Laparoscopic Versus Open Simple Prostatectomy: A Comparative Study

Laparoscopic Versus Open Simple Prostatectomy: A Comparative Study H. Baumert,* A. Ballaro, F. Dugardin and A. V. Kaisary From the Fondation Hôpital Saint Joseph (HB, FD), Paris, France, and Royal Free Hospital (HB, AB, AVK), London, United Kingdom

Purpose: Laparoscopic simple prostatectomy has recently been developed to remove large prostatic adenomas causing bladder outflow obstruction. To our knowledge the advantages of the laparoscopic vs the standard open approach to this procedure remain undefined. We compared laparoscopic and open simple prostatectomy. Materials and Methods: Perioperative data on the first 30 consecutive laparoscopic simple prostatectomies performed by 1 surgeon were collected prospectively and compared with retrospectively collected data on a series of 30 consecutive open simple prostatectomies. A Millin and a transvesical-prostatic technique were used in the laparoscopic group and a transvesical technique was used in the open group. Results: There was no significant difference in prostatic size, patient age or body mass index between the 2 groups. In the laparoscopic group the mean International Prostate Symptom score ⫾ SD improved from22.4 ⫾ 6.9 to 5.7 ⫾ 3.6 and the urinary flow rate improved from 8.1 ⫾ 2.5 to 24.6 ⫾ 12.1 ml per minute (each p ⬍0.001). Mean total blood loss (367 ⫾ 363 vs 643 ⫾ 647 ml), irrigation time (0.33 ⫾ 0.7 vs 4 ⫾ 3.5 days), duration of catheterization (4 ⫾ 1.7 vs 6.8 ⫾ 4.7 days) and hospital stay (5.1 ⫾ 1.8 vs 8 ⫾ 4.8 days) were significantly less in the laparoscopic group than in the open group. Mean operative time was longer in the laparoscopic group (115 ⫾ 30 vs 54 ⫾ 19 minutes). Of the 30 patients in the laparoscopic group 24 did not require bladder irrigation. There was no apparent difference in the incidence or severity of complications. There was no difference in perioperative parameters or functional results between the 2 different laparoscopic techniques. Conclusions: Laparoscopic simple prostatectomy has inherent advantages over the open technique. Further studies are indicated to determine whether this technique should be considered the treatment of choice for prostatic adenomas too large for safe endoscopic resection. Key Words: prostate, laparoscopy, prostatectomy, prostatic hyperplasia, adenoma

espite the increasing popularity of HoLEP and evidence that the technique may be superior to conventional treatment modalities1,2 open simple prostatectomy remains the procedure of choice for prostate adenomas too large for safe endoscopic resection.3 Advancements in laparoscopic urological expertise and the drive to apply the minimally invasive approach to all surgical procedures in which it is practical have led to the recent development of laparoscopic simple prostatectomy.4 – 8 The results of early series suggest that laparoscopic simple prostatectomy may offer advantages over the open procedure.6,8 However, to our knowledge a direct comparison of the 2 techniques remains to be performed. We compared the results of laparoscopic and open simple prostatectomy.

D

METHODS From March 2002 to March 2005, 1 surgeon (HB) experienced with open prostatectomy and laparoscopy performed 30 consecutive laparoscopic simple prostatectomies in men with symptomatic bladder outflow obstruction and a prostate gland estimated to be larger than 80 cc on TRUS. All

Submitted for publication June 23, 2005. * Correspondence: Department of Urology, Royal Free Hospital, Pond St., London NW3 4QG, United Kingdom (telephone: 0044 207 794 0500; FAX: 0044 207 830 2906; e-mail: baumertherve@ yahoo.fr).

0022-5347/06/1755-1691/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION

patients provided appropriate consent. Preoperative and 3-month postoperative I-PSS, urinary flow rate, prostatic size on TRUS, surgical specimen weight, operative time, intraoperative blood loss, transfusion rate, complications, catheterization period, irrigation requirement and hospitalization time were determined prospectively. The data were compared to retrospectively collected data on the last 30 consecutive open simple prostatectomies performed between January 2001 and March 2002. In all patients in the 2 groups bladder irrigation was stopped and the catheter was subsequently removed when the urine was light rose or clear. No suprapubic catheter was inserted. Patients were discharged home the day after the catheter was removed. Blood transfusion was initiated when serum hemoglobin was less than 8 gm/dl or symptoms of acute blood loss were apparent. All statistical comparisons were done using the Student t test except the transfusion rate, which was compared using the Mann-Whitney U test.

Operative Techniques The procedure used in open cases was standard transvesical simple prostatectomy. Two techniques were used in laparoscopic cases. In the first 17 cases a Millin-type procedure was used. In the following 13 cases a transvesical-prostatic approach was used.

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Vol. 175, 1691-1694, May 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00986-9

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LAPAROSCOPIC VERSUS OPEN SIMPLE PROSTATECTOMY TABLE 1. Preoperative and perioperative parameters in laparoscopic and open groups Mean Laparoscopic ⫾ SD

Age BMI Preop prostate size (ml) Operative time (mins) Blood loss (ml) Specimen wt (gm) Irrigation time (days) Catheterization time (days) Hospital stay (days)

Mean Open ⫾ SD

p Value

67.4 ⫾ 6.0 26.8 ⫾ 2.5 121.8 ⫾ 39

69.7 ⫾ 7.4 26.8 ⫾ 3.0 106.2 ⫾ 25

0.21 0.92 0.07

115 ⫾ 30

54 ⫾ 19

⬍0.01

367 ⫾ 363 77.2 ⫾ 32.4 0.33 ⫾ 0.7

643 ⫾ 647 78.1 ⫾ 42.2 4 ⫾ 3.5

0.045 0.93 0.003

4 ⫾ 1.7

6.8 ⫾ 4.7

0.004

5.1 ⫾ 1.8

8.0 ⫾ 4.8

0.003

Transfusion was given in 1 of 30 patients (3.33%) in the laparoscopic group and in 5 of 30 (16.7%) in the open group (p ⫽ 0.19).

Laparoscopic Millins Procedure Five ports were placed, including a 10 mm port at the umbilicus for the lens and 2, 5 mm ports between the umbilicus and anterior superior iliac crest on each side. Extraperitoneal dissection of the space of Retzius was performed and the endopelvic fascia was not opened. A transverse opening was made in the prostatic capsule and the adenoma was enucleated using scissors, bipolar diathermy or a harmonic scalpel. Hemostasis of the capsule was achieved using bipolar diathermy. The trigone was secured to the posterior prostatic capsule, which was then closed using a 2-zero polyglactin running suture. A bladder catheter was inserted and a suction drain was inserted into the space of Retzius. At the end of the procedure 20 mg furosemide were administered intravenously. The prostatic lobes were placed in an endoscopic bag and morcellated as required. Laparoscopic Transvesical-prostatic Approach Five ports were positioned as described. Using an extraperitoneal approach dissection of the space of Retzius was performed. A longitudinal opening was made in the anterior aspect of the bladder and extended to the anterior aspect of the prostatic capsule using scissors, bipolar diathermy or a harmonic scalpel. Stay sutures were placed between the edges of the open bladder to Cooper’s ligament on each side. The bladder neck mucosa was incised to expose the prostate base and the plane between the adenoma and surgical capsule was developed. The adenoma was enucleated using scissor or a harmonic scalpel. Capsular hemostasis was achieved using bipolar cautery. The prostatic capsule and bladder were closed using a double 2-zero polyglactin running suture. A catheter was inserted into the bladder. At the end of the procedure 20 mg furosemide were administered intravenously. The space of Retzius was drained as described. The prostatic lobes were placed in an endoscopic bag and morcellated as required. RESULTS There was no significant difference in patient age, BMI or estimated preoperative prostatic size between the 2 groups (table 1). Mean total blood loss, irrigation time, duration of catheterization and hospital stay were significantly less in

the laparoscopic group than in the open group, although mean operative time was longer in the laparoscopic group (table 1). Only 6 laparoscopic cases (20%) required bladder irrigation. In the laparoscopic group I-PSS improved from a mean ⫾ SD of 22.4 ⫾ 6.9 to 5.7 ⫾ 3.6 and the mean urinary flow rate improved from 8.1 ⫾ 2.5 to 24.6 ⫾ 12.1 ml per minute (each p ⬍0.001). Bladder calculi were removed in 3 patients in the laparoscopic and 3 in the open group. There were complications in 8 patients (27%) in the laparoscopic group and in 9 (30%) in the open group. In the laparoscopic group 1 patient who had previously undergone bilateral mesh inguinal hernia repair had an abdominal wall hematoma, which was managed conservatively. He was the only patient in the laparoscopic group who required transfusion, which was given for blood loss from the abdominal wall, not from the prostatic fossa. This patient did not require bladder irrigation. In 2 patients a trial without a catheter failed when the catheter was removed on day 2. The catheter was successfully removed a few days later. One patient had mild stress incontinence that resolved completely by the 3-month followup. One patient had bladder neck stenosis, which did not require intervention. One patient had a port site infection, 1 had transient fever and 1 had secondary hematuria that required repeat catheterization and bladder irrigation. In the open group 5 patients required blood transfusion, of whom 1 had a pelvic hematoma that was managed conservatively. One patient had self-limited stress incontinence, 1 required reoperation to evacuate bladder clots and in 2 a trial without a catheter failed but was later successful. Histological findings were benign in all patients. There was no significant difference in preoperative or perioperative parameters, or in functional results between the laparoscopic Millin approach and the laparoscopic transvesicalprostatic approach (table 2). During the study period the incidence of patients with bladder outflow obstruction due to prostatic enlargement that was treated with simple vs endoscopic prostatectomy was 29%.

TABLE 2. Perioperative parameters in Millin and transvesical laparoscopic groups

Age BMI TRUS size (ml) Specimen wt (gm) I-PSS: Preop Postop Max urine flow rate (ml/sec): Preop Postop Operative time (mins) Blood loss (ml) Irrigation time (days) Catheterization time (days) Hospital stay (days)

Mean Millin ⫾ SD

Mean Transvesical ⫾ SD

p Value

66.8 ⫾ 5.8 26.4 ⫾ 2.0 120 ⫾ 30 74 ⫾ 30

68.4 ⫾ 6.4 27.2 ⫾ 3.4 123 ⫾ 49 81 ⫾ 36

0.5 0.5 0.8 0.6

21.3 ⫾ 6.4 4.8 ⫾ 3.5

24.7 ⫾ 7.8 8.2 ⫾ 2.7

0.35 0.07

7.8 ⫾ 2.6 22.1 ⫾ 8.9 120 ⫾ 32

8.7 ⫾ 2.3 34.9 ⫾ 13.3 108 ⫾ 27

0.46 0.07 0.32

394 ⫾ 453 0.5 ⫾ 0.9

330 ⫾ 207 0.08 ⫾ 0.3

0.64 0.08

3.9 ⫾ 1.4

4.3 ⫾ 2

0.5

5.1 ⫾ 2.1

0.8

5 ⫾ 1.6

Transfusion was given in 1 of 17 patients (5.9%) in the laparoscopic group and in none of 13 in the open group (p ⫽ 0.39).

LAPAROSCOPIC VERSUS OPEN SIMPLE PROSTATECTOMY DISCUSSION The results of this comparative study show that laparoscopic simple prostatectomy is associated with a lower blood loss and irrigation requirement, and a shorter postoperative catheterization period and hospital stay at the expense of a longer operative time. Although the surgeon was an experienced laparoscopist, the laparoscopic simple prostatectomies performed during this study were the first that he had performed, whereas the technique of transvesical open prostatectomy is well standardized. Therefore, the data on the laparoscopic group incorporates a learning curve and could be expected to improve in relation to the open series. The absence of functional data (I-PSS and urinary flow rate) in the open group prevents direct comparison of these variables for the 2 techniques. However, a similar proportion of the estimated prostatic size was removed in each group and the functional results in the laparoscopic group are similar to those reported for HoLEP and open simple prostatectomy in other series.1,2 The lack of a significant difference in preoperative prostatic size, patient BMI or surgical specimen weight between the 2 groups in this study suggests that a comparison of blood loss, the irrigation requirement and catheterization time between the open and laparoscopic groups is valid. These variables are likely to be related to adenoma size and patient BMI rather than to functional parameters. Because the laparoscopic cases in the current series were the first ones that the surgeon had performed, operative time might be expected to improve. The operative technique for the laparoscopic procedure was changed during the study from a Millin-type procedure to a transvesical-prostatic approach because enucleation of the adenoma was found to be difficult through a capsular incision, particularly with large glands or when a large median prostatic lobe was present. Removing concomitant bladder stones was also easier with the transvesical-prostatic approach. By extending the bladder incision to the anterior aspect of the prostatic surgical capsule we found that visualization was improved during enucleation of the adenoma and hemostasis. There was no significant difference in the perioperative variables measured between the 2 laparoscopic techniques to suggest that one was superior to the other. Therefore, we prefer the transvesical-prostatic technique for laparoscopic simple prostatectomy. Prostate adenomas larger than 80 to 100 gm causing symptomatic bladder outflow obstruction have traditionally been removed using an open retropubic approach because of the increased risk of transurethral resection syndrome associated with prolonged endoscopic resection. However, the transfusion requirement and recovery time are generally greater for open prostatectomy than for transurethral prostatic resection. In a series of 1,800 open simple prostatectomies from Southern Italy mean postoperative hospital stay was 7 days and there was severe bleeding in 11.6% of patients with 8.2% requiring blood transfusion.9 In contrast, HoLEP can result in a shorter postoperative catheterization period, earlier hospital discharge and a greater mass of tissue removed compared with endoscopic resection of prostates of the same TRUS estimated preoperative size with little or no blood loss.1 A nonrandomized, retrospective study comparing HoLEP to open simple prostatectomy suggested that the advantages

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of laser enucleation can be sustained for the removal of glands larger than 100 cc.2 However, in this study the complication rate was higher in the laser group. Early studies of high power KTP laser vaporization of large prostates showed results similar to those of HoLEP. In a group of 64 men with a mean prostatic volume of 101 ⫾ 40 cc no transfusions were required and 62 were discharged home without a catheter within 23 hours.10 Since the first demonstration of laparoscopic simple prostatectomy by Mariano et al,4 several variations of technique and series demonstrating the feasibility of the procedure have been reported.5– 8 van Velthoven et al reported a series of 18 laparoscopic simple prostatectomies with a mean operative time of 145 ⫾ 32 minutes and a mean blood loss of 192 ⫾ 178 ml.6 The mean weight of the surgical specimen was 47.6 ⫾ 30 gm compared to a preoperative estimated size of 95.1 ⫾ 28.1 ml. There was a complication rate of 27.7% and the catheter was removed after 3 days, although 4 patients required repeat catheterization. More recently Sotelo et al reported a series of 17 laparoscopic simple prostatectomies with a mean operative time of 156 minutes (range 85 to 380), mean blood loss of 516 ml (range 100 to 2,500) and mean catheterization time of 6.3 days (range 3 to 7).8 Mean preoperative estimated prostate size was 93 gm and the weight of the surgical specimen was 72 gm (range 32 to 120). Data on the laparoscopic group in the current study compare favorably to those in previously published series. Results suggest that laparoscopic simple prostatectomy can be associated with decreased blood loss and shorter postoperative recovery with no apparent increase in postoperative complications compared with open simple prostatectomy for prostate adenomas of a similar size. The decrease in blood loss is likely to be a direct result of the use of cauterizing instruments during enucleation of the adenoma from the surgical capsule instead of the manual technique, the better visualization of bleeding points provided by laparoscopic magnification and the compressive effect of insufflation gas under pressure on vessels in the prostatic capsule. The more rapid postoperative recovery probably results directly from decreased blood loss and decreased wound morbidity.

CONCLUSIONS Most traditional surgical procedures can now be performed laparoscopically. The goal is now to be able to provide individuals with reliable information about surgical alternatives, so that an informed choice can be made regarding the best operation for the disease.11 We believe that laparoscopic simple prostatectomy is a valid option for removing large, benign prostate adenomas and it has inherent advantages compared with the open approach that can result in significantly lower morbidity. However, long-term data are required and further studies, including comparison with laser prostatectomy, are needed to determine whether laparoscopic simple prostatectomy should be considered the optimum surgical treatment for prostate adenomas too large for endoscopic resection.

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LAPAROSCOPIC VERSUS OPEN SIMPLE PROSTATECTOMY

Abbreviation and Acronyms BMI HoLEP I-PSS TRUS

⫽ ⫽ ⫽ ⫽

body mass index holmium laser prostatectomy International Prostate Symptom Score transrectal ultrasound

REFERENCES 1. Tan, A. H. H., Gilling, P. J., Kennett, K. M., Frampton, C., Westenberg, A. M. and Fraundorfer, M. R.: A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol, 170: 1270, 2003 2. Moody, J. A. and Lingeman, J. E.: Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy. J Urol, 165: 459, 2001 3. Debruyne, F. M. J., Djavan, B., de la Rosette, J. J. M. C. H., Desgrandchamps, F., Fourcade, R. O., Gibbons, R. P. et al: Interventional therapy for benign prostatic hyperplasia. In: Benign Prostatic Hyperplasia. Edited by C. Chatelain, L. Denis, K. T. Foo, S. Khoury and J. McConnell. Plymouth, United Kingdom: Plymbridge Distributors, pp. 399-421, 2001

4. Mariano, M. B., Graziottin, T. M. and Tefilli, M. V.: Laparoscopic prostatectomy with vascular control for benign prostatic hyperplasia. J Urol, 167: 2528, 2002 5. Nadler, R. B., Blunt, L. W., Jr., User, H. M. and Vallancien, G.: Preperitoneal laparoscopic simple prostatectomy. Urology, 63: 778, 2004 6. van Velthoven, R., Peltier, A., Laguna, M. P. and Piechaud, T.: Laparoscopic extraperitoneal adenomectomy (Millin): pilot study on feasibility. Eur Urol, 45: 103, 2004 7. Rey, D., Ducarme, G., Hoepffner, J. L. and Staerman, F.: Laparoscopic adenectomy: a novel technique for managing benign prostatic hyperplasia. BJU Int, 95: 676, 2005 8. Sotelo, R., Spaliviero, M., Garcia-Segui, A., Hasan, W., Novoa, J., Desai, M. M. et al: Laparoscopic retropubic simple prostatectomy. J Urol, 173: 757, 2005 9. Serretta, V., Morgia, G., Fondacaro, L., Curto, G., Lo bianco, A., Pirritano D. et al: Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology, 60: 623, 2002 10. Sandhu, J. S., Ng, C., Vanderbrink, B. A., Egan, C., Kaplan, S. A. and Te, A. E.: High-power potassium-titanyl-phosphate photoselective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates. Urology, 64: 1155, 2004 11. Guillonneau, B.: Editorial comment. Eur Urol, 45: 103, 2004