Endoscopic extraperitoneal radical prostatectomy: critical analysis of outcomes and learning curve.
McNeill AS., Nabi G., McLornan L., Cook J., Bollina P., Stolzenberg J-U.
OBJECTIVE: To assess the outcomes and learning curve of extraperitoneal endoscopic radical prostatectomy (EERP) using cumulative summation charts from a single tertiary referral centre. PATIENTS AND METHODS: The data from 300 consecutive men with localized prostate cancer who underwent EERP at Western General Hospital, Edinburgh, UK, between February 2006 and July 2009 were prospectively maintained in a database. The data collected included demographic details, perioperative outcomes, complications and follow-up for functional and oncology outcomes. The learning curve was analysed using generalized linear models for complication rate, operative time and blood loss, using procedure experience. RESULTS: The mean (sd, range) operative duration was 160.52 (40.84, 100-310) min, and the intraoperative blood loss was 229.3 (172, 20-1000) mL. There was no conversion to open surgery and no patient required intraoperative blood transfusion. Only one of 250 (0.3%) patients required a blood transfusion after EERP. The median (range) hospital stay was 3 (2-20) days and the median catheterization time before cystography was 9 days. There was evidence that the complication rate reduced as experience was gained (odds ratio 0.98, 95% confidence interval, CI, 0.97-0.99; P= 0.002), with the estimated probability of a complication decreasing from 29% for the first to <1% for the 250th procedure. Also there was evidence of a decrease in operative duration (-0.0020 rate parameter on log scale; 95% CI -0.0024 to -0.0017; P < 0.001) and blood loss (-0.01 rate parameter on log scale; 95% CI -0.003 to -0.0002; P= 0.021). The positive surgical margin rate in pT2 disease decreased from 27% in the first 50 to 14.7% in the last 50 operated cases. The continence rate and biochemical recurrence-free rate at a minimum follow-up of 1 year for the first 100 patients was 89% and 94%, respectively. CONCLUSION: The results from this series suggest that the benefits of minimally invasive surgery for localized prostate cancer (EERP) can be replicated after mentored fellowship training of a surgeon. The complication rate reduced substantially as experience was gained, suggesting a continuous surgical learning curve.