Comparison of oncological results and functional outcomes of radical prostatectomy techniques – retropubic, laparoscopic and robot-assisted

Radical prostatectomy (RP) continues to be the «gold standard» in the treatment of localized prostate cancer (PC) for patients with a life expectancy of 10 years.

The purpose of this article is to review pertinent literature to the several surgical approaches for PC and compare both functional outcomes and oncological results of radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP). We chose and systematically reviewed 44 articles published between 1999 and 2013. Comparison analysis showed that the mean blood loss during RRP, LRP and RARP was 935, 442 and 191 ml respectively. Intraoperative transfusion required 19,9; 6,3 and 4,6 % patients respectively. We’d like to outline in our functional outcomes that within the 6-months and 12-months period of follow-up acute urinary retention experienced 89,1 and 92,7 % patients undergoing RARP.

However, lack of certain data and absence of standard assessment methods made objective evaluation of erectile function quite complex. Oncologic results revealed that positive surgical margin rates were higher for RARP in comparison to patients after RRP and LRP (the difference was statistically significant).

Nevertheless, the absence of randomized approach in an overwhelming majority of cases, as well as the short follow-up period are serious deterrents limiting the number of such trials. Therefore it’s still impossible today to draw certain conclusions about the superiority of any surgical approach for RP

1. Heidenreich A., Aus G., Bolla M. et al. EAU guidelines on prostate cancer. Part 1: Screening, diagnosis, and treatment of clinically localized disease. Eur Urol 2011;59:61–71.

2. Schuessler W., Sculam P., Clayman R., Kavoussi L. Laparoscopic radical prostatectomy: initial short-term experience. Urology 1997;50:854–7.

3. Guillonneau B., Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000;163:1643–9.

4. Rassweiler J., Hruza M., Teber D., Su L.M. Laparoscopic and robotic assisted radical prostatectomy – critical analysis of the results. EurUrol 2006;49:612–24.

5. Menon M., Shrivastava A., Tewari A. et al. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002;168:945–9.

6. Ficarra V., Cavalleri S., Novara G. et al. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. Eur Urol 2007;51:45–56.

7. Artibani W., Cavalleri S., Iafrate M. et al. Learning curve of an experienced open surgeon with da Vinci-assisted laparoscopic radical prostatectomy. Urol Int 2008;80: 237–44.

8. Bolenz C., Freedland S., Hollenbeck B. et al. Costs of radical prostatectomy for

9. prostate cancer: a systematic review. Eur Urol 2014;65:316–24.

10. Salomon L., Levrel O., de la Taille A. et al. Radical prostatectomy by the retropubic, perineal and laparoscopic approach: 12 years of experience in one center. Eur Urol 2002;42:104–11.

11. Fracalanza S., Ficarra V., Cavalleri S. et al. Is robotically assisted laparoscopic radical prostatectomy less invasive than retropubic radical prostatectomy? Results from a prospective, unrandomized, comparative study. BJU Int 2008;101:1145–9.

12. Smith J.A. Jr, Chan R.C., Chang S.S. et al. A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol 2007;178:2385–9.

13. Cagiannos I., Karakiewicz P., Eastham J.A. et al. A preoperative nomogram identifying

14. decreased risk of positive pelvic lymph nodes in patients with prostate cancer. J Urol 2003;170:1798–803.

15. Prasad S.M., Keating N.L., Wang Q. et al. Variations in surgeon volume and use of pelvic lymph node dissection with open and minimally invasive radical prostatectomy. Urology 2008;72:647–52.

16. Remzi M., Klingler H.C., Tinzl M.V. et al. Morbidity of laparoscopic extraperitoneal versus ransperitoneal radical prostatectomy versus open retropubic radical prostatectomy. Eur Urol 2005;48:83–9.

17. Jurczok A., Zacharias M., Wagner S. et al. Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy. BJU Int 2007;99:1461–6.

18. Touijer K., Eastham J.A., Secin F.P. et al. Comprehensive prospective comparative

19. analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to 2005. J Urol 2008;179:1811–7.

20. Close A., Robertson C., Rushton S. et al. Comparative cost-effectiveness of robotassisted and standard laparoscopic prostatectomy as alternatives to open radical prostatectomy for treatment of men with localised prostate cancer: a health technology assessment from the perspective of the UK National Health Service. Eur Urol 2013;64:361–9.

21. Anastasiadis A.G., Salomon L., Katz R. et al. Radical retropubic versus laparoscopic prostatectomy: a prospective comparison of functional outcome. Urology 2003;62: 292–7.

22. Bhayani S.B., Pavlovich C.P., Hsu T.S. et al. Prospective comparison of shortterm convalescence: laparoscopic radical versus open radical retropubic prostatectomy. Urology 2003;61:612–6.

23. Roumeguere T., Bollens R., Vanden Bossche M. et al. Radical prostatectomy: a prospective comparison of oncological and functional results between open and laparoscopic approaches. World J Urol 2003;20:360–6.

24. Artibani W., Grosso G., Novara G. et al. Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? An analysis of perioperative morbidity in two contemporary series in Italy. Eur Urol 2003;44:401–6.

25. Egawa S., Kuruma H., Suyama K. et al. Delayed recovery of urinary continence after laparoscopic radical prostatectomy. Int J Urol 2003;10:207–12.

26. Atallah F., Khedis M., Seguin P. et al. Postoperative analgesia and recovery after open and laparoscopic prostatectomy. Anesth Analg 2004;99:1878–9.

27. Brown J.A., Garlitz C., Gomella L.G. et al. Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy. Urol Oncol 2004;22:102–6.

28. Poulakis V., Witzsch U., de Vries R. et al. Laparoscopic radical prostatectomy in men older than 70 years of age with localized prostate cancer: comparison of morbidity,econvalescence, and shortterm clinical outcomes between younger and older men. Eur Urol 2007;51: 1341–9.

29. Silva E., Ferreira U., Silva G.D. et al. Surgical margins in radical prostatectomy: a comparison between retropubic and laparoscopic surgery. Int Urol Nephrol 2007;39:865–9.

30. Terakawa T., Miyake H., Tanaka K. et al. Surgical margin status of open versus laparoscopic radical prostatectomy specimens. Int J Urol 2008;15:704–7.

31. Fromont G., Guillonneau B., Validire P., Vallancien G. Laparoscopic radical prostatectomy. Preliminary pathologic evaluation. Urology 2002;60:661–5.

32. Rosen R.C., Riley A., Wagner G. et al.The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822–30.

33. Rassweiler J., Seemann O., Schulze M. et al. Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol 2003;169:1689–93.

34. Salomon L., Anastasiadis A.G., Levrel O. et al. Location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer. Urology 2003;61:386–90.

35. Martorana G., Manferrari F., Bertaccini A. et al. Laparoscopic radical prostatectomy: oncological evaluation in the early phase of the learning curve comparing to retropubic approach. Arch Ital Urol Androl 2004;76:1–5.

36. Menon M., Tewari A., Baize B. et al. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology 2002;60:864–8.

37. Tewari A., Srivasatava A., Menon M. A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU Int 2003;92: 205–10.

38. Farnham S.B., Webster T.M., Herrell S.D., Smith J.A. Jr. Intraoperative blood loss and transfusion requirements for robotic-assisted radical prostatectomy versus radical retropubic prostatectomy. Urology 2006;67:360–3.

39. Nelson B., Kaufman M., Broughton G. et al. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol 2007;177:929–31.

40. Guazzoni G., Cestari A., Naspro R. et al. Intra and perioperative outcomes comparing radical retropubic and laparoscopic radical prostatectomy: results from a prospective, randomised, single-surgeon study. Eur Urol 2006;50:98–104.

41. Porpiglia F., Morra I., Lucci Chiarissi M. et al. Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy. Eur Urol 2013;63:606–14.

42. Krambeck A.E., DiMarco D.S., Rangel L.J. et al. Radical prostatectomy for prostatic adenocarcinoma: a matched comparison of open retropubic and robot-assisted techniques. BJU Int 2009;103:448–53.

43. Ahlering T.E., Woo D., Eichel L. et al. Robot-assisted versus open radical prostatectomy: a comparison of one surgeon’s outcomes. Urology 2004;63:819–22.

44. Novara G., Ficarra V., D’Elia C. et al. Preoperative criteria to select patients for bilateral nerve-sparing robotic-assisted radical prostatectomy. J Sex Med 2012;7: 839–45.