Extraperitoneal robot-assisted radical prostatectomy: Comparison with transperitoneal technique

Table 1 Comparision of peri-operative and safety profiles of transperitoneal and extraperitoneal approaches to robot-assisted radical prostatectomy

Characteristic	tRARP (n = 50)	eRARP (n = 70)
Mean total operative time (min)	255.7 (155-490)	236.8 (170-375)
Prostatectomy console time (min)	198.3 ± 64 (120-420)	145.1 ± 38.7 (96-293)
Mean blood loss (mL)	342 ± 320 (50-2000)	372 ± 368 (100-2500)
Drain use	50/50	25/70
Length of stay (mean)	3.52 ± 2 (2-12)	1.94 ± 1.38 (1-8) (P < 0.0002)
Intra-operative complications (Clavien Grade)	1 Ureteric injury (Grade 2)	1 Rectal injury (Grade 2)
Post-operative complications (Clavien Grade)	1 Arm neuropraxia (Grade 1)	1 Urinary retention (Grade 1)
	1 Blood transfusion (Grade 2)	2 Blood transfusions (Grade 2)
	1 Anastomotic leak requiring suprapubic catheter insertion on readmission (Grade 3b)	2 Pelvic collection/haematoma requiring percuataneous drainage (Grade 3a)

Data are presented as number or mean ± SD (range). eRARP: Extraperitoneal robot-assisted radical prostatectomy; tRARP: Transperitoneal robot-assisted radical prostatectomy.

Table 2 Clinical characteristics between patients undergoing transperitoneal robot-assisted radical prostatectomy and extraperitoneal robot-assisted radical prostatectomy

Variables	tRARP (n = 50)	eRARP (n = 70)
Age (yr)	60.5 ± 7.5 (42-72)	62.1 ± 6 (47-72)
PSA (ng/mL)	8.67 ± 6.1 (2.8-34.8)	8.66 ± 8.58 (1.3-71.8)
Prostate volume (cc)	39.5 ± 14.66 (15-70)	44.9 ± 17.4 (18-82)
Biopsy Gleason score
6	26	30
7	20	38
8	3	2
Pathological stage
T2	37	51
T3a	11	12
T3b	2	7
Specimen Gleason score
5	1
6	11	10
7	30	52
8	4	3
9	4	4
Cancer volume (cc)	3.9 ± 3.2 (0.06-14.7)	3.2 ± 3.58 (0.2-23.7)
Positive surgical margin
T2	13.5% of 37 patients	12.7% of 48 patients
T3	30.5% of 13 patients	22.7% of 22 patients

Data are presented as number or mean ± SD (range). eRARP: Extraperitoneal robot-assisted radical prostatectomy; tRARP: Transperitoneal robot-assisted radical prostatectomy; PSA: Prostate specific antigen.

Table 3 Summary of studies determining perioperative, oncological and safety profiles for extraperitoneal robot-assisted radical prostatectomy

Reference	Centre	Level of evidence	No. of patients	Mean operative time (min)	Mean blood loss (mL)	Complication rate (transfusion rate)	PSM rate	Hospital stay (d)	Conversions
Joseph et al[12]	Rochester, United States	4	325	180	196	9.8% (1.3%)	13%	96% < 24 h	2 converted to TP
Atug et al[4]	New Orleans, United States	4	40	229	221	12.5% (NS)	20%	Mean 1.2	none
Rozet et al[13]	Institut Montsouris, France	4	133	166	609	19.4% (9.8%)	19.50%	Mean 5.4	4 converted to LRP
Capello et al[6]	Rochester, United States	2b	31	181	199	0% (0%)	3.20%	NS	none
Madi et al[5]	Ann Arbor, United States	4	34	214	125	5.9% (0%)	23.50%	Median 1	none
Ploussard et al[16]	Henri Mondor, France	4	206	160	504	8.3% (3.4%)	27.70%	Mean 4	1 converted to LRP
Chung et al[7]	South Korea	4	155	150	351	7.1% (NS)	22.60%	Mean 5.1	none
This study	St George’s, United Kingdom	4	70	145.1	372	8.5% (2.8%)	15.70%	Mean 2	none

NS: Not stated; LRP: Laparoscopic radical prostatectomy; PSM: Positive surgical margin; TP: Transperitoneal.

Table 4 Advantages of transperitoneal and extraperitoneal approaches to robot-assisted radical prostatectomy

Advantages of tRARP	Advantages of eRARP
Larger working space	Reduction in robotic console time
Allows extended pelvic lymphadenectomy	Reduction in bowel related morbidity
Lower incidence of lymphocele	Physiological effects of laparoscopy less marked due to minimal Trendelenburg position
Preferred in patients with mesh hernia repairs	Containment of leak (urine, blood) within retropubic space
	Preferred in patients with pre-existing inguinal hernia (allows mesh repair)
	Preferred in patients with intra-abdominal adhesions (reduces peritoneal viscera interference)

eRARP: Extraperitoneal robot-assisted radical prostatectomy; tRARP: Transperitoneal robot-assisted radical prostatectomy.