Minimale Invasivität der laparoskopischen radikalen Prostatektomie: Wirklichkeit oder Wunsch?

Zusammenfassung

Die radikale retropubische Prostatektomie ist derzeit der Standardeingriff für die operative Behandlung des klinisch lokalisierten Prostatakarzinoms. Die operative Technik ist über Jahrzehnte kontinuierlich verfeinert worden, was zu einer Reduzierung der Morbidität und zu einer Verbesserung der funktionellen und onkologischen Ergebnisse geführt hat. Seit Ende der 90er-Jahre wird zunehmend die radikale Prostatektomie auf laparoskopischem Wege durchgeführt. Greift man die hierzu verfügbare Datenlage ab, so haben die bisher veröffentlichten Studien die Machbarkeit des Eingriffes bewiesen, der Nachweis einer geringeren Invasivität wurde aber nie erbracht. In Anlehnung an frühere Studien zur Evaluation der Invasivität verschiedener offener und laparoskopischer Eingriffe sind wir als Klinik an der seit Jahren beide Techniken routinemäßig vorgehalten werden, der Frage nachgegangen, ob die laparoskopische Prostatovesikulektomie für den Patienten tatsächlich ein geringeres Operationstrauma darstellt. Für die vorliegende prospektive nicht randomisierte Vergleichsstudie wurden an der Universitätsklinik und Poliklinik für Urologie der Martin-Luther-Universität Halle-Wittenberg insgesamt 64 Patienten rekrutiert, die sich einer laparoskopischen radikalen Prostatektomie (n = 32) oder einer offenen retropubischen radikalen Prostatektomie (n = 32) zwischen Januar 2003 und April 2004 unterzogen haben. Die Patienten beider Kollektive waren bezüglich des präoperativen Stagings, PSA und Gleason-Scores vergleichbar. Neben den perioperativen Parametern wie Operationszeit, intra- und postoperative Komplikationen, Blutverlust und Transfusionsrate, Analgetikabedarf und Krankenhausverweildauer wurden onkologische Daten (Gleason-Score, pathologisches Stadium und die Anzahl der positiven Schnittränder) verglichen. Um reproduzierbare objektive Daten zu erhalten, wurde das Ausmaß der systemischen Antwort auf das operationsbedingte Gewebstrauma laborchemisch erfasst. Bei allen untersuchten Patienten wurden prä-, intra- und postoperativ die Marker der Akuten Phase C-reaktives Protein, Serum Amyloid A (ASS), Interleukin 6 (IL-6) und Interleukin 10 (IL-10) gemessen. Die Transfusionsrate lag bei den laparoskopischen Operationen bei 6 %, bei den offenen Prostatektomien bei 12 %. Intraoperativ musste bei einem laparoskopisch operierten Patienten eine Rektumläsion übernäht werden. Der postoperative Analgetikaverbrauch war für beide Gruppen vergleichbar. Die Krankenhausverweildauer der laparoskopisch operierten Patienten war median 12,4 Tage, der offen operierten Patienten 11,2 Tage. Positive Schnittränder waren in der Laparoskopiegruppe bei T2-Tumoren in 6 Fällen (17 %), in der „offenen” Gruppe in 4 Fällen (12 %) zu verzeichnen. Bezüglich der Mediatoren der systemischen Reaktion konnten im gesamten Verlauf keine signifikanten Unterschiede zwischen beiden Operationsmethoden festgestellt werden. Laparoskopisch radikal prostatektomierte Patienten hatten identische oder leicht höhere Serumkonzentrationen der Parameter der Akuten Phase, als Ausdruck einer gleichwertigen oder diskret ausgeprägteren systemischen Antwort auf das operative Trauma, im Vergleich zu konventionell prostatektomierten Patienten. Die bisher angenommene geringere Invasivität der laparoskopischen radikalen Prostatektomie konnte anhand der im Rahmen dieser Studie gemessenen Parameter nicht objektiviert werden. Somit muss, zumindest vorläufig, das Operationstrauma und die davon abhängige Invasivität für beide Methoden als gleichwertig eingestuft werden.

Abstract

Currently, radical retropubic prostatectomy is the standard procedure for clinically localized prostate cancer. The surgical technique has been continuously refined for decades, resulting in reduced morbidity and improved functional and oncologic results. Since the late 90s, radical prostatectomy has been increasingly performed laparoscopically. A search of the available data has found that the articles published so far have proven the feasibility of the laparoscopic procedure but never confirmed its less invasiveness. In accordance with previous studies that have evaluated the invasiveness of various open and laparoscopic procedures, our clinic, which has routinely performed both techniques for several years, addressed the question whether laparoscopic prostatovesiculectomy indeed induces less severe surgical trauma. This prospective nonrandomized comparison study of the University Clinic of Urology at the Martin-Luther University at Halle-Wittenberg recruited a total of 64 patients, who underwent laparoscopic radical prostatectomy (n = 32) or open retropubic prostatectomy (n = 32) from January 2003 to April 2004. Both patient groups were comparable as to preoperative staging, PSA value and Gleason score. Besides perioperative parameters, such as surgical time, intra- and postoperative complications, blood loss and transfusion rate, need for analgetics and length of hospital stay, the comparison included oncologic data, such as Gleason score, pathologic stage and numbers of positive specimen margins. To get objectively reproducible data, the range of the systemic answers concerning the surgically induced tissue trauma was recorded as laboratory data. In all patients, pre-, intra-, and postsurgical markers of the acute-phase C-reactive protein, serum amyloid A (SAA), interleukin-6 (IL-6) and interleukin-10 (IL-10) were measured. The transfusion rate was 6 % for laparoscopic prostatectomies and 12 % for open prostatectomies. A rectal tear had to be intraoperatively repaired in one laparoscopically operated patient. The postoperative use of analgetics was comparable in both groups. The median hospital stay was 12.4 days for the laparoscopic and 11.2 days for the open surgical group. For T2 tumors, positive specimen margins were found in 6 cases (17 %) of the laparoscopic and in 4 cases (12 %) of the open surgical group. As to the indicators of any systemic reaction, no significant difference could be found during the entire clinical course between both surgical methods. In comparison with patients who underwent conventional open prostatectomy, patients with laparoscopically radical prostatectomy had identical to slightly higher serum levels of the acute-phase parameters, as evidence of an equal or a discretely manifested systemic response to the surgical trauma. The so far assumed less invasiveness of laparoscopic radical prostatectomy is not objectively supported by the data from this study. Thus, surgical trauma and its linked invasiveness must be considered equal for both methods, at least for the time being.

Schlüsselwörter

Laparoskopische radikale Prostatektomie - retropubische radikale Prostatektomie - Stressreaktion - Laparoskopie - systemische Reaktion - Morbidität - Invasivität

Key words

Laparoscopic radical prostatectomy - retropubic radical prostatectomy - stress response - laparoscopy - systemic response - morbidity - invasiveness

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