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Should Robotic Assisted Radical Prostatectomy Be Extraperitoneal Like Open Surgery?
Kevin Tomera1, Brooke A Harnisch2, Jaspreet Batra1, Ingolf Tuerk1
1St. Elizabeth's Medical Center, Brighton, MA;2Boston University and Boston Medical Center, Boston, MA
Introduction:
The standard approach for open radical prostatectomy is extraperitoneal but most robotic surgeons have limited themselves to the transperitoneal approach. We compare our surgical and oncological Results for extraperitoneal (EP-RARP) to transperitoneal (TP-RARP) robotic assisted radical prostatectomy.
Materials & Methods:
We examined our departmental, IRB approved, retrospective database of RARP. Between October 2008 to March 2011, 611 patients underwent RARP of which 382 had EP-RARP.
Results:
EP-RARP was comparable to TP-RARP with mean operative times (126 vs. 124 minutes), estimated blood loss was identical at 150mls, similar nodal yield (8.3 vs. 8.5), low positive surgical margin rate (9.8 vs. 9.6%) despite 26% of patients having pT3 disease. Hospital stays were overnight (1.01 vs. 1.04 days) . The importance of lymphadenectomy is confirmed by our 9.6% yield. Major complications were only 0.6% with a small bowel obstruction and renal failure in the transperitoneal group (table attached).
Conclusions:
The advantage of extraperitoneal approach for open surgery is avoiding bowel complications. An experienced robotic surgeon can perform extraperitoneal radical prostatectomy retaining this advantage without oncological or surgical compromise.
Table 1: EP-RARP vs. TP-RARP data | | | | | Total | Extraperitoneal | Transperitoneal | | Number | 611 | 382 | 239 | | Age(mean+ s.d.) | 59.84+7.18 | 59.49+7.09 | 60.71+7.38 | | BMI kg/m2 | 28.3 +4.26 | 27.2 +3.31 | 31.0 +5.14 | Number of pts with
BMI> 30kg/m2 | 157 | 89 | 68 | | PSA(ng/dl) | 5.9 +5.0 | 5.9 +5.1 | 6.0 +4.6 | | Prostate size | 49 +19 | 49 +17 | 50 +23 | | OR time( minutes) | 125 +21 | 126 +20 | 124 +24 | | EBL(ml) median | 150 +154 | 150 +166 | 150 +100 | Pathologic stage
pT3a,pT3b | 26% | 25.6% | 30% | | PSM- prostate surgical margins | 9.7% | 9.8% | 9.6% | | Lymphadenectomy | 188pts | 144pts | 44pts | | Nodal Yield | 8.4 +4.2 | 8.3 +3.8 | 8.5 +5.3 | | Node positive | 9.6% | 6.4% | 13.6% | | Post operative Complications (Clavien grade 4 number or greater) | 0.6% (4pts) | STEMI x2 | Small bowel obstruction and renal failure; anastomotic disruption and renal failure | | Length of stay | 1.03 | 1.01 | 1.04 |
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