Urologic Oncology

SLIDES & TRANSCRIPTS
Saturday, December 14, 2002

Limitations of Laparoscopic Prostatectomy

Maxwell V. Meng, M.D.

Slide 1:

And as we have heard, despite all the efforts, many issues of prostate cancer treatment remain unresolved. And now, the optimal surgical technique, which I think previous was generally considered radical retropubic prostatectomy is also being questioned.

Slide 2:

Our technique at UCSF really is based on a lot of experience, and a study from many others over the past 20 years. And especially with this audience, I'm really just going to highlight a few of the points that Dr. Carroll wanted me to stress.

Slide 3:

Clearly, an understanding of the relevant anatomy forms the basis of the operation, whether it is performed laparoscopically or via an open approach. And with this knowledge, a careful and meticulous dissection is possible.

Important elements that we routinely rely on are clear visualization, and this is provided by excellent fixed retraction, as well as good lighting. And at UCSF we routinely use optical magnification loops at 2.5 to 4.5 times to improve our vision.

And finally, we use right angle instruments for the sharp dissection, especially at the level of the apex, as well as during release of the neuromuscular bundles.

Slide 4:

And so arguments about better visualization and magnification with the robotic or laparoscopic systems may be addressed with simply using loops and having excellent visualization and lighting with the head lights.

Slide 5:

Another supposed advantage of the laparoscopic technique is the multiple small incisions and better cosmoses. But we use a mini-laparotomy incision, as initially reported by Dr. Fray Marshall. And typically, our incision length is somewhere between 7 and 8 centimeters. So I think cosmetically, the patients are fairly happy. Recovery is an issue that we can discuss later.

Slide 6:

And these photos illustrate that use of the book walter retractor when properly applied, can give you excellent visualization of the bladder and the prostate. And again, I think the argument of having better visualization with the laparoscopic technique may not be as applicable.

Slide 7:

Here we have the prostate after we incised the endopelvic fascia and placed our gathering sutures on the proximal poria on top of the prostate just prior to division of the dorsal venus complex. And just as many others do, we place a distal suture across the dorsal venus complex and sew this sequentially as we are coming across the vein. And again, this gives us an excellent exposure and dissection at that level of the apex.

Slide 8:

Here are a few MRI images at the level of the mid-prostate nicely illustrating the posterioral lateral locations of the neural vascular bundles at the 5 and 7 o'clock positions.

Slide 9:

And with this knowledge, prior to division and approaching the apex and the urethra, we incise the lateral prostatic fascia at the level of the mid-prostate, not down at the apex. And this allows us to drop the neural vascular bundles away from the prostate prior to our apel dissection.

Slide 10:

The question of positive surgical margins, Dr. Menon has addressed using some interoperative frozen sections of the apex.

Slide 11:

We, as well, along with other groups, to better spare the nerves, occasionally we have been sending interoperative frozen sections from the side that we are potentially concerned about.

And we use several factors to determine whether we are going to spare the neural vascular bundle, such as the number and laterality of positive biopsies, the Gleason grade, and interoperative findings such as induration.

And in a recently published report of 101 patients in which we sent intraoperative frozen sections from the side that we were concerned about, that predicted the final pathology with a positive predictive value of 73 percent, and a negative predictive value of 94 percent. And in those 15 patients initially with positive interoperative frozen sections, the final tissue that was resected and sent was negative in 80 percent.
So in selected patients, intraoperative frozen section may serve as an adjunct to both help spare the neural vascular bundles, as well as to maximize cancer control outcomes.

Slide 12:

And again preceding the dissection more proximally here, we can see excellent exposure of the seminal vesicals. We routinely take all the seminal vesicals currently, and again, I think with adequate visualization and identification of the neurovascular bundles, we can do this without decreasing our potency rates.

Slide 13:

This demonstrates after removal of the prostate we have a nice urethral stump here.

And again, I think this will help us to perform our urethrovesicle anastomosis.

Slide 14:

With excellent visualization and retraction, we are typically able to place eight interrupted sutures. And we feel that we can achieve a nice mucosal-to-muchosal apposition similar with the laparoscopic technique.

Slide 15:

In selected high risk patients such as those undergoing prostatectomy after radiation therapy, those of older age, and those who undergo a more extensive apical dissection, recently we have been using an otologous rectus fascia sling at the time of surgery to try to help increase our continence rates in this population.

And here you can see typically our fascia sling is 1 centimeter by 8 centimeters. We try to place it at the level of the anastomosis or the proximal urethra, and tie the sutures above the rectus muscle.

Slide 16:

And in doing so, we have done this in over 70 patients now, in this high risk keep in mind, at 1, 2, and 3 months we have an increased rate of continence. However, if we look at the rates at 9-12 months, both of these approach 96 percent. So, while the overall ultimate continence may not be improved, the time to continence and rapidity of the continence may be more rapid with the use of the continence sling in these high risk patients. And this more rapid return to continence is similar to other novel techniques such as Dr. Walsh's recently described the bladder intersusception technique.

Slide 17:

Well, in talking about outcome for radical prostatectomy, we have to talk about kind of population we are operating on. This slide just demonstrates Dr. Carroll's last 880 patients, the make-up of these patients. And as defined by these risk criteria here, 20 percent fall into a high risk group, and 42 percent are in an intermediate risk stratification group.

Slide 18:

This Kaplan-Meyer curve for those 880 patients with a mean follow-up at 36 months obviously demonstrates in our low risk group, excellent cancer control as defined as PSA relapses without a PSA greater than 0.2. And also excellent long-term cancer control in our intermediate risk group.

In our high risk group out at 5 years, approximately 50 percent, and the thing we have noted over the last 5 years is this is a group that we have probably made the most progress in, in PSA survival. Most likely related to the fact that the ones we are operating on now likely only have one high risk feature, rather than two or three high risk features.

Slide 19:

And updated to 666, these numbers are fairly comparable to other large series from other institutions.

Slide 20:

In the last 1,200 patients, what's the morbidity of our surgery at UCSF? Rectal injury rates are low. We have had two rectal injuries. Neither of them required a colostomy. There is a low rate of urethral injury. Our mean and median blood loss are approximately 500 ccs, but more importantly, the non-autologous transfusion rate is down to 1 percent. And currently we leave it up to the patient whether they are going to donate blood pre-operatively.

In our last several hundred, the mean hospital stay is 48 hours. That's including the day of surgery. And this continues to decrease. We are having an increasing number of patients able to go home the day after surgery, so within 24 hours. But we have not sent home any patients four hours after surgery.

And in the last 50 patients that we have surveyed, their return to full work has been about three and a half weeks, 25 days.

Slide 21:

So I think in summary, if we are talking about open radical prostatectomy, and a lot of these factors apply to laparoscopic or robotic prostatectomy, it is important to select the appropriate cases, to have a knowledge the anatomy, use a meticulous technique. And to maximize cancer outcomes in certain cases, as we have heard here, appropriate use of adjuvant therapy.
And I think one of the large benefits of the laparoscopic and robotic prostatectomy is to have the open surgeon re-evaluate and re-adjust surgical techniques, and practices such as time of catheterization.

Slide 22:

How important is this issue of laparoscopic versus open? I think, as Dr. Menon has shown nicely, the outcomes can be good with either technique. And we probably need to focus most of our attention on the most relevant outcomes, obviously cure, continence, and potency. And I think with respect to these three, we will have to wait and see, especially with cancer outcomes. With continence it may be difficult to improve on a 95 or a 96 percent continence rate at 9 months, although again, time to continence we can probably improve, and potency as well.

And maybe not focus as much on factors such as hospital stay. Patients with open techniques are going home in 24 hours. The absolute volume of blood loss and the non-autologous transfusion rates are low. Typically, our patients are catheterized seven days. And a lot of that decision is based on practical reasons. A lot of our patients live far away from San Francisco, and the catheter removal is dependent on their home urologist to remove.

We have initiated at some points, early catheter removal at three days. Usually, urinary leakage has not been the problem. But there is probably a 5-10 percent of urinary tension likely due to some edema if we remove the catheter at two or three days.

Slide 23:

Is laparoscopic prostatectomy better? I think right now we really can't say one way or the other. Potentially, it could be worse, although the data from Dr. Menon's group would likely show that it's not going to be worse.

If it is better, it may not be better by very much again, with respect to cancer control, continence rate, and potency. And are these benefits limited merely to re-cooperation? And if so, are these differences significant? Looking at a poster from the Hopkins group yesterday, one of the differences was post-operative pain. But is there a big difference between taking 9 pain pills versus 17? I'm not sure that's significant.

And ultimately, I'm not sure the impact is going to be analogous to the impact that laparoscopic nephrectomy has had for upper urinary tract disease. But currently as UCSF we are performing both the robotic and open prostatectomy to test some of these hypotheses.

Slide 24:

And as was summarized by Dr. Gomella at the beginning, who is really going to perform the laparoscopic prostatectomy? Clearly, experienced laparoscopists were the ones who initially took this up, and experienced oncologists such as Dr. Menon have carried it on and applied it very well.

I think we are going to have to figure out where this is going to end up going. But I think regardless, whoever does it is going to have to be committed, and have a team approach I think, as Dr. Menon has an excellent team supporting him.

How are we going to teach this procedure? Again, as Dr. Menon has nicely published, he had some bona fide experts in laparoscopy spend an extensive amount of time with him to get him up and running. But clearly, that is not going to be feasible for everybody who is doing open prostatectomy at this time.

And laparoscopic versus robotic. Both of these are going to have associated costs. Probably longer time with a pure laparoscopic approach. And there is going to be some equipment-associated costs with the robotic system.

Slide 25:

And potentially are these minor issues of actual surgical approach and technique diverting our attention from other potentially more relevant issues, such as are we over-detecting clinically insignificant cancers now? The need for better pre-operative risk stratification and selection of the appropriate treatment. And really, we need to maintain the central role of the urologist in the treatment of men with prostate cancer.

Thank you.