Several years ago, Stolzenburg and colleagues at the University of Leipzig in Germany developed a form of laparoscopic prostate cancer surgery that they refer to as endoscopic extraperitoneal radical prostatectomy or EERPE. The basic difference between this technique and the forms of laparoscopic prostatectomy (robotic or non-robotic) commonly carried out in the USA involve the direction from which the surgeon approaches the prostate.
In the “transperitoneal” approach that is commonly used in the USA, the surgeon operates by coming through the peritoneal cavity. In Stolzenburg’s method, the surgeon avoids the peritoneal cavity by creating a “preperitoneal space.” Stolzenburg’s original technique was described in 2002, and this year his team published a description of a new nerve-sparing version of this procedure.
Now Stolzenburg and his colleagues have published the results of this technique on their first 2,000 patients:
- The average age of the patients was 63.2 years (with a range from 41 to 77 years).
- The average preoperative PSA was 10.2 ng/ml (0.64-82 ng/ml).
- 601 patients had undergone previous surgery (which we assume to refer largely to a transurethral resection of the prostate or TURP for treatment of BPH).
- The average operation time was 156 minutes (50-320 minutes).
- Positive surgical margins were found in 127 patients with pT2 stage (9.7 percent) and in 237 patients with pT3 stage (34.4 percent).
- Of the 937 pelvic lymph node dissections carried out, 44 (4.7 percent) were positive.
- The average postoperative catheterization time was 6.3 days.
- After 12 months, 92 percent of the patients were completely continent, 7 percent needed 1-2 pads/day, and 1 percent used > 2 pads daily.
- 730 patients underwent a nerve-sparing procedure.
- The 12-month potency rates with or without administration of PDE5 inhibitors (e.g., Viagra) were 34.1 percent in the patients who had just one nerve spared and 67.7 percent in the patients who had both nerves spared.
In this paper Stolzenburg et al. also give results specific to the group of patients who received treatment using the most recent evolution of his nerve-sparing technique (the co-called “intrafascial nsEERPE” technique):
- After 12 months, 93.2 percent of the patients were completely continent, 7.1 percent required 1-2 pads per day, and 0.6 percent > 2 pads per day.
- The 12-month potency rate for unilateral and bilateral nerve sparing using the intrafascial procedure was 33.3 percent and 78.5 percent, respectively.
- The rate of positive surgical margins was 6.3 percent in pT2 and 21.2 percent in pT3 specimens.
Whether Stolzenburg’s technique is any better than the transperitoneal procedure customary in the USA is likely to be less important than the skill of the individual surgeon carrying out whichever technique they have the most experience with. However, we now have another large published series demonstrating that high levels of post-surgical continence and reasonably high levels of potency are achievable using laparoscopic surgical techniques.
Filed under: Treatment | Tagged: laparoscopic surgery EERPE
EERPE, also known as extraperitoneal laparoscopic radical prostatectomy (LRP), has been around since virtually the beginning of LRP. Let us review.
The original technical manual that we published in 1999 describes an intraperitoneal approach: all instruments initially are placed into the peritoneal cavity and then the bladder is dropped so as to expose the extraperitoneal (retropubic) space of Retzius. In the extraperitoneal LRP, the instruments go directly to the retropubic space; this is easy to do.
I am aware of cases of extraperitoneal LRP dating as far back as 2000. If memory serves, Claude Abbou and his associates in Paris at one point did quite a number of such extraperitoneal cases. This paper supports the memory.
I have done intraperitoneal and extraperitoneal LRP. My preferred approach is intraperitoneal because it’s very fast to set up and because it affords more room for maneuver. In cases of suspected challenge in the peritoneum — for example in an LRP following a colon resection — I prefer the more limiting but safer extraperitoneal approach. Overall, the operation is the same and the results are the same, as supported by the paper cited above.
Why aren’t stats for post-op potency separated by those who truly regain function and those that require script meds to be potent? Actually, I was surprised that since my husband was operated on in a teaching hospital that he was not asked any info on things he may have been exposed to in his lifetime that may have contributed to his diagnosis.
Dear Ginny: Different researchers have different interests and focus for their research. I would agree with you that in theory it would be a good idea if the academic clinicians collected all the data they possibly could about every single patient, but the cost of collecting and managing all that data could become prohibitive.
Some researchers do collect the data you inquire about. However, such data are always open to all sorts of questions because of the “personal” factor regarding what really happens. (One man’s potency is another woman’s disappointment, so to speak.)
Mike,
Read in today’s paper that The House Passed the Breast Cancer and Envirnoment Research Act. Yet, nothing seems to be in the works for Pca.
The reason I made the statement regarding a teaching hospital, is that in the 1970’s my brother-in-law had Bone ca and was asked to fill out tons of paperwork to see what toxins he was exposed to in his lifetime.
Also, I have done a lot of reading on Pca ,and it seems that all drs that publish need to clearly state how they define continency and potency.
I am OFFENDED at your last comment. But it does not surprise me as you can not begin to imagine the insensitivity I have witnessed .
I actually find your responce condescending.
Dear Ginny:
I am sorry that you feel were offended by my prior response, and I had no intention to be condenscending. Please understand that I knew nothing about you or how much you know based on your first question. I respond as best I can based on the information provided. Sometimes it isn’t good enough. Clearly you have a great deal more knowledge than was evident to me from your initial question.
The politics of breast cancer vs. the politics of prostate cancer is a long-time problem. Men have completely failed to learn from the women! With new leadership at what used to be the National Prostate Cancer Coalition, I am hoping for a reinvigorated plan to come before Congress. If this is a topic that interests you, I strongly suggest you get in contact with Skip Lockwood at ZERO (if you aren’t already).
With respect to the issue of potency, continence, etc., I think nearly everyone would agree that we need standardized methods to assess these issues. However, every attempt to date has foundered over the details on the heads of academic pins. IMHO the urology community needs a strong leader to knock heads in this arena. It shouldn’t be so difficult to achieve some degree of consensus. There has been an ongoing discussion about this issue on the Social Network.
Unfirtunately I cannot tell you why your brother-in-law was asked to fill out detailed toxin reports and your husband wasn’t. However, as I stated earlier, I suspect this has more to do with the interests of specific sets of researchers than it does with logic.