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Stanford Report, October 22, 2003

Less invasive, less painful prostate surgery technique becomes reality Shorter hospital stay a benefit of laparoscopic approach


By SARA SELIS

Stanford is one of a few medical centers in the Bay Area to offer laparoscopic prostate surgery as an alternative to open surgery for the treatment of prostate cancer.

This less-invasive approach to removing the prostate gland has significant advantages for patients, including less blood loss, less postoperative pain, a shorter hospital stay and overall recovery, and a reduced risk of the surgery’s main side effects of incontinence and sexual dysfunction.

"From the patient’s perspective, this is a no-brainer," said Thomas Hsu, MD, assistant professor of urology, who has undergone specialized training in the procedure — known as laparoscopic radical prostatectomy — and was responsible for bringing it to Stanford.

With the laparoscopic approach, surgeons perform the operation using tiny lighted cameras and instruments that are threaded through five small holes called ports in the abdomen.

Hsu came to the School of Medicine in September 2002 from Johns Hopkins Medical Center, where he completed a fellowship in advanced laparoscopic urology procedures. At Stanford, he is training residents and faculty to do the procedure, as well as building awareness among referring physicians.

Cancer of the prostate — a walnut-sized gland just below the bladder that produces fluid for the sperm during ejaculation — affects more than 185,000 American men each year and is the second-leading cause of cancer deaths among men.

If the cancer is detected early, surgical removal of the prostate is recommended in most cases. This procedure is usually accomplished through open surgery, which requires a 6- to 8-inch incision in the patient’s lower abdomen.

The prostate is notoriously difficult to operate on because it is small and buried deep within the pelvis, next to delicate structures including the urethra and bladder. Surgeons must be careful not to damage these tissues, as this could cause permanent incontinence or impotence.

Despite these challenges, surgeons over the past three decades have perfected open prostate surgery, producing excellent results in terms of eliminating the cancer. Still, the operation is hard on the body.

This surgery can result in blood loss of up to two pints in some patients. They typically must stay in the hospital two or three nights, and recovery can be slow and painful. Patients generally cannot return to work for four to six weeks and for about the first two weeks they must rely on a catheter to urinate.

Seeing an opportunity to reduce patients’ pain and shorten recovery times, surgeons in the United States and in France developed laparoscopic prostatectomy in the early and mid-1990s. The operation has been done successfully in Europe and the United States for the past five to seven years. Still, from the surgeon’s perspective, it is a challenging operation — considered much more difficult than performing an open prostatectomy.

"In urology, this is one of the most difficult surgeries you can do," Hsu said.

That’s because surgeons, who are used to manipulating tissues with their hands and performing surgery by feel must learn to manipulate small laparoscopic tools and to do so in the narrow confines of the closed pelvis. "It’s like working with long chopsticks," Hsu explained.

The difficulty of laparoscopic prostatectomy has spurred concerns nationally that some physicians are doing the operation without adequate training.

"This is not a procedure just any physician can do — you need extensive training and experience," said Harcharan Gill, MD, associate professor of urology, who teams with Hsu and has assisted him on several laparoscopic prostatectomies.

"Removing an adrenal gland or a kidney laparoscopically is fairly straightforward, but taking out a prostate laparoscopically is a tough operation," Gill said.

Despite the difficulties, Hsu said the advantages of the laparoscopic approach are worth it. For the surgeon, a major advantage is excellent visibility of the tissues, because of the minimal bleeding involved and the laparoscopic instruments’ magnification features.

This clear visibility allows surgeons to make more accurate cuts and sutures, thereby minimizing the risk of damage to pelvic nerves and tissues.

With less blood loss and less postoperative pain under the laparoscopic approach, most patients can return to work and other daily activities within a week or two — compared with four to six weeks following open surgery — and require a catheter for just seven days. "The big advantage is that patients are up and about much sooner because there’s much less pain," Gill said. "The response from patients has been very favorable."

Robert Spellman (not his real name) can attest to the benefits of the less-invasive approach.

Last February, under Hsu’s care, he was the first patient at Stanford to undergo laparoscopic prostatectomy. Spellman had an early stage prostate cancer diagnosed in late 2002. After examining Spellman, Hsu recommended removing the prostate laparoscopically.

After the surgery, Spellman stayed in Stanford Hospital for two nights. Although he experienced discomfort and weakness, "I never had any serious pain," he said. About two weeks later, he returned to work as a systems information specialist at Stanford’s Linear Accelerator Center.

Hsu acknowledges that there’s insufficient long-term data to show that prostate cancer surgery yields better clinical outcomes when done laparoscopically, and some physicians remain skeptical.

But Hsu said the evidence thus far shows that outcomes with the laparoscopic method are at least as good as with open surgery, and he believes that over time the laparoscopic method will emerge as clearly superior.

"The laparoscopic approach is not going away. I believe it’s the future of this surgery," he said.



Researcher challenges value of widely used prostate cancer diagnostic tool (2/13/02)