Complications

Complication rates after laparoscopic radical prostatectomy have varied significantly, as shown in Table 1, ranging from 3.6% to 34%. Unclear and nonstandardized reporting makes interpretation of the reported complication rates difficult.

Not surprisingly, the difficult learning curve of laparoscopic radical prostatectomy skews the results strongly. In the series from Creteil and Heillbronn, the complication rate dropped significantly as experience increased, falling from 23% to 3.2% and from 13.7% to 6.4%, respectively (18,39).

In a large series from Paris, Guillonneau et al. (42) reported on the perioperative complications of laparoscopic radical prostatectomy in 567 patients. In this series, there were 21 major complications (3.7%) and 83 minor complications (14.6%) for an overall complication rate of 17.1%. Perioperative complications requiring reoperation occurred in 21 patients (3.7%), including 13 for a major complication (2.3%), and eight for a minor complication (1.4%). Major complications requiring reoperation included bowel or rectal injury (five patients), hemorrhage (five patients), and ureteral injuries (two patients). There were eight rectal injuries (1.4%), seven of which were noticed immediately and closed laparoscopically in two layers. Two patients with rectal injury required reoperation and temporary colostomy: one patient whose rectal injury was not immediately recognized and one whose injury was repaired but who developed an abscess. Minor complications requiring intervention included epigastric artery injury (0.5%), wound dehiscence (0.7%), and persistent lymphatic drainage (0.2%). Other minor complications included deep vein thrombosis (0.3%), paralytic ileus (1%), vesi-courethral anastomotic leakage (0.2%), upper extremity neuropathy (0.4%), and obturator nerve neuropraxia (0.2%). Conversion from laparoscopic radical prostatectomy to open retropubic radical prostatectomy occurred in seven patients (1.2%), all of whom were among the first 70 patients; there were no conversions among the last 500 patients.

In a subsequent report from Montsouris with 1000 patients, rectal injury occurred in 13 patients (1.3%) (43). In 11 patients, the injury was noted intraoperatively and closed primarily in two layers without colostomy or conversion to open retropubic radical prostatectomy. Two patients had delayed rectal injury noted due to development of peritonitis on postoperative day 2 and 4, respectively. These two patients, as well as two patients with immediately recognized and repaired rectal injury who developed peritonitis, required reoperation, and three required temporary colostomy (0.3%). One patient (0.1%) developed a rectourethral fistula despite rectal injury closure in two layers and diverting colostomy, requiring repair through a perineal approach. Of the 13 rectal injuries, 12 occurred during non-nerve sparing procedures, and one occurred during a unilateral nerve sparing procedure. Among the 11 injuries recognized intraoperatively, the injury occurred in 10 patients during dissection of the prostate posteriorly at the apex, and in one patient during wide excision of a neu-rovascular bundle.

Although rectal injury is a major complication when not recognized, the rate of rectal injuries was similar to that of open radial prostatectomy, and the vast majority was recognized immediately, allowing primary closure and no adverse sequelae (43,44).

TABLE2 ■ Oncologic and Functional Data After Laparoscopic Radial Prostatectomy in Series Worldwide

No. of patients

Positive surgical margin rate

PSA nonrecurrence

Urinary continence (length of follow-up)

Potency (in previously potent patients undergoing nerve sparing surgery)

Creteil (18)

134

25%

89.6% (11 months)

86.2% (1 year)

BNS: 46%a

Creteil (50)

235

N/A

N/A

90% no pad (1 year)

BNS: 58.8%b

Berlin (5)

125

26.4%

100% (6 months)

92% 1 pad or less (9 months)

UNS or BNS: 59% (with or without

sildenafil)

Brussels (7)

50

22%

94% (3 months)

85% (6 months)

BNS: 83% (with sildenafil)

Heidelberg (39)

438

Table 3

Table 3

90.3% (12 months)

Not reported

95.8% (18 months)

Montsouris (17)

550

16.7%

pT2a: 92.3%

82.3% no pad (12 months)

BNS: 85% spontaneous erections,

(36 months); pT2b:

66% intercourse

86.3% (31 months)

Montsouris (51)

1000

19.2%

90.5% (3 years)

N/A

N/A

Boston (10)

70

11.4%

Not reported

85% 1 or less pad at 3 months

Not reported

United Kingdom (9)

100

16%

100% (3 months)

90% no pad (1 year)

BNS: 62% spontaneous erections

Kobe (38)

26

Not reported

100% (1 month)

100% no pad (6 months)

BNS: 71% spontaneous erections,

14% intercourse

Leipzig (23)

70

21%

Not reported

90% no pad (6 months)

BNS: 33% intercourse with sildenafil

aDefined as intercourse without sildenafil. bSpontaneous erections.

Abbreviations: UNS, unilateral nerve sparing; BNS, bilateral nerve sparing.

The major underlying goal of laparoscopic radical prostatectomy is achieving the best cancer control with the least morbidity.

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