Laparoscopic technique is effective for cancer

Procedure moves to same-day surgery programs

Laparoscopic techniques moved from the gynecological field into general surgery and have now become the preferred method for some urologic surgeons to treat prostate cancer. Not only does the procedure offer the benefits of the less-invasive technique and quicker recovery from the surgery, it also is just as effective in cancer control as the open procedure, according to a study presented at the 2001 Clinical Congress of the Chicago-based American College of Surgeons.1

The study shows that no evidence of cancer was found at the margins of prostate tissue removed at surgery in 89% of the patients undergoing laparoscopic prostatectomies as compared to no finding of cancer in margins in 68% of the patients undergoing traditional open prostatectomies.

The first laparoscopic prostatectomies were performed in the United States in 1997, says Benjamin Lee, MD, director of the laparoscopic section of urology at North Shore — Long Island Jewish Medical Center in New Hyde Park, NY.

"The benefits to the patients include smaller incisions, less blood loss, and an earlier catheter removal than with open prostatectomy," Lee says. "The benefits from the surgeon’s perspective include a magnified field of vision that enables the surgeon to see the nerves in the area that results in a more precise dissection." Because it is a relatively new technique, surgeons are just beginning to study issues such as the five-year survival rate, incontinence, and erectile dysfunction following the laparoscopic procedure as compared to the open procedure, Lee says. For this reason, many surgeons are cautious about recommending the technique to some patients, he adds.

"We typically perform the laparoscopic technique on men who are 60 years of age or younger, physically fit, not overweight, and have had no prior abdominal surgery," says Inderbir S. Gill, MD, director of the section of laparoscopic and minimally invasive surgery at the Cleveland Clinic Urological Institute. "Laparoscopic patients also typically have prostate glands that are between 30 g and 40 g and must fully understand the procedure and be motivated to ambulate soon after surgery."

While the patients at Long Island Jewish are typically staying in the hospital a few days following surgery, 80% of the Cleveland Clinic patients are discharged fewer than 24 hours after admission. "We’ve been performing this procedure for more than two years and are comfortable with our skill level and our educational preparation of the patient," Gill says.

Surgeons at Long Island Jewish have been performing the laparoscopic procedure since late March 2001, and Lee agrees that as more surgeons become comfortable with the technique and the results of the procedure, more patients will be treated on a same-day surgery basis. Patients are given information about the laparoscopic and the open procedure during their pre-op consults, Gill explains. The benefits and disadvantages of both approaches are explained, and patients are told what they can expect during the recovery process, he adds.

"Even the laparoscopic procedure is a major operation, so we want our patients to have realistic expectations in terms of what they may be able to do following surgery," Gill says. These expectations are related to pain, incontinence, and erectile dysfunction, he adds.

Even though the laparoscopic procedure is newer, 90% of Gill’s patients request it, he says. "There is no restriction on activity unlike the open procedure, which limits lifting for six weeks, and the catheter is removed three days after surgery rather than two to three weeks later as in the open procedure," he explains.

While a same-day surgery program does not have to make any significant changes in equipment purchases, there is a time element to consider, Gill says. "While I average three hours per procedure, surgeons do have a learning curve and make take five or more hours to perform the procedure in the beginning," he says. This compares to an average of two hours for the open procedure, Gill says. The long operating room time is the most significant disadvantage to this procedure, he explains.

Gill and Lee point out that a laparoscopic prostatectomy is a complex procedure for which care should be taken in the credentialing process. "The surgeon should be credentialed in the open procedure but should also have credentials to perform advanced laparoscopic procedures such as laparoscopic nephrectomy and laparoscopic adrenalectomy," Lee says.

While there are a relatively small number of surgeons performing the laparascopic procedure, Gill sees the procedure’s popularity growing. "Early studies show that removal of the cancer is the same as the open procedure, and anecdotally, patients are experiencing fewer problems with incontinence," he says. "Patients also want to return to normal activity sooner and enjoy a better quality of life."

Reference

1. Paid V, Dahl D, Trainer A, et al. Evaluation of surgical margins achieved by laparoscopic radical prostatectomy. Presented at the 87th Annual Clinical Congress, American College of Surgeons. Chicago; 2001.

Sources

For more information about laparoscopic prostatectomy, contact:

Benjamin Lee, MD, Director of Laparoscopic Section, North Shore — Long Island Jewish Health System, Department of Urology, 270-05 76th Ave., New Hyde Park, NY 11040. Telephone: (718) 470-7221.

Inderbir S. Gill, MD, Director of the Section of Laparoscopic and Minimally Invasive Surgery, Cleveland Clinic Urological Institute, 9500 Euclid Ave., Cleveland, OH 44195. Telephone: (800) 553-5056, ext. 51530 or (216) 445-1530. E-mail: gilli@ccf.org.