Comparison of the extraperitoneal and transperitoneal laparoscopic radical prostatectomy

The laparoscopic radical prostatectomy (LRP) is a developing technique for treatment of localized prostate cancer, while the extraperitoneal approach has been highlighted recently.1 From May 2003 to April 2006, we performed laparoscopic radical prostatectomy by transperitoneal or extraperitoneal approaches in 31 patients with localized prostate cancer. Some parameters of these patients are compared in this article. METHODS Study sample Thirty-one patients with localized prostate cancer underwent laparoscopic radical prostatectomy by transperitoneal (n=12) or extraperitoneal (n=19) approach. All patients were evaluated by digital rectal examination, serum prostate specific antigen (PSA) test, MRI examination and ultrasound guided biopsy before operation. Gleason scores were 2–10; clinical stage was evaluated by MRI; patients with PSA higher than 10 ng/ml underwent radionuclide bone scans, all had negative outcome. There were no apparent differences in age, prostate volume, clinical stage, Gleason score or serum PSA between the two groups (Table).Table: Demographics of the two groupsExtraperitoneal procedure The operation is performed under tracheal intubation and general anaesthesia and the patient is placed in a 15° to 20° Trendelenburg position. A 2.5 cm incision reaching the rectus abdominis aponeurosis is made below the umbilicus, the anterior rectus fascia is incised and the rectus muscle fibres are vertically separated by blunt dissection. A space is built at the spatium extraperitoneale by digital dissection, a self made gasbag is inserted with 400 ml sufflating gas to build a pneumopreperitoneum and kept for 5 minutes to press peripheral tissue and inhibit bleeding. Another four 5-cm working trocars were inserted on both sides of lower abdomen under direct view. Preprostatic fat tissue was dissected to expose prostate, bladder, endopelvic fascia and puboprostatic ligament; endopelvic fascia and puboprostatic ligaments were cut with bipolar forceps. The dorsal venous complex was coagulated with bipolar forceps and sectioned. The bladder neck was incised at the prostatovesical junction, then the seminal vesicles and deferent duct were dissected, deferent duct ligated and transected with bipolar forceps. The deferent duct was pulled upward and Denonvillier's fascia kept on tension. The anterior layer of Denonvillier's fascia was incised to expose the perirectal fat. The posterior of the prostate was dissected to the apex. The lateral prostatic pedicle was controlled carefully to preserve the neurovascular bundles locating posterolateral tissue of the prostate. The urethra was sharply incised with laparoscopic scissors from the prostatic pedicle. The urethrovesical anastomosis was performed using 2-0 absorbable suture continuously from 5 to 7 o'clock, then Foley catheter was installed and the left part was sutured intermittently. The prostrate was extracted from an extended umbilical incision and a drainage tube was placed into the retropubic space through a port. Pelvic lymphadenectomy was performed followed the excision of the prostate on seven patients whose serum PSA was higher than 10 ng/ml. Transperitoneal procedure Transperitoneal approach was performed according to the technique described by Guillonneau and Vallancien, after initial dissection of the deferent duct and seminal vesicles, the anastomosis was finished using interrupted absorbable sutures. Perioperative and postoperative evaluation Blood loss was evaluated according to the blood drainage volume during operation. Intestinal function recovery time was decided by bowel sound and passage of gas by anus. Three months after operation, serum PSA was tested and the voiding function of patients was evaluated by questionnaire. Statistical analysis SPSS 10.0 statistical software was used. Comparisons of Gleason scores, clinical and pathological stages were made by the rank sum test; comparison of other parameters was made by t test of means. P<0.05 was considered statistically significant. RESULTS The 31 patients underwent laparoscopic radical prostatectomy successfully, and no one was converted to open surgery. The operative time, intestinal function recovery time and hospital stay of the extraperitoneal group were significantly shorter than transperitoneal group. Estimated blood loss of the two groups was the same and only one patient in transperitoneal group had transfusion. There was no positive node in 7 patients with pelvic lymphadenectomy. There was no significant difference in pathological stage, catheterization time, incontinence rate or PSA 3 months after operation between the two groups (Table). DISCUSSION Since Schuessler et al2 reported the transperitoneal laparoscopic radical prostatectomy, this procedure has been adopted widely for the treatment of localized prostate cancer. Erdogru et al3–10 suggested that laparoscopic radical prostatectomy causes less postoperative pain, a shorter catheterization time and hospital stay, and the short term results are comparable to those of conventional radical prostatectomy. In 1997, Raboy et al11 performed extraperitoneal laparoscopic radical prostatectomy, and then Salomon et al7,12 standardized it. A variety of studies showed that extraperitoneal laparoscopic radical prostatectomy is a feasible and safe method for localized prostate cancer. Erdogru et al3 found that there was no statistical difference in mean operative time, complication rate, positive surgical margins or 3 months incontinence rate between the transperitoneal and extraperitoneal approach. Recently, some studies reported extraperitoneal laparoscopic radical prostatectomy had similar oncological result as open radical prostatectomy and transperitoneal approach.13–15 In our study, operative time, intestinal function recovery time and hospital stay of extraperitoneal approach were shorter than transperitoneal approach, but there were no significant differences in blood loss, transfusion, positive surgical margin, Gleason score, pathological stage, catheterization time, incontinence rate or postoperative serum PSA at 3 months. Transperitoneal laparoscopic radical prostatectomy has its advantages: it allows faster placement of trocars and bladder mobilization, which is convenient for a tension free anastomosis; the larger cavity allows placement of the specimen bag out of the operative field, improving vision and facilitating the vesicourethral anastomosis. At the same time, transperitoneal laparoscopic radical prostatectomy has many disadvantages too: it requires a much steeper Trendelenburg position to move the bowel out of the pelvic cavity, this position can cause upper airway and facial swelling, which may postpone extubation, lengthen the recovery time and increase the risk of brachial plexus injury.16 The bowels may adhere in the retropubic space of Retzius after operation and radiation therapy can lead to radiation enteritis. Compared with transperitoneal laparoscopic radical prostatectomy, extraperitoneal laparoscopic radical prostatectomy has its typical advantages.17,18 The procedure can be finished extraperitoneally; the incidence rate of bowel lesion, ileus, peritonitis is lower and the procedure prevents herniating from the trocar ports.19 The peritoneum can isolate the operative field from the abdominal cavity, bleeding does not contact the bowel20 and reflex ileus is avoided; even a poor anastomosis could not result in urinary ascites with associated complications. But there is also a greater risk of rectal injury with the initial dissection of the seminal vesicles, especially for obese patients. In conclusion, the extraperitoneal laparoscopic radical prostatectomy is a safe, feasible and effective procedure, which is comparable to open radical prostatectomy and transperitoneal laparoscopic radical prostatectomy in some aspects; moreover, it could shorten operation time, benefit intestinal function recovery and eliminate some complications.