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Outcome and complications of radical prostatectomy in patients with PSA <10 ng/ml: comparison between the retropubic, perineal and laparoscopic approach

Abstract

The objective of this work was to evaluate the oncological outcomes and complications of prostate cancer patients with prostate specific antigen (PSA) <10 ng/ml after radical prostatectomy by retropubic, perineal and laparoscopic approach. From 1988 to 2001, 306 patients with PSA <10 ng/ml underwent radical prostatectomy by the retropubic, perineal or laparoscopic approach. Mean operative time, complication rates, length of hospital stay, catheterization time and pathological results were reviewed. Kaplan-Meier analysis was used to evaluate the likelihood of biochemical PSA recurrence. There were no statistical differences between the three groups in terms of preoperative characteristics except for PSA levels (5.5, 6.5 and 6.6 ng/ml for the retropubic, perineal, and laparoscopic approach, respectively, P<0.05) and for the T1c stage prevalence (50%, 43.1% and 68.4%, P<0.05). Operating time was significatively longer in the laparoscopic approach (266 min), whereas transfusion rate (22.1%), bladder catetherization (12.1 days), and length of hospital stay (12.1 days) were higher in the retropubic group (P<0.05). The percentage of medical and surgical complications were 6.9%, 3.1% and 3.4% (P<0.05) and 18.6%, 16.9% and 11.6% (P<0.05) for the retropubic, perineal, and laparoscopic approach, respectively. Pathological staging revealed pT2 in 76.7%, 78.4% and 81.3% for retropubic, perineal and laparoscopic approach, respectively (P<0.05). Positive surgical positive margins were noted in 20.9%, 18.4% and 20.6% (P>0.05). The actuarial 3-year recurrence-free survival rate was 89.3%, 89.2% and 86.2% (P>0.05) for retropubic, perineal and laparoscopic approach, respectively. It can be concluded that in patients with preoperative PSA<10 ng/ml, clinical outcome and complication rates were similar, regardless of the choice of surgical approach.

Introduction

Radical prostatectomy is a major curative procedure for the treatment of organ confined prostate cancer. Radical perineal prostatectomy was first described by Young in 1905.1 The retropubic approach to radical prostatectomy was pioneered by Millin in 1945.2 The majority of urologists use the radical retropubic approach, which is due to the familiarity with the surgical anatomy, as well as the nerve sparing technique first described by Walsh et al.3 In 1997, Raboy et al reported the first case of laparoscopic extraperitoneal radical retropubic prostatectomy, and Schuessler et al reported nine cases of transperitoneal radical prostatectomy in the same year.4,5 In 1999, Guillonneau and Vallancien reported 65 cases of laparoscopic radical prostatectomy, suggesting that it could become a routine laparoscopic procedure in urology.6

Goals of surgical treatment include cancer control and maintenance of continence and erectile function.7 Any new technique should be proven to be at least as good as the classic techniques in terms of oncological efficacy. We used to perform radical prostatectomy for localized prostate cancer by the retropubic and the perineal approach. In 1998, we successfully performed our first laparoscopic radical prostatectomy.8 Surgical approach preferences change over time. In our institution, the retropubic approach was the surgery of choice between 1988 and 1992, the perineal approach took over between 1993 and 1997 and since 1997 the laparoscopic approach has become the most opted for way to perform this operation. A stage migration could be observed during the evaluation period of 1988–2001.9 Patient selection and tumor characteristics also changed. To decrease the risk of having an inhomogenous population, we limited our study to patients with preoperative prostate specific antigen (PSA) levels <10 ng/ml. PSA is an objective and reproducible factor and therefore allows a comparison between these patient populations.9 In this study, we report our experience of the three techniques of radical prostatectomy regarding oncologic results for patients with PSA <10 ng/ml.

Patients and methods

From 1988 to 2001, 306 men with a PSA <10 ng/ml underwent radical prostatectomy for localized prostate cancer by the retropubic (n=184), perineal (n=119) and laparoscopic (n=235) approach. In every patient, serum PSA levels were measured preoperatively (Hybritech assay, normal limit <4 ng/ml) and prostate cancer diagnosis was confirmed by biopsy. The number of positive biopsy specimens and the Gleason score of positive specimens were recorded. Lymphadenectomy was performed intraoperatively in all retropubic cases, and in all perineal and laparoscopic cases with a preoperative Gleason score ≥7. Total operative time including pelvic lymphadenectomy, medical and surgical complications, heterologous blood transfusion rate, length of hospital stay and catheterization time were recorded.

All prostatectomy specimens were analyzed according to the Stanford protocol10 and evaluated according to the 1997 TNM classification.11 The weight of the specimen, tumor volume, pathological stage and status of the surgical margins were recorded by the same pathologist. Postoperative follow-up data were obtained through routine serum PSA assays and digital rectal examinations after 1 and 3 months, and half-yearly thereafter.

A biochemical recurrence was defined as a single postoperative PSA level >0.2 ng/ml.12 Kaplan-Meier analysis was used to determine the actuarial biochemical recurrence-free likehood. Fisher's test, the Mann– Whitney test and the Log-rank test were used for statistical analysis. Differences were considered significant when the P-value was <0.05.

Results

Three hundred and six patients with preoperative PSA levels <10 ng/ml underwent radical prostatectomy by retropubic (n=86), perineal (n=65) or laparoscopic (n=155) approach. The characteristics of the patients are shown in Table 1 and Figure 1. There were no statistical differences between the three groups in terms of preoperative characteristics except for PSA level and for the T1c stage prevalence (both P<0.05).

Table 1 Preoperative patient characteristics
Figure 1
figure1

Clinical stage.

Mean operating time for radical prostatectomy, mean transfusion rate, mean length of hospital stay (pre- and post-surgery) and mean duration of bladder catheterization are presented in Table 2. Operating time was significantly longer with the laparoscopic approach whereas transfusion rate, bladder catetherization, and hospitalization stay were higher in the retropubic group.

Table 2 Pre and postoperative data

Pathological results are shown in Table 3. Surgical margins were found to be positive in pT2 tumors in 15.1%, 13.7% and 15.8% (P>0.05) and in pT3 tumors in 40%, 35.7% and 41.4% (P>0.05) for the retropubic, perineal and laparoscopic approach, respectively.

Table 3 Pathological results

Medical and surgical complications are shown in Table 4. They were significantly higher in the retropubic group compared to the perineal and laparoscopic group. Some complications were specific to the surgical approach as postoperative neuropathy for the perineal approach (two cases) and transitory ileus for the laparoscopic approach (four cases). One patient died after pulmonary embolism the first day after laparoscopic radical prostatectomy.

Table 4 Medical and surgical complications

The mean follow-up was 4.7 y (0.27–13.9 y), 5.4 y (1.7–8.6 y) and 1.3 y (0.1–3.5 y) for retropubic, perineal and laparoscopic approaches, respectively. The actuarial 3-y recurrence-free rate was 89.3% for the retropubic approach, 89.2% for the perineal approach and 86.2% for the laparoscopic approach (P>0.05, Figure 2).

Figure 2
figure2

Actuarial progression-free likelihood.

Discussion

Surgical removal of the prostate is a main curative option for organ confined prostate cancer. Two surgical techniques, retropubic and perineal, have been widely described, studied and compared using large series of patients with long follow-up periods. It could be demonstrated that cancer control is identical with the retropubic and perineal approaches. However, Boccon-Gibod et al reported a higher risk of iatrogenic surgical margins with the perineal approach.13 In contrast, perineal prostatectomy is associated with reduced blood loss and shorter hospital stay compared with the retropubic technique.14,15,16,17,18,19,20,21

Since the description of anatomical radical retropubic prostatectomy by Walsh and with the advent of technical refinements concerning the sparing of the neurovascular bundles and the continence mechanisms,3 this procedure has become widely accepted by urologic surgeons. Perineal radical prostatectomy has been the approach of choice in selected centers and became more popular because of the possible combination of the procedure with laparoscopic lymph node sampling. The laparoscopic approach has emerged in the past few years as a feasible, reproducible technique with more than 1200 cases reported in the literature.22 The advantages of this technique over the open procedures are yet to be scientifically proven.

A randomized comparison between the three techniques was technically difficult. A retrospective comparison was, however, possible in our institution. In order to reduce the differences between the groups due to patient selection, we focused on the patient population with a PSA <10 ng/ml. The three groups of patients were similar in terms of age, and mean Gleason score. The mean PSA value was significantly lower in the retropubic group than in the perineal and laparoscopic groups. Together with a higher prevalence of clinical T1c stage in the last groups this can probably be explained by the selection of patients that occured over time. In the late 1980s and early 1990s the relationship between PSA values and extent of the disease was not yet clearly defined so that patients with high PSA underwent retropubic radical prostatectomy and the latter fact is the reason why we limited the comparison to patients with PSA<10 ng/ml.

In agreement with Guillonneau and Vallancien23 and in our population studied, the laparoscopic approach appears to have some potential advantages over the open approaches. Transfusion rate, catheterization period and length of hospital stay are significantly lower in the laparoscopic group. It is noteworthy, however, that these are retrospective results and during the last years all three before mentioned variables have decreased for the retropubic approach. On the other hand, operative time is significantly higher in this group which reflects the complexity of the laparoscopic procedure and the difficult learning curve. Despite this fact, medical and surgical complication rates were not higher in the laparoscopy group, but in the open groups, which also had a higher rate of wound related problems.

Analysis of all specimens was performed by the same pathologist, therefore eliminating interpretation biases. Pathologic analysis showed a heterogenous distribution of the patients regarding pathological stage in the three groups. Pathological findings in the laparoscopic group probably reflect a strong selection bias, with 81.3% of patients having organ confined disease vs 76.2% and 78.4% in the retropubic and perineal group. Patient selection is also responsible for the higher prevalence of T1c tumors in the laparoscopic group.

The overall incidence of positive surgical margins was slightly lower in the perineal group than in the retropubic or the laparoscopic groups: 18.4% vs 20.9% and 20.6%, respectively. Taken together, there was no statistical difference regarding the surgical margin rate between the three groups. The slightly lower rate of surgical margins might be explained by the extensive resection we used in the perineal approach. In a review of published reports, Wieder and Soloway reported that the overall rate of positive surgical margins in retropubic and perineal prostatectomies for organ-confined disease is 28% (5%–53%).24

When the incidence of positive margins was analyzed by stage, we found that in the pT2 group the three approaches had equivalent results with 15.1%, 13.7% and 15.8% for retropubic, perineal and laparoscopic approach, respectively. The percentage for the pT3 group were 40%, 35.7% and 41.4%, respectively.

The follow-up of our population of patients showed that at 3 y the biochemical recurrence free survival rates were equivalent in the three groups. The risk of metastatic seeding after oncologic laparoscopic procedures is controversial. Our short-term cancer control after laparoscopic radical prostatectomy is comparable to our open surgery results and therefore allows us to continue with the laparoscopic procedure.

Significant factors which have to be taken under consideration in interpreting the present data are not only stage migration, but also changes in technical advances and discharge pathways through the years. The mean operating time for the retropubic approach includes lymph node dissection and is probably shorter today, since patients with low Gleason score will not undergo lymph node dissection at all. Due to improvement of the retropubic surgical technique, overall transfusion rates, bladder catheterization times, and complications such as lymphoceles will be reduced in the year 2002 compared to the late 1980s and early 1990s. As a result, length of hospital stay also has been reduced in recent years. In the USA, the postoperative stay after a perineal or retropubic prostatectomy is only a few days, therefore comparable to the laparoscopic group.

Functional results (continence and erectile function) also have to be evaluated. They should be analyzed in a prospective fashion and not retrospectively. Since 1998, we have been conducting such a prospective study. Unfortunately, no patient operated with the perineal approach was involved in the study. Long-term studies have to show if the laparoscopic approach has a better functional outcome with comparable oncological results in this selected group of patients.

Conclusion

In this retrospective analysis, retropubic, perineal and laparoscopic radical prostatectomy were equivalent in terms of cancer control for patients with PSA<10 ng/ml. The incidence of positive surgical margins and actuarial PSA recurrence free survival at 3 y was similar in all three groups. Lower morbidity, fewer blood transfusions and a shorter length of hospital stay were the advantages of the laparoscopic approach. It has to be noted, however, that these results are preliminary, since the median follow-up periods vary greatly between the groups. Especially for the laparoscopic approach, studies with a longer follow-up and prospective data on functional outcome are needed to further support the efficacy of this surgical technique.

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Salomon, L., Levrel, O., Anastasiadis, A. et al. Outcome and complications of radical prostatectomy in patients with PSA <10 ng/ml: comparison between the retropubic, perineal and laparoscopic approach. Prostate Cancer Prostatic Dis 5, 285–290 (2002). https://doi.org/10.1038/sj.pcan.4500605

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Keywords

  • retropubic
  • perineal
  • laparoscopic
  • radical prostatectomy
  • oncological results

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