Laparoscopic Prostatectomy: Minimally Invasive Surgery Without a Robot

What is laparoscopic prostatectomy?

Laparoscopic radical prostatectomy (LRP) is a minimally invasive surgical procedure to remove the prostate gland using long, thin instruments inserted through small incisions in the abdomen. Unlike robotic prostatectomy, the surgeon holds the instruments directly (not controlling a robot).

LRP was the first minimally invasive approach for prostate cancer and remains an option at centres without robotic technology. However, it has largely been replaced by robotic prostatectomy in most developed countries due to technical advantages.

How does laparoscopic prostatectomy work?

Laparoscopic prostatectomy uses traditional laparoscopic instruments:

• Laparoscope: A thin camera with a light source (provides 2D magnification on a screen)
• Long instruments: Graspers, scissors, dissectors inserted through small ports (5-10 mm)
• Insufflation: Carbon dioxide gas inflates the abdomen to create working space

Key differences from robotic surgery:

• 2D vision (robotic has 3D)
• No tremor reduction – surgeon's hand tremors are transmitted
• No wristed instruments – rigid instruments have 4 degrees of freedom (robotic has 7)
• Surgeon stands at the operating table (robotic surgeon sits at a console)

Benefits over open surgery

Laparoscopic prostatectomy offers several advantages compared to open radical prostatectomy:

• Less blood loss: Average 300-500 mL vs. 500-1,000 mL for open surgery
• Smaller incisions: 5-6 small incisions (5-10 mm) vs. 8-10 cm open incision
• Shorter hospital stay: 1-2 days vs. 2-3 days for open
• Shorter catheter duration: 10-14 days vs. 14-21 days for open
• Faster recovery: Return to work in 3-5 weeks vs. 4-6 weeks for open
• Lower wound complication rate: Less pain, fewer wound infections

Limitations compared to robotic surgery

Laparoscopic prostatectomy has several limitations compared to robotic prostatectomy:

• Steeper learning curve: 100-200 cases to achieve proficiency (vs. 20-50 for robotic)
• 2D vision: Less depth perception, harder to identify neurovascular bundles
• No tremor reduction: Surgeon's hand tremors are amplified by long instruments
• Rigid instruments: Less dexterity, especially for suturing the bladder to the urethra (anastomosis)
• Higher conversion rate: More likely to convert to open surgery if bleeding or difficult anatomy
• Longer operative time: Typically 3-5 hours (vs. 2-4 hours for robotic)

Who is a candidate?

Ideal candidates for laparoscopic prostatectomy are the same as for open or robotic surgery:

• Localized prostate cancer (T1-T2): Cancer confined to the prostate
• Life expectancy >10 years: Surgery provides benefit only if you live long enough to see it
• Good surgical candidate: No major contraindications (severe heart disease, uncontrolled bleeding disorder)
• Intermediate or high-risk cancer: Gleason 7+ (3+4, 4+3, 8-10)
• Low-risk cancer (Gleason 6): Active surveillance is preferred

Procedure details – steps, anaesthesia, duration

Before surgery:

• Stop blood thinners as directed (usually 5-7 days before)
• Bowel preparation (enema) the night before
• Antibiotics to prevent infection

Day of surgery:

• Anaesthesia: General anaesthesia (you are asleep)
• Position: Lying on back with legs elevated (lithotomy position), steep Trendelenburg (head down)
• Duration: 3-5 hours (longer than robotic)
• Hospital stay: 1-2 days

Step-by-step:

1. 5-6 small incisions are made in the abdomen
2. A laparoscope (camera) is inserted through one port
3. Carbon dioxide gas inflates the abdomen for visibility
4. The surgeon inserts instruments through other ports
5. The prostate is dissected free from the bladder and urethra
6. Neurovascular bundles are preserved (nerve-sparing) if possible
7. The prostate and seminal vesicles are removed through one of the incisions
8. The bladder is reattached to the urethra (anastomosis) – technically challenging
9. A urinary catheter is placed

Recovery and downtime

Hospital stay:

• 1-2 days

Catheter:

• 10-14 days
• You will go home with the catheter

Return to activities:

• Walking: Day of surgery
• Desk work: 3-5 weeks
• Light exercise: 4-6 weeks
• Heavy lifting (>10 lbs): 6-8 weeks
• Sexual activity: 6-8 weeks

Side effects – ED, incontinence, dry ejaculation

Side effects are similar to other radical prostatectomy approaches:

Erectile dysfunction (ED):

• Rate: 30-60% at 2 years (with bilateral nerve-sparing)
• Note: Potency rates may be slightly lower than robotic due to less precise nerve-sparing
• Treatment: PDE-5 inhibitors (Viagra, Cialis), penile injections, vacuum devices, implants

Urinary incontinence:

• Rate: 10-15% require pads at 12 months (slightly higher than robotic)
• Treatment: Pelvic floor exercises (Kegels), urethral sling, artificial urinary sphincter

Dry ejaculation (anejaculation):

• Rate: 100% – no semen is produced after prostatectomy
• Effect: Orgasm still occurs but is "dry" (no fluid)

Success rates – cancer control

Laparoscopic prostatectomy has good cancer control outcomes in experienced hands:

• 10-year biochemical recurrence-free survival: 70-85% (depends on risk group)
• 10-year prostate cancer-specific survival: >95% for localized disease
• Positive margin rate: 10-25% (may be higher than robotic in some studies)

By risk group:

• Low-risk (Gleason 6): 10-year recurrence-free survival ~85-90%
• Intermediate-risk (Gleason 7): 10-year recurrence-free survival ~70-80%
• High-risk (Gleason 8-10): 10-year recurrence-free survival ~50-70%

Laparoscopic vs. robotic vs. open – comparison table

Feature	Laparoscopic	Robotic	Open
Incision size	5-6 small (5-10 mm)	5-6 small (8-12 mm)	8-10 cm
Blood loss	300-500 mL	150-250 mL	500-1,000 mL
Hospital stay	1-2 days	1 day	2-3 days
Catheter duration	10-14 days	7-10 days	14-21 days
Return to work	3-5 weeks	2-4 weeks	4-6 weeks
Vision	2D	3D (10-15x magnification)	Direct (3D)
Tremor reduction	No	Yes	No
Wristed instruments	No (rigid)	Yes (7 DOF)	Direct (human wrist)
Learning curve	100-200 cases	20-50 cases	50-100 cases
Cost	Moderate	Higher	Lower

Interactive FAQ – Laparoscopic prostatectomy

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Disclaimer: This information is for educational purposes. Laparoscopic prostatectomy requires significant surgical expertise. Discuss with a urologist at Vivekananda Hospital to determine the best surgical approach for you.