The major underlying goal of laparoscopic radical prostatectomy is achieving the best cancer control with the least morbidity.
Since the introduction of the modern anatomic open retropubic radical prostatectomy by Walsh and Donker in 1982 (21), the reported five- and 10-year prostate specific antigen nonprogression rates have been 77-80% at five years after open retropubic radical prostatectomy and 54-75% at 10 years (45-49). Because laparoscopic radical prostatectomy has been performed only within the past six years, long-term data on prostate specific antigen nonprogression after laparoscopic radical prostatectomy are unavailable. The short-term oncologic data after laparoscopic radical prostatectomy, however, are encouraging, as shown in Table 2.
The Montsouris experience of about 1000 cases of laparoscopic radical prostatectomy with a median follow-up of 12 months has been published (51). The final pathologic stage was pT2N0/Nx in 775 patients (77.5%), pT2a in 203 patients (20.3%) and pT2b in 573 patients (57.3%), pT3aN0/Nx in 142 patients (14.2%), pT3bN0/Nx in 77 patients (7.7%), and pT1-3N1 in six patients (0.6%). The positive surgical margin rates for each clinical and pathologic stage and each Gleason score are shown in Table 2. The positive surgical margin rate was 19.2% overall, and it varied with pathologic stage from 6.9% for pT2a patients up to 32% for pT3b patients.
In a recent series of laparoscopic radical prostatectomy at Memorial Sloan-Kettering Cancer Center, 77% of the patients had pT2 disease, 19% had pT3, and 4% had pT4 cancers. The positive surgical margin rate by pathological stage was after laparo-scopic radical prostatectomy was 3.8% for pT2, 26% forpT3, and 100% for pT4 tumors; the total tumor volume in this series was 2.02 (+2.6) cm3.
In a retrospective study from Germany, Rassweiler et al. (39) compared three consecutive patient cohorts as Rassweiler's institution made a transition from open retropubic radical prostatectomy to laparoscopic radical prostatectomy. The cohorts consisted of 219 patients receiving open retropubic radical prostatectomy before routine laparo-scopic radical prostatectomy was performed, the initial 219 patients who received laparoscopic radical prostatectomy during the "learning curve" (early), and the next 219 patients undergoing laparoscopic radical prostatectomy (late). To maintain the accuracy of comparison, the cohorts included only patients who had concurrent pelvic lymphadenectomy, and 83 patients who had laparoscopic radical prostatectomy without lymphadenectomy were excluded. These patient cohorts were consecutive rather than concurrent, with the open retropubic radical prostatectomy patients having surgery between 1994 and 1999 and the laparoscopic radical prostatectomy patients having surgery from 1999 to 2002. Understandably, the median follow-up was different for each group: 67 months for the open retropubic radical prostatectomy group versus 30 months for the early laparoscopic radical prostatectomy group and eight months for the late laparoscopic radical prostatectomy group. Probably because of stage migration, the percentage of patients with organ-confined (pT1/T2) tumors was lowest in the retropubic radical prostatectomy group (45.7% vs. 55.3% vs. 65.3% in open retropubic radical prostatectomy, early laparoscopic radical prostatectomy, and late laparoscopic radical prostatectomy, respectively), but not significantly different. The positive surgical margin rate also did not differ significantly in these three groups, as shown in Table 2. With the relatively short median follow-up of 30 months, the PSA nonprogression rate in the early laparoscopic radical prostatectomy cohort was 86.8%.
In a similar, earlier study from Montsouris, Fromont et al. (52) compared a matched cohort of 139 open retropubic radical prostatectomy and 139 laparoscopic radical prostatectomy patients with procedures done by two senior surgeons. The laparo-scopic radical prostatectomy patients were matched by preoperative serum PSA level with patients who received open retropubic radical prostatectomy performed by the same two surgeons during an earlier period (1994-1997). There was no significant difference between the open retropubic radical prostatectomy and laparoscopic radical prostatectomy groups in PSA (10.6 vs. 10.4), age (64.3 vs. 63.5 years), biopsy Gleason score (5.7 vs. 5.8), or number of positive biopsy cores (2.3 vs. 2.3). The proportion of T1 tumors was higher in the laparoscopic radical prostatectomy group (46% vs. 69%, P < 0.01), likely representing stage migration. In the final pathologic analysis, there were no significant differences between open retropubic radical prostatectomy and laparoscopic radical prostatectomy in the rate of positive lymph nodes (1.4% vs. 1.7%), prostate weight (53.4 vs. 55.5 g), or pathologic stage (pT2a: 20% vs. 18%, pT2b: 80% vs. 82%, pT3: 25% vs. 28%). Additionally, there was no significant difference in the final Gleason score, although there was a trend towards a higher percentage of high-grade cancers (Gleason 8-9) in the open retropubic radical prostatectomy group (8.6% vs. 4.3%). The overall rate of positive surgical margins was significantly lower in the laparoscopic radical prostatectomy group compared to the matched open retropubic radical prostatectomy group (13.7% vs. 25.9%, P < 0.02). When examining organ-confined cancers, the positive surgical margin rate for pT2 patients was also significantly lower for laparoscopic radical prostatectomy (10% vs. 20.9%, P < 0.05). Apical positive surgical margins appeared to account for the differences. Positive apical surgical margins occurred in laparoscopic radical prostatectomy and open retropubic radical prostatectomy in 7.2% versus 15.5% of patients overall, and in 7% versus 18% of patients with pT2 tumors (P < 0.05), with no significant difference in positive surgical margins occurring at other sites (posterolat-eral, base, bladder neck, or multiple sites). From this study, the authors concluded that laparoscopic radical prostatectomy does not lead to higher positive surgical margin rates compared to open retropubic radical prostatectomy.
Other studies have attempted to delineate anatomic differences between open and laparoscopic approaches, to better understand how positive surgical margins occur. A study by Salomon et al. (53) examined 371 patients with organ-confined prostate cancer (pT2) treated by retropubic prostatectomy (116 patients), radical perineal prostatectomy (PRP, 86 patients), or laparoscopic radical prostatectomy (169 patients). There was no significant difference between each group for age, Gleason grade, or clinical stage, but the serum prostate specific antigen level was significantly lower for laparoscopic radical prostatectomy versus retropubic radical prostatectomy and PRP patients (8.9 ng/mL vs. 11.1 and 11.1, respectively). The overall rate of positive surgical margins did not differ significantly for the three groups. The location of positive surgical margins, however, appeared different among the groups. The apical positive margin rate was lower in PRP compared to retropubic radical prostatectomy or laparoscopic radical prostatectomy; the bladder neck positive margin rate was lower for laparoscopic radical prostatectomy than for retropubic radical prostatectomy or PRP; and the posterolateral positive margin rate was higher for laparoscopic radical prostatectomy than retropubic radical prostatectomy or PRP (8.8%, 4.3%, and 3.4%, respectively). These differences, however, did not reach statistical significance. In a follow-up study from the same institution, changes in laparoscopic radical prostatectomy technique reduced the positive surgical margin rate (54). After switching from a bladder neck sparing approach to wide resection of the bladder neck, the rate of positive margins at the bladder neck decreased. Similarly, after changing technique to avoid preservation of the puboprostatic ligaments by incising them each time, the rate of positive margins at the apex decreased. Attempts at neurovascular bundle preservation in selected patients did not result in more positive surgical margins. These studies demonstrate that differences in technique
The lack of uniformity in defining, assessing, and reporting functional results after radical prostatectomy leads to a disparity of results between different series. The definition used the methodology by which data are gathered and analyzed, and the time of assessment need to be taken into consideration while interpreting the results of potency and continence.
The measurement of potency after surgery appears somewhat convoluted, with some centers reporting only the rate of spontaneous erections and others including use of sildenafil as satisfactory for potency. The length of follow-up is another important facet in analysis of sexual function after prostate surgery, since potency can return months or years after surgery.
directly relate to the chance of having a positive surgical margin, but neurovascular bundle preservation does not appear to affect the rate of positive surgical margins significantly. In another retrospective case-control study by Brown et al. (57), 60 laparoscopic radical prostatectomy patients were analyzed for pathologic efficacy and compared with 60 concurrent open retropubic radical prostatectomy patients, and with 60 patients undergoing open retropubic radical prostatectomy matched with the laparoscopic radical prostatectomy patients by clinical stage and biopsy Gleason grade. In this study, the positive surgical margin rate in laparoscopic radical prostatectomy was not significantly different from that in either of the open retropubic radical prostatectomy groups, and the incidence of isolated apical positive margins and multiple-site positive margins was lower in the laparoscopic radical prostatectomy group.
Because of concerns of positive surgical margins in laparoscopic radical prostatectomy during nerve sparing procedures, surgeons at the Montsouris Institute prospec-tively sent all laparoscopic radical prostatectomy specimens for frozen section analysis in 100 patients undergoing bilateral nerve sparing laparoscopic radical prostatectomy (58). On each side of the prostate specimen, a wedge of tissue from the posterolateral margin in the vicinity of the neurovascular bundle was excised and immediately analyzed. In patients whose frozen section analysis demonstrated a positive surgical margin, the ipsilateral neurovascular bundle was excised. The frozen section analysis revealed positive surgical margins in 24%, and the complementary resection of the ipsilateral neu-rovascular bundle revealed residual tumor in one-third of these. Intraoperative frozen section analysis decreased the overall positive surgical margin rate from 33% to 12% and from 26% to 8% in organ-confined (pT2) tumors.
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