Radical Prostatectomy After Previous Transurethral Resection of the Prostate: Robot-Assisted Laparoscopic Versus Open Radical Prostatectomy in a Matched-Pair Analysis

Abstract

Purpose:

To determine whether previous transurethral resection of the prostate (TURP) compromises the surgical outcome and pathologic findings in patient who underwent either radical robot-assisted laparoscopic prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, because TURP is reported to complicate radical prostatectomy and there are conflicting data.

Patients and Methods:

From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 (5.3%) patients had undergone previous TURP. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen, the biopsy Gleason score, the American Society of Anesthesiologists classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons.

Results:

Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217±51.9 minutes for RALP and 174±57.7 minutes for RRP (P<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT₂ tumors: 10.5% for RALP and 5.3% for RRP; P=1.0). Mean estimated blood loss was 333±144 mL in RALP patients and 1103±636 mL in RRP patients (P<0.001). The difference between preoperative and postoperative hemoglobin levels was 3.22±0.98 g/dL for RALP and 5.85±1.95 g/dL for RRP (P=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58±1.17 vs 11.74±5.22 days; P=0.0037), duration of catheterization (7.95±5.69 vs 11.78±6.97 days; P=0.0016), postoperative complications according to the Clavien classification system (6 vs 15 patients; P=0.0027), and transfusion rate (0% vs 10.5%; P<0.001).

Conclusion:

RALP offers advantages over open radical prostatectomy after previous surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.

Introduction

T he current standard treatment for patients with low-risk and intermediate-risk localized prostate cancer and a life expectancy of more than 10 years is open retropubic radical prostatectomy (RRP).¹ Robot-assisted laparoscopic prostatectomy (RALP) has become an established minimally invasive option for managing localized prostate cancer. Reviews and cumulative analyses of comparative studies have shown that the functional and oncologic results provided by RALP are at least comparable to those obtained with laparoscopic radical prostatectomy (LRP) or open RRP.^2,3

Prostate cancer develops in the first 7 years after surgery in approximately 4% of the patients who underwent transurethral resection of the prostate (TURP).⁴ Urologists perform open RRP even in difficult situations, such as after previous laparoscopic hernia repair, TURP, or external beam radiotherapy for different medical conditions.⁵ As a result of the presence of periprostatic fibrosis, scar tissue, and inflammation, RRP is reported to be technically demanding in patients with localized prostate cancer after previous transurethral prostate surgery for bladder outlet obstruction and is associated with poor surgical, pathologic, and functional outcomes.⁶ A higher percentage of capsular violation,⁷ higher morbidity,⁷ and a higher incidence of bladder neck stenosis⁸ have been described as well.

Recent studies showed no difference in operative complication rates, morbidity, and oncologic results between patients without previous surgery and patients with previous open^5,9 or laparoscopic surgery,^10,11 although radical prostatectomy was found to be technically more difficult. Colombo and associates⁷ recommended that candidates for radical prostatectomy after previous prostate surgery should be informed that the functional results of radical prostatectomy are less predictable and usually less satisfactory in patients with previous surgery than in patients without previous surgery. A nerve-sparing technique during RRP was found to be technically feasible and safe in patients with a history of holmium laser enucleation, TURP, or open prostatectomy.¹² Two recent studies showed that RALP after TURP is feasible but challenging and does not compromise the perioperative outcome.^13,14

In the literature, there is still a paucity of data on the influence of previous prostate surgery on RALP. For this reason, we performed a matched-pair analysis comparing RALP with open RRP in patients with previous prostate surgery on the basis of surgical outcomes and histopathologic findings. Our focus of attention was on perioperative and postoperative morbidity.

Patients and Methods

Our study population (total n=973) consisted of 357 consecutive patients who underwent RALP for localized prostate cancer at our institution between July 2008 and July 2010. Of these men, 19 (5.3%) patients had a history of prostate surgery. All patients had undergone previous TURP. No patient had undergone simple prostatectomy or bladder neck incision. Prostate cancer had been diagnosed either incidentally during TURP (RALP: 6 patients, RRP: 11 patients) or later on the basis of an elevated prostate-specific antigen (PSA) level or an abnormal digital rectal examination (RALP: 13 patients, RRP: 8 patients).

A case-control design was used to compare the surgical outcomes of the aforementioned patients with those of controls selected from a database of 616 post-RRP patients on the basis of operative and perioperative data. The control patients had undergone RRP between January 2006 and July 2010.

Matching criteria were age, clinical stage, the level of preoperative total PSA, the biopsy Gleason score, the American Society of Anesthesiologists (ASA) classification score, and prostate volume assessed during transrectal ultrasonography (Table 1).

Table 1.

Preoperative Characteristics of the Patients

	RALP	RRP
Variable	n=19	n=19	P value
Age (years)	69.05±4.78	67.58±5.34	0.5581
Clinical stage
T₁	10	11	n.s
T₂	9	8	n.s
T₃	0	0	n.s
PSA level (ng/mL)	5.24±4.12	5.63±4.32	0.9302
Biopsy Gleason score
<= 6	12	11	n.s
7	3	4	n.s
>= 8	4	4	n.s
ASA classification
1	1	2	n.s
2	14	13	n.s
3	4	4	n.s
TRUS volume (cc)	26.84±10.05	27.26±11.29	0.7256

RALP=robot-assisted laparoscopic prostatectomy; RRP=retropubic radical prostatectomy; PSA=prostate-specific antigen; ASA=American Society of Anesthesiologists; TRUS=transrectal ultrasonography.

All preoperative, operative, and postoperative data of our patients were collected prospectively. The ASA score was used to assess comorbidity. All patients underwent a preoperative digital rectal examination, PSA measurement, and transrectal ultrasonography for prostate volume estimation. In patients with T_1a and T_1b tumors, prostatectomy was performed only after a minimum period of 1 month had elapsed.

RALP was performed via a transabdominal approach. A single-stitch technique was used for vesicourethral anastomosis during RALP (7–8 stitches per anastomosis). In open RRP, ureteral stents were placed during surgery and removed after completion of the vesicourethral anastomosis (4 stitches) in all patients. No ureteral stent placement was performed during RALP. All patients underwent lymphadenectomy according to our standard procedures.

The RALP and RRP groups were compared in terms of operative time, estimated blood loss, difference between preoperative and lowest postoperative hemoglobin levels, use of hemostatic agents, blood transfusion rate, margin status, length of hospital stay, duration of catheterization, and postoperative complication rate according to the Clavien classification system.¹⁵ Oncologic results were evaluated according to the 2002 Tumor-Node-Metastasis classification.

We compared the two groups using the Student t test for numerical data and a chi-square test for clinical and pathologic variables. Data were evaluated using the SAS statistical package (Cary, NC). A P value <0.05 was considered significant.

Results

The mean interval between previous surgery and radical prostatectomy was 67.4 months in the RALP group (range 1.6–228.2 mos) and 53.1 months in the RRP group (range 1.2–225.0 mos).

Operative time was defined as the period from first incision to final closure of the wound. The mean operative time was 43 minutes longer for RALP (217±51.9 min; range 126–318 min) than for RRP (174 57.7 min; range 70–293 min). This difference was significant (P=0.0207). Intraoperative blood loss data were obtained from anesthesia records. The mean estimated blood loss was 333±144 mL (range 100–700 mL) in the RALP group and 1103±636 mL (range 400–2500 mL) in the RRP group (P<0.001). The intraoperative blood transfusion rate was 0% during RALP and 10.5% during RRP (P<0.001). Mean preoperative hemoglobin levels were comparable in both groups (14.99 g/dL for RALP and 14.66 g/dL for RRP). When we calculated the differences between preoperative and lowest postoperative hemoglobin levels, we found a mean difference of 3.22±0.98 g/dL (range 1.7–5.7 g/dL) for the RALP group and 5.85±1.95 g/dL (range 2.6–8.8 g/dL) for the RRP group (P=0.0002).

Hemostatic agents were used in two RALP patients (Floseal^®) and in one RRP patient (TachoSil^®). No conversions from RALP to open surgery were needed. Four RALP patients and four RRP patients had a Gleason score sum of 8 or more. Five patients in the RALP group and six patients in the RRP group chose to maximize oncologic safety and did not undergo a nerve-sparing procedure. A nerve-sparing procedure was performed unilaterally in one RALP patient, bilaterally in four RALP (50%) patients, unilaterally in one RRP patient, and bilaterally in two RRP (33.3%) patients. Neurovascular bundle preservation was technically impossible in five patients in the RALP group and in six patients in the RRP group. During the nerve-sparing procedures, neurovascular bundle specimens were obtained and submitted for frozen-section analysis. Results from all specimens were negative.

Anastomotic leakage was defined as the presence of extravasation on cystography. All patients underwent initial cystography between day 5 and day 7 after surgery. The catheter was removed if no extravasation was detected. The two groups showed differences in the duration of catheterization. Catheters were removed after a mean period of 7.95±5.69 days (range 5–29 days) in the RALP group and after 11.78±6.77 days (range 6–31 days) in the RRP group (P=0.0016). Both groups also showed differences in hospital stay. The mean length of hospital stay was 8.58±1.17 days (range 6–10 days) for RALP patients and 11.74±5.22 days (range 7–30 days) for RRP patients (P=0.0037). Postoperative complications according to the Clavien-Dindo classification system¹⁶ are shown in Table 2.

Table 2.

Postoperative Complications According to Clavien-Dindo-Classification System

	RALP	RRP
Clavien grade	n=19	n=19	P value
0	13	4	0.0081
I	0	1	1.0
II	2	8	0.0625
IIIa	4	2	0.6599
IIIb	0	4	0.105
IV	0	0	1.0

RALP=robot-assisted laparoscopic prostatectomy; RRP=retropubic radical prostatectomy.

Postoperative analgesia consisted of up to 15 mg of piritramide (at the anesthetist's discretion) for patients on the intermediate care ward until the morning after surgery and 500 mg of metamizole four times daily for patients on a general ward until discharge. Additional use of analgesics was classified as Clavien grade I. Postoperative complications consisted of opening of the wound at the bedside (RRP Clavien grade I), the use of lorazepam for sedation and corticosteroids (RALP Clavien grade II), postoperative blood transfusions, the use of metoprolol for the treatment of hypertension, and additional antibiotics (RRP Clavien grade II). Some patients also needed puncture of lymphoceles and repeated cystography (RALP Clavien grade IIIa), recatheterization (RRP Clavien grade IIIa), or surgical intervention for hematoma or bleeding (RRP Clavien grade IIIb). A comparison of hospital stays with and without complications showed a significant difference in the rate of postoperative complications (P=0.0081).

Mean prostate weight was 43.47 mg for RALP patients and 43.57 mg for RRP patients. There was no statistical difference between the groups. Histopathology results revealed stage pT₁/pT₂ tumors in 89.5% and stage pT₃ tumors in 10.5% of the RALP patients. By contrast, pT₁/pT2 tumors were found in 84.2% and pT₃ tumors in 15.8% of the RRP patients. Pathologic findings are shown in detail in Table 3.

Table 3.

Pathologic Findings

	RALP	RRP
Variable	n=19	n=19	P value
Pathologic stage
pT₁	1	1	1.0
PT_1a	1	0
pT₂	16	15	1.0
pT_2a	0	6
pT_2b	0	0
pT_2c	16	9
pT₃	2	3	0.6599
pT_3a	2	1
pT_3b	0	2
Positive margins (R1)	3	3	1.0
Apex	2	2
Right lateral	0	0
Left lateral	0	1
Base	1	0

RALP=robot-assisted laparoscopic Prostatectomy; RRP=retropubic radical prostatectomy.

Extracapsular disease (pT₃) was present in similar proportions in both groups. We found a higher proportion of pT_2a tumors in the RRP group and a higher proportion of pT_2c tumors in the RALP group.

A positive surgical margin was defined as the presence of tumor cells at the inked surface of the resected specimen. The overall positive surgical margin rate was 15.8% for both groups. The positive margin rate in pT₂ tumors was 10.5% for RALP cases and 5.3% for RRP cases. The difference is not statistically significant (P=1.0).

Discussion

Evidence from the literature shows that there is general agreement among urologists that radical prostatectomy is a reliable and effective procedure after previous prostate surgery.^7,17 Irrespective of the method used, however, previous prostate surgery can cause difficulties for the surgical team during radical prostatectomy.

Dissection is reported to be more difficult because of periprostatic fibrosis and distortion of the surgical planes that result from infections of the prostate or seminal vesicles and from perforation of the prostatic capsule and fluid extravasation during TURP.^18,19 Colombo and associates⁷ found in their study that dissection and preservation of urethral stump integrity constantly appeared to be the most difficult step. Previous resection of the bladder neck could distort the position of the ureteral orifices and could thus increase the risk of ureteral damage if the incision of the bladder neck was too posterior or increase the risk of positive surgical margins if the incision was too anterior.²⁰

Preservation of the bladder neck after TURP is difficult for both open and laparoscopic surgeons.^21,22 For this reason, Katz and colleagues²⁰ did not attempt to preserve the bladder neck but, instead, made a wide incision and redesigned the bladder neck in the form of a racket handle to increase the distance between the ureteral orifices and the region of the ureterovesical anastomosis. Further benefit might be gained by relocating the neck to a more mobile part of the bladder, thereby decreasing tension.²⁰ In addition, the vesicourethral anastomosis was reported to be technically difficult as a result of the rigidity of the bladder neck and the loss of elasticity of the urethra, which are caused by the previous surgical procedure.⁹ Prolonged urinary leakage at the anastomosis may be attributable to inflammation and/or fibrosis of the previously resected bladder neck and the fragile membranous urethra. This can result in poor healing of the anastomosis.^6,9

Apart from these intraoperative findings, the influence of previous prostate surgery on the outcome of radical prostatectomy remains controversial.^4,6,7,19,20 Although radical prostatectomy is considered to be technically more demanding in patients with previous surgery, there are no differences between these patients and patients without a history of TURP in terms of operative complication rates, intraoperative and perioperative morbidity, as well as oncologic and functional outcomes—ie, urinary continence and erectile function.^6,7,19,20

Our literature review did identify only two studies addressing RALP after previous prostate surgery but not comparing RRP with RALP in patients with previous surgery. To our knowledge, this is the first study to use a case-control design to compare patients with previous prostate surgery who undergo these different surgical procedures. Table 4 provides a comparison of published data on open RRP, LRP, and RALP with our own results.

Table 4.

Patients with Previous Prostate Surgery in Literature

	RRP ^5,7,9		LRP ^10,18,20,23		RALP
	n=216		n=242		n=19
Variable	Min	Max	Min	Max	Present study
Blood loss (mL)	790	1374	212	884	333
Transfusion rate (%)	0	46	3.4	7.1	0
Length of hospital stay (days)	7.4	11	2.9	8.7	8.6
Operative time (min)	135	173	179	273	217
Positive surgical margins (%)
Overall	19	25.7	21.8	34.2	15.8
pT₂			17.9	22.2	10.5
Duration of catheterization (days)	10	14	8.7	13.7	7.95
Time to radical prostatectomy (months)	4.2	70.6	53	66.2	67.4

RRP=retropubic radical prostatectomy; LRP=laparoscopic radical prostatectomy; RALP=robot-assisted laparoscopic prostatectomy.

Other studies reported that approximately 7.0% of patients with previous prostate surgery underwent radical prostatectomy.^10,18 This is comparable to our group of patients (5.3%).

In our study, the mean operative time was 217 minutes for RALP and 174 minutes for RRP. Eden and coworkers¹⁸ reported a mean operative time of 186.9 minutes in patients who underwent LRP after previous surgery. In other studies, the duration of LRP in patients with previous prostate surgery ranged from a minimum of 179 minutes to a maximum of 273 minutes.^20,23 The mean duration of open RRP is reported to range from a minimum of 135 minutes to a maximum of 173 minutes in patients with a history of TURP and from a minimum of 125 minutes to a maximum of 143 minutes in patients without a history of TURP.^5,7,9 For RALP, 200 and 189 minutes after transurethral resection and 186 and 166 minutes without previous surgery were reported.^13,14

Irrespective of whether a laparoscopic or open approach was used, previous TURP was associated with a significant increase in mean operative time, ranging from 8 to 31 minutes. Clinically, standard deviations of 44 to 105 minutes may indicate more complicated intraoperative procedures in individual cases.^5,7,10,20,23

Mean estimated intraoperative blood loss was 333±144 mL for RALP patients and 1103±636 mL for RRP patients. In the literature, the mean estimated blood loss ranged from a minimum of 212±163 mL to a maximum of 884±565 mL for laparoscopic procedures,^10,18 from 790±425 mL to 1374±679 mL for open RRP,^5,9 and from 155 to 494 mL for RALP.^13,14 In the literature, open RRP after previous prostate surgery is associated with transfusion rates varying from 0% to 46%.^5,9 Only one study reported that LRP patients (3.4%) needed transfusions during LRP after previous surgery.²³ In our patient groups, transfusion rates in RALP were relatively low compared with 11% in other studies.¹⁴ Transfusions were needed by 0% of the patients undergoing robotic-assisted laparoscopic surgery and by 10.5% during open RRP. A comparison of patients undergoing laparoscopic surgery with and without previous TURP revealed no significant difference in blood loss between the two groups.10,18,23 By contrast, blood loss was significantly greater in open RRP patients with a history of previous surgery than in those without previous surgery.^7,9

In our study, the mean duration of catheterization was 7.95±5.69 days for RALP patients and 12.0±6.97 days for RRP patients. The literature reports mean durations of catheterization from 8.7 to 13.7 days in patients who underwent LRP,^10,18 from 10 to 14 days in patients who underwent open RRP,^5,7,9 and from 8 to 14.2 days for RALP patients undergoing RALP.^13,14 Apart from one study, in which catheters were invariably removed on day 14, different catheterization times are reported for patients with or without previous prostate surgery. Temporary urinary leakage was experienced by 24.7% of the patients after catheter removal on day 11 after RRP.⁷ In comparison, 5.7% of the patients who underwent laparoscopic surgery needed reoperation for anastomotic leakage.²⁰ Jaffe and coworkers²³ found in their study on LRP that patients with previous prostate surgery had a significantly higher rate of anastomotic leakage (15.1%) than patients without previous surgery (6.7%). Higher rates of prolonged urinary leakage were also reported in patients who underwent RRP after previous TURP.²⁴

A possible reason for the higher rate of anastomotic leakage in patients with previous TURP is the presence of scarring and fibrosis of the previously resected bladder neck, which can lead to poor healing of the anastomosis.

Positive surgical margins were associated with biochemical progression in 21% to 30.8% of patients depending on the location of the positive margins.²⁵ In our study, the positive surgical margin rate was 15.8% for both groups. The positive margin rate for pT2 tumours was 10.5% in RALP patients and 5.3% in RRP patients. Other authors reported higher positive margin rates in patients who underwent either LRP (21.8%–34.2%),^20,23 open RRP (19.0%–25.7%),^5,7,9 or RALP (12.5%–22.6%)^13,14 as a second procedure after TURP. Colombo and colleagues⁷ found that residual prostate tissue could not be removed en bloc during RRP after TURP in 28% of their patients. In RRP studies, patients with and without previous surgery did not appear to differ in positive margin rates.7,19 By contrast, some studies on LRP patients reported significant group differences in favor of patients without previous surgery.^18,23 Other studies, however, did not detect such differences.^10,20

Compared with other studies, our rates of positive surgical margins appear to be relatively low. A possible explanation may be the lower percentage of nerve-sparing procedures in our study. A nerve-sparing procedure was performed either unilaterally or bilaterally in 50% of the RALP patients and in 33.3% of the RRP patients. In other studies, neurovascular bundle preservation was technically feasible in approximately 33% to 56.5% of LRP patients^10,18 and 20% to 40% of RRP patients.^5,7,9

These findings should be interpreted within the context of the limitations of our study. First, the small number of patients leads to relatively low statistical power. The design of our study, however, allowed us to obtain an ideal negative control group, because the two groups were matched on the most important preoperative clinical variables. We are fully aware that our study does not provide functional results. The objective of our study was, however, to assess the influence of the second operation on histopathologic and perioperative variables and, in doing so, to compare two different surgical approaches. Furthermore, the small number of nerve-sparing procedures would have led to low statistical power of statistical analyses.

Another potential limitation of our study is that the time interval between TURP and RALP/RRP was not standardized because not all patients underwent the initial procedure at our institution. Although the patient groups were carefully matched, there is a minor difference in cT_1b and cT_1c cases. This, too, may be a limitation of our study. We believe, however, that the difference did not affect our results, because the cases would be grouped together as low risk on the basis of the D'Amico classification.

Irrespective of the approach used, radical prostatectomy after previous prostate surgery remains a surgical challenge. Surgeons and patients alike must be aware of the risks involved. In addition, these procedures should be performed only in appropriately selected and well-informed patients. Jaffe and associates²³ advised that such demanding operations should be performed by experienced surgeons rather than novice laparoscopic surgeons.

Conclusion

Previous prostate surgery can cause technical difficulties during radical prostatectomy. Both RALP and RRP can be offered to patients who have a diagnosis of localized prostate cancer and have a history of previous TURP. Both procedures can be performed without compromising either oncologic safety or the radical nature of cancer surgery. Such operations, however, should be performed by experienced surgeons, because they are technically more challenging than operations on patients without previous prostate surgery. RALP appears to be ideal for navigating through altered tissue planes. In our study, the robot-assisted approach seemed to be superior to open radical prostatectomy in patients with previous prostate surgery. We were able to show in a prospective matched-pair analysis that robot-assisted prostatectomy takes longer to perform but is associated with less blood loss, better nerve preservation, a shorter hospital stay, and a decreased duration of catheterization.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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