Surgical,Oncologic,and Short-Term Functional Outcomes in Patients Undergoing Robot-Assisted Prostatectomy After Previous Transurethral Resection of the Prostate

Abstract

Purpose:

The objective of this study was to assess the surgical, oncologic, and short-term functional outcomes of patients with a history of transurethral resection of the prostate (TURP) who underwent robot-assisted laparoscopic prostatectomy (RALP).

Patients and Methods:

The records of 2000 men who underwent RALP from February 2006 to April 2010 were retrospectively reviewed. A total of 80 men had undergone TURP before RALP. A match-paired analysis was performed using our database to identify 80 additional men without a history of TURP with equivalent clinicopathologic characteristics to serve as a control group (non-TURP group). The parameters compared included patient preoperative clinicopathologic characteristics, intraopeoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, continence, and potency.

Results:

The mean time between TURP and RALP was 3.6 months (3–6 months). Regarding preoperative characteristics, a statistical difference was only observed regarding preoperative patient potency in the TURP vs non-TURP group. Regarding intraopeoperative characteristics, a statistical difference was observed regarding the need for bladder neck reconstruction and skin-to-skin operative time. Regarding postoperative pathologic characteristics, the positive surgical margin rate was not significant when the two groups were compared. The continence and potency rates in 12 months were similar (87.5%/91.25%) and (70.3%/86.5%) for both patient cohorts.

Conclusion:

Although the procedure is technically more demanding, exhibits a prolonged operative time and time interval before continence and potency returns, it can be safely performed without compromising functional results as well as the radical nature of cancer surgery.

Introduction

D uring the past years, robot-assisted laparoscopic radical prostatectomy (RALP) has become profoundly popular among urologists for the treatment of pat ients with localized prostate cancer (PCa). Although there might be a lack of randomized trials, there is reasonable evidence to suggest that RALP is a well-tolerated, safe, and efficacious intervention for the management of localized PCa.^1,2 Historically, retropubic radical prostatectomy (RP) after previous transurethral resection of the prostate (TURP) was associated with increased intraoperative and postoperative morbidity.³ Recently published data have exhibited that patients who had undergone laparoscopic RP after previous TURP had similar outcomes as well and that erectile function and urinary continence were adversely affected when compared with patients with no previous treatment.^4,5

Although RALP seems ideal to navigate the difficult tissue planes of a previously treated surgical field, literature evaluating the outcomes of RALP in this group of patients is sparse. The objective of this study is to assess the surgical, oncologic, and short-term functional outcomes of patients with a history of TURP who underwent RALP.

Patients and Methods

The records of 2000 men who underwent RALP from February 2006 to April 2010 were retrospectively reviewed. All perioperative and postoperative data were recorded prospectively in our database. A total of 80 men had undergone TURP before RALP. The TURP cohort consisted of men who received a diagnosis of PCa by TURP as well as men with a history of TURP who later had a diagnosis of PCa because of increased prostate-speicific antigen (PSA) levels or suspicious digital rectal examination (DRE) (TURP group).

Systematically a 3-month waiting period was used between the dates of TURP and RALP. A match-paired analysis was performed using our database to identify men without a history of TURP with equivalent clinicopathologic characteristics to serve as the control group (non-TURP group). The matching criteria used to select patients were age, body-mass index (BMI), prostate size (in transrectal ultrasonography), clinical stage, PSA level, and biopsy Gleason score.

RALP was performed using the da Vinci Robotic 3-Arm System (Intuitive Surgical, Sunnyvale, CA) via a transperitoneal approach. Pelvic lymph node dissection was performed in patients with a PSA level >10 ng/mL and/or Gleason score >6. Bilateral neurovascular bundle (NVB) preservation was attempted in patients with a PSA level <10 ng/mL and/or Gleason score <7.

Men with preoperative impotence or who underwent a unilateral or non–nerve-sparing surgery were excluded from sexual function analysis. Preoperative potency was evaluated with the five-item version of the International Index of Erectile Function (IIEF-5).⁶ The possible scores for the IIEF-5 ranged from 1 to 25, and a score above 21 was considered as normal erectile function and at or below this cutoff, erectile dysfunction. According to this scale, it was classified into four categories based on IIEF-5 scores: Severe (1–7), moderate (8–11), mild to moderate (12–16), mild (17–21), and no dysfunction (22–25). Patients with a severe dysfunction were considered impotent.

The procedures in both patient cohorts were performed by five experienced RALP surgeons by a standard transperitoneal approach as reported by Patel⁷ with a few minor modifications. The distribution of the RALP performed in the TURP cohort of patients among the five surgeons was surgeon A: 49 cases (61.25%); surgeon B: 12 cases (15%); surgeon C: 8 cases (10%); surgeon D: 8 cases (10%); surgeon E: 3 cases (3.75%).

The parameters compared between the two groups included patient preoperative clinicopathologic characteristics (age, BMI, prostate size, clinical stage, PSA level, biopsy Gleason score, preoperative potency, and continence), intraopeoperative characteristics (bladder neck reconstruction, NVB preservation, lymph node dissection, estimated blood loss, hemorrhage, need for transfusion, skin-to-skin operative time, duration of catheterization, and intraoperative complications), postoperative oncologic characteristics (prostate size, tumor volume, Gleason score, pathologic stage, positive surgical margins [PSM] and positive lymph nodes), minor (retention, urinary leakage, urinary tract infection, lymphocele, superficial abscess, and subcutaneous emphysema) and major (infected lymphocele, bowel injury, acute renal failure, and reoperation) complications, continence, and potency. Information regarding the detection method for prostate cancer (TURP or routine examination after TURP) was also recorded.

Postoperative complications and reinterventions encountered up to 30 days postoperatively were stratified by the Clavien classification⁸ and were characterized as minor (Clavien grade I–IIIa) and major postoperative complications (Clavien grade IIIb–IVa). Hemorrhage was defined as greater than 500 mL of blood loss during the operation. A PSM was defined as tumor at the inked surface of the specimen. Oncologic results were evaluated by staging the operative specimens according to the Tumor-Node-Metastasis 2002 classification.

All patients underwent cystography at postoperative day 4. The catheter was then removed if no extravasation was recorded. If extravasation was present, the catheter was left in place for 7 additional days. Functional results regarding urinary continence were evaluated prospectively 3, 6, and 12 months after surgery. Complete urinary continence was defined as no pad use and/or no urinary leakage. Requirement for 1 to 2 pads daily was considered as mild incontinence and >2 pads daily as incontinence.

Functional results regarding potency were evaluated prospectively 6 and 12 months after surgery. Potency was defined as erections sufficient for penetration with or without phosphodiesterase inhibitors. The analysis of potency was limited to patients who were potent before RALP, had bilateral nerve-sparing surgery, and had a follow-up of ≥6 months with no adjuvant therapy. Once a patient was potent or continent, he was considered potent or continent on further analysis. The median postoperative follow-up of the patients was 13.5 months (range 3–48 mos).

For comparison between two groups of continuous values, the Student t test was used. For comparison between three or more groups, the one-way analysis of variance with the Tukey correction for multiple comparisons was used. For comparison of binomial values, the chi-square test was used. Simple linear regression was used to test the effect of one continuous parameter against another. A P value of<0.05 was considered significant.

Results

The preoperative clinicopathologic characteristics of the two groups are listed in Table 1. A statistical difference was only observed regarding preoperative patient potency in the TURP vs non-TURP group (67.5%/83.75%) (P=0.056). In the TURP group, according to patients' IIEF-5 score, 26 (32.5%) patients exhibited severe erectile dysfunction, 7 moderate (8.75%), 3 mild to moderate (3.75%), 3 mild (3.75%), and 30 (37.5%) patients no dysfunction. In the non-TURP group, according to patients' IIEF-5 score, 13 (16.25%) patients exhibited severe erectile dysfunction, 13 moderate (16.25%), 6 mild to moderate (7.5%), 15 mild (18.75%), and 33 (41.25%) patients no dysfunction.

Table 1.

Patient Preoperative Clinicopathologic Characteristics

	TURP group	Non–TURP group	P value
Age (y)	67.5 (51–78)	66.1 (48–74)	_
PSA (ng/mL)	9.5 (0.4–77)	9.2 (0.9–49.1)	_
Prostate size (g)	30.9 (5–123)	30.1 (16–65)	_
BMI (kg/m²)	26.8 (17–37)	24.6 (22–31)	_
Gleason score
<7	67.5%	75%	–
=7	25%	25%	–
>7	7.5%	–	–
Clinical stage
Organ-confined disease	100%	98.75%	–
Extraprostatic extension	0%	1.25%	–
Continence	80 (100%)	80 (100%)	–
Potency	54 (67.5%)	67 (83.75%)	0.056

TURP=transurethral resection of the prostate; PSA=prostate-specific antigen; BMI=body mass index.

In the TURP group, 31.2% of PCa had been incidentally diagnosed during TURP (stage T_1a–T_1b) and 68.8% after biopsy because of an increased PSA level and/or abnormal DRE subsequent to TURP. In 43 (53.7%), the mean time between TURP and RALP was 3.6 months (3–6 mos). In the remaining 37 (46.3%) patients, the time interval between TURP and RALP was not known but was at least 3 months.

The intraopeoperative characteristics of both groups are presented in Table 2. A statistical difference was observed regarding the need for bladder neck reconstruction and skin-to-skin operative time in the TURP vs non-TURP group 58.7%/2.5% (P=0.073) and 189 min/149 min (P=0.069), respectively.

Table 2.

Patient Intraopeoperative Characteristics

	TURP group	non-TURP group	P value
Bladder neck reconstruction	47 (58.7%)	2 (2.5%)	0.073
Bilateral nerve sparing	42 (52.5%)	54 (67.5%)	_
Lymph node dissection	59 (73.7%)	59 (73.7%)	_
Estimated blood loss (mL)	165 (100–300)	144 (50–1000)	_
Hemorrhage	2 (2.5%)	1 (1.25%)	_
Transfusion	1 (1.25%)	_	_
Operative time (min)	189 (50–500)	149 (80–340)	0.069
Duration of catheter (d)	6.8 (5–26)	5.2 (5–6)	_
Intraoperative complications	2 (2.5%)	1 (1.25%)	_

Patient Postoperative Pathologic Characteristics
	TURP group	Non-TURP group	P value
Prostate size (g)	49.4 (23–152)	48.5 (28–130)	_
Tumor size (%)	12.1 (1–92)	14.3 (1–50)	_
Gleason score
<7	52.5%	70%	0.076
=7	37.5%	28.75%	0.054
>7	10%	1.25	0.084
Clinical stage
Organ-confined disease	70%	87.5%	0.059
Extraprostatic extension	30%	12.5%	00.61
Positive margins	6 (6.25%)	4 (5%)	_
Positive lymph nodes	2 (2.5%)	_	_

The postoperative pathologic characteristics of both groups after RALP are listed in Table 2. A statistical difference was observed regarding Gleason score <7 (52.5%/70%) (P=0.076), Gleason score=7 (37.5/28.75) (P=0.054), Gleason score >7 (10%/1.25%) (P=0.084), organ-confined disease (70%/87.5%) (P=0.059), and extraprostatic extension (30%/12.5%) (P=0.061) in the TURP vs non-TURP group. The PSM rate was not significant when the two groups were compared (6.25%/5%).

Minor complications were observed in 20 (25%) patients in the TURP group compared with 8 (10%) in the non-TURP group (P=0.066) (Table 3). The most common minor complication for both patient cohorts was urinary leakage (13.7%/8.75%). Major complications were evident in only two (2.5%) patients in the TURP group compared with one (1.25%) in the non-TURP group (Table 3).

Table 3.

Patient Minor Postoperative Complications

	TURP group	Non-TURP group	P value
Retention	3 (3.75%)
Urinary leakage	11 (13.7%)	7 (8.75%)	_
Urinary tract infection	3 (3.75%)	_	_
Lymphocele	_	1 (1.25%)	_
Hematoma	1 (1.25%)	_	_
Superficial abscess	1 (1.25%)	_	_
Subcutaneous emphysema	1 (1.25%)	_	_
Overall	20 (25%)	8 (10%)	0.066

Patient Major Postoperative Complications
	TURP group	Non-TURP group	P value
Infected lymphocele	_	1 (1.25%)	_
Bowel injury	1 (1.25%)	_	_
Acute renal failure	1 (1.25%)	_	_
Overall	2 (2.5%)	1 (1.25%)	_

Table 4 lists the postoperative functional results of both patient cohorts. Continence rates in 12 months were similar (87.5%/91.25%); however, previous TURP was associated with a lower continence rate at 3 and 6 months in comparison with the non-TURP group (43.75%/68.6%) (P=0.064) and (56.25%/31.4%) (P=0.059), respectively. Postoperatively at 3, 6, and 12 months, none of the patients of both groups needed more than two pads/d. Regarding potency, the rates in 12 months were similar (70.3%/86.5%); however, previous TURP was associated with a lower potency rate at 6 months in comparison with the non-TURP group (42.5%/68.6%) (P=0.072).

Table 4.

Patient Postoperative Functional Results

	TURP group	Non-TURP group	P value
Continence
3 months
Complete	35 (43.75%)	46 (68.6%)	0.064
Mild	45 (56.25%)	34 (31.4%)	0.059
Incontinence	-	-	-
6 months			0.061
Complete	54 (67.5%)	66 (82.5%)	0.059
Mild	26 (32.5%)	14 (17.5%)	-
Incontinence	-	-
12 months			-
Complete	70 (87.5%)	73 (91.25%)	-
Mild	10 (12.5%)	7 (8.75%)	-
Incontinence	-	-
Potency
6 months	23 (42.5%)	46 (68.6%)	0.072
12 months	38 (70.3%)	58 (86.5%)	-

Discussion

The effect that previous TURP has on RP has been controversial.^9
–11 Although it was thought that RP after previous TURP led to increased intraoperative and postoperative morbidity as well as worse oncologic and functional outcomes, today it is believed that RP might sometimes be technically more difficult to perform, but outcomes are no different from those in patients without a history of TURP.^9
–11 Most studies comparing the oncologic and functional outcomes in patients with and without previous TURP are inferred from perineal, retropubic, laparoscopic, and endoscopic extraperitoneal RP, data that ignore the advances of the robotic technique, such as an enhanced visibility and dexterity, which allows difficult tissue planes to be dissected more easily than with other approaches.

The proposed hypothesis that previous TURP leads to worse outcomes in patients undergoing RP is because of a difficult dissection resulting from obscured planes caused by periprostatic inflammation and fibrosis. The mechanism of this periprostatic inflammation and fibrosis is theoretically from prostatic infection along with capsular perforation and extravasation of the irrigation fluid during TURP. Oncologically, the difficulty in identifying the proper surgical planes leads to a PSM status, and functionally, the difficulty in the dissection and isolation of the NVBs leads to worse potency rates.⁹ Regarding NVB preservation, not only did we not encounter this phenomenon, but in some cases, NVB preservation was actually very easy. Nevertheless, the time interval between TURP and RALP at our institution was at least 3 months in an attempt to decrease the amount of the possible postoperative inflammation.

Colombo and associates⁵ evaluated retropubic RP after TURP and noted a longer operative time. They found a mean operative time of 135 to 105 minutes in the TURP group vs 125 to 85 minutes in the control group. Complications were encountered in up to 50% of patients. They reported that 74% and 86% of patients were dry at 6 and 12 months, respectively, and that 28% of patients were potent at 6 months. They considered RP feasible in patients after TURP, however. Jaffe and colleagues⁴ in a study including 117 patients reported that patients with a history of TURP who underwent laparoscopic RP have worse outcomes with respect to operative time, length of stay, overall complication rate, and functional outcomes.

Similar results were not encountered in our study. Although there was a prolongation of the operative time of approximately 40 minutes (P<0.05) and the overall minor complications were significantly higher in the TURP group, the remaining parameters, such as length of stay, major complications, and functional results in 12 months, were not different between the two groups. Minor complications were observed in 20 (25%) patients in the TURP group compared with 8 (10%) in the non-TURP group. The most common minor complication for both patient cohorts was urinary leakage (13.7%/8.75%). This higher rate of prolonged urinary leakage was previously documented in patients who underwent RRP after previous TURP.¹² Major complications were evident in only two (2.5%) patients in the TURP group compared with one (1.25%) in the non-TURP group.

Leewansangtong and Taweemonkongsap¹² exhibited that although there was no difference in operative times when comparing laparoscopic RP, PSMs were encountered in 14.3% and 0% of patients with localized disease in the TURP and control groups as well as PSMs in 100% and 60% of patients with locally advanced disease in the TURP and control groups, respectively. As seen from the results of our study, the PSM rate was not significantly different when comparing both groups (6.25%/5%).

In a study by Do and coworkers,¹³ the authors investigated a series of 100 patients who had undergone endoscopic extraperitoneal RP after previous TURP. At 12 months, 93% of patients were continent, 4% used 1 to 2 pads/d, and 3% needed more than two pads/d. The potency rates were 52.6% and 66.7% at 6 and 12 months, respectively. As seen in the results of our study, the continence rates in 12 months were similar (87.5%/91.25%), none of the patients of both groups needed more than two pads/d, and potency rates in 12 months were similar (70.3%/86.5%) as well.

In a study by Teber and colleagues,¹⁴ the authors evaluated the effect of previous TURP on surgical, functional, and oncologic outcomes after laparoscopic RP in comparison with a control group. The positive surgical margin rates were 14.5% and 16.3%, and the long-term continence rates were similar; however, previous TURP was associated with a lower continence rate (49.1%) at 3 months compared with 61.8% for the control group. There was no significant difference in the potency rates between the two groups at 12 months.

Similar outcomes were encountered in our study as well. Previous TURP was associated with a lower continence rate at 3 and 6 months in comparison with the non-TURP group (43.75%/68.6%) (P<0.05), as well as lower potency rates at 6 months in comparison with the non-TURP group (42.5%/68.6%) (P<0.05). We believe that these findings are not surprising, because a significant portion of the TURP group had undergone bladder neck reconstruction as well as that it has been previously documented that the proportion of patients who undergo TURP in whom erectile dysfunction develops is approximately 14%.¹⁵

Although the current study benefits from the largest cohort of patients with a history of TURP who underwent RALP analyzed, there are two certain limitations that should be addressed. The first one is that the interval between TURP and RALP was not standardized, because this was a retrospective review, and which could be an important variable, considering the degree of inflammation and scarring over time. In 43 (53.7%), the mean time between TURP and RALP was 3.6 months (3–6 mos). In the remaining 37 (46.3%) patients, the time interval between TURP and RALP was not known but was at least 3 months.

The second limitation is that the procedures in both patient cohorts were performed by five RALP surgeons. Although all are considered experienced (>100 RALP performed), a deference in surgical experience regarding cases exhibiting a previous TURP was still evident: Surgeon A: 49 cases (61.25%); surgeon B: 12 cases (15%); surgeon C: 8 cases (10%); surgeon D: 8 cases (10%); surgeon E: 3 cases (3.75%).

Conclusion

RALP is ideal to navigate the difficult tissue planes of a previously resected prostate. Although the fact that the procedure is technically more demanding, exhibits a prolonged operative time, and the interval before continence and potency returns might be an end point, it should not minimize the importance that the procedure can be safely performed without compromising functional results as well as the radical nature of cancer surgery.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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