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Tursunkulov Azimdjon Nazirjonovich, Tillyashahov M. N.., Alijanov N. A., Ibragimov A. Yu., Republican Clinical Hospital № 1 of the Ministry of Health of the Republic of Uzbekistan National Cancer Research Center of Uzbekistan E-mail: azimweb@yahoo.com
COMPARATIVE EVALUATION OF THE RESULTS OF OPEN AND LAPAROSCOPIC PROSTATECTOMY FOR LOCALIZED PROSTATE CANCER
Abstract: Prostate cancer (PC) currently occupies one of the first places in the incidence of malignant neoplasms (MN) among the male population in the world. In Russia in 2011, the prostate cancer was rated 2nd (11%) in the cancer incidence in men, while the incidence rate was 43.2 per 100,000 male population (O. I. Apolikhin, 2012; A. D. Kaprin, 2014).
According to the State Statistics Committee of the Republic of Uzbekistan and the Cancer-Register of the Republic of Uzbekistan [13], the incidence rate of prostate cancer in Uzbekistan is 1.2 per 100.000 male population and tends to increase over time, and therefore the issue of finding effective treatments are important and relevant to clinical oncology.
Today, radical retropubic prostatectomy (RPE) remains the standard treatment for localized prostate cancer [14; 15; 16; 18]. But it should be noted that carrying out various surgical interventions on the prostate gland entails a different number of complications, the most common and socially significant of which is the development of erectile dysfunction (ED) and urinary incontinence, which in turn greatly reduces the quality of life for patients.
One of the ways to prevent these complications was the nerve-saving technique of RPE, which was proposed by Walsh in 1982, which provides for the complete or partial preservation of the neurovascular bundles, significantly reducing the incidence of ED in patients who do not have oncological contraindications to preserve the neurovascular bundles (NVB). According to (Walsh P., 2000; Hisasue S., Ghavamian R.) the frequency of ED after using this technique when performing RPE exceeds 25% in patients younger than 60 years and depends on a large number of factors [1; 3; 5; 7].
Urinary incontinence, which can develop after performing various variants of RPEs, reaches 20% [9; 10; 17] and is a significant factor that worsens the quality of life for patients in the postoperative period (Miller D., 2005; Penson D., 2005).
One of the main factors influencing the reduction of the risk of ED in the postoperative period is the minimization of injury to the elements of the NVB, which can be solved by implementing a clear intraoperative identification of the elements of the NVB.
The literature describes a large number of techniques proposed by various authors - a technique of mediated intraoperative identification of elements of the NVB, as well as direct visualization of the NVB during an operation [2; 4; 8].
Given the lack of equipping clinics with modern high-tech endoscopic equipment, despite the obviousness of the use of laparoscopic access, the use of conventional RPE remains open [6; 11; 12]. In this regard, the study was aimed at assessing and comparing direct results of RPE and laparoscopic prostatectomy (LSP), as well as the study of some factors contributing to the monitoring of the ongoing processes of complex treatment of this category of patients.
Keywords: prostate cancer, radical prostatectomy, laparoscopic prostatectomy, open prostatectomy, urinary incontinence, PSA, erectile dysfunction.
Materials and methods: Surgical procedures for all pa- Walsh P. and to the generally accepted standard procedure tients were performed according to the recommendation of [15]. After the operation, the patients were admitted to the
intensive care department for 1 day, where, 1 hour after completion of the anesthesia, the patients were offered cold drink.
The patients were put in a semi-sitting position, and in the evening they got out of bed and had a short walk. These measures, as well as the use of anti-adhesive gel, prevent the development of postoperative dynamic intestinal obstruction. The next day after surgery, the patients are transferred to the ward. An ultrasound examination of the abdominal cavity and small pelvis is necessary in order to control the
General characteristics of research methods
presence of discharge in the insurance drain, which is removed at a volume of less than 100 ml. We are widely using methods of early mobilization, combined with liquid paraffin intake. The patients return to the normal diet on 2 or 3 day after the first defecation. Cystoradiogram is performed on days 6-7 to eliminate the inconsistency of the urethro-vesical anastomosis. The catheter is removed the next day after the test. A day later, the patient is discharged from the hospital [7; 12].
Table 1. - Innate characteristics of patients with prostate cancer depending on the type of surgical intervention
Characteristics of patients Radical retropubic prostatectomy (n = 38) Laparoscopic prostatectomy (n = 41)
Age 61. 8 ± 7.1 63.1 ± 7.3
PSA level, ng/ml 12.7 ± 1.3 12.3 ± 2.1
The average size of the prostate, cm3 39.4 ± 4.1 42.8 ± 5.4
1 stage 23-60 ± 2.7 24-58.5 ± 2.6
2 stage 14-36.8 ± 2.1 15-35.5 ± 5.1
3 stage 2-5.2 ± 5.1 2-4.9 ± 4.9
NVB intersection from 1 side 21-55.3% 18-43.9 ± 6.6
From 2 side 13-34.2% 11-26.8 ± 4.4
Saved 4-10.5% 9-21.9 ± 8.8
Gleason - 6 22 (57.8%) 23-56.1%
Gleason - 7 14 (36.8%) 16-39.1%
Gleason - 8 2 (5.2%) 2-4.9%
The standard observation method is the periodical monitoring of the results of total PSA in blood every three months for the first 2 years after surgery, followed by a transition to semi-annual monitoring for 3 years.
In this study, the following indicators were analyzed: time spent on surgery, the degree of blood loss, the conversion of the operation, the level of intra- and postoperative complications, as well as oncological and functional results.
To determine the level of recovery of erectile function after the intervention, PC-QOL questionnaire was used, the existence of potency was defined as "the ability to achieve and maintain a satisfactory erection in more than 50% of attempts" [9; 10]. Urine continence was defined by us as "no need for pads". Biochemical recurrence was diagnosed in the case of
Table 2.- Intraoperative indicators and functional r
two consecutive values of total PSA more than 0.2 ng/ml. Complications arising in the first 90 days after the operation were recorded and classified according to the modified Clay-len system.
Results and discussion
By analyzing the results it was discovered that the average operating time was 203 minutes and 229.7 minutes in case of LSP and 246.4 minutes in case of RPE, while the average blood loss was 169 ml and 145 ml in case of LSP and 178 ml in case of RPE. Analysis has shown that experience and skills of surgeon affect the time spent on surgery, as well as the degree of blood loss. Totally, the need for blood transfusion was needed in 8 cases during RPE and 5 cases during LSP (12.2%) (Table 2).
ults depending on the type of surgical intervention
Radical retropubic prostatectomy (n = 38) Laparoscopic prostatectomy (n = 41)
1 2 3
Total operating time, 203 min 246.4 ± 25.3 229 ± 24.8
Average blood loss, 169 ml 178.1 ± 21.2 145.6 ± 18.9
Blood transfusion, 2.3% 8-21.5 5-12.2
Average hospital admission term, 11.7 days 10. 2 ± 3.1 6. 7 ± 2.3
1 2 3
Complications, 27% 11-28.9% 9-21.9%
Urine continence, 3 months, 83.2% 32-84% 36-87.8%
Urine continence, 12 months, 91% 34-89% 38-92.6%
Erectile function, 3 months, 43.8% 14-36.8 ± 5.4% 23-56.1 ± 8.8%
Erectile function, 12 months, 75.4% 26-68.4 ± 4.6% 33-80.8 ± 4.4%
The overall rate of complications associated with RPE according to the Clayline classification was 28.9%, with a significant proportion of non-life-threatening, and non-surgical interventions complications - I and II degrees (the so-called "minor" complications). LSP-related complications were noted in 21.9% of cases.
Total urine retention, defined as "no need for the use of pads" during RPE, was achieved in 84.2% and 89% of patients after 3 and 12 months of monitoring; 31% of patients reported immediate complete retention after removal of the urethral catheter. Patients who underwent neuro-preserving surgical treatment noted the ability to achieve and retain a satisfactory erection in more than 50% of attempts to have sexual intercourse with or without taking type 5 phospho-diesterase inhibitors in 43.8% and 75.4% of cases after 3 and 12 months of monitoring respectively. In the compared groups of patients (LSP), complete retention of urine was noted after 3 months in 87.8% cases, and after 12 months in 92.6% cases.
The recovery of EF in this group was found in patients in 56.1% of cases after 3 months and 80.8% after 12 months of monitoring.
Therefore, a comparative analysis conducted in this study showed a significant absence of differences in the results obtained for the majority of the main criteria studied (P < 0.05), except for a clear tendency for a more rapid recovery of lost functions during LSP (P < 0.05).
Anatomical features of the prostate gland determine the formation of maj or difficulties when performing sigmoidoscopy. Of these, the most common are the following: a large size
of the prostate gland, the presence of an average prostate lobe, and a condition after transurethral resection of the prostate (TRP). The presence of these changes has a pronounced effect during the training of specialists, as well as the development of pronounced complications during operations.
At the same time, we consider it possible to note that the technically correct execution of the RPE can be successfully carried out in the absence of the equipment necessary for carrying out the LSP. The goal of radical prostatectomy is the complete removal of the prostate gland with seminal vesicles, accompanied by the absence of a positive surgical margin, the minimal incidence of intra- and postoperative complications, as well as full restoration of the patient's ability to hold urine and erectile function. To achieve this goal, the surgeon needs not only to know in detail and be able to perform all the steps of the standard sigmoidoscopy, but also to be ready to perform complex manipulations in cases of complications during the surgical treatment.
Summary
The study analyzed conditions of 78 patients with verified diagnosis of localized prostate cancer that were treated in the urology department of the Russian Cancer Research Center, who underwent various types of radical prostatectomy (RPE). It has been established that the performance of an open retropubic prostatectomy does not significantly differ from laparoscopic prostatectomy in time, the volume of additional measures and the number of possible complications. Certain advantages of LPE are noted, not excluding the significance of conducting open RPEs as a method of choice in case of lack in equipment.
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