Research Article
Clinical Outcomes Associated with Robot-Assisted Radical Prostatectomy (RARP) Using the Extraperitoneal Approach in Japanese Men
Kiyoshi Takahara*, Atsuhiko Yoshizawa, Masashi Nishino, Masahiro Ito, Masaru Hikichi,
Kosuke Fukaya, Manabu Ichino, Naohiko Fukami, Hitomi Sasaki, Mamoru Kusaka and Ryoichi
Shiroki
Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
*Corresponding author: Kiyoshi Takahara, Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi 470-1192 Japan
Published: 30 Apr, 2018
Cite this article as: Takahara K, Yoshizawa A, Nishino
M, Ito M, Hikichi M, Fukaya K, et al.
Clinical Outcomes Associated with
Robot-Assisted Radical Prostatectomy
(RARP) Using the Extraperitoneal
Approach in Japanese Men. Clin Surg.
2018; 3: 1952.
Abstract
Background: Robot-Assisted Radical Prostatectomy (RARP) has become a widely adopted
procedure to treat localized Prostate Cancer (PCa). However, it is sometimes difficult to perform
such a procedure using the typical Transperitoneal (TP) approach in those cases that have undergone
prior abdominal operations. Herein, we performed RARP using the Extraperitoneal (EP) approach
for Japanese PCa cases with prior abdominal operations to evaluate the feasibility and clinical
outcomes associated with this procedure.
Material and Methods: Seven hundred eighty-eight Japanese PCa cases underwent RARP from
August 2009 to March 2017; 15 cases that were operated on using the EP approach comprised the
study cohort.
Results: The abdominal operations in the 15 cases were performed for the following reasons:
three for nephrectomy, two for panperitonitis, two for appendectomy, and nine for other reasons,
including overlap. There were no significant differences with respect to six factors (operation time,
console time, estimated intraoperative blood loss volume, surgical margin positivity, postoperative
catheterization time, and postoperative hospital length of stay) between the cases that underwent
the procedure using the TP and EP approach, despite the total number of cases in each group being
different.
Conclusions: We propose that RARP could be safely performed using the EP approach in Japanese
PCa cases that have had prior abdominal operations.
Keywords: Prostate cancer; RARP; Extraperitoneal approach
Introduction
Robot-Assisted Radical Prostatectomy (RARP) has become profoundly popular among
urologists for the treatment of localized Prostate Cancer (PCa) due to the reasonable evidence
that has amassed to suggest that RARP is a well-tolerated, safe, and efficacious intervention for
the management of localized PCa [1,2]. The predominant technique of RARP is performed with
Transperitoneal (TP) access; however, notably, it can be difficult to perform RARP using the TP
approach in cases that have had prior abdominal operations.
Gettman et al. reported the first clinical cases of Extraperitoneal (EP) RARP (EP-RARP) in
2003, and several studies since have compared the oncological outcomes and complications of TPversus
EP-RARP [3]. Some studies have reported that EP-RARP may be similar or even superior to
TP-RARP in terms of perioperative outcomes [4]. However, only a few reports have discussed the
clinical outcomes of EP-RARP in Japanese cohorts. In the present study, we performed RARP using
the EP approach on Japanese PCa cases that have undergone prior abdominal operations in order to
evaluate the procedure’s feasibility and associated clinical outcomes.
Methods
During the EP-RARP operation, the trocar was placed below the navel, and the retroperitoneal space was dilated using a balloon dilator. Each port was placed at locations approximately 1 cm, 2 cm more caudal than the positions used during TP-RARP (Figure 1). We maintained at least 6 cm of distance between each port, and the case was placed in a 10-degree head-down (Trendelenburg) position. All values are presented as mean ± SD, and a statistical comparison of the results was performed by Student’s t-test, Mann-Whitney test, Chi-square test, or Fisher's exact test. In all statistical analyses, a p value < 0.05 was considered significant. All data were analyzed using IBM SPSS Statistics version 23 (SPSS Japan Inc, Tokyo, Japan).
Figure 1
Figure 2
Figure 2
Clinical outcomes of EP-RARP cases. A: Operation Time, B: Console Time, C: Estimated Intraoperative Blood Loss, D: Postoperative Catheterization
Time, E: Postoperative Hospital Length of Stay. Histograms represent each point and the mean with SD.
Figure 3
Figure 3
Clinical outcomes of TP- or EP-RARP cases. A: Operation Time, B: Console Time, C: Estimated Intraoperative Blood Loss, D: Postoperative
Catheterization Time, E: Postoperative Hospital Length of Stay. Histograms represent the mean with SD.
Results
A total of 788 Japanese PCa cases underwent RARP from August
2009 to March 2017; 773 cases underwent TP-RARP, whereas 15
cases underwent EP-RARP. Clinical characteristics of these cases
were shown in (Table 1). The mean age of the cases that underwent
TP- and EP-RARP were 65.1 (45-77) years and 67.7 (57-78) years,
respectively. The mean initial serum Prostate-Specific Antigen
(PSA) level of each group was 9.3 (1.6-158.3) ng/ml and 5.9 (4.3-
10.7) ng/ml. Information about clinical stage, Gleason score, and
D’Amico risk classification is shown in (Tables 1). In the context of
Neoadjuvant Treatment, 504 patients (65.2%) were not performed
in TP-RARP cohort, while 9 patients (60%) not in EP-RARP cohort.
In these six factors (Age, Serum PSA level, Gleason score, D’Amico
Risk classification, and Neoadjuvant Treatment), only Serum PSA
level showed a significant difference between the EP- and TP-RARP
cohorts.
In the 15 EP-RARP cases, before RARP, nephrectomy was
performed in three, panperitonitis in three, appendectomy in two,
and other operations in nine, including overlap (Table 2).
The mean operation time and console time of EP-RARP cases
were 173 (124-279) minutes and 116 (81-219) minutes, respectively.
The mean estimated intraoperative blood loss was 227 (50-600) ml,
and none of the cases required the conversion to open surgery or the
use of intraoperative blood transfusions. The mean postoperative
catheterization time and postoperative hospital length of stay
were 7.2 (6-13) days and 10.7 (8-17) days, respectively (Figure 2).
Postoperative complications included urinary retention (Clavien II)
(one case), lymphocele (Clavien I) (one case), and anastomotic leak
(Clavien I) (one case). Surgical margin positivity was 26.7%.
In the 773 cases who underwent RARP using the TP approach
during the same period, the mean operation time and console time
were 169 (80-570) minutes and 130 (53-515) minutes, respectively,
and the mean estimated intraoperative blood loss was 171 (10-1000)
ml. The mean postoperative catheterization time and postoperative
hospital length of stay were 6.5 (4-43) days and 9.7 (4-47) days,
respectively. Surgical margin positivity was 20.2%.
There were no significant differences with respect to these six
factors (including surgical margin positivity) between the cases that
underwent the procedure using the TP and EP approach, despite the total number of cases in each group being different (Figure 3). These
results indicate that the EP-RARP procedure is similarly effective
to the TP approach for managing cases with small pelvises, such as
Japanese men.
Discussion
PCa is the most common cancer worldwide, and radical
prostatectomy is the standard therapy for treating cases with localized
PCa [5,6]. Retropubic Radical Prostatectomy (RRP), Perineal Radical
Prostatectomy (PRP), Minimum-Incision Endoscopic Radical
Prostatectomy (MIERP), and Laparoscopic Radical Prostatectomy
(LRP) have also been performed; however, these procedures require
the use of accurate methods of handling in the pelvis. Since the average
pelvic cavity of a Japanese man is smaller than those of men in other countries, it could be difficult to perform RP on Japanese PCa cases.
In Japan, RARP was introduced in 2006 [7], and the public health
insurance program began to cover the cost of RARP in April 2012.
Thereafter, the number of RARP operations has increased rapidly.
The RARP technique is predominantly performed with TP
access; however, the TP approach is sometimes difficult to execute
successfully in cases who have had previous abdominal surgery. As
mentioned above, since the first report by Gettman et al. there have
been several studies that have compared the oncological outcomes
and complications of TP- versus EP-RARP. Lee et al. conducted
a meta-analysis of studies that compared the TP versus the EP
approach in RARP [8]. A study had demonstrated that operating
room time was shorter with EP-RARP than with TP-RARP. This was mainly achieved by the inclusion of a shorter console time in EPRARP,
because no further mobilization of the peritoneum and the
bladder was necessary [9]. In this study, there were no significant
differences in terms of operation time and console time between
the TP and EP groups. For estimated blood loss and surgical margin
positivity, Lee et al. indicated that there was no statistical difference
between the EP- and TP-RARP cohorts using random-effects models,
which is consistent with the result obtained in our study [8]. It could
be difficult to analyze postoperative length of hospital stay because
the average stay in two studies conducted in the United States was
only one day [10,11], but there is also no discernable difference
between the groups in our cohort with respect to this. Regarding the
complications, Liatsikos et al. [12] indicated that, since the bowel is
minimally manipulated and there is no leakage of intraperitoneal
fluids, the peritoneum still works as a natural barrier before and after
EP-RARP operation. Moreover, bowel injuries that infrequently
occur during trocar insertion and dorsal dissection of the overlying
rectum prostatic apex are considered less severe complications in the
EP approach because the risk of generalized peritonitis is diminished
with this approach [13]. In the 15 cases who underwent the EPRARP
procedure in this study, none of them had a Clavien-Dindo
classification of or more.
In this study, we evaluated the procedural feasibility of EP-RARP
and the associated clinical outcomes of 15 Japanese PCa cases that
underwent this procedure and compared them with those of 773 PCa
cases who underwent TP-RARP. Although the number of cases who
underwent each procedure was different, the efficacy of EP-RARP for
Japanese PCa cases was still evident.
In conclusion, the EP-RARP procedure could be a safe and
effective treatment for Japanese PCa cases with prior abdominal
operations.
Table 1
Table 2
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