Extraperitoneal vs. transperitoneal robot-assisted laparoscopic radical prostatectomy—analysis of perioperative outcomes, a single surgeon’s experience

Robot-assisted laparoscopic radical prostatectomy (RRP) has traditionally been done using transperitoneal (TP) approach. This requires patients to be in the steep Trendelenburg position with antecedent risks of high intraoperative ventilatory pressure, post-operative confusion status, corneal and cerebral edema, deep vein thrombosis (DVT), predisposes risk of intestinal injury and slight delay in bowel recovery. Extraperitoneal (EP-RRP) approach circumvents the above given issues. Between July 2013 and October 2016, 57 patients underwent RRP for adenocarcinoma done by a single surgeon (NR). Salvage prostatectomies were excluded. RRP was performed using techniques TP (n = 23) and EP (n = 34). Patients were selected in a non-randomized fashion. Clinico-pathologic parameters and perioperative outcomes were compared in both groups using nonparametric tests. Patient demographics, clinico-pathological features, length of stay and total operative time were similar in both groups. Dock (Trendelenburgh) time was shorter in EP-RRP compared to TP-RRP [median (1st–3rd quartiles) (p value)] [180 (150–220) min vs. 220 (180–230) min (p = 0.039)]. Other significant differences includes EP-RRP vs. TPRRP, ventilatory pressures (cm of H₂O) [34 (32–34) vs. 40 (38–40) (p = 0.000)], ETCO2 (mm of Hg) [38 (36–40) vs. 32 (30–34) (p = 0.000)], ambulation (day) [0.00 (0–1) vs. 0.00 (0–2) (p = 0.022)], return of bowel activity (day) [1.0 (1.0–2.0) vs. 2.0 (2.0–2.0) (p = 0.000)] and opening of bowel (day) [2.0 (1.0–2.0) vs. 3.0 (3.0–3.0) (p = 0.000)]. EP-RRP offers similar clinical outcomes to TPRRP but with the advantages of shorter Trendelenburgh time, early recovery of bowel functions with avoidance of bowel injury and intraperitoneal urine leak. Overall, early recovery of patients who had undergone EP-RRP potentiates it to be performed as day care procedure.