Advantages of extraperitoneal laparoscopic, robotic radical prostatectomy confirmed

October 15, 2007

Use of an extraperitoneal approach for either laparoscopic or robot-assisted radical prostatectomy yields excellent results and has significant advantages over performing these minimally invasive procedures via a transperitoneal route.

Key Points

"The majority of urologists who have trained to perform LRP or RARP use the transperitoneal approach because it is easier to learn," said lead author Jean V. Joseph, MD, MBA, associate professor of urology at the University of Rochester. "However, the extraperitoneal technique has advantages that potentially enable faster recovery and fewer complications over the longer term. That is perhaps why open radical prostatectomy has evolved to become an extraperitoneal procedure.

Dr. Joseph was the primary surgeon for the RARP cases in this review. Clement-Claude Abbou, MD, was the lead surgeon for the French series of laparoscopic cases.

Patients in the two series had a similar body mass index (~28 kg/m2 ), but the mean age and mean preoperative PSA reflected the tendency for prostate cancer to be detected at an earlier stage in the United States than in Europe as a result of more proactive screening. Men in the RARP series had a mean age of 60 years and a mean preoperative PSA of 6.6 ng/mL compared with a mean age of 65 years and a mean preoperative PSA of 10.1 ng/mL in the French group.

Although the RARP and LRP groups were similar with respect to mean preoperative Gleason scores (6.2 vs. 6.3), postoperative Gleason scores (6.5 vs. 6.9), clinical stage distributions (75%-80% T1c), and proportions of men who underwent lymph node dissection (37.3% vs. 40.3%), pathologic stage data showed the French men had more advanced cancers. Stage pT3-4 disease was present in 147 RARP patients (19.4%) compared with 349 LRP patients (43.6%) in that data set.

"The difference in cancer screening patterns between the two countries likely also explains the higher positive margin rate in the French series compared with ours (30.8% vs. 13.1%)," Dr. Joseph said. "A greater number of patients in the French series had advanced or higher-stage cancers compared to the Rochester series."

Total operative time was slightly longer with RARP compared with LRP (194 vs. 179 minutes), but both mean estimated blood loss and transfusion rate in the LRP group were higher than in the RARP group (768 mL and 4.3% vs. 190 mL and 1.3%, respectively).