6.6 Extraperitoneal Versus Transperitoneal Laparoscopic Radical Prostatectomy

Contents

Introduction 177

Indications and Contraindications 177 Techniques 178

Transperitoneal Approach 179 Extraperitoneal Approach 179 Preoperative Preparation 180 Positioning of the Patient 180 Postoperative Management 181 Results 181

Morbidity 181 Continence 182 Potency 182

Oncological Results 182 Controversies 183 References 183

Introduction

Radical prostatectomy is the gold standard treatment for localized prostate cancer, since the laparoscopic approach is an excellent option because by maintain- ing oncological control it offers the combined benefits ofthe minimally invasive approach and good func- tional results.

Currently our experience adds up to over 2,000 lap- aroscopic radical prostatectomies, distributed as fol- lows: 1,400 transperitoneal and 600 extraperitoneal, among which 100 have been robot-assisted (70 trans- peritoneal and 30 extraperitoneal procedures). In this chapter we will briefly discuss our different tech- niques, benefits, difficulties, complications and the differences between the transperitoneal and the extra- peritoneal laparoscopic approaches.

Indications and Contraindications

The indications for laparoscopic radical prostatectomy are exactly the same as in open surgery, no matter

which approach is used, or ifit is robot-assisted.

Minimally invasive surgery has not modified the se- lection criteria for the patient to be eligible for this technique. However, as in open surgery, there are cer- tain characteristics that will impact on the difficulty ofthe procedure and the results obtained.

Either laparoscopic approach can be performed in selected T3N0M0 stages, without neurovascular bundle preservation, with the implied risk ofresidual disease that may require complementary treatment. Finally, salvage laparoscopic radical prostatectomy after radio- therapy or brachytherapy can be performed by either laparoscopic approach, because neither will modify the higher risk ofrectal injury [1].

The only absolute anesthetic contraindications for any laparoscopic procedure is high intracranial pres- sure ofany etiology (primary or secondary to the in- tracranial process). There are relative anesthetic con- traindications for abdominal laparoscopic surgery, be- cause they cause an increased partial pressure ofcar- bon dioxide (pCO

), which requires increased minute ventilation in order to maintain a pCO

between 30 and 35 mmHg. These include severe emphysema, car- diac insufficiency, atrioventricular defects, chronic res- piratory disease and glaucoma.

There are no anatomical contraindications for either approach, nor the robot assistance. However, there are some cases that can make the procedure po- tentially challenging, which include a large prostate volume (over 100 g), neoadjuvant hormone therapy, previous prostatic surgery, history ofprostatitis, radio- therapy, brachytherapy and thermal ablation ofthe prostate (Ablatherm) [2, 3].

Finally for an extraperitoneal approach, the history ofprevious bilateral mesh hernia repair can make this approach difficult because of the adhesion formation that can make the Retzius space dissection difficult [4].

An important consideration for surgeons at the be- ginning oftheir learning curve is to carefully select

6.6 Extraperitoneal Versus

Transperitoneal Laparoscopic Radical Prostatectomy

Franœois Rozet, Carlos Arroyo, Xavier Cathelineau,

Eric Barret, Guy Vallancien

their cases, because it has been shown that the sur- geon's experience is inversely related to in-hospital complications and length ofstay in open radical pros- tatectomy [5].

Techniques

In placing trocars, we routinely use five trocars, the same with either approach, except for a slight dis- placement in the extraperitoneal approach in which the trocars tend to be slightly lower than for the transperitoneal approach. They depend on the sur- geon's preferences.

These include linear distribution, in which a 10- mm trocar is inserted in the umbilicus for the camera.

The surgeon will work with two 5-mm trocars that are inserted, one above and medial to the iliac spine and another one lower and lateral to the umbilical port.

The assistant will work with a 5-mm trocar that is placed above and medial to the right iliac spine, and a second 10-mm trocar between the umbilical and lat- eral ports on the right (Fig. 1).

Fig. 1. Linear trocar position at the same height as the um- bilicus, the left-side ports are used by the surgeon and the right by the assistant

Fig. 2. The triangular trocar variation involves placement of

the surgeon's ports on the left side between the umbilical

port andthe left iliac spine andthe other two-thirds of the

distance between the umbilical port and the suprapubic

rim along the midline

The triangular trocar variation involves placement ofthe surgeon's ports on the left side between the um- bilical port and the left iliac spine and the other one two-thirds ofthe distance between the umbilical port and the suprapubic rim along the midline (Fig. 2).

In case a robot-assisted procedure is used, whether it is extra- or transperitoneal, the trocar distribution is as follows: a 12-mm trocar is inserted in the umbili- cus for the camera, two 8-mm trocars for the robot arms are placed on both sides five fingerbreadths lat- eral to the opti and slightly lower. Finally for the as- sistant, a 5-mm trocar is inserted above and medial to the left iliac spine and a 10-mm trocar for the suture is placed slightly higher, between the opti and right robot trocar (Fig. 3).

Transperitoneal Approach

Since 1998, we have used the Montsouris I technique [6, 7] and have divided it into seven critical steps:

1. Incision ofthe posterior vesical peritoneum with dissection ofthe vas deferens and seminal vesicles, finishing by opening the Denonvilliers fascia.

2. Dissection ofthe Retzius space, with incision ofthe intrapelvic fascia with selective suture ligation of the Santorini's plexus.

3. Identification of the bladder neck, with dissection ofthe seminal vesicles.

4. Dissection ofthe lateral surfaces ofthe prostate in the intrafascial plane in order to preserve the neu- rovascular bundles (when indicated).

5. Selective dissection ofthe urethra with the aid ofa metal Bniqu dilator.

6. Extraction ofthe prostate using a laparoscopic bag for frozen section analysis.

7. The vesicourethral anastomosis is performed with interrupted or running Vicryl sutures.

Finally a Foley catheter is placed and a suction drain is left in the surgical space.

Extraperitoneal Approach

This approach has been previously described in the literature [8±10], and our Montsouris II technique [11] can also be divided into critical steps, shared with the transperitoneal approach except for:

1. The surgery starts with the dissection ofthe Ret- zius space, which is done by blunt dissection with the laparoscope or by the use ofa balloon.

2. The next step is to open the intrapelvic fascia floor as in the transperitoneal approach.

3. The bladder neck is dissected and reveals the initial plane ofdissection ofthe seminal vesicles that are dissected after this step, compared to the transperi- toneal approach in which they are dissected at the beginning.

The rest ofthe procedure follows the same steps as the transperitoneal approach.

In case a robot-assisted procedure is used, it can be done following the same critical steps in the transperi- toneal or extraperitoneal approach; the only variation involves the trocar placement as previously described [12].

Fig. 3. The robot-assistedlinear trocar placement involves

the robot ports on both sides and the assistants on either

side to one of the robotic arms

Preoperative Preparation

The patient is admitted to the hospital the night be- fore the surgery to start prophylactic anticoagulation with an injection oflow-molecular-weight heparin, which is continued for at least 7 days postoperatively.

Another measure to prevent thromboembolic compli- cations is the systematic use ofvaricose vein stock- ings. We do not do any gastrointestinal or skin prepa- ration (shaving), nor do we prescribe any antibiotic prophylaxis.

Positioning of the Patient

Laparoscopic radical prostatectomies by the transperi- toneal or extraperitoneal approach are performed un- der general anesthesia, with the patient placed in a dorsal supine position. During the transperitoneal technique, an exaggerated Trendelenburg position is preferred to a moderate position in the extraperitoneal approach. The lower limbs are in abduction for in- traoperative access to the rectum. The upper limbs are positioned alongside the body to avoid the risk of stretch injuries to the brachial plexus. Two security belts are placed across the thorax in an X pattern, to Fig. 4. This drawing shows the patient position with respect the surgeon and assistant, as well as the operating room arrangement

Fig. 5. Operating room arrangement in

a robot-assistedlaparoscopic radical

prostatectomy

ensure that there is no patient movement during sur- gery, while ensuring there is no risk ofpressure injury in using shoulder rests.

The surgeon stands on the left side of the patient with the operating room nurse and instrument table, and the assistant stands on the right side ofthe oper- ating table. The video column with the insufflator and light source are placed between the legs ofthe patient and the electrocautery and aspirator behind the assis- tant (Fig. 4).

When a robot assisted technique is used, before the patient is brought into the operative room, the robot is set up (Fig. 5). The system is started and goes through a self-testing procedure during which it rec- ognizes its own spatial position and various compo- nents. The cameras are black-and-white balanced and calibrated. The patient positioning is the same except for a slight flexion of the lower limbs to allow the ro- bot to come as close as possible to the surgical table.

The surgeon remains in the console during the entire procedure and a scrub nurse and assistant remain on the left side of the patient.

Postoperative Management

The bladder catheter is left for 3±7 days depending on the quality ofthe suture evaluated by the surgeon. A postoperative cystogram is not routinely performed.

Our analgesia scheme is limited to IV paracetamol during the first 24 h, followed on day 1 by oral para- cetamol/dextropropoxyphene ifnecessary. Major an- algesics are administered ifnecessary. The intravenous perfusion is stopped on day 1, and oral fluids are started the morning after surgery and a normal diet can generally be resumed on day 2.

Results

We have been performing laparoscopic radical prosta- tectomy since 1998, and our current experience adds up to over 2,000 cases, which include 1,400 transperi- toneal cases and 600 extraperitoneal cases. Among them we have performed 100 robot-assisted laparo- scopic radical prostatectomies, 70 transperitoneal and 30 by the extraperitoneal approach.

The patient characteristics are summarized in Ta- ble 1, and our surgical results are in Table 2. We have converted to open surgery in only ten cases: the first

nine were at the beginning ofour experience, and the last one was in the extraperitoneal group and was due to a malfunction of the laparoscopic camera. Concern- ing the approach, we have had to convert from extra- peritoneal to transperitoneal at the beginning ofthe procedure in five cases because they had previous mesh hernia repair (two unilateral and three bilateral), which made it impossible to open the extraperitoneal space to perform the operation.

Morbidity

Our complications are summarized in Table 3. To date, we have had no deaths or cardiac complications. Our major complications include four cases of pulmonary embolism. Intermediate complications were similar in both groups and were the most frequent: lymphocele and rectal injury. It is interesting to note that although the rate ofrectal injury is lower in the extraperitoneal Table 1. Preoperative patient characteristics

Approach Transperitoneal Extraperitoneal

No. of patients 1,400 600

Mean age 61 62

PSA 9.2 7.4

Gleason score 6.5 7

Table 2. Perioperative andpathological stage

Approach Transperitoneal Extraperitoneal

Mean surgical time 157 173

Mean bloodloss 350 380

% Transfusion rate 3.3 1.3

Conversion to open 9 patients convertedto open

1 patient convertedto open 5 to transperito- Pathological stage TNM 1997 neal TNM 2002

pT2a 20% 13%

pT2b 58% 8%

pT2c 52%

pT3a 14% 20%

pT3b 8% 9%

Mean hospital stay 4.2 days 6.3 days Mean Foley catheter 4.5 days 7.6 days

Visual pain scale Score Score

Day 1 <3.6 2.8

Day 2 <2 2.4

approach, the risk remains the same during the final part ofthe dissection ofthe prostatic apex.

Among the possible benefits offered by the extra- peritoneal approach is the easier management ofan abdominal wall hematoma or urinary leaks, because the peritoneum is intact, and these complications are limited and do not involve the abdominal cavity [13].

Continence

To evaluate continence results, the patient is sent a self-administered questionnaire by regular mail. The median follow-up is at 12 months, when patients re- port continence in terms ofusing no protection pads, being continent but preferring to use a precautionary pad or using one pad on a daily basis because ofmi- nor urine leaks. Our results are encouraging with a continence rate higher than 84% (Table 4).

Potency

Our results from both series are difficult to compare, as in the initial transperitoneal approach erectile func- tion was evaluated clinically, with results depending on the procedure (bilateral or unilateral nerve-sparing procedure). The mean rate ofspontaneous erection was between 62% and 77%. Currently in the extraperi- toneal series, we are evaluating the erectile function with a self-administered questionnaire that is mailed to our patients postoperatively. With a median follow- up of6 months, in the preoperatively potent patients (International Index ofErectile Function [IIEF]

5>20), the erectile function rate was 64% for the bi-

lateral nerve-sparing technique and 43% in unilateral nerve-preserving surgery.

Oncological Results

Histopathological exam ofthe prostate revealed simi- lar characteristics in both groups. The positive margin rate ofboth approaches is similar (13% transperito- neal vs 17% extraperitoneal). In our experience, we have seen that as the surgeon's experience increases, the rate ofpositive margins decreases (Table 5). This occurred both in the transperitoneal approach and later with the extraperitoneal approach, until they reached a plateau. It is logical to observe that in both groups, as the tumor volume increases, the positive margins also increase. In both groups, the positive margin rate was higher in the pT3 than the pT2 pa- tients (Table 5).

Concerning the postoperative PSA values, in the ex- traperitoneal approach, the follow-up is still too short to make any assumptions. However, in the transperito- neal group, we have observed that the actuarial PSA at 3 years is less than 0.1 ng/ml in 90.5% ofour patients.

In patients with a good prognosis, with a Gleason score ofless than 7 and preoperative PSA lower than 10 ng/ml, the actuarial PSA at 3 years is less than 0.1 ng/ml in 97.5% ofthese patients. Finally, it is im- portant to mention that to date, we have not had any port site metastasis [14, 15].

Table 3. Number of complications

Approach Transperitoneal Extraperitoneal

Deaths 0 0

Major complications

Thrombotic events 0.1% 0.3%

Intermediate complications

Rectal injury 0.8% 0.6%

Intestinal injury 0.1% 0%

Vesicocutaneous fistula 0.2% 0.1%

Anastomotic stenosis 0.3% 0.1%

Ureter injury 0.2% 0%

Lymphocele 0.2% 0.8%

Anastomotic leak 10% 5%

Abdominal wall abscess 0% 0.3%

Urinary retention 0.2% 3.5%

Table 4. Continence results evaluatedby questionnaire after the surgery

Approach Transperitoneal Extraperitoneal Continence

No. of pads used 86% 84%

1 preventive pad8%

1 padroutinely 14% 8%

Table 5. Average positive margins by pathological stage Approach Transperitoneal Extraperitoneal

Positive margins 13% 17.7%

pT2a 5% 7%

pT2b 13% 15%

pT2c 17%

pT3a 30% 27%

pT3b 33% 23%

Controversies

Which approach is best for a laparoscopic radical prostatectomy continues to be currently debated [16].

In a prospective comparative study, we concluded that there are advantages and disadvantages to both approaches; however, the quality ofthe surgery de- pends on the surgeon's experience and standardization ofthe procedure. This is why we consider that there is no gold standard in terms ofa technique or approach, but rather success depends on the surgeon's experi- ence [17, 18].

However, we do consider that, as mentioned earlier, the extraperitoneal approach might reduce direct bow- el injury. Nevertheless, the risk remains and it is im- portant to always place the ports under visual control.

Another possible advantage is the visualization ofthe epigastric vessels, which, although it does not reduce the risk ofinjury, it does allow easy coagulation with bipolar forceps.

There are some reports that mention fewer rectal injuries with the extraperitoneal approach [19]. In our experience, the risk remains, although it may change the clinical presentation.

Another area ofdiscussion is the possible tension during the vesicourethral anastomosis, the result ofa partial dissection ofthe bladder in the extraperitoneal approach compared to the transperitoneal [20]. In our experience, various maneuvers can reduce bladder traction, for example, leveling the operating table, emptying the bladder, further dissection of the blad- der, enlarging the bladder neck anteriorly and lower- ing the pneumoperitoneal pressure.

In brief, we consider that the extraperitoneal approach can be slightly faster with easier management ofminor complications (hematoma or urine leak), while preserving the oncological results observed with the transperitoneal approach. However, it is important to keep in mind that the extraperitoneal approach can be difficult if the patient has a history of previous mesh hernia repair, the anastomosis can involve more ten- sion, and the working space might be slightly smaller when compared to the transperitoneal approach.

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