, Anastomotic stricture and deep vein thrombosis (11) (see table 2)


Table 2: LRPP postoperative complications

Mean (%)

Urinary retention

4.6

Anastomotic Stricture

2.5

Post operative ileus

2.3

Rectal injury

1.9

Bladder injury

1.4

Deep Vein Thrombosis

1.3

Conversion to Open Surgery

1.3

Rectal Injury

0.9

Iliac Vein Injury

0.8

Epigastric Artery Damage

0.5

Blood Loss and Transfusion Rates

In a review of 1228 LRPP at six European centres, the mean blood loss was 448ml with an overall transfusion rate of 3.5% (11). Farouk from the Cleveland clinic reported a mean blood loss of 332cc and a similar transfusion rate of 2% in 100 consecutive LRPPs (12).

Continence

Urinary incontinence is a serious concern for patients undergoing radical prostate surgery. Continence rates from published studies range from 82-92% (6-9), which compare favourably with open RPP (61-95%) (15,16) (see table 3).

In a prospective comparison – non-randomized - between two cohorts of patents undergoing RPP (n=70) and LRPP (n=230) there was no significant difference in continence rates at one year, however the LRPP group had an earlier return to continence resulting in a significant benefit to quality of life (14).

Table 3: Continence rates following LRPP.

Author

Centre

N

% Urinary Continence

Follow-up

Guillonneau

Paris

550

82.3

12 months

Rassweiller

Heidelberg

438

90.3

12 months

Salomon

Creteil

235

90

12 months

Turk

Berlin

125

92.1

12 months

Eden

Basingstoke

100

90

12 months


Erectile Dysfunction.

The preservation of the neurovascular bundles in order to preserve erectile function is a well known challenge to open prostatectomists. A laparoscopic approach should give a magnified, well illuminated view of the NVBs however long term data is not yet available.

The three largest studies (see table 3) report potency rates of 58.8-82.3% (6-9). In these cohorts there was at least six months follow-up, however the definitions of erectile function varied from ‘spontaneous’ erections to others including sildenafil use.

Longer follow-up is required as it is well known from ORPP studies that erectile function can return up to fifteen months post procedure.

A new technique in the refinement of nerve sparing procedure has been described by Gill and co-workers (16). A trans-rectal ultrasound and colour Doppler probe is used to monitor the NVBs during resection of the lateral pedicles. Functional results are awaited.

Table 4: Potency Rates following LRPP.

Centre

N

% Potency with Nerve Sparing Procedure in Previously Potent

Patients

Creteil

235

58.8

Montsouris

550

82.3

Basingstoke

100

62


Oncologic Outcome

  • Surgical Margins

One of the potential concerns about LRPP has been positive margin rates due to the lack of tactile feedback that is possible in open surgery. Results from open series for positive margins range from 19.9-37% (17). Data from larger laparoscopic series range from 13.8-26.4% which compare favourably but firm comparison can be drawn as prospective nor randomized data are yet available.

A comparative study from Paris analysed a cohort of 139 ORPP and 139 LRPP performed by senior surgeons between 1994 to 1997. There was no statistical difference in tumour grade or volume, however the rate of positive surgical margins was statistically lower in the LRPP group compared to open (13.7% vs. 25.9% p<0.02) (13).

  • PSA recurrence

As yet, the long term efficacy of LRPP is unproven. Guilloneau and co-workers reported on 1000 LRPP patients with a minimum follow-up of 3years (6). 91.8% of patients with pT2a tumours exhibited no PSA progression, 88% for pT2b and 77% for pT3a. They also noted that 94% of patients with negative surgical margins had progression free survival. Eden reported a 100% disease free progression with a mean follow-up of 9.8 months (9).

  • Cost

In other areas of surgical intervention, laparoscopic surgery has benefited the patient in reduced length of hospital stay, operation related morbidity and a speedier recovery. In Bristol our average length of stay for LRPP is 2 days with even shorter length of stay elsewhere (Cleveland). A quality of life study on 50 consecutive LRPP patients reported that 68% of patients could return to work two weeks after the procedure (18).

To date, there is a paucity of data on cost analysis between the two approaches. The Montsouris group evaluated the differences between LPPP and ORPP and found that average costs were lower for LRPP ($5058 vs. $6295)(2). An American study, however, showed that LRPP was theoretically 1.2 times more expensive than an open procedure (19).


 

Conclusions


LRPP has been shown to be an effective treatment for localized prostate cancer. The advantages of magnification and better visualization afforded by the laparoscopic approach herald the possibility of improving the procedure of radical prostatectomy rather than replacing it. Whilst the procedure has a steep learning curve, the complication rates and functional outcomes of LRPP compare favourably to open prostatectomy. Long term survival results are awaited, but disease progression data obtained thus far are encouraging.

References

1. Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short term experience. Urology 1997: 50: 854-7

2. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol. 2000:163(6):1643-9.

3. Raboy A, Ferzli G, Albert P. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 1997: 859-62

4. Meininger D, Byhahn C, Bueck M, Binder J, Kramer W, Kessler P, Westphal K. Effects of prolonged pneumoperitoneum on hemodynamics and acid-base balance during totally endoscopic robot-assisted radical prostatectomies. World J Surg. 2002;26(12):1423-7

5. Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis:the single knot method. Urology. 2003;61(4):699-702.

6. Guillonneau B, el-Fettouh H, Baumert H, Cathelineau X, Doublet JD, Fromont G, Vallancien G. Laparoscopic radical prostatectomy: oncological evaluation after 1,000 cases a Montsouris Institute. J Urol. 2003 Apr;169(4):1261-6

7. Rassweiler J, Schulze M, Teber D, Marrero R, Seemann O, Rumpelt J, Frede T. Laparoscopic radical prostatectomy with the Heilbronn technique: oncological results in the first 500 patients. J Urol. 2005 Mar;173(3):761-4.

8. Turk I, Deger S, Winkelmann B, Schonberger B, Loening SA. Laparoscopic radical prostatectomy. Terchnical aspects and experience with 125 cases. Eur. Urol. 2002: 40: 46-50.

9. Eden CG, Cahill D, Vass JA, Adams TH, Dauleh MI. Laparoscopic radical prostatectomy: the initial UK series. BJU Int 2002: 90: 876-882.

10. Guillonneau B, Gupta R, El Fettouh H, Cathelineau X, Baumert H, Vallancien G. Laparoscopic management of rectal injury during laparoscopic radical prostatectomy. J Urol. 2003:169: 1694.

11. Susler T, Guillonneau B, Vallancien G, Gaston R, PiecchaudT, Turk I. Complications and initial experience with 1228 laparoscopic prostatectomies at 6 European centres. J Urol. 2001: 165: 615A.

12. Farouk A, Gill I, Kaouk J, et al. 100 laparoscopic radical prostatectomy (LRP): learning curve in the United States. J Endourol. 2002: 16 (Suppl.1): 33A.

13. Salomon L, Levrel O, de la Taille A, Antiphon P, Abbou CC. Radical prostatectomy by the retropubic, perineal and laparoscopic approach: 12 years experience.

14. Rassweiler J, Seemann O, Schulze M, Teber D, Hatzinger M, Frede T. Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol. 2003:169: 1689.

15. Walshe PC, Marschke P, Ricker D. Patient reported urinary continence and sexual function after anatomic radical prostatectomy. Urol. 2000: 55: 58-61.

16. Gill IS, Ukimura O, Rubinstein M, Finelli A, Moinzadeh A, Singh D, Kaouk J, Miki T, Desai M. Lateral pedicle control during laparoscopic radical prostatectomy: refined technique. Urol. 2005;65(1):23-7.

17. Pound CR, Partin AW, Epsein JI, Walshe PC. Prostate-specific antigen after anatomic radical prostatectomy. Patterns of recurrence and cancer control. Urol Clin North Am 1997: 24: 1821-9.

18. Zippe CD, Meraney AM, Sung GT, Gill IS. Laparoscopic radical prostatectomy in the USA. Cleveland clinic series of 50 patients. J Urol. 2001: 165 (Suppl): 135A.

19. Link RE, Su LM, Bhayani SB, Pavlovich CP. Making ends meet: a cost comparison of laparoscopic and open radical retropubic prostatectomy. J Urol. 2004; 172: 6-7.

List of Illustrations and Legend.

Figure 1. Patient set-up for LRPP

Figure 2. Preparation of the apex for dorsal venous complex suture ligation.

Figure 3. Dorsal venous complex ligation.

Figure 4. Posterior bladder-neck dissection.

Figure 5. Posterior dissection demonstrating ampullae.

Figure 6. Preservation of the left neuro-vascular bundle.

Figure 7. Urethro-vesical anastomosis demonstrating the Van Velthoven technique.


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