Laparoscopic Radical prostatectomy: Is it still a treament of choice? Ferry Safriadi Department of Urology Hasan Sadikin Hospital Medical School of University of Padjadjaran National Workshop of Urological Laparoscopy II, May 6-8 2010

Introduction Radical Prostatectomy is a treatment of choice for organ confined Prostate cancer. In USA ; 186.000 new cases/yrs, 90% organ confined or regional stage. Of 90.000 cases was underwent radical prostatectomies. Of 30.000 pts prostate cancer death/yrs. Barocas DA et al. J urol 2010 Berryhill R et al. Urology 2008

At 3 Teaching hospital (Jkt, Bdg, Jogja); 695 cases of Prostate cancer in the last 5 years. Hasan Sadikin Hospital in th 2004-2009; 252 cases of Prostate cancer Start in 2005: 57 radical prostatectomy procedures LRP started in 2007: 2007: 1 case 2008: 9 cases 2009: - 2010: 1 case Asian Advisory Board Meeting Prostate Cancer. 2010 Safriadi F. Unpublished data

Indications: general condition Organ confined Consideration : life expectancy general condition co-morbid T1a : Optional, preferred for younger pts, Skor Gleason score 8- 10 (recommendation B). T1b-2c: Standard therapy for life expectancy >10 th (recommendation A). T3-4: Optional, limited for Gleason score < 8, PSA <20, life expectancy >10 years (recommendation C). EAU Guidelines. 2009 NCCN. 2010

Laparoscopic and open radical comparison: Main parameter: a. Perioperative outcomes b. Tumour control (positive surgical margin) c. Sexual potency d. Urinary continence B. Additional parameter: a. Pain control b. Cost c. Convalescens

Main parameter: a. Perioperative outcomes: Operative time, Estimated blood loss + transfusion rate, Complications (Clavien’s classification), Indwelling catheter duration

Berryhill R et al. Urology 2008

Laparoscopy 227 mnt vs open 147 mnt Operative time: Laparoscopy 227 mnt vs open 147 mnt Estimated blood loss+ transfusion rate: Laparoscopy 406 ml vs open 697 ml 2.9% vs 24% Complication: Laparoscopy 15,6% vs open 10,3% Catheterization: Laparoscopy 6,9 days vs open 8,4 days

Tumour control (Positive margin rate): Laparoscopy 19,6% vs open 23,5%

Metaanalysis; estimated blood loss Parsons JK et al. Urology 2008

Meta-analysis Risk ratio of transfusion Parsons JK et al. Urology 2008

Meta-analysis Risk ratio of PSM Parsons JK et al. Urology 2008

Perioperative complications: Ghavamian R et al. Urology 2006

Wagner AA et al. Urology 2007

Urinary continence : Berryhill R et al. Urology 2008

Dahl DM et al. J Urol 2009 Anastasiadis AG et al. Urology 2003

Sexual potency: Berryhill R et al. Urology 2008

Dahl DM et al. J Urol 2009 Anastasiadis AG et al. Urology 2003

Dahl DM et al. J Urol 2009 Anastasiadis AG et al. Urology 2003

Tumour control (Positive margin rate): Laparoscopy 19,6% vs open 23,5% Urinary continence 3 bln 6 bln 12 bln Laparoscopy 51 -94% 73-96% 60-98% Open 54-70,4% 38,6-87,2% 60,5-92,1% Sexual potency UNS BNS Laparoscopy 35-64% 43-78,9% Open 16,7-53% 36,7-86%

Pain control: No significant difference between LRP and RRP. Guazzoni G et al. Eur Urol 2006

Early post-operative results: No significant difference in early post-operative day except catheterization lenght. Guazzoni G et al. Eur Urol 2006

Cost comparison: The costs of LRP are significantly greater than the costs for RRP, and most of this cost difference was a result of the higher surgical supply and operating room costs. Anderson JK et al. Urology 2005

Anderson JK et al. Urology 2005

Bolenz C et al. Eur Urol 2010

Our Result: Demography, pathology and perioperative condition Characteristic Open (n=46) Laparoscopy (n=11) Mean age 63,83 62,54 Mean PSA (ng/ml) 28,49 32,06 Mean GS 5,92 5,90 Stadium pre-op (n) T1c 28 8 T2a 6 1 T2b T2c T3 5 T4 2 OR Time (hour) 3 hr 50 mnt 6 hr 10 mnt EBL(mL) 1208,62 654,54 Complication (n) 5(10,8%) 3(27%) Rectal injury Urethrocutaneous fistula Urinary retention Bladder neck stenosis Safriadi F . Unpublished data

Additional procedures after RRP or LRP Variable Open (n=46) Laparoscopy(n=11) Patient’s no 5 3 D V I U 1 Urethral fistula repair Urethrorectal fistula repair Colostomy Office urethral dilatation Indweeling catheter 2 Safriadi F . Unpublished data

Germany’s laparoscopic evolution: Rassweiler J et al. J Urol 2003

Rassweiler J et al. J Urol 2003

Rassweiler J et al. J Urol 2003

Most problem in Indonesia Number of prostate cancer is not many as in USA/ europe - Limited access to urological practice - Limited number of urologist and no sparse - Early detection is not wellknown - Urological care promotion is limited especially for uro-oncology.

Laparoscopic equipment is expensive. Limited number of skilled laparoscopic urologist. Learning curve is slow to be reached.

What do you do to short a Learning curve time: Mentor –trainee method - To cut of time become expert. - Expert≥ 200 cases, =± 50 cases. - Prerequirement: - Basic laparoscopic technique - Already done a “easier” laparoscopic procedures.

Fabrizio MD et al. J Urol 2003

Laparoscopic radical prostatectomy is...... Requires a longer operative time Associated with less blood loss Requires fewer analgesics Enables earlier mobilisation Leads to a high rate of early catheter removal Shows the same rates of positive margins

Reduction in rates of PSM - Improve video technology NOTES LESS Robotic Egawa S. Eur Urol 2009

CONCLUSION LRP is comparable with traditional RRP LRP is a bridge between traditional to the next advanced/ sophisticated equipment

Thank you