Laparoscopic Radical Prostatectomy: Less is More

In the world of surgery, laparoscopic radical prostatectomy—removing the prostate through tiny keyholes, instead of a larger incision—is the “new kid on the block,” but its results are exciting. Over the last three years, urologists Li-Ming Su, M.D., and Christian Pavlovich, M.D., at the Johns Hopkins Bayview Medical Center, have performed more than 330 of these laparoscopic procedures. Comparing their results with those for the “gold standard” procedure, the nerve-sparing radical prostatectomy, the surgeons have found that their patients need less pain medication after surgery, and have a shorter convalescence— four weeks, instead of six weeks.

In a review of the first 200 laparoscopic radical prostatectomy procedures performed at Hopkins, Su and Pavlovich found that 70 percent of their patients recovered full urinary control at six months, 90 percent were continent at one year; and only a very small percentage (0.6 percent) of men experienced a bladder neck contracture (a treatable condition)— scar tissue that can impede urine flow.

What about cancer cure? Early results, again, are very encouraging, says Su. With an average follow-up time of one year, “98 percent of our patients have shown no recurrence of PSA.”

And potency after surgery? The surgeons have worked to modify their procedure to preserve the nerves responsible for erection. “Our goal is to replicate the meticulous dissection achieved during open surgery, in the anatomic nerve-sparing radical prostatectomy,” says Su. He and Pavlovich use fine dissecting instruments to ease the fragile nerves from the prostate surface as gently as possible. Also, the surgeons avoid using any electrical or heat energy, such as cautery, during their dissection of the nerves. This is because animal studies, done by Su and colleagues, have suggested that these energy sources produce a dramatic and immediate detrimental effect on nerve function. “By incorporating these concepts into our nervesparing laparoscopic procedure, we’ve been able to achieve short-term potency results similar to that of open surgery,” says Su. He adds that in men who were potent before surgery and who had both nerve bundles spared, 55 percent reported having successful intercourse at 6 months and 75 percent at 12 months. However, they were only able to spare both nerve bundles in about half of the patients. “We are continuing to refine our techniques to make it possible to save both neurovascular bundles more often,” says Su.