Editorial Comment to Transperitoneal versus extraperitoneal robot‐assisted laparoscopic radical prostatectomy: A prospective single surgeon randomized comparative study

摘要

The debate of whether a transperitoneal or an extraperitoneal approach is more suitable for radical prostatectomy first started in standard laparoscopy.1 Already in this technique some authors preferred the transperitoneal approach because of its larger working space, and others the extraperitoneal approach with its reduced risk of intra-abdominal complications. Currently, this debate continues in robot-assisted radical prostatectomy (RARP). Several single-center evaluations2, 3 and one randomized trial4 showed some distinct advantages of the extraperitoneal approach in RARP by avoiding the abdominal cavity. The present study by Akand et al. confirmed the advantages of the extraperitoneal approach with a high level of evidence in a prospective randomized trial.5 Significant advantages were found for extraperitoneal RARP with a lower blood loss, a shorter console time and a shorter hospitalization. The study design of a randomized trial makes the data highly comparable, and furthermore underlines the mentioned advantages in a cohort of average patients. In this setting, however, the choice of the approach in the individual patient seems to be arbitrary and independent of the patients’ characteristics. This strategy is, in my opinion, misleading because it does not take into account that some patients benefit more from the extraperitoneal and others more from the transperitoneal approach. Morbidly obese patients and patients with pulmonary restrictions benefit more from the extraperitoneal approach, whereas in contrast, it is difficult or impossible to carry out the extraperitoneal approach in patients with previous preperitoneal mesh hernia repair. In transplanted pelvic kidneys it is even contraindicated. In contrast to the extraperitoneal approach, the transperitoneal approach requires a steeper Trendelenburg position, and is not tolerated by all patients. Furthermore, it presents a higher level of risk and is difficult in patients with severe abdominal adhesions.6 Therefore, individual patient selection for both approaches cannot be done by randomization. The second main reason why individual patient selection for the choice of the approach is important, is the issue of lymph node dissection. Even though an adequate lymph node dissection can be carried out by an extraperitoneal approach, its cranial extension remains limited.3, 6 Therefore, I prefer the transperitoneal approach in patients with intermediate and high-risk tumors, in whom an extended lymph node dissection is mandatory. This gives us a wider working space, and allows a meticulous en bloc lymph node dissection up to the ureter with clear visualization of the iliac bifurcation. In summary, the authors should be applauded for their important prospective randomized trial with high-evidence data, but according to clinical practice the choice of the approach should be based on individual patient selection criteria. To offer both approaches for the highest benefit of individual patients centers with robotic expertise, training in the parallel use of both approaches should be carried out. None declared.