Background: Technical modifications to radical prostatectomy aimed at improving quality of life are ongoing. Recently these have focused on preservation of the lateral prostatic fascia due to histologic evidence of nervous tissue in this area. Initial exuberance about the implications of this technique for potency have been tempered by the theoretical increased risk of positive surgical margins. This issue has not been settled in a prospective manner. Furthermore, published series need to be duplicated by multiple institutions. We report preliminary results of a prospective comparison between conventional and intrafascial laparoscopic prostatectomy.
Methods: Between November 2005 and March 2006, 74 patients who were candidates for laparoscopic prostatectomy were randomized to either a conventional extraperitoneal laparocopic radical prostatectomy (ELRP) as previously described, or an intrafascial technique (iELRP). In the latter, the endopelvic fascia is not incised, and dissection begins at the bladder neck. The antegrade dissection continues on the prostate capsule, preserving lateral prostatic fascial envelopes as described by others. Surgery was performed by a single surgeon (IT). Demographic data (age, BMI, PSA, Gleason score), intraoperative data (surgical time, EBL), perioperative data (narcotic equivalents, length of stay, complications), and pathologic data (prostate size, margin positivity) were entered into a prospective database. Comparisons between groups used either Fisher’s exact test or Pearson chi square test where appropriate.
Results: 42 patients underwent ELRP and 32 underwent the iELRP. There was no significant difference between groups with regard to demographics, prostate, or tumor characteristics, with the exception of preoperative PSA, which was lower in the iELRP group (4.5 vs 5.8, p=0.04). Operative time was significantly lower in the iELRP group (126 vs 142 min, p=0.0008), whereas EBL, prostate size, and distribution of pathologic stage were not statistically different. There was no statistically significant difference between overall or stage-grouped margin positivity between techniques (p>0.05).
Conclusions: The technical feasibility of iELRP has been shown elsewhere, and is supported here. iELRP does not appear to compromise margin positivity, an important concern when treating a predominantly peripherally located disease. For the experienced surgeon, operative time is faster with the iELRP technique. Functional data are being collected, to be reported after adequate followup time.