J Endourol. 2016 Mar;30(3):312-8.
One-Year Outcome Comparison of Laparoscopic, Robotic, and Robotic Intrafascial Simple Prostatectomy for Benign Prostatic Hyperplasia
Oscar Dario Martín Garzón, MD,1 Raed A. Azhar, MD,2,3 Leonardo Brunacci, MD,1 Nelson Emilio Ramirez-Troche, MD,1 Luis Medina Navarro, MD1, Luciano Nuñez Bragayrac, MD,1 and René Javier Sotelo Noguera, MD1,3
1Instituto Medico La Floresta. Centro de Cirugía Robótica Mínimamente Invasiva-CIMI. Caracas Venezuela
3 Keck Medical Center of University of South California (USC). Los Angeles. California USA
3King Abdulaziz University, Jeddah, Saudi Arabia
Objective: To compare preoperative, intraoperative, and postoperative variables at 1, 6, and 12 months after laparoscopic simple prostatectomy (LSP), robotic simple prostatectomy (RSP), and intrafascial robotic simple prostatectomy (IF-RSP).
Patients and Methods: From January 2003 to November 2014, 315 simple prostatectomies were performed using three techniques, LSP, RSP, and IF-RSP; of the patients who underwent these procedures, 236 met the inclusion criteria for this study.
Results: No statistically significant difference (SSD) was found in preoperative or perioperative variables. Of the postoperative variables that were analyzed, an SSD (p > 0.01) in prostate-specific antigen levels was found, with levels of 0.07 – 1.1 ng/mL following IF-RSP, and the detection rate of prostate adenocarcinoma (26%) and high-grade prostatic intraepithelial neoplasia (HG-PIN; 12%) was higher for IF-RSP. We also found that lower International Prostate Symptom Scores (IPSS) were associated with LSP, at 4.8 – 3.2. Erectile function was reduced in IF-RSP patients in the first 6 months after surgery but was similar in all patient groups at 12 months after surgery; continence and other measured parameters were also similar at 12 months for all three techniques.
Conclusion: The IF-RSP technique is safe and effective, with results at 1-year follow-up for continence, IPSS, and Sexual Health Inventory for Men scores similar to those for the LSP and RSP techniques. IF-RSP also offers the advantages that it does not require postoperative irrigation, has an increased ability to detect prostate cancer (CA) and HG-PIN, and avoids the risk of future cancer and subsequent intervention for possible new prostate growth.
The focus of surgical management of low urinary obstructive symptoms secondary to benign prostatic growth is selected according to the technique to be used, the prostate’s size and skill of the surgeon.
Techniques today are: the endoscopic as Transurethral resection of prostate (TURP) (gold standard), the new trends in laser technology (HoLEP-Holmium laser enucleation, green laser, among others); open surgery and laparoscopic surgery and robotic (1).
In size usually considered that less than 80 grams’ prostates should be performed using endoscopic techniques, although there are reports of endoscopic operation in prostates of larger size (>120 gr) and above the standard value of 80 g, preferred open boarding, laparoscopic and robotic, showing the last two ahead of the open.
The skill of the surgeon is achieved by endoscopic technique resect the greater amount of tissue in the shortest time possible, to avoid possible complications such as bleeding, irritative symptoms, syndrome post resection, etc. He is considered that expert hands achieve drying 1 to 1.5 g per minute, then this, the limit oneself, puts it since for some urologists with ease could perform procedures in prostates of 70 grams, other 90 grams, 100 grams, or 150 grams.
Endoscopic techniques coined them that they fail to remove the same amount of prostate tissue in comparison to the open approach which is reflected in the effectiveness long term by new prostate growth and subsequent blockage (2). And recent techniques describe them further irritative symptoms and learning curve long along with the high initial cost of the equipment.
Laparoscopic surgery and robotic manages to duplicate the open technique, showing the same results, is safe, efficient, with less loss of blood, hospital stay shorter, but with longer surgical (3), and to compare laparoscopic surgery with Turp, was able to demonstrate that it has the highest percentage of resection of tissue and less stay bladder catheter, at the expense of greater bleeding. (4) . The main criticism of the robotic surgery is the high cost and short follow-up of patients in the serious published.
Figure 1. Laparoscopic simple prostatectomy. A crescent-shaped cut is made upwards to locate the plane between the upper capsule (where the dorsal complex is located) and the adenoma. Each incision runs from point A to point B. Systematically dissected via the synchronized uses of the electro-ultrasonic scalpel and/or blunt dissector, the suction-irrigation cannula, and laparoscopic scissors.
Taking into account all of the above and following the principles of preservation of package neurovascular and fascia endo-pelvic, to improve the results of Continence and sexual function post-operative, described in Prostatectomy intrafascial for low-risk prostate adenocarcinoma (5), proposes an innovative technique of minimally invasive management of lower urinary tract obstructive pathology by benign prostate growth, simple intrafascial Prostatectomy (IF-RSP. intrafascial simple robotic prostatectomy), to search not only preserve the structures described but also preserve the seminal vesicles, the fascia of Denonvillier and urethra to the verum montanum, with the advantage of not requiring subsequent bladder irrigation, reduction of blood loss, and the Elimination of residual prostate cancer risk or in the future, without jeopardizing the potency and Continence. (6)
The introduction of the simple technical intrafascial was very controversial by applying concepts of radical surgery to a benign surgery, why it was decided, the first study comparing three different techniques, Prostatectomy simple laparoscopic, robotic simple Prostatectomy and robotic simple Prostatectomy intrafascial. Improvement of low urinary symptoms, with the international rating of prostate symptoms (IPSS), maximum flow (Qmax), percentage of removal of the prostate is evaluated among many factors in this study, specific prostate Antigen (PSA), bleeding, complications and in greater detail, the result of the pathology of the surgical specimen, continence and sexual function (SHIM.) Sexual Health Inventory for Men) at 12 months of follow-up.
The first step that I determine the veracity of the results was to find that you although I am not realized randomization, or randomization, blinding in the study population, there was no statistically significant difference between the study groups, which allowed us to determine that the analyzed population was homogeneous. It is important to highlight that all patients with high PSA were previously studied and discarded malignant pathology of prostate biopsy of prostate in one or more opportunities, or by using other tools for the follow-up of elevated PSA, as required in each case.
In the analysis of the intra-surgical factors, there was no statistically significant difference in bleeding, surgical time, intra-surgical complications, conversion, time of urethral catheter, hospital stay, however it is important to highlight that any patient with simple Prostatectomy intrafascial required intravesical irrigation. In terms of the immediate post-surgical factors more exactly in pathology, found as expected the first big advantage in simple Prostatectomy intrafascial, there was increased detection of prostate adenocarcinoma and high-grade intraepithelial neoplasia, in addition to greater percentage of prostate removal, which in theory will give a great advantage to avoid new prostate growth and the risk of future prostate cancer.
About the post-surgical factors analyze continence, prostate-specific antigen (PSA), the peak flow (Qmax), quality of life (QoL), the IPSS, the SHIM and complications to the 1, 6 and 12 months. As expected significant difference was found in the PSA from the first month with 0.07 ng/ml (+ 1.1) p = 0.001 for the IF-PSLR with respect to the other two techniques. Other factors there was no statistically significant difference, Qmax, QoL, the complications, the total of the SHIM and continence the 1.6 and 12 months’ follow-up. It is seeking to make a better analysis of the data for this reason was conducted an analysis post-hoc, for Continence without statistical difference. And analyze specifically to patients who were powerful (SHIM > 21), at 1, 6 and 12 months and as expected found that month and 6-month power was lower in the PSLR-IF p = 0.01 and p = 0.001 respectively in relation to the other two techniques, however at 12 months was not found statistically significant difference in the analyzed available data , which allowed to corroborate the theory of preservation of the neurovascular bundle bilateral in relation to erectile year monitoring function as originally described in the radical technique (5) and the initial of the first cases of intrafascial simple Prostatectomy report (6).
The importance of this study: allows us to demonstrate that prostate cancer and concomitantly, high grade intraepithelial neoplasia with benign prostatic growth is more common than is wise. It also allows us to propose and conclude that the PSLR-IF is a safe, feasible and reproducible, technique that can be used for the management of obstructive symptoms urinary side low benign prostate growth, with the advantage of avoiding future growth and the risk of cancer. In addition to clarify that in order to be the gold standard and recommended openly for all scenarios is expected a study with greater number of patients and long-term follow-up.
Figure 2. robotic simple prostatectomy. Systematic dissection of adenoma (synchronized use of robotic Maryland, the suction-irrigation cannula and robotic scissors). Each incision runs from point A to point B. The prostatic urethra is identified and cold cut. The specimen is retrieved using an Endocatch device.
- Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. European urology. 2015.
- Ou R, You M, Tang P, Chen H, Deng X, Xie K. A randomized trial of transvesical prostatectomy versus transurethral resection of the prostate for prostate greater than 80 mL. Urology. 2010;76(4):958-61.
- Asimakopoulos AD, Mugnier C, Hoepffner JL, Spera E, Vespasiani G, Gaston R, et al. The surgical treatment of a large prostatic adenoma: the laparoscopic approach–a systematic review. Journal of endourology / Endourological Society. 2012;26(8):960-7.
- Xie JB, Tan YA, Wang FL, Xuan Q, Sun YW, Xiao J, et al. Extraperitoneal laparoscopic adenomectomy (Madigan) versus bipolar transurethral resection of the prostate for benign prostatic hyperplasia greater than 80 ml: complications and functional outcomes after 3-year follow-up. Journal of endourology / Endourological Society. 2014;28(3):353-9.
- Stolzenburg JU, Schwalenberg T, Horn LC, Neuhaus J, Constantinides C, Liatsikos EN. Anatomical landmarks of radical prostatecomy. European urology. 2007;51(3):629-39.
- Clavijo R, Carmona O, De Andrade R, Garza R, Fernandez G, Sotelo R. Robot-assisted intrafascial simple prostatectomy: novel technique. Journal of endourology / Endourological Society. 2013;27(3):328-32.
Oscar Dario Martín Garzón
Robotic and Laparoscopic Surgery
Chief Deparment of Urology Hospital Militar de Oriente Apiay Villavicencio –Meta Colombia