Candidates undergoing laparoscopic radical prostatectomy, a minimally invasive option for treating prostate cancer, experience less postoperative pain, disability and a shorter recovery. Douglas Dahl, MD, explains the procedure.

This year 395,000 men worldwide will get the unwelcome news that they have prostate cancer. In addition to worrying about their disease, these men also will contend with the side effects of treatment. The search for less invasive therapies with less morbidity has led to the development of an innovative surgery – laparoscopic radical prostatectomy – that offers men another treatment choice.

Patient selection

Surgery is not the best treatment option for all prostate cancer patients, but most patients who are candidates for open radical prostatectomy also are candidates for the laparoscopic procedure. Patients who have had previous extensive abdominal surgery may not be ideally suited to benefit from laparoscopic prostatectomy. Both open and laparoscopic surgeries are more difficult in obese
patients, but results of laparoscopic prostatectomy in obese patients appear to be equal to those in thinner patients.

Procedure

The procedure is performed through four small ports in the abdomen. The total incision length is less than 1.25 centimetres as compared with up to 20 cm for open surgery. An incision through the umbilicus allows access for fibreoptic equipment that provides a
clear, magnified view of the prostate and the nerves.

The angle of approach for the laparoscopic procedure is different from that of open surgery, and the surgeon needs to be experienced
in understanding this view as compared with the overhead view in open surgery. This approach allows us to see and handle the nerves better.

We also employ a nervesparing technique known as hydrodissection which was pioneered at Massachusetts General Hospital in the United States and involves injecting fluid along the nerves to help separate them from prostate tissue. The fluid contains some epinephrine which helps control bleeding and minimises nerve damage.

Technology

Advances in technology have made laparoscopic radical prostatectomy feasible and successful. Technological innovations
include:

• Fibreoptics that give us the ability to view the field up to 10x magnification, affording an exquisitely clear view, which helps particularly in dissecting nerves from the prostate

• Ultrasonic dissector, a type of ultrasonic scissors that cut and coagulate small vessels

• Voice-activated robotic camera holder that is steadier than the human hand, freeing human hands for more precise tasks

• Entrapment sack. The surgeon places the prostate in the sack, cinches it, and pulls it out through a very small incision without worrying about the cancer seeding

• Latest-generation trochars that spread rather than cut muscle fibers, causing less trauma and fewer complications. They save time in the operating room because we only have to close one of the four incisions

Experience

The experience of the surgeon and the team are also critical factors in the success of laparoscopic radical prostatectomy. We
are working in the relatively small space of the male pelvis – a high-rent neighbourhood – very close to critical structures, and the margin of error is slim. Expert teams including anaesthesiologists, nurses, technical specialists and others also makes a difference to the outcome of the surgery.

Advantages

Patients who choose laparoscopic prostatectomy experience less postoperative pain and disability and a shorter recovery as compared with open radical prostatectomy. The laparoscopic procedure is associated with less blood loss, reduced incidence of
stricture of the bladder neck, and decreased incidence of post-surgical inguinal hernia.

The oncologic results to date appear to be equal and men seem to recover urinary continence more rapidly. Although we expect that functional outcomes, including continence and potency, will compare favourably with the results of open surgery, these benefits are as yet unproven.

Reliable data on continence and potency are notoriously difficult to obtain for any surgery, so we are currently conducting a study using an independent evaluator to compare the outcomes of open and laparoscopic prostatectomy. We expect to have preliminary results within one year, and we hope to be able to determine whether there are subsets of patients who are better suited for one procedure or the other.

The future of laparoscopic radical prostatectomy

Laparoscopic radical prostatectomy is perhaps the most demanding urologic laparoscopic surgery, but the challenge is well worth the effort in terms of benefits for patients, and on the near horizon, a number of innovations will enhance our ability to perform this procedure successfully.

They include:

• Improvements in technology and instruments. We are working with CIMIT (Center for the Integration of Medicine and Innovative Technology) to develop the best tools and the most appropriate operating environment for minimally invasive procedures

• Advances in imaging, including laparoscopic ultrasound, will provide a better view of both the cancer and the nerves

• New chemical agents will better protect the nerves from the trauma of surgery. 
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