Laparoscopic Radical Prostatectomy: The Technique
Radical prostatectomy (RP) is the most effective treatment for localized prostate cancer and the treatment recommended by the majority of urologists to their patients [1]. The retropubic route is most commonly used as the anatomy is more familiar and it a
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Christopher Eden and Anthony Hutton
Introduction Radical prostatectomy (RP) is the most effective treatment for localized prostate cancer and the treatment recommended by the majority of urologists to their patients [1]. The retropubic route is most commonly used as the anatomy is more familiar and it allows synchronous pelvic lymphadenectomy and always permits removal of a large prostate intact. In contrast with perineal prostatectomy, the retropubic approach is not associated with an incidence of postoperative fecal incontinence. The motivation behind developing laparoscopic RP (LRP) lay in the wish to expand the number of patients who might benefit from the claimed generic advantages of laparoscopic surgery, namely, less postoperative pain and a shorter convalescence. LRP also appeared to greatly reduce intraoperative blood loss and provided the surgeon with a consistently evenly illuminated and magnified view of the pelvic anatomy and suggested the possibility of superior results through superior vision. Subsequent publications have quashed this hope [2] and have demonstrated a clear link between surgical volume and patient outcomes but no advantage of LRP or robot-assisted LRP in terms of oncological or functional superiority.
Historical Perspective Increasing experience with laparoscopic renal surgery more than a decade ago made it inevitable that attempts would eventually be made to replicate RP laparoscopically. Schuessler’s initial series of LRP failed to inspire other surgeons to follow his example, chiefly because of the very long operating time (mean = 564 min), and led
C. Eden, M.B.B.S., M.S., FRCS (Urol) (*) A. Hutton, FRACS (Urol) Department of Urology, The Royal Surrey County Hospital, Egerton Road, Guildford, Hampshire GU2 7XX, UK e-mail: [email protected] A. Tewari (ed.), Prostate Cancer: A Comprehensive Perspective, DOI 10.1007/978-1-4471-2864-9_56, © Springer-Verlag London 2013
him to incorrectly conclude that a laparoscopic approach for radical prostatectomy conferred no advantage over open surgery, despite good oncological and early functional results [3]. The seminal paper published in 2000 by Vallancien and Guillonneau demonstrated for the first time that LRP could be performed in an operating time similar to that of open surgery with significantly less blood loss compared to open RP (ORP), good oncological and early functional results, and all the generic advantages of laparoscopic surgery [4]. The Montsouris series inspired a number of urologists to begin their own program of LRP, but some of the initial results served only a reminder that poor surgery produces poor outcomes [5] and others, since updated, that even well-prepared surgeons face a steep learning curve when embarking on a new program of complex surgery [6, 7]. LRP has undergone a great deal of development since the initial cases, and although certain technical details are common between contemporary series, alternative options exist for a number of steps, depending on surgeon preference.
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