Int Urol Nephrol (2013) 45:129–133 DOI 10.1007/s11255-012-0310-1
UROLOGY - ORIGINAL PAPER
Simple preoperative parameters to assess technical difficulty during a radical perineal prostatectomy Rahim Horuz • Cemal Go¨ktas¸ • Cihangir A. C ¸ etinel ¨ nder Cangu¨ven • Cahit S¸ ahin • Oktay Akc¸a • O Alper Kafkaslı • Selami Albayrak
•
Received: 18 June 2012 / Accepted: 27 September 2012 / Published online: 7 October 2012 Ó Springer Science+Business Media Dordrecht 2012
Abstract Purpose We aimed to propose a practical selection method predicting the easier radical perineal prostatectomy (RPP) cases before the operation. Methods Fifty sequential RPP cases were divided into two groups according to the estimated difficulty of the operation (Group I: Easier, Group II: Difficult) which was assessed by using a RPP difficulty scale, constituted by three parameters (operation time, blood loss, and the judgment of the surgeon) each ranging between 1 and 3 points. As the localization parameters, skin-to-prostatic apex (SPAD) and skin-to-prostatic base (SPBD) distances and distance between bilateral ischial tuberosities (ITD) were measured. During suprapubic ultrasonography, a probe-divergence angle (PDA) and prostate volumes (PV) were recorded. These parameters were compared between the groups. Results In Group I (n = 29) and Group II (n = 21), the difficulty scores were 4.37 (3–5) and 6.80 (6–9), respectively. Data of age, clinical stages, and findings of digital rectal examination were not different between groups. While SPBD, SPAD, and ITD values were found similar (p [ 0.05), PDA and PV were
R. Horuz (&) C. Go¨ktas¸ C. A. C¸etinel ¨ . Cangu¨ven C. S¸ ahin A. Kafkaslı O. Akc¸a O S. Albayrak Kartal Egitim Arastırma Hastanesi, Uroloji Klinig˘i, Ana Bina, Kat 9, Cevizli, Kartal, Istanbul, Turkey e-mail:
[email protected]
significantly different. PDA was [ 45 degree in 21 cases in Group I (72.4 %) and in 7 cases in Group II (33.3 %) (p = 0.011). The mean of PV was 37.4 (20–60) cc and 49.9 (30–75) cc in Group I and Group II, respectively (p = 0.001). Conclusions While planning RPP operations, by selecting the prostate cancer cases with a prostate of low volume and localized deeper in the pelvis during suprapubic ultrasonography, urologists may have a chance to perform this technique more easily during the learning period. Keywords Perineal prostatectomy Prostate cancer Radical prostatectomy Learning Curve
Introduction Radical perineal prostatectomy (RPP) is one of the major urologic surgical procedures performed in the perineum. Although it is the oldest method of surgical treatment of localized prostate cancer, RPP is only performed in certain select centers [1–3]. Although RPP has been generally accepted as a technique which is difficult-to-learn and difficult-to-perform by some urologists when compared with retropubic approaches [4], it is shown that the learning period of RPP is not longer than that of RPP [5]. On the other hand, once an urologist has full knowledge of the anatomical
123
130
Int Urol Nephrol (2013) 45:129–133
topography of perineum and has completed his learning curve, it will be possible to perform RPP with decreased morbidity [6]. Besides gaining required anatomical knowledge, being able to predict and select the particular cases of localized prostate cancer, in whom it is expected that performing RPP would be easier, may be helpful for an urologist who is interested in learning and performing RPP [7]. Additionally, differentiating the potentially difficult cases of RPP may even be helpful for urologists at any level of experience during deciding/planning the surgical treatment of patients with localized prostate cancer. In this prospective study, we aimed to evaluate whether it is possible to predict the potential difficulty of a RPP operation by using some certain preoperative criteria regarding the localization of prostate, with an intention to propose a practical selection method that would be helpful in determining the easier cases of RPP preoperatively.
Patients and methods Fifty sequential RPP cases, who had been operated by a single experienced surgeon (SA) between January and September in 2010 with a diagnosis of localized prostate cancer, were included in this prospective study. All cases were primary with no history of prostatic and/or perineal surgery. In order to use as predictive parameters in estimating the difficulty of operation, some measurements were performed during physical examination and suprapubic ultrasonography before the operation. For that purpose, skin-to-prostatic apex (SPAD) and skinto-prostatic base (SPBD) distances (by measuring depth of the examining finger during rectal examination) and the distance between bilateral ischial tuberosities (ITD) were measured as the localization parameters by using a standard surgical ruler. In addition, during suprapubic ultrasonographic examination of the patient, a probe-divergence angle (PDA), the angle between the vertical axis and the oblique plane of the probe while it was being directed at the base of prostate (Fig. 1), was measured. If the angle was [45 degree, then the prostate was accepted as located in a deeper position in the pelvis, so near to the perineum. Prostate volumes (PV) were also recorded during ultrasonographic examination.
123
Fig. 1 Probe divergence angle (PDA) examined in suprapubic ultrasonography
Routine perineal radical prostatectomy was performed in all of the patients. After the operation, three particular parameters (i.e., blood loss, operative time, and the surgeon’s general assessment about the difficulty of the case) were noted in each patient in order to be evaluated in difficulty assessment. By using a RPP difficulty scale developed in our clinic (Table 1), the patients were divided into two groups according to the estimated difficulty of the operation (Group I: Easier, Group II: Difficult). In this scale, three parameters (operation time, blood loss, and the judgment of the surgeon) were evaluated, and each Table 1 Parameters used in evaluating the level of difficulty of operation (difficulty scale) Difficulty scores (range 1–3)
1
2
3
Operative time (min)
B120 min
121–149 min
C150 min
Blood loss (ml)
B250 ml
251–499 ml
C500 ml
Surgeon’s assessment
Easy
Moderate
Difficult
Parameters
Int Urol Nephrol (2013) 45:129–133
131
ranged between 1 and 3 points. Out of 9 total points in difficulty scale, the cases with a total point of 5 or less were included in Group I (easier), and patients with 6–9 total points were included in Group II (difficult). In order to evaluate their predictive value in estimating the difficulty of perineal prostatectomy operation, all selected predictive parameters (SPAD, SPBD, ITD, PDA, PV) were compared between two groups. Chi square, Kolmogorov–Smirnov, and Mann–Whitney U tests were used for statistical analysis. In addition, multivariate analyses were performed to evaluate factors predicting difficulty of operation. Multiple regression analyses using backward elimination for variables were used. p value \ 0.05 was accepted as statistically significant. Statistical analysis was performed using SPSS version 11.0.
Results In overall, the mean age of the patients was calculated as 60.81 ± 5.44 (53–77) years, and the mean PSA level was 7.09 ± 3.37 (1.5–17) ng/ml. Group I included 29 cases, and Group II included 21 cases; difficulty scores were 4.37 (3–5) and 6.80 (6–9), respectively. Distribution of the difficulty parameters in both groups is shown in Table 2. Mean age and PSA values between Group 1
and Group 2 were not statistically different (60.64 ± 6.13 years and 6.91 ± 4.36 ng/ml versus 61.04 ± 4.45 years and 7.35 ± 3.32 ng/ml, respectively) (p = 0.63 for age; p = 0.54 for PSA). The mean operative time was 117.58 ± 276.14 (75–240) minutes and 142.14 ± 40.23 (75–220) minutes in Group 1 and Group 2, respectively (p = 0.010). While the mean volume of blood loss was 187.24 ± 121.68 (50–600) milliliters in Group 1, it was 429.52 ± 33.69 (100–1100) milliliters in Group 2 (p = 0.0003) (Table 3). There was no difference in rectal trauma, hospitalization, catheter duration, and margin status between the groups. While no blood transfusion was needed in Group 1, two cases required transfusion in Group 2. Gleason score and pathological stages were similar between the groups (p [ 0.05). Anatomical parameters measured in preoperative physical examination (SPBD, SPAD, and ITD) were found similar in both groups (p [ 0.05). However, PDA and PV were significantly different between the groups. PDA was C45 degree in 21 cases in Group I (72.4 %), and in 7 cases in Group II (33.3 %) (p = 0.011). The mean PV was 37.4 (20–60) milliliters and 49.9 (30–75) milliliters in Group I and Group II, respectively (p = 0.001) (Table 4). In addition, multiple regression analyses of the data confirmed these results (Table 5).
Table 2 Distribution of the difficulty parameters in groups Difficulty parameters
Group 1 (Easier) (n)
Group 2 (Difficult) (n)
Table 3 Comparative data of the parameters of difficulty in both groups
Operative time score 1
17
2
8
5
3
4
10
Mean score
1.55
Group 1(n = 29)
Group 2 (n = 21)
p
Operative time (min, range)
117.58 ± 276.14 (75–240)
142.14 ± 40.23 (75–220)
=0.010*
Blood loss (ml, range)
187.24 ± 121.68 (50–600)
429.52 ± 33.69 (100–1100)
=0.0003*
6
2.19
Blood loss score 1
21
4
2
7
10
3
1
7
1.31
2.14
Surgeon’s Judgment
1.51
2.14
=0.001*
1
Difficulty Score
4.37 (3–5)
6.80 (6–9)
=0.000*
Mean score Surgeon’s assessment 1
14
2
15
9
3
0
11
Mean score
1.51
2.47
Chi square, Kolmogorov–Smirnov, and Mann–Whitney U tests were used for statistical analysis *
Statistically significant (between Group I and Group II)
123
132
Int Urol Nephrol (2013) 45:129–133
Table 4 Comparative data of the predictive parameters measured before the surgery in both groups Group 1(n = 29)
Group 2 (n = 21)
p
Prostate volume (cc) (range)
37.4 (20–60)
49.9 (30–75)
=0.001*
ITD (cm)
10.33 ± 1.03
9.98 ± 1.12
=0.262
SPAD (cm)
5.51 ± 1.16
6.00 ± 1.04
=0.138
SPBD (cm)
7.92 ± 1.37
8.61 ± 1.11
=0.670
21 (72.4 %)
7 (33.3 %)
=0.011*
8 (27.6 %)
14 (66.7 %)
PDA (degree)
C45 (n) (%) \45 (n) (%)
Chi square, Kolmogorov–Smirnov, and Mann–Whitney U tests were used for statistical analysis *
Statistically significant (between Group I and Group II)
Table 5 Predictive factors for difficulty of operation: outcome of multivariate binary logistic regression analysis Parameter
Significance
PDA degree
0.033
OR (95 % CI) 1 4.62 (1.13–18.86)
C45 degree (reference) \ 45 degree Prostate volume B 40 ml (reference)
0.002
1 10.20 (2.42–43.47)
[40 ml
Discussion In general, the perineum is not a commonly used surgical field in urology, so it is not as familiar as retropubic space to urologists [4, 5]. Additionally, despite its confirmed position among the alternatives in the surgical treatment of localized prostate cancer, especially when compared to retropubic approach, there are still limited number of centers and select surgeons with adequate experience routinely performing and/or training RPP [2, 3]. For that reasons, perineal prostatectomy and perineal surgical anatomy remain foreign to many practicing urologists [6]. Furthermore, RPP has been generally accepted as a technique which is difficult-to-learn and difficult-toperform by some urologists [6]. All these factors might have impeded preferring RPP, although it has been a technique known for over 100 years. In fact, it has been shown that the learning curve of RPP is not longer than that of its alternatives [8–10].
123
However, we believe that the most important reason of why urologists refrain from performing RPP is concerns about the perineal anatomy. First of all, an ordinary urologist is not generally familiar with the perineum since he does not routinely operate in this site [6]. Secondly, although it is inappropriate, operating in a surgical site very near to the rectum may be uncomfortable for an urologist generally operate in retropubic space. Lastly, the perineum, as a deeper and narrower space when compared to the retropubic route, may be expected to cause a difficult operative session with significant exposure problems especially when the prostate is unusually large. A reasonable way to overcome these concerns and to decrease the morbidity of the surgery in initial cases is a better understanding of the perineal anatomy and the technique before practicing RPP [7]. It has previously been reported that the morbidity of the operation decreases if the surgeon is completed his learning period and has a full understanding of the anatomical topography of perineum [6, 7]. Secondly, selecting the initial RPP cases of personal learning curve from among ‘‘easier’’ ones may be beneficial. It is known that, in general, surgical technique and morbidity of the operations performed in pelvic and/or perineal space are also directly related to the anatomy of pelvic region [11]. Due to the differences in individual anatomical properties, difficulty of a RPP operation may depend on certain factors such as prostatic volume, perineal width and depth, and, most importantly, the bony structure of the pelvic anatomy of the male. Just like in the retropubic approach, some ‘‘larger prostates’’ or ‘‘deeper cases’’ may be difficult to operate by using perineal approach. For that purpose, in this study we aimed to define practical parameters that may be used in selecting ‘‘easier’’ cases depending on their anatomical features, and we have defined our five objective predictive parameters (ITD, SPAD, SPBD, PV, PDA) related to the prostatic and perineal anatomy. After we grouped our 50 RPP cases according to the difficulty of the operation assessed by the above-mentioned difficulty scale, we compared predictive parameters between these groups. When evaluating the difficulty, operative time, blood loss, and surgeon’s overall assessment about difficulty of the case were used. Prostatic volume and the level of location of the prostate in pelvis examined by suprapubic ultrasonography (PDA) were found significant in differentiating
Int Urol Nephrol (2013) 45:129–133
the ‘‘easier’’ cases from the ‘‘difficult’’ ones. Interestingly, the only significant parameter of the deepness of the prostate in the perineum was PDA (C45 degree) measured by ultrasonography, not the apical or basal distance of the prostate to the perineal skin measured during digital rectal examination. On the basis of our prospective data, we conclude that the relatively ‘‘easier’’ cases of radical perineal prostatectomy may be selected among from the patients with the prostates of low volume and lower location (nearer to the perineum in ultrasonography). Taking these preoperative parameters that have potential to predict the difficulty level of a RPP operation into the account would be helpful not only in the learning curve of an urologist interested in performing radical perineal prostatectomy, but also for all urologists at various levels of experience in RPP during the decision making process of the surgical treatment of localized prostate cancer.
Conclusions We believe that the major obstacle among the urologists for performing radical perineal prostatectomy is being foreign to the perineum as a surgical field. Overcoming this obstacle would be possible only with self-confidence depending on appropriate knowledge and experience about perineal radical prostatectomy. By selecting the cases with the prostates of low volume and localized deeper in the pelvis (near to the perineum during suprapubic ultrasonography), urologists may have a chance to perform RPP safer and more easily particularly during the learning period of the technique. Acknowledgments The authors thank Dr. Tolga Akman for his valuable support in statistical analysis of the data.
133 Conflicts of interest conflict of interest.
The authors declare that they have no
References 1. Young HH (1905) The early diagnosis and radical cure of carcinoma of the prostate. Being a study of 40 cases and presentation of radical operation which was carried out in four cases. Johns Hopkins Hosp Bull 16:315–321 2. Weldon VE, Tavel FR, Neuwirth H (1997) Continence, potency and morbidity after radical perineal prostatectomy. J Urol 158:1470–1475 3. Parra RO (2000) Analysis of an experience with 500 radical perineal prostatectomies in localized prostate cancer. J Urol 163(suppl):284–285 4. Albayrak S, Canguven O, Goktas C, Cetinel C, Horuz R, Aydemir H (2010) Radical perineal prostatectomy and early continence: outcomes after 120 cases. Int Braz J Urol 36(6): 693–699 5. Janoff DM, Parra RO (2005) Contemporary appraisal of radical perineal prostatectomy. J Urol 173:1863–1870 6. Matsubara A, Murakami G, Arakawa T, Yasumoto H, Mutaguchi K, Akita K et al (2003) Topographic anatomy of the male perineal structures with special reference to perineal approaches for radical prostatectomy. Int J Urol 10: 141–148 7. de Arruda HO, Cury J, Ortiz V, Srougi M (2007) Rectal injury in radical perineal prostatectomy. Tumori 93(6): 532–535 8. Mokulis J, Thompson I (1997) Radical prostatectomy: is the perineal approach more difficult to learn? J Urol 157: 230–232 9. Gillitzer R, Melchior SW, Hampel C, Wiesner C, Fichtner J, Thu¨roff JW (2004) Specific complications of radical perineal prostatectomy: a single institution study of more than 600 cases. 172: 124–128 10. Burgess SV, Atug F, Castle EP, Davis R, Thomas R (2006) Cost analysis of radical retropubic, perineal, and robotic prostatectomy. J Endourol 20:827–830 11. Seike K, Koda K, Oda K, Kosugi C, Shimizu K, Miyazaki M (2009) Gender differences in pelvic anatomy and effects on rectal cancer surgery. Hepatogastroenterology 56(89): 111–115
123
