Simple Prostatectomy: A Step Too Far for Laparoscopy?

Abstract

In this issue of European Urology, Autorino et al [1] report retrospectively on outcomes for minimally invasive simple prostatectomy (MISP) involving either a laparoscopic (LASP) or, increasingly, a robotic approach (RASP). This is truly a multi-institutional series, with 23 centres contributing 1330 cases over a 14-yr period. Of these, the majority of cases (63.4%) were laparoscopic, although in recent years the robotic approach has dominated. The results suggest that simple prostatectomy can be safely and effectively performed with laparoscopic or robotic surgery for large prostatic adenomas, particularlywhen compared to an open approach. What is a large prostate, though, and what are the other alternatives? The median prostate size in this series was 100 ml, with an interquartile range of 89–126ml. That is certainly big, but not that big. The European Association of Urology (EAU) guidelines suggest that anything >80 ml is ‘‘large’’ and is an indication for open simple prostatectomy (OSP), but only ‘‘in the absence of endourological armamentarium and a holmium laser’’ [2]. Thus, while the authors suggest that OSP remains a standard procedure for large (>80ml) glands, this would not be the case in many institutions around the world. Undoubtedly holmium laser enucleation of the prostate (HoLEP) is the approach of choice for these larger prostates and the EAU guidelines corroborate this, stating ‘‘Available RCTs indicated that in large prostates HoLEP was as effective as open prostatectomy for improving micturition, with equally low reoperation rates after 5 yr (5% vs 6.7% respectively)’’ [2]. Thus, any comparison for the emerging MISP has to be with the established modern laser prostatectomy techniques. There are currently no randomised trials for MISP and we hope that this series leads to an appropriate trial thatwould allowus to really judgewhether MISP has a useful role in this setting. LASP was described as a technique in 2002 [3], with robotics being a logical step with advances in technology. Both have been shown to be safe and feasible compared to open surgery in different reviews and a recent metaanalysis on MISP [4]. Obvious benefits shown include less blood loss and shorter hospital stays compared to the open approach. There is also little doubt that MISP is effective in removing the adenoma, relieving symptoms, and improving flow rates, as demonstrated in this series: the median resection weight was 75 g, the median International Prostate Symptom Score (IPSS) fell from 23 to 4, and the median maximum flow (Qmax) improved from 5 to 22 ml/s. As a further indicator of effectiveness, postoperative prostate-specific antigen (PSA) fell from 6.5 to 1.1 ng/dl. These improvements are comparable to open and HoLEP series. However, the key issue is the comparative perioperative morbidity. For moderately large glands, bipolar transurethral resection of the prostate and GreenLight laser are reasonable options [5] and both techniques have been shown to be effective in larger prostates [6,7] although neither removes as much prostatic adenoma as OSP, MISP, or endoscopic enucleation. The latter, primarily with a holmium laser, has become an established technique for the treatment of larger prostates [8], with 10-yr outcome data available [9]. HoLEP would seem to offer significant benefits over MISP, with lower transfusion rates (both intraoperatively and postoperatively) and far shorter catheterisation duration and a length of stay of 1 d [10]. These benefits have also been shown for very large prostates (>175 g), with mean catheterisation time of 18 h and inpatient stay of 26 h [8]. Aswell as the health economic benefits of this short stay length, the disposable costs (particularly of robotics) are likely to make MISP far more expensive. E U RO P E AN URO LOGY 6 8 ( 2 0 1 5 ) 9 5 – 9 6