Mini-lap RRP limits surgical morbidity without sacrificing outcomes in a urologic practice population with significant comorbidity. Moreover, with costs and manpower being an ever present issue in surgery, a second surgical assistant has become a rare luxury. The retractor, with specially designed blades, functions as a stationary robot with multiple degrees of freedom. It replaces the second operative assistant by providing fixed deep and superficial retraction. Such a system allows the surgeon ample exposure to perform the dissection through a 7-8 cm incision while reducing the incisional morbidity. Patients tolerate the small mini-lap incision well with minimal analgesia requirements after discharge. In fact, many of our patients find the catheter more bothersome that the incision.
Other operative modifications, including sparing of the puboprostatic ligaments, passage of a suture ligature rather than a right angle for securing the dorsal venous complex and sharp resection at the apex allows for more precise dissection. These maneuvers act to preserve the external sphincter with its fixation intact, contributing to improved continence rates. Preservation of the external sphincter has been shown in several series to be significant in preservation of continence.11'12 It was rare for patients to note full continence initially more than 5 years ago, but it occurs more frequently now.13 Although the role bladder neck preservation plays in continence remains controversial, many believe it provides a speedier return of continence14 and reduces the incidence of bladder neck contracture.15 Dissection of the bladder neck is performed more carefully now, aided by palpating the catheter and defining the natural plane of dissection between the prostate and bladder. Some may question whether the small incision limits the surgeon's ability to perform the operation effectively, but our resultant rates for continence, impotence and margin positive specimens follow historic norms. In addition, the technical challenge of bladder neck sparing is executed without undue difficulty or surgical compromise as only 1 of 93 patients where the bladder neck was spared exhibited residual positive adenocarcinoma on bladder neck biopsy.
Technology has similarly evolved with the advancements in anatomic dissection. Most notably, several studies to date have documented the feasibility of laparoscopic prostatectomy, but prolonged surgical times and technical skills training are necessary. Even the most able laparoscopic surgeons report mean operative times ranging from 4 to 6 hours with a steep learning curve.16,17 Some experts estimate 80 cases or more may be needed to reach a plateau with regard to operative time and complication rates.18 Five ports are typically used for the dissection with a 3-5 cm extension of the umbilical port for specimen extraction. Nascent results appear promising and equal those found in open prostatectomy in relation to continence, potency and margin status, but long-term oncologic results are pending.
Regarding laparoscopy, do these outcomes confer superiority and, if so, can these techniques be utilized by urologists at large? Adding the port incisions with the extension for specimen extraction approaches the totality of the mini-lap incision.
Some proponents offer that blood loss is better with laparo-scopic technique, but collaborative care pathways reducing preoperative autologous blood donation along with improved anatomic definition has limited transfusion to as low as 1% in some open series.19 Patients generally leave the hospital on postoperative day 2 or 3. Equivalent outcomes do not cross the necessary threshold to embrace the technology when satisfactory alternatives exist.
Technically familiar to most urologists, mini-lap prostatectomy requires no additional training, utilizes standard equipment, is minimally invasive and extraperitoneal, can be performed under regional anesthesia and is performed reliably in 2-3 hours. With decreased postoperative morbidity provided by a shortened incision and faster operative times, a mini-lap should be competitive in terms of morbidity and cost in relation to other less invasive laparoscopic techniques. In addition to cost, these factors favorably contrast with laparoscopic series and make mini-lap prostatectomy a more attractive minimally invasive operative approach. We believe mini-lap prostatectomy compares favorably with standard open RRP and laparoscopic RRP.
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