1. 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

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

3. At 3 Teaching hospital (Jkt, Bdg, Jogja);
695 cases of Prostate cancer in the last 5 years.
Hasan Sadikin Hospital in th ;
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Safriadi F. Unpublished data

4. Indications: general condition Organ confined
Consideration : life expectancy
general condition
co-morbid
T1a : Optional, preferred for younger pts, Skor Gleason score (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

5. 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

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

7. Berryhill R et al. Urology 2008

8. 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

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

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

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

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

13. Perioperative complications:
Ghavamian R et al. Urology 2006

14. Wagner AA et al. Urology 2007

15. Urinary continence :
Berryhill R et al. Urology 2008

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

17. Sexual potency:
Berryhill R et al. Urology 2008

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

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

20. Tumour control (Positive margin rate):
Laparoscopy 19,6% vs open 23,5%
Urinary continence 3 bln bln bln
Laparoscopy % % %
Open ,4% 38,6-87,2% 60,5-92,1%
Sexual potency UNS BNS
Laparoscopy % ,9%
Open ,7-53% ,7-86%

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

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

23. 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

24. Anderson JK et al. Urology 2005

25. Bolenz C et al. Eur Urol 2010

26. 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

27. 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

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

29. Rassweiler J et al. J Urol 2003

30. Rassweiler J et al. J Urol 2003

31. 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.

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

33. 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.

35. Fabrizio MD et al. J Urol 2003

36. 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

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

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

39. Thank you