“Mini-Incision” Radical Prostatectomy?

2 May 2006 Prostate Cancer

In the February 2005 issue of UROLOGY, Dr. Miki et al from Kyoto, Japan descibes their initial experience using a running suture anastamosis during minilaparotomy radical retropubic prostatectomy for prostate cancer. They performed this anastamosis in 21 patients, utilizing a 6-cm midline incision. They used the Ethicon Endostitch device and a double-arm absorbable suture, starting at the 6 o’clock position. (similar to the priniciple used in the Van Velthoven anastamosis during robotic prostatectomy). Early continence was excellent among these 21 patients, but the initial 2 patients did develop early bladder neck contractures requiring dilation. Time to perform the anastamosis was 15 minutes on average.
Why post this on a robotic surgery blog? I think this is indicative of the trend in surgery towards minimally-invasive approaches. With the advancement of robotics & laparoscopy, “traditional” open surgeons are feeling compelled to minimize morbidity of their comparable open operations. However, I have issues with this minilaparotomy operation which I feel, erroneously, focuses on open & laparoscopic surgeons’ obsession with “incision size”.

When it comes to surgical incisions.. size does not matter!
I have never been an advocate of minimizing the number or cumulative size of my laparoscopic or robotic incisions. This is NOT the main advantage of laparoscopy and robotic surgery! The advantages are: superior visualization and more accurate, meticulous dissection, decreased blood loss, better neurovascular bundle preservation, superior water-tight vesicourethral anastamosis.. and finally, smaller, less painful incisions with less wound infections, incisional herniae, cosmesis, etc..
In my opinion, to try and achieve the advantage of improved visualization alone in the open surgery, I would need a BIGGER incision and an O.R. microscope. Trying to accomplish pelvic prostate surgery via a 6-cm incision just does not make any sense. How can the surgeon have adequate visualization of the prostate and urethra? Especially with the surgeon’s & assistant’s hands inside this 6-cm incision. Also, with any open incision, there is no pneumoperitoneum. So via this smaller incision, on top of the more crowded, poorly visualized space, there is ongoing bleeding due to the lack of hemostatic pressure from pneumoperitoneum. And finally, with this disadvantageous situation, how good a job can be done with neurovascular bundle preservation? I would suspect that much of it is done by “feel” rather than magnified, hemostatic, 3-D direct visualization. Likewise, think of why the authors felt a need to use the Ethicon Endostitch device to perform the anastamosis? I suspect it is because their surgical capabilities were greatly hindered by this small incision into a deep space. (By the way, there is a much better device for this.. called the Capio by Boston Scientific/Microvasive. Used primarily for sacrospinous fixation, it is perfectly suited for placement of sutures into a retracted urethral stump during non-robotic laparoscopic or open prostatectomy)
I have no concerns about open radical prostatectomy in general. Since the Walsh prostatectomy was developed, it continues to be a the “gold standard” in terms of fundamental technique. My concern about this article is that it appears to advocate a potentially inferior cancer operation in exchange for a smaller incision. There wasn’t specific mention of blood loss or nerve-sparing details, but I’m basing much of this on my opinions and prior experiences with open, laparoscopic, and robotic prostatectomy.