Complete solo laparoscopic radical prostatectomy: initial experience

OBJECTIVES

To demonstrate the feasibility of "complete solo" (CS) laparoscopic radical prostatectomy (LRP) performed solely with robotic manipulation of the laparoscope and without any human assistant at all. A comparison was made between CS LRP and the standard technique to identify the advantages and drawbacks.

METHODS

Sixteen consecutive patients undergoing CS LRP were compared with the last 16 patients undergoing standard LRP. The standard procedure was performed with five trocars and one human assistant. Therefore, the surgeon had three instruments immediately available and could switch quickly from one to another, while the assistant held the laparoscope and a retractor. The CS method used a voice-controlled robotic arm to manipulate the laparoscope and a mechanical arm for the assisting instrument.

RESULTS

The mean operative time in the CS and standard groups was 324 and 347 minutes, respectively (P >0.5). An additional human assistant was required, for 1 hour, in 3 patients of each group. No significant difference was noted between the two groups in terms of catheterization time, hospital stay, positive margin rate, complications, short-term cancer control, or functional results. The CS method has been demonstrated to be highly cost-effective compared with the standard technique.

CONCLUSIONS

The CS LRP is feasible and compares favorably with the standard technique. It offers unique advantages in terms of direct control of the operative view, standardization of the assistance, and higher stability of the laparoscope, thus greatly enhancing the surgeon's comfort. The diminished need for human operative assistance provides significant economic and organizational benefits.

Laparoscopic radical nephroureterectomy: results of an international multicenter study

OBJECTIVE

To report a multicenter analysis after laparoscopic radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma.

MATERIALS AND METHODS

A total of 116 patients (72 males; mean age 68 years) underwent laparoscopic radical nephroureterectomy at five international institutions: 51 transperitoneally, 65 retroperitoneally. Location of the primary tumor was pelvicalyceal in 70 patients (60%), ureteral in 27 (23%), and multifocal in 19 (17%). In 18 patients (15%), transurethral resection was performed for concomitant bladder tumor. The median follow-up time was 25 months (range 3-93). A minimum follow-up of 1 and 2 years was available in 77 and 41 patients, respectively.

RESULTS

Five patients (4%) were converted to open surgery. The specimen was extracted intact in all 116 patients: using an Endocatch bag in 78 patients, a Lapsac in 5, and manually in 33. Pathologic staging was pTis in 5 (4%), pTa in 41 patients (35%), pT1 in 31 (26%), pT2 in 18 (15%), pT3 in 16 (13%), and pT4 in 5 (4%). Pathological grade was grade I in 26 patients (23%), grade II in 41 (35%), grade III in 34 (29%) and grade IV in 15 (12%). Histopathology revealed a positive surgical margin in five patients (4.5%): renal hilum (one), periureteral soft tissue (two), distal edge of the ureter/ bladder cuff (two). Local recurrence was noted in two patients (1.7%). Bladder recurrence was noted in 28 patients (24%) with a mean time to recurrence of 13.9+/-11.5 months. Distant metastases occurred in 11 patients (9%): lung (5), liver (3), bones (2), adrenal (1); mean time to metastasis was 13 months. Overall, 23 patients (20%) died. One-year and 2-year cancer-specific survival was 92% and 87%, respectively. Two-year cancer-specific survival according to pathologic stage was 89% for patients with pT1 disease, 86% for pT2, 77% for pT3, and 0% for pT4 (p=0.0001). Two-year survival according to pathologic grade was 88% for grade I, 90% for grade II, 80% for grade III, and 90% for grade IV (p>0.05).

CONCLUSION

Laparoscopic radical nephroureterectomy appears to be an effective minimally invasive treatment for select patients with upper tract transitional cell carcinoma. Although the 2-year survival data reported herein are encouraging, longer follow-up is needed before laparoscopy can be considered as a standard treatment.

[Prostatic adenocarcinoma revealed by disseminated intravascular coagulation and fibrinolysis]

Disseminated intravascular coagulation (DIC) revealing a prostatic adenocarcinoma is rare. Most of the case are limited to biological abnormalities. We report a case of a 73 year old man with metastatic prostatic carcinoma and CIVD. The patient consulted for epistaxis and ecchymosis with thrombocytopenia and low coagulate factors. The prostatic specific antigen was 2200 ng/ml and fine needle aspiration of bone marrow biopsy detected metastatic cells. The patients received hormonotherapy, heparine and antithrombine III with a good follow up. About this case, we discuss the management of the patient with metastatic prostatic cancer and CIVD.

Laparoscopic radical prostatectomy: a European virus with global potentials

OBJECTIVES

To review the current status of the Laparoscopic Radical Prostatectomy in Europe (LRP).

METHODS

The published peer reviewed articles on the experience of the European groups performing Laparoscopic Radical Prostatectomy.

RESULTS

Three different approaches have been described for LRP, two of them transperitoneally (early dissection of seminal vesicles or of the prostatic apex) and one totally extra peritoneally. Results in terms of per operative performances and immediate outcomes seem to be comparable with the exception of the bleeding and the transfusion rate that seem higher in the transperitoneal approach with early dissection of the prostatic apex. Conversion rates have been described up to 5% but it is rare after the 20 first cases; after the learning curve has been overcome the complication rate varies between 10% and 17%. Being a novel technique, all the series have a short median follow-up of around one year. The one-year continence rates are comparable to the ones described with the classical open approach, as it is the potency rate. The rate of positive margins bounces between 2 and 49% depending mainly on case selection. A long and steady learning curve burdens the technique in terms of complications.

CONCLUSIONS

LRP is feasible, teachable and reproducible. Although no comparative series with the open approach are available yet, functional and oncological results seem to be comparable to the ones reached after open Retropubic Radical Prostatectomy.

[Arterial reconstruction with detubulated aortic patch in simultaneous kidney-pancreas transplantation]

Simultaneous pancreas kidney transplantation has become an accepted therapy for the treatment of patients with insulino-dependant diabetes and renal chronic failure. The arterial arrangement of the pancreatic graft is necessary in order to avoid surgical complications of vascular thrombosis. We reported three cases of simultaneous pancreas kidney, a simple procedure using aortic arterial patch preleved with the superior mesenteric artery and detubulated, than the splenic artery is directly anastomosed to the patch.

[Classification, favorable characteristics, prevention and treatment of adverse side-effects associated with Bacillus Calmette-Guerin in the treatment of superficial bladder cancer]

The efficacy of Bacillus Calmette-Guérin (BCG) in the treatment of superficial bladder cancer was first reported by Morales in 1976. Several authors have since demonstrated the efficacy of BCG in the prophylaxis and treatment of high-risk superficial bladder tumors (pT1G3, CIS). Although BCG is now recommended as an adjunctive treatment for superficial bladder tumors, the optimal treatment schedule remains to be defined. Results reported by Lamm suggest that an initial induction cycle of six weekly intravesical BCG instillations is suboptimal unless maintenance therapy (three consecutive weekly instillations) is given 3, 6, 12, 18, 24, 30 and 36 months later. However, the use of maintenance therapy is hindered by troublesome adverse reactions. This article reviews adverse reactions associated with BCG treatment, proposed a classification and discusses their prevention and treatment.

Outcome of radical cystectomy for bladder cancer according to the disease type at presentation

OBJECTIVE

To examine whether the outcome of cystectomy for invasive transitional cell carcinoma (TCC) of the bladder was influenced by the type of disease at initial presentation.

PATIENTS AND METHODS

The charts of 76 patients treated for TCC by radical cystectomy from 1987 to 1997 in our unit were reviewed. The patients were divided into three groups: group 1 comprised 43 patients with primary invasive disease; group 2 included 12 patients with progression of an initial superficial bladder tumour after failure of conservative treatment; and group 3 comprised 21 patients who had a radical cystectomy for superficial TCC, with a high risk of progression after attempts at conservative treatment. The pathological findings on transurethral resection and cystectomy specimens, cancer-specific survival and the time to progression were compared among the three groups.

RESULTS

The rate of pT0 in cystectomy specimens was 16%, 41% and 24% in groups 1, 2 and 3, respectively. Under-staging occurred in 24% of cases in group 3. The 10-year cancer-specific survival rates were 48%, 47% and 82% in groups 1, 2 and 3, respectively. The cancer-specific survival rate and progression rate were not significantly different between groups 1 and 2, but were significantly lower/higher in these patients than in group 3 (P < 0.01).

CONCLUSIONS

These data suggest that the prognosis of superficial TCC which progresses despite conservative management is no better than that of invasive TCC at initial presentation, despite the closer follow-up received by the former patients. Early identification of this group of patients may improve the cancer-specific survival, as early cystectomy for high-risk superficial TCC yields better results.

Prognostic value of a T helper 1 urinary cytokine response after intravesical bacillus Calmette-Guerin treatment for superficial bladder cancer

PURPOSE

Interleukin (IL)-2 and interferon-gamma are released during T helper 1 lymphocyte responses, while IL-10 is released during T helper 2 responses. We evaluated the prognostic value of urinary IL-2, interferon-gamma and IL-10 levels in patients with superficial bladder cancer treated with bacillus Calmette-Guerin (BCG) instillation.

METHODS

Urinary IL-2, interferon-gamma and IL-10 were measured by enzyme-linked immunosorbent assay in 37 patients receiving BCG for stages Ta/T1 superficial bladder cancer, and carcinoma in situ. Measurements were made after instillations 5 and 6 during a course of 6 weekly instillations of 150 mg. BCG, Pasteur strain. Correlations of cytokine levels with the clinical outcome were evaluated using the log rank test.

RESULTS

Median followup was 29 months. Patients with urinary IL-2 less than 27 pg./micromol. creatinine were significantly more likely to have recurrences than those with higher values (log rank test p = 0.0009). Urinary IL-10 and interferon-gamma levels had no apparent impact on the risk of recurrence or progression.

CONCLUSION

Urinary IL-2 levels may serve to identify patients at risk for bladder cancer recurrence after a single course of BCG and, thus, to tailor individual treatment.

Retroperitoneal laparoscopic living-donor nephrectomy. Preliminary results

PURPOSE

Living-donor nephrectomy is performed via a standard flank approach during open surgery in contrast to laparoscopy where kidneys are procured transperitoneally. Being more familiar with retroperitoneal laparoscopy for the surgery of the upper urinary tract, we investigated the feasibility of live donor nephrectomy by this approach.

MATERIAL AND METHODS

We performed laparoscopic retroperitoneal left-sided nephrectomy in 3 living donors. The patients were placed in lumbotomy position. The retroperitoneal space was developed with blunt finger dissection, through a 2-cm mini-lumbotomy under the 12th rib in the posterior axillary line. 5 trocars were inserted. After primary access to the renal artery and vein, these were dissected to their junctions with the aorta and inferior vena cava, respectively, before freeing the kidney of its perinephric attachments. The kidney was delivered manually, through the slightly enlarged initial subcostal incision.

RESULTS

The average duration of surgery was 83 min; warm ischemia time less than 5 min. Average blood loss was 120 cm(3). Donors did not present any postoperative morbidity and were discharged after an average of 2.3 days. Mean analgesic requirement was 5 mg morphine sulphate equivalent (0-15). Average convalescence was 13.3 days (10-18). All 3 kidneys harvested laparoscopically had immediate function with urine production after graft revascularization; serum creatinine levels returned to normal within 1 week. The first patient presented ureteral stenosis 2 months after surgery. He underwent ureteropyeloplasty using his native ureter.

CONCLUSIONS

Laparoscopic living-related-donor nephrectomy become a new standard for organ harvesting. Our data suggest that retroperitoneal laparoscopic donor nephrectomy may represent a reasonable option in centers in which more extensive experience has been accumulated with retroperitoneal than with transperitoneal laparoscopy for the surgery of the upper urinary tract.

Multi-institutional study of complications in 1085 laparoscopic urologic procedures

OBJECTIVES

To assess the incidence of the complications in laparoscopic urologic procedures with regard to clinical presentation, etiology, and treatment.

METHODS

From January 1994 to December 2000, 1085 laparoscopic procedures were performed at three institutions in 1075 patients (702 men, 373 women). A referent surgeon for laparoscopy was at each institution. The major procedures were radical prostatectomy (n = 232), different types of nephrectomy (n = 171) and nephroureterectomy (n = 15), adrenalectomy (n = 130), pyeloplasty (n = 61), pelvic lymph node dissection (n = 130), genitourinary prolapse repair (n = 86), bladder neck suspension (n = 104), and treatment of benign kidney pathologic findings (lithiasis, cysts, and diverticula, n = 55). The complications were listed by incidence and etiology according to the procedure attempted.

RESULTS

A total of 75 complications (6.9%) occurred in this multi-institutional series. The mortality rate was 0.09%, and the conversion rate was 2.1%. Vascular (n = 7) and visceral injuries (n = 11) occurred in 24% of complications. Hematomas (n = 10), urinomas (n = 8), and wound infections (n = 7) at the trocar sites were the most frequent postoperative surgical complications. Pulmonary disorders (n = 9) and urinary infections (n = 9) were predominant in the postoperative medical problems.

CONCLUSIONS

Even though it appears to be minimally invasive, laparoscopy remains major surgery, with serious complications possible. These complications should be preventable with better mastery of the different steps of the procedures. Increased knowledge of the possible complications is essential for urologists in laparoscopic training and may help them improve their learning curve.

[Tendinopathy associated with fluoroquinolones: individuals at risk, incriminated physiopathologic mechanisms, therapeutic management]

The use of fluoroquinolones in urology has grown considerably over recent years. Unfortunately, although these molecules are not associated with severe life-threatening complications, they have nevertheless been associated with tendon lesions responsible for functional disability. The frequency of these complications is probably underestimated. There is a variable lag-time (3 to 5 days) between introduction of the antibacterial and onset of pain. The symptom most frequently reported is pain over the tendon affected and the tendons most frequently affected are those submitted to high constraints. Bilateral lesions are present in 66% of cases. Although Pefloxacin is associated with the highest frequency of tendon complications (2.7% versus 0.2-0.3% for other fluoroquinolones), the duration of treatment appears to be important in every case, with a peak frequency after a fortnight of treatment. Although these complications were considered for a long time to be associated with patients presenting certain risk factors (age, steroid therapy, renal failure), they can also occur suddenly, in young adult sportsmen or non-sportsmen, with no known tendon disease. Several hypotheses have been proposed to explain the development of these cases of tendinopathy: immuno-allergic mechanisms, direct toxicity of the molecule on collagen fibres, cell-mediated oxidative aggression, or tendon necrosis due to vascular mechanisms. The outcome remains favourable in 75% of cases of tendinitis and in 49% of cases for tendon rupture. Contraindications must therefore be identified and the duration of treatment must be adapted, as the functional handicap can be long and particularly severe.

T helper 1/2 lymphocyte urinary cytokine profiles in responding and nonresponding patients after 1 and 2 courses of bacillus Calmette-Guerin for superficial bladder cancer

PURPOSE

Interleukin (IL)-2 and interferon-gamma are released during T helper 1 lymphocyte responses and IL-10 is released during T helper 2 lymphocyte responses. We have previously reported that a T helper 1 lymphocyte urinary cytokine profile is associated with a favorable prognosis after bacillus Calmette-Guerin (BCG) treatment. We evaluated the T helper 1/2 lymphocyte cytokine profiles during courses 1 and 2 of 6 weekly BCG instillations.

MATERIALS AND METHODS

Urinary interferon-gamma, IL-2 and IL-10 were measured by enzyme-linked immunosorbent assay after each of 6 weekly instillations of 150 mg. BCG, Pasteur strain, in 19 patients with superficial stages Ta and T1 bladder cancer, and carcinoma in situ. The 11 patients who did not respond to course 1 were re-treated according to the same schedule and reevaluated.

RESULTS

During course 1 interferon-gamma was higher than during course 2 (p <0.001), which was associated with nonrecurrence (p <0.001). In contrast, IL-2 cytokine was higher after course 2 (p <0.01), which was associated with a BCG response (p = 0.01). Interferon-gamma and IL-10 correlated during courses 1 and 2 (p = 0.04 and 0.0004, respectively). We distinguished groups 1-immediate T helper 1 lymphocyte profile consisting of responders to course 1 with high interferon-gamma, IL-2 and IL-10, 2-delayed T helper 1 lymphocyte profile consisting of responders to course 2 with early high IL-2 and 3-consisting of nonresponders to the 2 courses with low interferon-gamma, IL-2 and IL-10.

CONCLUSIONS

A T helper 1 lymphocyte urinary cytokine profile was associated with a clinical response to BCG. A repeat BCG course induces a favorable immune response in a subset of patients, suggesting that maintenance therapy may be beneficial.

[Urinary leukocytes as a new prognostic marker of therapeutic response and of adverse effects associated with the maintenance treatment with endovesical BCG, for the prophylaxis of superficial bladder tumors]

The use of Bacillus Calmette-Guérin (BCG) vaccine as immunotherapy for superficial bladder cancer constitutes a major progress, although it remains limited by the development of adverse effects and problems related to safety. No individual tool is currently available in clinical practice to predict the efficacy or adverse effects of BCG therapy. These problems are accentuated in the case of maintenance therapy according to the protocol of D.L. Lamm.

OBJECTIVES

To define whether the urinary leukocyte count observed after intravesical BCG instillation could be associated with adverse effects and efficacy of treatment.

MATERIAL AND METHODS

A cohort of 72 consecutive patients (518 instillations) was studied prospectively. We defined four classes of adverse effects associated with BCG, according to their type, severity and duration. In combination with this classification, we performed systematic optical urinary leukocyte count on the third day after each instillation (KOVA-Slide 10).

RESULTS

A high urinary leukocyte count (cut-off value: 165,000/ml) was correlated with absence of recurrence (p = 0.009). The adverse effect classification also demonstrated that urinary leukocyte count was related to the severity and duration of adverse effects (p < 0.0001). Median values observed for class I, II and III adverse effects were 40,000 leukocytes/ml, 150,000 leukocytes/ml and 350,000 leukocytes/ml, respectively. No class IV adverse effects were observed. The risk of developing class III adverse effects was increased when the urinary leukocyte count was greater than 86,000 leukocytes per ml.

CONCLUSION

These results suggest a probable relationship between efficacy and safety of BCG, during maintenance therapy. Randomized prospective studies are necessary to evaluate urinary leukocyte count as a tool for adaptation and optimization of BCG therapy.

Early removal of the catheter after laparoscopic radical prostatectomy

PURPOSE

We prospectively tested the safety of routine removal of the catheter as early as 2 to 4 days after laparoscopic radical prostatectomy.

MATERIALS AND METHODS

Between March 1998 and March 2001, 228 patients underwent laparoscopic radical prostatectomy for clinically organ confined prostate cancer. The last 113 consecutive patients were included in a prospective study according to gravitational cystography performed 2 to 4 days postoperatively. If no leak was seen the catheter was removed. If a leak was apparent the catheter was left indwelling for another 6 days and cystography was repeated.

RESULTS

Cystography 2 to 4 days postoperatively showed an anastomosis without a leak in 96 (84.9%) patients who subsequently had the catheters removed. There were 28 patients who had the catheter removed on postoperative day 2, 28 day 3 and 40 day 4. In 17 (15.1%) patients an anastomotic leak was observed, and the catheter was not removed at that time. Of the 96 patients in whom the catheter was removed early 10 (10.4%) had urinary retention that necessitated re-catheterization. This procedure was performed without the need for cystoscopy. After the catheter was removed all patients were able to void 24 hours later. Median followup was 7 months (range 1 to 15) and showed continence rates greater than 93%. No anastomotic stricture, pelvic abscess or urinoma developed in any patient.

CONCLUSIONS

Patients who undergo laparoscopic radical prostatectomy can have the catheter safely removed 2 to 4 days postoperatively without a higher risk of incontinence, stricture or leak related problems.

p15(INK4b) in bladder carcinomas: decreased expression in superficial tumours

The p15 gene which encodes a cyclin-dependent kinase inhibitor, is located in the 9p21 chromosomal region that is frequently deleted in human bladder transitional cell carcinomas (TCCs). The aim of the present paper is to study the potential involvement of the p15 gene in the evolution of TCCs. p15 mRNA expression was investigated by semi-quantitative RT-PCR in a series of 75 TCCs, 13 bladder cell lines and 6 normal bladder urothelia by semi-quantitative RT-PCR. p15 was expressed in the normal urothelium but p15 mRNA levels were significantly decreased in 66% of the superficial (Ta-T1) TCCs (P = 0.0015). In contrast, in muscle-invasive (T2-T4) TCCs, p15 expression differed widely between samples. p16 mRNA levels were also studied and there was no correlation between p15 and p16 mRNA levels, thus indicating that the two genes were regulated independently. Lower p15 expression in superficial tumours did not reflect a switch from quiescence to proliferative activity as normal proliferative urothelial controls did not present decreased p15 mRNA levels relative to quiescent normal urothelia. We further investigated the mechanisms underlying p15 down regulation. Homozygous deletions of the p15 gene, also involving the contiguous p16 gene, were observed in 42% of the TCCs with decreased p15 expression. No hypermethylation at multiple methylation-sensitive restriction sites in the 5;-CpG island of p15 was encountered in the remaining tumours. Our data suggest that decreased expression of p15 may be an important step in early neoplastic transformation of the urothelium and that a mechanism other than homozygous deletions or hypermethylation, may be involved in p15 down regulation.

Prospective patient-reported continence after laparoscopic radical prostatectomy

OBJECTIVES

To perform a prospective study using confidential patient-completed questionnaires about their urinary habits before and after laparoscopic radical prostatectomy. Published reports on urinary continence after radical prostatectomy vary depending on the definitions of urinary continence and methods of data collection.

METHODS

From May 1998 to February 2000, 228 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer. The patients were given questionnaires before surgery and at 1, 3, 6, and 12 months postoperatively.

RESULTS

Before surgery, no patient reported incontinence. At 1, 3, 6, and 12 months postoperatively, perfect diurnal urinary control (no pads, no leakage at all) was reported in 9.9%, 28.6%, 57.4%, and 56.8% of patients, respectively. No pads were used in 18.8%, 58.4%, 68.9%, and 78.4% at 1, 3, 6, and 12 months, respectively. No patient reported use of more than 1 pad daily at 6 months of follow-up.

CONCLUSIONS

Continence after laparoscopic radical prostatectomy is comparable to the results after traditional radical retropubic prostatectomy. Ongoing use of the laparoscopic route for treating clinically localized prostate cancer is warranted.

Evaluation of cellular tumour rejection mechanisms in the peritumoral bladder wall after bacillus Calmette-Guérin treatment

OBJECTIVE

To compare the immunological status of normal and peritumoral bladder walls, and to characterize immunocompetent cells before and during intravesical instillations of bacillus Calmette-Guérin (BCG).

PATIENTS AND METHODS

Twenty-three patients with superficial urothelial bladder carcinoma (stages pTa to pT1, grades 1-3) were treated with six weekly instillations of 150 mg of BCG (Pasteur strain). Biopsies of cystoscopically normal bladder wall were taken before, 3 weeks and 3 months after BCG instillation. The controls comprised bladder biopsy specimens from 13 brain-dead ventilated kidney donors. Local infiltrating cell types, i.e. lymphocyte infiltrates (CD4, CD8, CD20, CD3, interleukin-2-receptor-positive, natural killer, gammadelta), macrophages and dendritic cells, adhesion and costimulatory molecules (ICAM-1 and B7-BB1) and major histocompatibility complex (MHC) class I and class II antigens were assessed using semi-quantitative immunohistochemical analysis.

RESULTS

Before BCG the peritumoral bladder wall had fewer macrophages than control bladder wall. BCG treatment restored normal numbers of macrophages and enhanced T helper lymphocytes, B lymphocytes, natural killer cells, activated lymphocytes, dendritic cells, normal MHC class I, adhesion (ICAM-1) and costimulatory (B7-BB1) expression. The enhancement of these immunological variables was transient, with a return to baseline 3 months after BCG instillation.

CONCLUSIONS

These results support the concept that there is a host-immune escape associated with bladder cancer. BCG therapy may temporarily restore impaired tumour rejection mechanisms in the peritumoral bladder wall, suggesting a need for maintenance therapy after the first course of BCG.

[Tolerance and efficiency of intravesical instillation of Calmette-Guérin in the prophylactic treatment of superficial bladder tumors, using a maintenance treatment]

Maintenance treatment with complementary BCG instillations in the prevention of superficial bladder tumour could improve the results of this immunotherapy. This maintenance treatment is limited by accentuation of the adverse effects related to BCG.

OBJECTIVES

To evaluate the impact of maintenance treatment on tumour recurrence and progression, and to evaluate the influence of adverse effects on maintenance treatment and the recurrence rate.

MATERIAL AND METHODS

72 patients were treated with six weekly instillations of 81 mg of BCG (Immucyst) followed by three complementary instillations 3, 6, 12, 18, 24, 30 and 36 months later. Adverse effects (AE) were classified into four classes, according to their type, severity and duration, and were recorded prospectively for 518 instillations. An adverse effect score was determined for each patient.

RESULTS

84.9% of patients did not present any recurrence, 12.5% developed recurrence and 2.6% progressed. The instillation regimen was completed by 19% of patients, the dose had to be decreased for 57% of patients and treatment had to be discontinued for 39% of patients. An initial adverse effect score (AESi) greater than 1.5 was associated with an increased risk of discontinuation of treatment or reduction of the dosage during maintenance treatment (p = 0.01).

CONCLUSIONS

Maintenance treatment was associated with a very low recurrence and progression rate. We have established and validated an adverse effect severity scale and the consequences of these adverse effects on maintenance treatment. This scale could be used to prospectively define the most appropriate maintenance instillation regimen, by preventively decreasing the doses or deferring instillation.

EAU guidelines on prostate cancer

OBJECTIVES

To develop clinical guidelines for the management of patients with prostate cancer.

METHODS

Guidelines were compiled by a working panel based on current literature following a literature review using MEDLINE. Already published structured analysis from national and international guidelines was used, and panel consensus was employed when literature evidence was absent or of poor quality.

RESULTS

The full text of the guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article summarizes the main conclusions from the guidelines concerning the diagnosis and staging, treatment and follow-up of patients with prostate cancer. The diagnosis of prostate cancer should be based on histopathological or cytological examinations. N- and M-staging may be omitted in selected patients with a low serum prostate-specific antigen due to low risk of metastasis. Active treatment is warranted in most stages of prostate cancer but active monitoring is recommended for elderly patients with early stage tumours and is still optional in some other situations. Follow-up is based on a disease-specific history, serum-prostate-specific antigen supplemented by a digital rectal examination. Routine imaging is not necessary in asymptomatic patients.

CONCLUSIONS

Prostate cancer is one of the most common malignancies in men. These guidelines have been drawn up to provide support in the management of this large group of patients.

Impact of interventional therapy for benign prostatic hyperplasia on quality of life and sexual function

Considering the epidemiologic impact of benign prostatic hyperplasia (BPH), the use of minimally invasive surgery in the treatment of this condition is one of the main ambitions of contemporary urology. Compared with the prevalence of BPH and LUTS in elderly men, only a small percentage of patients requires surgery for indications such as renal insufficiency, chronic retention, and infection. The majority of patients seek treatment because of the bothersome nature of their symptoms and expect improvement in their quality of life. The goal of interventional therapy is to restore the comfort and well being of the patients, including preserving their sexuality. Therefore, there is increased focus on the quality of life and sexual function in the evaluation of the outcome of interventional therapy for BPH.

Experience with retroperitoneal laparoscopic adrenalectomy in 115 procedures

PURPOSE

Laparoscopic adrenalectomy has become an effective option for removing small adrenal tumors. We evaluated the retroperitoneal approach with regard to operative complications, morbidity and hospital stay.

MATERIALS AND METHODS

Between January 1995 and March 2000 we performed a total of 115 laparoscopic adrenalectomies via the retroperitoneal approach, including 70 on the left and 45 on the right side, in 64 women and 42 men 17 to 74 years old (mean age 49.3) with adrenal neoplasms. Average adrenal tumor size was 31 mm. (range 10 to 65). All procedures required 4 trocars and mean operative time was 118 minutes (range 45 to 240).

RESULTS

There were no patient deaths. The conversion rate to open surgery was 0.8% and estimated blood loss was 77 ml. (range 0 to 550). At a mean followup of 23.4 months, morbidity was 15.5% with intraoperative vascular injury in 3 cases (3.4%) and postoperative complications in 12.1%, including wound infection, deep hematoma, parietal dehiscence and severe pneumopathy. Average hospital stay was 4 days and mean duration of analgesic requirement was 2 days (range 1 to 5).

CONCLUSIONS

The retroperitoneal approach to laparoscopic adrenalectomy appears to be minimally invasive and safe for adrenal tumors not larger than 5 cm.

Extraperitoneal laparoscopic pyeloplasty: a multicenter study of 55 procedures

PURPOSE

We assessed the feasibility, reproducibility and morbidity of retroperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction.

MATERIALS AND METHODS

A total of 55 retroperitoneal laparoscopic pyeloplasties were performed at 3 institutions between September 1996 and May 2000 in 33 women and 21 men. Results were analyzed in regard to radiological assessment by excretory urography at 3 months, complications and hospital stay.

RESULTS

We performed dismembered pyeloplasty in 48 cases and Fenger plasty in 7 cases. Crossing vessels were noted in 23 patients. The conversion rate was 5.4%. Mean operative time was 185 minutes (range 100 to 260), mean hospital stay was 4.5 days (range 1 to 14) and mean followup was 14.4 months (range 6 to 43.6). The overall complication rate was 12.7%. Complications in 7 patients included hematoma in 3, urinoma in 1, severe pyelonephritis in 1 and anastomotic stricture in 2 requiring open pyeloplasty at 3 weeks and delayed balloon incision at 13 months, respectively. Excretory urography in 50 patients and ultrasound in 4 showed decreased hydronephrosis in 88.9% at 3 months. Normal physical activity and absent pain were reported by 47 patients (87%) 1 month after surgery.

CONCLUSIONS

Retroperitoneal laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for ureteropelvic junction obstruction. The long-term outcome must be assessed before this procedure may be definitively validated.

Laparoscopic radical prostatectomy. The Créteil experience

OBJECTIVES

In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency.

METHODS

200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogeneous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi-circumferential or a single circumferential running suture.

RESULTS

All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night.

CONCLUSIONS

Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.