Laparoscopic radical prostatectomy. The Créteil experience

In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency.

200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogeneous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi-circumferential or a single circumferential running suture.

All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night.

Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.