Robert P Myers

Department of Urology, Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minnesota, U.S.A.

Minimally invasive therapy has as its basic premise the reduction of iatrogenic trauma. This approach must imply that the therapeutic procedure succeeds in a manner no less effective than is currently achievable by established methods of treat-ment.—J.E.A. Wickham, 1993 (1).

The surge of interest in laparoscopic radical prostatectomy (LRP) is certainly an offshoot of the concept of minimally invasive surgery, for which due credit must be extended to John Wickham, who has had so much influence (1). Open radical perineal prostatectomy has been accomplished for more than 100 years (2) and open radical retropubic prostatectomy for more than 50 years (3). Much is known about the long-term results of these open operations in terms of cancer control and functional outcome. The laparoscopic approach is so new, relatively speaking, that long-term outcomes are not at all clear at this time.

There are three distinct arguments for laparoscopic radical prostatectomy over the open retropubic operation. The first argument is reduced blood loss with, on average, likely a higher hemoglobin level at dismissal. This is associated with increased strength, quicker recovery, and more rapid return to work. This argument does not hold for the perineal operation, in which blood loss is minimal and same-day dismissal conceivable. The perineal route is the most direct access to the prostate, and the non-nerve-sparing operation can be completed skin to skin in 40 minutes, as the late Ormond Culp did when I first assisted him as a resident-in-training.

The second argument is the tremendously magnified (X10 to X15) and detailed view of the relevant anatomy with laparoscopic radical prostatectomy. However, this advantage can be attained in open surgery by wearing magnifying optical loupes of X2 to X4.5. I use X2.5 and have excellent three-dimensional depth of field. In laparoscopic radical prostatectomy, the two-dimensional field must be learned, and the Da Vinci robotic device with three-dimensional imaging makes the two-dimensional learning curve unnecessary.

The third argument for laparoscopic radical prostatectomy is the improved cosmetic result from using multiple tiny ports rather than a mid-line incision. But this can be achieved for the insistent patient by using either the transverse Langer line Pfannenstiel (in thin patients) or Cherney incisions, the latter providing wide pelvic access even in the deepest pelvis (4). The Cherney incision with its disarticulation of the rectus abdominis tendons

FIGURE 1 ■ Postoperative scar of transverse Cherney incision extended from previous left lower quadrant scar of incision used for placement of kidney transplant.

does necessitate careful reconstruction and convalescence to avoid subsequent hernia and is particularly useful for patients who have had a kidney transplantation to an abdominal lower quadrant (Fig. 1).

Laparoscopic radical prostatectomy provides no obvious advantage in terms of duration of hospitalization. The introduction of preemptive analgesia has made the open retropubic operation virtually pain free and patients are up and about, eating, and able to be dismissed in 24 to 48 hours. (Patients undergoing the perineal operation have very little pain). With careful hemostasis during the open retropubic operation, a hemoglobin value at dismissal of 10 to 12 g/dL, without having a transfusion, is possible; patients, thus, have a sense of strength and well-being at dismissal. If blood bank guidelines allowed transfusion for patients whose hemoglobin value was less than the ideal dismissal range of 10 to 12 g/dL, laparoscopic radical prostatectomy would not have an advantage in this regard.

Cost is not an insignificant issue. If patients who have the open techniques can be dismissed the same day as, or within 24 to 48 hours of, operation, these approaches will be more cost effective not only in operating room time for most surgeons but also certainly in the cost of material and "disposables." In the United States, Medicare reimbursement for radical prostatectomy is so fine-tuned that it is an extraordinary challenge to come in under reimbursement. The da Vinci® robotic system, which has an initial cost of $1.2 million, yearly maintenance cost of about $100,000, and a cost for "disposables" of more than $2000 per case, is economically impractical for most institutions. Furthermore, the number of candidates for radical prostatectomy exceeds the number of qualified practitioners of laparoscopic radical prostatectomy, both traditional and robotic.

The ability to succeed in the goals of cancer control, urinary control, and maintenance of erectile function depends on the skill of the surgeon to extract the prostate, seminal vesicles, and portions of the vasa deferentia with the least disturbance possible to the structures that need preservation. Structures that need preservation include the striated urethral sphincter and the "distal sphincter mechanism," to credit Richard Turner Warwick's terminology (5), and the "neurovascular bundles," to credit Patrick Walsh's terminology (6). For successful outcome, it may help to preserve the bladder neck longitudinal smooth muscle, the so-called Bundle of Heiss (7), which can be usefully incorporated for initial passive continence in the bladder neck plication during open surgery (8). Currently, it is not at all clear that laparoscopic radical prostatectomy can achieve minimal disturbance of these structures critical to functional outcome in the same way afforded by open surgery, particularly the open retropubic approach. "Below the abdominal wall level, laparoscopic radical prostatectomy is clearly no less invasive than an open approach." To date, video demonstrations of laparoscopic radical prostatectomy that I have witnessed exhibit remarkable traction on the nerve bundles, and the extensive cautery used must generate considerable heat in the region of the pedicles and nerve bundles. In laparoscopic radical prostatectomy, discrimination and separation of the vascular pedicles from the nerve bundle appear challenging, as does accurate antegrade apical dissection of the prostate. As recently suggested, realtime transrectal ultrasonography can assist in the apical dissection during laparoscopic radical prostatectomy (9). Also, this latter difficulty of apical dissection has been overcome to some degree by takedown of the puboprostatic (pubovesical) ligaments close to their pubic insertion points. This then allows better direct access to the anterior prostatourethral junction for the purpose of optimal urethral transection. If the takedown of the puboprostatic ligaments is not done carefully, the immediately and laterally adjacent tendinous insertions of the puborectalis (puboanalis) sling could be disrupted and postoperative fecal control compromised. With the hands-on control and tactile feedback of open surgery, all of the above issues can be avoided.

Critical appraisal of laparoscopic radical prostatectomy and the open operations will be forthcoming only with prospective studies using internationally recognized, validated questionnaires under third-party control to probe general quality of life, functional outcomes and bother, and cancer control in suitable numbers of patients. Time to functional recovery of pad-free urinary control and erectile function suitable for satisfactory intercourse is another matter. How quickly do patients recover those functions? For laparoscopic radical prostatectomy to be fully acceptable, the best results of laparoscopic radical prostatectomy must be shown to match, unequivocally, the best results of an open operation.

Finally, how do we improve training opportunities? How many patients are hurt in anybody's learning curve for any type of approach, and how can needless injury be avoided, for example, the 12-hour procedure with ultimate urinary and fecal diversion? This is not a criticism directed at laparoscopic radical prostatectomy. The open retropubic and perineal operations can become instant disasters in the hands of the unknowing when patients become victims of reckless behavior. Importantly, the bottom line is always going to be proper training and judgment in whatever approach is used.

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