Endoscopic extraperitoneal radical prostatectomy: critical analysis of outcomes and learning curve

To assess the outcomes and learning curve of extraperitoneal endoscopic radical prostatectomy (EERP) using cumulative summation charts from a single tertiary referral centre.

The data from 300 consecutive men with localized prostate cancer who underwent EERP at Western General Hospital, Edinburgh, UK, between February 2006 and July 2009 were prospectively maintained in a database. The data collected included demographic details, perioperative outcomes, complications and follow-up for functional and oncology outcomes. The learning curve was analysed using generalized linear models for complication rate, operative time and blood loss, using procedure experience.

The mean (sd, range) operative duration was 160.52 (40.84, 100-310) min, and the intraoperative blood loss was 229.3 (172, 20-1000) mL. There was no conversion to open surgery and no patient required intraoperative blood transfusion. Only one of 250 (0.3%) patients required a blood transfusion after EERP. The median (range) hospital stay was 3 (2-20) days and the median catheterization time before cystography was 9 days. There was evidence that the complication rate reduced as experience was gained (odds ratio 0.98, 95% confidence interval, CI, 0.97-0.99; P= 0.002), with the estimated probability of a complication decreasing from 29% for the first to <1% for the 250th procedure. Also there was evidence of a decrease in operative duration (-0.0020 rate parameter on log scale; 95% CI -0.0024 to -0.0017; P < 0.001) and blood loss (-0.01 rate parameter on log scale; 95% CI -0.003 to -0.0002; P= 0.021). The positive surgical margin rate in pT2 disease decreased from 27% in the first 50 to 14.7% in the last 50 operated cases. The continence rate and biochemical recurrence-free rate at a minimum follow-up of 1 year for the first 100 patients was 89% and 94%, respectively.

The results from this series suggest that the benefits of minimally invasive surgery for localized prostate cancer (EERP) can be replicated after mentored fellowship training of a surgeon. The complication rate reduced substantially as experience was gained, suggesting a continuous surgical learning curve.