Extraperitoneal laparoscopic versus transperitoneal robot-assisted laparoscopic approaches during radical prostatectomy for low-risk or intermediate-risk prostate cancer
Highlight box
Key findings
• This study found that transperitoneal robotic-assisted laparoscopic radical prostatectomy (TRA-LRP) may have advantages over extraperitoneal laparoscopic radical prostatectomy (E-LRP) in reducing intraoperative risk, improving oncologic outcomes, and early postoperative rehabilitation.
What is known and what is new?
• TRA-LRP and E-LRP are two types of radical prostatectomy that are widely used. Previous studies have compared the two approaches in the treatment of high-risk prostate cancer (PCa).
• The aim of our study was to compare the efficacy of these two procedures (E-LRP vs. TRA-LRP) in the treatment of low- or intermediate-risk PCa, and to make up for the shortcomings of previous studies.
What is the implication, and what should change now?
• TRA-LRP can reduce the blood loss and positive surgical margin rate in low-risk or intermediate-risk PCa, and may help patients to regain early continence and potency after operation. TRA-LRP is superior to E-LRP and worthy of promotion.
Introduction
With the increasing popularity of prostate-specific antigen (PSA) screening, the number of patients with low- or intermediate-risk prostate cancer (PCa) has gradually increased in recent years. At present, radical prostatectomy is considered the main treatment for localized PCa, especially for PCa with clinical stage T1–2c (1). Techniques have progressed from traditional open approaches to laparoscopy, and then to robot-assisted laparoscopic approaches. Although laparoscopic and robotic-assisted laparoscopic radical prostatectomy (RALRP) have been widely applied, and various operation approaches have also emerged (2), there are still few studies comparing extraperitoneal laparoscopic and transperitoneal robot-assisted laparoscopic approaches, especially for low- or intermediate-risk PCa. In this retrospective study, we compared the efficacy and safety of extraperitoneal laparoscopic radical prostatectomy (E-LRP) with transperitoneal robotic-assisted laparoscopic radical prostatectomy (TRA-LRP) in low- or intermediate-risk PCa. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-748/rc).
Methods
Patient selection
From June 2020 to May 2024, in our department (Department of Urology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University), a total of 80 patients with low-risk or intermediate-risk PCa (PSA ≤20 ng/mL, biopsy Gleason score ≤7, and clinical stage T1–2N0M0), including 45 cases who received E-LRP (E-LRP group) and another 35 cases who received TRA-LRP (TRA-LRP group), were enrolled in our research. Patients chose the operation method independently after listening to the doctor’s introduction and suggestions. All patients underwent magnetic resonance imaging (MRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT; 18F-PSMA-1007) scan preoperatively, which indicated no evidence of lymph node and bone metastasis, and none of the patients underwent intraoperative lymph node dissection. Immediate androgen deprivation therapy (apalutamide combined with goserelin) was performed on PCa with high-risk indications [pathologic Gleason score ≥8, pathologic stage T3–4, or positive surgical margin (PSM)] based on postoperative pathology (3). All patients were followed up for 6–24 months postoperatively. The incidence of complications was graded according to the modified Clavien system. Sexual and urinary function were evaluated using the International Index of Erectile Function (IIEF) diaries and International Continence Society (ICS) questionnaire, respectively. Potency was defined as an IIEF-6 score ≥18 with or without phosphodiesterase 5 inhibitors (PDE5-Is) support. Continence was defined as no need for incontinence pads. Biochemical recurrence was defined as at least 2 consecutive detectable PSA levels >0.2 ng/mL (4,5). Patients were counseled about the pros and cons of each operation (E-LRP or TRA-LRP), and they chose the plan and signed the informed consent. All operations were performed by a stationary chief urologist and two non-stationary assistants.
E-LRP
The main operational procedures were as follows: (I) establish the extraperitoneal space; (II) expose the anterior surface of the bladder and prostate, as well as the endopelvic fascia; (III) sequentially dissect the bladder neck, vas deferens, and seminal vesicles, and then separate Denonvilliers’ fascia; (IV) ligate and transect the lateral prostatic ligaments; (V) transect the urethra, remove the prostate, and perform a vesicourethral anastomosis; (VI) close the incision and place a drainage tube (6).
TRA-LRP
The main operational procedures included the following: (I) the main port (establish the intra-abdominal space) was located on 1 cm above the umbilicus (a 1-cm longitudinal incision along the anterior midline). The other ports were mainly located on the left and right sides of the abdomen at the horizontal line of the umbilical cord. (II) Peritoneal incision and space entry: The peritoneum was opened along the midline of the umbilicus and the prevesical space was entered. (III) Subsequent surgical procedures were the same as those for E-LRP (7).
Statistical analysis
We compared the two groups (E-LRP vs. TRA-LRP) by Student’s t-test for numeric values, and chi-square test for non-numeric values. Significance was defined by P<0.05. Data were analyzed using the software SPSS 26.0 (IBM Corp., Armonk, NY, USA).
Ethical statement
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics board of the Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University (No. 2024-421-01PJ) and individual consent for this retrospective analysis was waived.
Results
There were 80 patients (E-LRP 45, TRA-LRP 35) enrolled in accordance with the inclusion criteria. Based on the D’Amico risk assessment, all patients were categorized as having low- or intermediate-risk PCa preoperatively. There was no significant difference between the 2 groups regarding clinical and pathological parameters preoperatively (Table 1).
Table 1
| Parameter | E-LRP (n=45) | TRA-LRP (n=35) | P value |
|---|---|---|---|
| Age, years | 67.8 [52–84] | 68.1 [48–81] | 0.87 |
| BMI, kg/m2 | 23.4 [21.5–25.6] | 23.2 [21.6–25.4] | 0.69 |
| ASA score | 0.84 | ||
| 1 | 26 | 21 | |
| 2 | 19 | 14 | |
| Prostate volume, mL | 41.16 [19.31–100.08] | 40.22 [18.67–84.86] | 0.83 |
| PSA, ng/mL | 9.95 [4.20–18.87] | 9.48 [4.16–19.50] | 0.61 |
| Biopsy Gleason Score | 0.48 | ||
| 3+3 | 8 | 10 | |
| 3+4 | 18 | 11 | |
| 4+3 | 19 | 14 | |
| Clinical stage | 0.94 | ||
| T1c | 10 | 8 | |
| T2a | 8 | 5 | |
| T2b | 9 | 6 | |
| T2c | 18 | 16 | |
| D’Amico risk | 0.80 | ||
| Low | 8 | 7 | |
| Intermediate | 37 | 28 |
Data are presented as n or mean [range]. ASA, American Society of Anesthesiology; BMI, body mass index; E-LRP, extraperitoneal laparoscopic radical prostatectomy; PSA, prostate-specific antigen; TRA-LRP, transperitoneal robotic-assisted laparoscopic radical prostatectomy.
Table 2 shows the comparison of intraoperative and postoperative parameters between the 2 groups. It indicates that TRA-LRP resulted in longer operative time (P=0.004) and lesser intraoperative blood loss (P=0.02) compared with E-LRP. There were no significant differences in blood transfusion rate (BTR) and nerve sparing rate between the 2 groups. Besides, TRA-LRP resulted in a lower PSM rate compared with E-LRP (P=0.04). There were no significant differences in postoperative hospital stays (PHS), pathologic Gleason score, pathologic stage, and complications between the 2 groups. All patients had no biochemical recurrence during the follow-up.
Table 2
| Parameter | E-LRP (n=45) | TRA-LRP (n=35) | P value |
|---|---|---|---|
| Operative time, min, mean [range] | 128.4 [85–200] | 165.3 [93–230] | 0.004 |
| EBL, mL, mean [range] | 139.4 [50–400] | 89.6 [20–300] | 0.02 |
| BTR | 0 | 0 | >0.99 |
| Nerve sparing, n (%) | 0.92 | ||
| Bilateral | 6 (13.3) | 5 (14.3) | |
| Unilateral | 20 (44.4) | 14 (40.0) | |
| PHS, d, mean [range] | 5.2 [3–7] | 5.1 [3–7] | 0.66 |
| Pathologic Gleason Score, n | 0.60 | ||
| 3+3 | 6 | 8 | |
| 3+4 | 14 | 10 | |
| 4+3 | 11 | 10 | |
| 4+4 | 9 | 6 | |
| 4+5 | 0 | 0 | |
| 5+4 | 1 | 0 | |
| 5+5 | 4 | 1 | |
| Pathologic stage, n | 0.18 | ||
| pT2a | 3 | 1 | |
| pT2b | 1 | 4 | |
| pT2c | 31 | 26 | |
| pT3a | 6 | 1 | |
| pT3b | 4 | 3 | |
| PSM, n (%) | 17 (37.8) | 6 (17.1) | 0.04 |
| Complications, n | 0.67 | ||
| Minor (Clavien I–II) | |||
| Anastomosis leakage | 2 | 1 | |
| Urinary infection | 0 | 0 | |
| Major (Clavien III–IV) | |||
| Rectal injury | 0 | 0 | |
| Anastomotic stricture | 3 | 1 | |
| Biochemical recurrence, n | 0 | 0 | >0.99 |
BTR, blood transfusion rate; EBL, estimated blood loss; E-LRP, extraperitoneal laparoscopic radical prostatectomy; PHS, postoperative hospital stay; PSM, positive surgical margin; TRA-LRP, transperitoneal robotic-assisted laparoscopic radical prostatectomy.
All patients had urinary continence before operation and were followed up for at least 6 months. The continence in the first month after TRA-LRP was significantly higher than that after E-LRP (P=0.04). From the second month after operation, there was no significant difference in continence between the 2 groups (Table 3). All patients recovered continence at 12 months after operation.
Table 3
| Urinary continence (timing) | E-LRP (n=45) | TRA-LRP (n=35) | P value |
|---|---|---|---|
| Preoperative baseline, n (%) | 45 (100.0) | 35 (100.0) | >0.99 |
| Postoperative, n (%) | |||
| 1 month | 12 (26.7) | 17 (48.6) | 0.04 |
| 2 months | 20 (44.4) | 23 (65.8) | 0.06 |
| 3 months | 31 (68.9) | 27 (77.1) | 0.41 |
| 6 months | 40 (88.9) | 32 (91.4) | >0.99 |
E-LRP, extraperitoneal laparoscopic radical prostatectomy; TRA-LRP, transperitoneal robotic-assisted laparoscopic radical prostatectomy.
Table 4 shows the comparison of erectile function between the 2 study groups. The initial potency was 44.4% (E-LRP, 20/45) and 51.4% (TRA-LRP, 18/35) in the 2 groups, respectively, which had no statistical difference. For patients with preoperative potency (E-LRP 20, TRA-LRP 18), there was no significant difference in potency recovery between the 2 groups at 1, 2, and 3 months postoperatively. The potency at 6 months after TRA-LRP was significantly higher than that after E-LRP (P=0.04).
Table 4
| Potency (timing) | E-LRP | TRA-LRP | P value |
|---|---|---|---|
| Preoperative baseline, n (%) | 0.54 | ||
| ≥18 | 20 (44.4) | 18 (51.4) | |
| Postoperative, n | |||
| 1 month | >0.99 | ||
| ≥18 | 0 | 0 | |
| <18 | 20 | 18 | |
| 2 months | 0.47 | ||
| ≥18 | 0 | 1 | |
| <18 | 20 | 17 | |
| 3 months | >0.99 | ||
| ≥18 | 2 | 2 | |
| <18 | 18 | 16 | |
| 6 months | 0.04 | ||
| ≥18 | 4 | 10 | |
| <18 | 16 | 8 |
E-LRP, extraperitoneal laparoscopic radical prostatectomy; IIEF, International Index of Erectile Function; TRA-LRP, transperitoneal robotic-assisted laparoscopic radical prostatectomy.
Discussion
E-LRP and TRA-LRP are classic surgical procedures for the treatment of early PCa and have been widely used. Since E-LRP does not enter the abdominal cavity, it can significantly reduce the risk of intra-abdominal complications, such as intestinal adhesion and intestinal obstruction. At the same time, it has less interference with the surrounding organs such as the bladder and rectum (8). However, TRA-LRP has a large operating space and flexible operation due to the transperitoneal approach. Besides, it presents the additional benefits of a clearer operation field, less surgical trauma, and more accurate cutting (9). A separate systematic review and meta-analysis about RALRP versus LRP for PCa showed that RALRP was associated with less blood loss, lower transfusion rate, and longer operative time compared with LRP (10). Similarly, our study also suggested that TRA-LRP resulted in lesser intraoperative blood loss and longer operative time compared with E-LRP. The lesser blood loss in TRA-LRP might be attributed to the precision cutting of robot and a better field of view. This indicated that TRA-LRP may be helpful in reducing intraoperative risk. However, because the time required for port placement and establishing the operative space in TRA-LRP was longer, the whole time was longer than that in E-LRP (9,11).
There is no evidence that lymph node dissection is associated with a survival benefit for patients with low- or intermediate-risk PCa without lymph node metastasis by preoperative PSMA-PET/CT scan. A new study suggested that only 2.9% of intermediate-risk patients had lymph node metastasis. Based on this, the Chinese Society of Clinical Oncology (CSCO) guidelines recommend PSMA-PET/CT instead of lymph node dissection to assess metastasis to avoid unnecessary damage (12). A study with 4 years of follow-up showed that the oncological outcome (biochemical recurrence-free survival) between the two operative procedures (E-LRP vs. TRA-LRP) in the treatment of high-risk PCa was equivalent (13). However, other research has suggested that RALRP had lower biochemical recurrence and overall PSM rate than LRP (14,15). Our study showed that the PSM rate was significantly lower with TRA-LRP than with E-LRP in low- or intermediate-risk PCa, but there was no statistically significant difference in biochemical recurrence between the 2 groups (E-LRP vs. TRA-LRP), which may be due to the aggressive postoperative androgen deprivation therapy in patients with pathological high-risk factors and short follow-up duration. Therefore, in terms of surgical margin, TRA-LRP is superior to E-LRP in improving oncological outcomes, and this might be related to the precision cutting of the Da Vinci robotic system (9).
Urinary continence and erectile function recovery are the most critical factors affecting the quality of life after radical prostatectomy. The results of a 5-year prospective randomized controlled study showed that RALRP was significantly better than LRP in continence and erectile function recovery at 18, 30, 42, 48, 54, and 60 months, postoperatively (16). Another study showed that RALRP was higher than LRP in terms of continence recovery at 1, 3, 6, and 12 months postoperatively, and potency recovery at 3 and 12 months postoperatively (10). Haney et al. reported that RALRP was significantly better than LRP in continence at 3 and 6 months postoperatively, but there was no difference in continence between RALRP and LRP at 12 months after surgery. Potent patients who received RALRP consistently showed better potency than those who received LRP at 12 months postoperatively (17). Stolzenburg et al. reported that RALRP was superior to LRP in continence recovery at 6 months postoperatively. A significant benefit in early potency recovery was also identified in patients with RALRP (18). Our study suggested that patients treated with TRA-LRP had better continence recovery than those who were treated with E-LRP in the first month postoperatively, and cases after TRA-LRP also had more advantageous potency recovery at 6 months after surgery. However, from the second month after operation, there was no significant difference in continence between the 2 groups. These results were basically similar to previous studies and suggested that RALRP might have advantages over LRP in terms of early urinary continence and overall sexual function recovery (10,16-18). These may be attributed to the fact that the Da Vinci robotic surgical system can allow the surgeon to perform all procedures (preservation of membranous urethra, reconstruction of the bladder neck, and so on) that affect functional outcomes more comfortably (19).
Our study still has limitations, including the small sample size and short follow-up time, which need to be further supplemented in the future. Besides, retrospective studies have limitations such as recording bias, selection bias, and insufficient control of confounding factors.
Conclusions
Compared with E-LRP, TRA-LRP can reduce the blood loss and PSM rate in low- or intermediate-risk PCa, and may help patients regain early continence and potency after operation. It may be superior in reducing intraoperative risk, improving oncological outcomes, and early postoperative rehabilitation. Although the TRA-LRP takes longer to conduct, there is currently no evidence that the longer duration increases the complications compared with E-LRP.
Acknowledgments
The authors acknowledge financial support received from Sanming Project of Medicine in Shenzhen (No. SZSM202111007), Shenzhen Key Medical Discipline Construction Fund (No. SZXK020), and Shenzhen High-level Hospital Construction Fund.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-748/rc
Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-748/dss
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-748/prf
Funding: The study was supported by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-748/coif). The authors have no conflicts of interest to declare.
Ethical Statement:
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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