Myth of lower morbidity for laparoscopic radical prostatectomy vs. radical retropubic prostatectomy dispelled

October 15, 2008

Complications after laparoscopic radical prostatectomy demonstrates the effect of a learning curve and the benefits of improved surgical technique, but shows little difference in overall morbidity when compared with those of anatomic radical retropubic prostatectomy .

"There has been an assumption that LRP, whether performed robotically or using a standard/open approach, minimizes morbidity relative to open surgery." said Wilmer B. Roberts, MD, PhD, a urology resident at Johns Hopkins Hospital and Medical Institutions, Baltimore, who presented the data at the AUA annual meeting. "However, this concept is based on findings from some small series or extrapolations from general laparoscopic care.

"We sought to assess whether a true difference exists, based on a more rigorous review from a single institution with multiple surgeons. Our results fail to demonstrate a substantial benefit of the laparoscopic approach, but they also indicate that the risk of perioperative complications associated with LRP, as performed by surgeons experienced in the procedure, is not significantly worse compared with contemporary RRP."

The LRP data were divided into two periods: 2001-04 and 2005-07. About two-thirds of the laparoscopic procedures were performed during the last 3 years. Overall, patients in the LRP and RRP groups were similar with respect to mean age, PSA, Gleason score, clinical stage, and pathologic stage distributions.

"The morbidity and mortality records at Johns Hopkins Hospital are an excellent source for our study because it is a faithfully kept database that is independent of surgeon bias," Dr. Roberts said. "As a limitation, it only includes events resulting in an inpatient stay."

The overall morbidity rate was decreased by about 50% in the latter LRP series compared with the initial period (4.98% vs. 10.32%), but it was still lower in the RRP group (3.89%). The mortality rate for RRP also was lower than that of the mature LRP series (0.03% vs. 0.12%), although the differences were not statistically significant.

In addition, no significant differences were identified in the rates of individual complication types between the 2005-07 LRP and the RRP groups. However, there were some clinically interesting findings, according to Dr. Roberts.

Bleeding complications were actually higher in the early LRP group compared with the RRP series (0.72% vs 0.34%), but for laparascopic procedures performed between 2005 and 2007, the rate of bleeding complications was lower at 0.23%.

"Considering that individual surgeon decisions about whether to order a transfusion can be arbitrary, the bleeding complications listed include only bleeding requiring hemodynamic monitoring and transfusions or bleeding requiring re-exploration," Dr. Roberts said. "Using these strict criteria, it was not a particular surprise to see that the rate was lower with the minimally invasive procedure."

"Undoubtedly, the higher risk of small bowel complications for LRP is a result of the intraperitoneal approach that is used for the robotic procedures and for some of the standard laparoscopic prostatectomies, and the increased risk of anesthesia-related complications with LRP likely reflects its longer operative time," Dr. Roberts said.

Technical/surgery-related injuries, such as ureteral, obturator nerve, or rectal injury, showed rates of 1.68% in the early LRP series, 0.70% for LRP between 2005 and 2007, and 0.40% in the RRP group.

"These data show an effect of improvement in surgical skill and technique in the LRP group and that its associated rate of technical complications is rapidly ap-proaching the RRP baseline," Dr. Roberts concluded.