Elsevier

European Urology

Volume 55, Issue 5, May 2009, Pages 1037-1063
European Urology

Review – Prostate Cancer
Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis of Comparative Studies

https://doi.org/10.1016/j.eururo.2009.01.036Get rights and content

Abstract

Context

Despite the wide diffusion of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP), only few studies comparing the results of these techniques with the retropubic radical prostatectomy (RRP) are currently available.

Objective

To evaluate the perioperative, functional, and oncologic results in the comparative studies evaluating RRP, LRP, and RALP.

Evidence acquisition

A systematic review of the literature was performed in January 2008, searching Medline, Embase, and Web of Science databases. A “free-text” protocol using the term radical prostatectomy was applied. Some 4000 records were retrieved from the Medline database; 2265 records were retrieved from the Embase database;, and 4219 records were retrieved from the Web of Science database. Three of the authors reviewed the records to identify comparative studies. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).

Evidence synthesis

Thirty-seven comparative studies were identified in the literature search, including a single, randomised, controlled trial.

With regard to the perioperative outcome, LRP and RALP were more time consuming than RRP, especially in the initial steps of the learning curve, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates all favoured LRP. With regard to the functional results, LRP and RRP showed similar continence and potency rates. Similarly, no significant differences were identified between LRP and RALP, while a single, nonrandomised, prospective study suggested advantages in terms of both continence and potency recovery after RALP, compared with RRP. With regard to the oncologic outcome, LRP and RALP were associated with positive surgical margin rates similar to those of RRP.

Conclusions

The quality of the available comparative studies was not excellent. LRP and RALP are followed by significantly lower blood loss and transfusion rates, but the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. Further high-quality, prospective, multicentre, comparative studies are needed.

Introduction

The increase in prostate-specific antigen (PSA) screening, combined with a reduction in the threshold of indications for prostate biopsy and the greater number of samples taken, has contributed to an increase in the diagnosis of prostate cancer. This has led to earlier diagnosis, to downstaging of the disease, and to an increase in the number of patients presenting with clinically organ-confined disease. This, in turn, has led to an increase in the number of candidates for radical prostatectomy (RP) [1].

RP is a common treatment for patients with clinically localised prostate cancer (cT1–cT2) and life expectancy >10 yr [2]. RP has been associated with complications and sequelae, including intraoperative blood loss, postoperative urinary incontinence, and erectile dysfunction. However, the improvements in the knowledge of the anatomy of Santorini's dorsal venous complex and of cavernous nerves have led to significant updates of the surgical technique and to the standardisation of the anatomic retropubic RP (RRP), as described by Walsh in 1982 [3]. Since then, many authors have provided important contributions to the optimisation of the surgical technique, with the purposes of reducing short-term and long-term complications and of improving functional results both in terms of urinary continence [4], [5], [6], [7], [8] and of erectile function [9], [10], [11].

With the intent of reducing the invasiveness of traditional open surgery and improving functional results, since 1999 several European authors have developed the technique of laparoscopic RP (LRP) [12], [13]. Subsequently, there has been a slow but consistent increase in the popularity of LRP in many countries worldwide. Specifically, the data of the Laparoscopic Working Group of the Germany Urological Association show that in 2002, 15% of the German and Swiss centres performed LRP, with only 5% having completed >15 cases. In 2004, 19.2% of the German urologic centres offered LRP, with 26.9% and 60.6% of the patients undergoing perineal RP and RRP, respectively [14]. Further data from the same multicentre cooperation show that in 2006, >5800 LRP had been performed by 50 different surgeons in Germany [14].

The shift from open to laparoscopic surgery represented a completely new experience for surgeons, who were exposed to the surgical anatomy through a different perspective and were required to learn new operative procedures and to deal with new surgical tools. More specifically, surgeons faced a steep learning curve associated with the restrictions related to LRP, including the reduction of the range of motion (ie, only 4 df), two-dimensional (2D) vision, impaired eye–hand coordination (ie, misorientation between real and visible movements), and reduced haptic sense (ie, only minimal tactile feedback) [13], [15].

Robotic systems have recently been introduced in an attempt to reduce the difficulty involved in performing complex laparoscopic urologic procedures, particularly for nonlaparoscopic surgeons [16], [17]. The presence of three-dimensional (3D) magnification and tools with 7 df that are able to duplicate hand movements with high accuracy have allowed many urologists to hypothesise that, despite the absence of tactile feedback, the application of robotic surgery to RP might yield real advantages, not only in terms of shorter learning curves but also in the ability to improve functional results without impairment of early oncologic outcomes [15].

Robot-assisted laparoscopic RP (RALP) began in 2000, with the first cases performed by Binder et al in Frankfurt, Germany, [18] and by Abbou et al in Creteil, France [19]. Menon et al standardised the RALP technique by describing the Vattikuti Institute Prostatectomy (VIP) [20], which led to significant popularity of RALP both in the United States and in Europe.

Despite the wide diffusion of LRP and RALP over the past 5 yr in Europe and the United States, only a few studies comparing the results of the new approaches to the classical retropubic technique are currently available. The purpose of the present systematic review and cumulative analysis was to evaluate the perioperative, functional, and oncologic results deriving from the comparative studies evaluating RRP, LRP, and RALP.

Section snippets

Evidence acquisition

A literature search was performed in January 2008 using the Medline, Embase, and Web of Science databases. The Medline search included only a “free-text” protocol using the term radical prostatectomy across the “Title” and “Abstract” fields of the records. Subsequently, the following limits were used: humans, gender (male), and language (English). The searches of the Embase and Web of Science databases used the same free-text protocol and the same key words, applying no limits. We took into

Statistical analyses

Cumulative analysis was conducted using the Review Manager v.4.2, software designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK). Specifically, statistical heterogeneity was tested using the χ2 test. A p value <0.10 was used to indicate heterogeneity. In case of lack of heterogeneity, fixed-effects models were used for the cumulative analysis. Random effects models were used in case of heterogeneity. The results were expressed as weighted means and standard deviations for

Conclusions

Although pure LRPs and RALPs are followed by significantly lower blood loss and transfusion rates and have all traditional advantages of a minimally invasive procedure, the data from this systematic review did not allow us to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. To be strict, however, it might be hypothesised that more solid and accurate studies could show some differences that do not currently appear. It is likely that the most critical

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