Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy

RAPID

COMMUNICATION

ELSEVIER

INITIAL EXPERIENCE WITH EXTRAPERITONEAL ENDOSCOPIC RADICAL RETROPUBIC PROSTATECTOMY ADLEY RABOY, GEORGE FERZLI,

AND

PETER ALBERT

ABSTRACT Objectives. We report our initial experience using laparoscopic instruments and techniques in the performance of radical retropubic prostatectomy (RRP) through an entirely extraperitoneal endoscopic (EE) approach. Methods. A 62-year-old man with a Gleason score of 7 and clinical Stage Tic adenocarcinoma of the prostate underwent EERRP. The procedure was evaluated for achievement of removal of the prostate and seminal vesicles and for complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathologic findings were also evaluated. Results. Complete endoscopic removal of the prostate and seminal vesicles was achieved. Endoscopic reconstruction of the bladder neck with a watertight anastomosis was successful. Operative time was 5 hours and 45 minutes, with an estimated blood loss of 600 cc. Hospital stay was 2.5 days. Final pathologic evaluation was a Gleason score of 7 and Stage T2 disease with negative margins. Conclusions. The initial experience for EERRP is encouraging. Further evaluation to refine the technique and determine its efficacy and role in treating prostate cancer is in order. UROLOGY 50: 849-853, 1997. 0 1997, Elsevier Science Inc. All rights reserved.

aparoscopy has been utilized in numerous urologic conditions, including the evaluation and treatment of nonpalpable testes,1 staging of urologic malignancies, 2 bladder neck suspension,3 renal biopsy,4 renal cyst surgery,* nephrectomy,e partial nephrectomy,’ ureterolysis,s varix ligation? pyeloplasty,1° and ureterolithotomy.ll Because of the high prevalence of prostate cancer and the role of the urologist in its surgical treatment, it becomes tempting to explore the role of laparoscopy in performing radical prostatectomy. Successful attempts at transperitoneal laparoscopic radical prostatectomy have been reported12; however, early experience has shown significant difficulties with dissection and vesicourethral anastomosis. Using new technologies, Price et a1.13 successfully performed transperitoneal laparoscopic prostatectomy in a canine model. However,

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From the Departments oj’ Urology and Laparoendoscopic Surgery, Staten Island University Hospital, Staten Island, New York; a&Department ofUrology, State University ofNew York, Health Science Center, Brooklyn, New York Reprint requests: Adley Raboy, M.D., Staten Island Urological Associates, P.C., 1460 Victory Boulevard, Staten Island, NY 10301 Submitted: June 17, 1997, accepted (with revisions): August 12,1997 0 1997, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED

differences in canine and human anatomy may necessitate modifications in the approach. Because of the extraperitoneal location of the human prostate, urologists traditionally perform open radical retropubic prostatectomy (RRP) with a completely extraperitoneal approach. We previously demonstrated the feasibility of performing extraperitoneal endoscopic (EE) surgery using laparoscopic instruments and techniques applied to pelvic lymph node dissection and bladder neck suspension.l+17 We present here our initial experience with EERRP. MATERIAL

AND METHODS

A 62-year-old man with a prostate-specific antigen (PSA) level of 8 ng/mL underwent evaluation. Digital rectal examination revealed a moderately enlarged prostate without nodules, His past medical and surgical histories were negative. Transrectal ultrasound-guided biopsy revealed localized adenocarcinoma of the prostate with a Gleason score of 7. On June lo,1997 he underwent RRP via a totally EE approach. OPERATIVE TECHNIQUE The patient was placed supine with the table sacral area to improve exposure to the pelvis. pneumatic compression stockings were placed After induction of general anesthesia, the patient

flexed at the Intermittent on both legs. was prepared

0090-4295/97/J 17.00 PI1 SOO90-4295(97)00485-8

849

FIGURE 2. All trocars were placed in the extraperito-

neal space to maintain a totally extraperitoneal approach.

1. Five trocars were used. The laparoscope was placed through the Hassan trocar. An endo-Babcock was used for traction on the Foley catheter through the 1O-mm port. Both midline trocars were used to bluntly dissect laterally before placement of the lateral 12-mm trocars. Endoscopic gastrointestinal anastomosisstaplers, endoshears,suction, and various retractors were used through the 12-mm ports. FIGURE

and draped sterilely, and a 20F Foley was then inserted transurethrally to drain the bladder, and the balloon was inflated. A l-cm incision was made infraumbilically and carried down to the anterior rectus fascia. Stay sutures were placed in the fascia, and a l-cm incision was made between the sutures slightly off the midline. Blunt finger dissection deep to the fascia but superficial to the peritoneum was performed in the midline toward the pubis to create an extraperitoneal space. The Hassan trocar was inserted into the space, and insufflation of CO, via the trocar was carried out at 12 mm Hg. The laparoscope was placed into the umbilical trocar. A lo-mm trocar was placed one-third of the way from the umbilicus to the symphysis, and a 5mm trocar was placed in the midline 2 cm superior to the symphysis through small skin incisions. Using blunt dissection with graspers, the extraperitoneal space was extended laterally to both anterosuperior iliac spines, deep to the epigastric vessels. Two 12-mm trocars were placed bilaterally two-thirds of the way from the suprapubic trocar to the iliac spines through 12-mm skin incisions (Fig. 1 and 2). The 12-mm trocars were used to accommodate endoclips and endoscopic gastrointestinal anastomosis staplers. The lo-mm trocar was primarily used to accommodate an endoBabcock for traction of the Foley catheter. Endoshears, graspers, suction irrigators, and various retractors were used through all ports during the procedure. Endoshears were used with intermittent electrocautery to divide the endopelvic fascia. Smoke from cautery was evacuated via the trocars as necessary, and resection was continued each time after reestablishment of the pneumopelvis. Veins superficial to the puboprostatic ligaments and dorsal

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FIGURE 3. Endoscopic gastrointestinal anastomosis staplers were used to divide the puboprostatic ligaments and dorsal vein complex.

vein were fulgurated with bipolar cautery. The dorsal vein complex and puboprostatic ligaments were divided with the vascular endoscopic GIA via a 12-mm port (Fig. 3). Because of the thickness of this tissue, multiple firings were required. Each time, after closure of the GIA on the tissue, intermittent traction was placed on the Foley catheter to ensure that the urethra is not included in the GIA before firing. Intermittent traction was placed on the Foley catheter, and the urethra was identified at the prostatic apex. Under the magnification of the endoscope, the neurovascular bundles were identified, and endoshears were spread to develop a plane between the urethra and the bundles (Fig. 4). Dissection was carried out posterior to the urethra. The anterior urethral wall was divided with endoshears, and the Foley catheter was identified and pulled into the pelvis with an endo-Babcock through the lo-mm port. A free tie was placed around the Foley catheter, tied extracorporeally, and then secured down with a pusher. This tie maintained the Foley balloon inflated while the catheter was divided distally and the distal end removed. The posterior urethra was then divided with endoshears, as was the rectourethralis muscle. Using the endo-Babcock, traction was placed on the Foley catheter to aid dissection of the prostate off the rectum. Endoshears were used with a combination of blunt and sharp dissection to peel the posterior prostate off the rectum. Dissection was then carried out antegrade with endoshears and electrocautery to control bleeding. The anterior bladder neck UROLOGY

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Stapled dorsal vein complex and puboprostatic ligaments

Neurovascular

A plane was developed between the urethra and neurovascular bundles with endoshearsunder laparoscopic magnification. FIGURE 4.

was divided in the midline, and dissection continued laterally and deep until the Foley balloon was encountered. The balloon was punctured and the distal end brought out by the endo-Babcock to aid in traction. The ureteral orifices were easily identified with the laparoscope before division of the posterior bladder neck. After division of the posterior bladder neck, the ampullas of the vas were identified and divided between endoclips. The seminal vesicles were then identified and dissected from surrounding tissues with endoshears. The lateral pedicles were then divided with a combination of electrocautery, endoclips, and endoscopic GIAs to complete the dissection. The prostate was placed in a sterile endocatch bag and removed via the original incision for a 12-mm port. No extension of the incision was required to remove the prostate. The trocar was then replaced, the pneumopelvis was reestablished, and reconstruction of bladder neck proceeded. After inspection to rule out inadvertent rectal injury, attention was focused on the bladder neck. A 4-O vicryl suture on a ski needle was placed down a 12-mm trocar and positioned in the pelvis onto an endoscopic needle holder. A second needle holder through a separate port was used to pick up tissue. The bladder mucosa at the anterior bladder neck was then everted with several interrupted sutures placed under endoscopic control. The sutures were tied extracorporeally and secured down with knot pushers. A running 2-O vicryl suture was used to close the bladder neck posterior to anterior in tennis racket fashion, keeping the ureteral orifices in view at all times with the laparoscope. The ends of the suture were secured with intracorporeal ties or specialized polydioxanone suture tie clips. The new bladder neck was able to accommodate the 2OF Foley catheter. Four separate 2-O vicryl sutures on ski needles were placed through the urethral stump and bladder neck and brought out untied through a 12-mm port (Fig. 5). A new 2OF Foley catheter was placed through the urethra and bladder neck under endoscopic control, and the balloon was inflated. Traction was placed on the Foley catheter as the sutures were individually tied extracorporeally and secured down with knot pushers (Fig. 6). Irrigation was placed through the catheter to ensure watertightness. A fenestrated red rubber catheter was placed through one of the 12-mm trocar incisions for drainage, and all trocars were removed after evacuating the remaining CO,. The wounds were closed in two layers with vicryl fascial sutures and skin staples. UROLOGY

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FIGURE 5. Four separate sutures were placed for the

vesicourethral anastomosis and brought out untied via a 12-mm trocar.

6. After placement of anastomotic Sutures, each suture was individually tied extracorporeally and secured down with a knot pusher. FIGURE

RESULTS Complete resection of the prostate and seminal vesicles, along with reconstruction of the bladder neck and a watertight urethrovesical anastomosis were achieved. Operative time was 5 hours and 45 minutes, and the estimated blood loss was 600 cc. The patient received 2 U of autologous blood intraoperatively because the starting hemoglobin was only 10 g/dL several weeks after autologous donation. End-tidal CO, was monitored throughout the procedure, and no hypercarbia was noted. Postoperatively, regular diet was tolerated 12 hours after surgery, and drainage was minimal, despite excellent urinary output. The pelvic drain was removed 48 hours postoperatively. The patient ambulated well on postoperative day 1 and was discharged home 2.5 days postoperatively. Postoperative analgesic requirements consisted of 700 mg of intramuscular meperidine hydrochloride divided into seven doses, followed by 20 mg of oxy851

codone in two doses over 60 hours. No further analgesia was administered. The catheter was removed on postoperative day 14. Minimal stress urinary incontinence was noted at the time of catheter removal. The patient was fully continent by 6 weeks postoperatively. The patient reports no spontaneous erections as of 6 weeks after operation and has not attempted sexual relations. The patient returned to full employment (office work) within 2 weeks of the procedure. Pathologic evaluation demonstrated pathologic Stage T2 disease and negative surgical margins, The total weight of the specimen was 33 g. COMMENT

EE surgery using laparoscopic equipment and techniques has been previously shown to be efficacious in certain pelvic operations.14-l7 We recently reported on 125 cases of EE pelvic lymph node dissection (PLND) as a minimally invasive way to stage prostate cancer.17 It can be performed without intraperitoneal side effects or hypercarbia, with a low rate of complications and minimal analgesic requirements and hospital stay. Given the extraperitoneal location of the prostate and that open prostatectomies are performed via an extraperitoneal approach, EERRP is a natural extension of the approach used in EEPLND. A successful attempt at laparoscopic (transperitoneal) radical prostatectomy has been reported,il but the procedure was considered technically difficult, and development of this technique has been slow to progress. Moore et ~1.1~ have described Schuessler’s expanded experience with this approach, but the series has yet to be published. We are encouraged by our initial experience with EERRP. Total removal of the prostate was achieved along with reconstruction of the bladder neck with a watertight urethrovesical anastomosis. Pathologic evaluation showed negative margins. These results warrant further evaluation and refinement of the procedure. In future procedures, positioning the patient with legs spread can allow intraoperative digital rectal examination, rectal tube insertion, or even sigmoidoscopy to aid in preserving rectal integrity during dissection. During development of the extraperitoneal space, a visual balloon-dilating trocar can be used to reduce operative time, as we now do before EEPLND.17 Other refinements may reduce operative time as well. Current endoscopic GIA designs do not allow for wide opening of the jaws to accommodate large amounts of tissue. Therefore, multiple firings are required. Refining the design of these with wider jaw angles, such as those used in the vascular GIAs used in open surgery, may permit securing the dor852

sal vein complex and lateral pedicles with single firings. The use of harmonic scalpel and scissors instead of endoshears with cautery may be beneficial during much of the dissection. By producing less smoke with harmonic instruments than cautery, one could eliminate much of the interruptions required to evacuate smoke in the pelvis and reestablish the pneumopelvis. The running suture used to reconstruct the bladder neck was secured on one end with an intracorporeal tie and on the other with a PDS tie clip. Certainly the clip can be applied more quickly and can be used on both ends. Whether clip migration can be a problem remains to be seen. It must be noted that EEPLND can be performed before EERRP in one procedure. In this era of early detection, positive nodal yield is low when all patients are surgically staged for lymph node metastasis. On the basis of our experience of EEPLND before brachytherapy, and the experience of others, we have adopted selection criteria for lymphadenctomy according to the presence of two of three of the following: PSA level greater than 20 ng/mL, Gleason score 7 or higher, and clinical Stage T2b or greater. i9-z2 We have also adopted this for cases of perineal prostatectomy and more recently for open RRP as well. Our patient did not meet two of these criteria, and EEPLND was not performed before EERRP. One would expect an additional hour of operating time if EEPLND was done first. Our initial experience with EERRP is encouraging. Further refinements and experience with a larger series will help to determine its effect on hospital stay, recovery time, and, if the microscopic properties of the endoscope can help to reduce blood loss, impotency and incontinence rates. ACKNOWLEDGMENT. To Richard J. Macchia, M.D., Professor and Chairman, Department of Urology, State University of New York, Health Science Center Brooklyn, for help in preparing the manuscript.

REFERENCES 1. Lowe D, Brock W, and Kaplan G: Laparoscopy for localization of nonpalpable testes. J Urol 134: 728-729, 1984. 2. Winfield H, Donovan J, See W, Loenig S, and Williams R: Laparoscopic pelvic lymph node dissection for genitourinary malignancies: indications, techniques and results. J Endour01 6: 103-l 11,1992. 3. Albala D, Schuessler W, and Vancaille T: Laparoscopic bladder neck suspension. J Endourol6: 137-141,1992. 4. Healey D, Newman R, Choen M, and Mars D: Laparoscopically assisted percutaneous renal biopsy. J Urol 150: 1218-1221,1993. 5. Sidney R, John H, Daniel P, Schuessler W, and Vancaille T: Laparoscopic ablation of symptomatic renal cysts. J Ural 150: 1103-1106,1993. 6. Kavoussi L, Kerbl K, Capelouto C, McDougall E, and UROLOGY

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Clayman R: Laparoscopic nephrectomy for renal neoplasia. Urology 42: 603-609, 1993. 7. Winfield H, Donovan J, Godet A, and Clayman R: Laproscopic partial nephrectomy: initial case report for benign disease. J Endourol7: 521-526, 1993. 8. Kavoussi L, Clayman R, Brunt L, and Soper N: Laparoscopic ureterolysis. J Urol 147: 426-429, 1992. 9. Donavan J, and Winfield H: Laparoscopic varix ligation. J Urol 147: 77-88, 1992. 10. Schuessler W, Grune M, Tecuanhuey L, and Preminger G: Laparosoic dismembered pyeloplasty. J Urol 150: 17951799,1993. 11. Raboy A, Ferzh G, Ioffreda R, and Albert P: Laparoscopic ureterolithotomy. Urology 39: 223-225, 1992. 12. Schuessler W, Kavoussi L, Clayman R, and Vancaille T: Laparoscopic radical prostatectomy: initial case report (abstract). J Urol 147: 246A, 1992. 13. Price D, Chari R, Neighbors J, Eubanks S, Schuessler W, and Preminger G: Laparoscopic radical prostatectomy in the canine model. J Laparoendosc Surg 6: 405-412, 1996. 14. Ferzli G, Trapasso J, Raboy A, and Albert P: Extraperitoneal endoscopic pelvic lymph node dissection. J Laparoendose Surg 2: 39-44,1992. 15. Ferzli G, Raboy A, Kleinerman D, and Albert P: Extraperitoneal endoscopic pelvic lymph node dissection vs. laparoscopic lymph node dissection in the staging of prostatic and bladder carcinoma. J Laparoendosc Surg 2: 219-222, 1992.

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16. Raboy A, Hakim L, Ferzli G, Antario J, and Albert P: Extraperitoneal endoscopic vesicourethral suspension. J Laparoendosc Surg 3: 505-5081993. 17. Raboy A, Adler H, and Albert P: Extraperitoneal endoscopic pelvic lymph node dissection: a review of 125 patients. J Urol (in press). 18. Moore R, Partin A, and Kavoussi L: Role of laparoscopy in the treatment of prostate cancer. Semin Surg Oncol 12: 139-144,1996. 19. Rukstalis D, Gerber G, Vogelzang N, Haraf D, Straus F, and Chodak G: Laparoscopic pelvic lymph node dissection: a review of 103 consecutive cases. J Ural 151: 670-674, 1994. 20. Hakim L, Raboy A, Antario J, and Albert P: Extraperitoneal pelvic lymph node dissection versus laparoscopy: advantages and selection criteria for the staging of localized prostate cancer (abstract 118). J Urol 148: 118, 1993. 21. Kleer E, Larsen-Keller J, Zincke H, and Oesterling J: Ability of preoperative serum prostatic specific antigen value to predict pathological stage and DNA ploidy: influence of clinical stage and tumor grade. Urology 41: 207216, 1993. 22. Partin A, Yoo J, Carter H, Pearson J. Chan D, Epstein J, and Walsh P: The use of prostatic specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol 150: 110-114, 1993.

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