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.

Simulators and endourological training

Acquisition of skills laboratory training seems to be of importance in the training of surgeons, and is intended to cover the gap between theoretical learning and real practice. Economic and ethical reasons limit the use of animals during the learning process, while trends in medical change have severely restricted the available time to teach and to learn. With the incorporation of laparoscopy and the blossoming of minimally invasive techniques, mainly endoscopy, simulators have gained wide acceptance as an important tool in the surgeon's learning process. Two types of simulators are currently available: inanimates or mannequins and virtual reality simulators. A review of the recent literature shows that there is generally a significant improvement in dexterity after using simulators, whichever type is used. It is still unknown whether training simulation influences the patient's outcome positively.

Baseline prostatic specific antigen does not predict the outcome of high energy transurethral microwave thermotherapy

PURPOSE

We assessed the prognostic value of baseline prostate specific antigen (PSA) for outcome after high energy transurethral thermotherapy in patients with lower urinary tract symptoms.

MATERIAL AND METHODS

Data were collected prospectively in 404 consecutive patients treated with high energy transurethral thermotherapy with the Prostatron device (EDAP-Technomed, Lyon, France). Patients were followed a minimum of 1 year. At baseline certain criteria were assessed, including pretreatment PSA, uroflowmetry, ultrasound measurement of prostatic volume, voided and post-void residual urine volume, and International Prostate Symptom Score (I-PSS) and quality of life scores. Outcome assessment included I-PSS, quality of life score and uroflowmetry of peak urine flow. Linear regression analyses were performed to correlate baseline PSA with improved clinical parameters at 12 months of followup. Logistic regression analyses and receiver operating characteristics curves characterized the ability of baseline PSA to discriminate patients with a more or less favorable outcome.

RESULTS

An evident linear association was identified for prostate size at baseline and PSA. After 1 year 36 patients were treated again due to transurethral thermotherapy failure and 16 had died, which was not related to lower urinary tract symptoms or treatment for lower urinary tract symptoms. To include re-treated patients in the analyses we considered that their I-PSS, quality of life and peak urine flow values at 1 year were unchanged compared with baseline. Of the 388 evaluable patients an improvement of 50% or more in I-PSS, quality of life and peak urine flow was observed in 57%, 62% and 44%, respectively. Absolute mean changes at 1 year were -9.7, -2 and 5.2 ml. per second for I-PSS, quality of life and peak urine flow, respectively. Neither linear nor logistic regression analysis showed any clinically relevant correlation between baseline PSA and changes in I-PSS (r = -0.004), quality of life (r = -0.135) or peak urine flow (r = 0.105) at 1 year. Receiver operating characteristics curves failed to distinguish more or less favorable outcomes in all evaluated parameters.

CONCLUSIONS

Pretreatment PSA cannot predict the clinical outcome after high energy transurethral thermotherapy.

The endoscopic approach to the distal ureter in nephroureterectomy for upper urinary tract tumor

PURPOSE

We reviewed the current status of the endoscopic distal ureteral approach to nephroureterectomy for transitional upper urinary tract cancer.

MATERIAL AND METHODS

We reviewed the English, French and Spanish literature using a PubMed and MEDLINE search, and compared the stripping and pluck techniques. Statistical analysis was done using Fisher's exact test. Individual case reports are discussed but they were not included in the statistical analysis.

RESULTS

The mean rate of bladder carcinoma recurrence after ureteral resection and detachment is 19.3% for the stripping and 24% for the pluck technique. This difference is not statistically significant. In 3.1% of cases invasive bladder cancer has been noted but only after distal ureteral resection using the pluck technique.

CONCLUSIONS

The endoscopic approach to the distal ureter during nephroureterectomy is feasible. Bladder cancer recurrence was similar after each technique. However, isolated case reports illustrate the need for cautious selection of surgical candidates.

Transurethral hot water balloon thermoablation

The inclusion of a determinate technique among the "minimally invasive treatments" of the symptoms due to benign prostatic hyperplasia is a long and careful process. The technique has to be more patient-friendly than conventional techniques, but also needs to be time-tested against older methods. Most of these minimally invasive treatments are based upon distinct types of thermoablation; the method discussed here, hot water balloon thermoablation, is based on the heat conductive properties of the prostatic tissue.

EAU guidelines on testicular cancer

OBJECTIVES

To establish guidelines for the diagnosis, staging, treatment and follow-up of germ cell testicular cancer.

METHODS

A search of published work was conducted using Medline. Highly evidence-based articles were selected and their findings analysed by the members of the Oncological Urology Working Group of the EAU. Testis cancer is rare and affects young men in their 3rd and 4th decades of life. The majority of these tumours are derived from germ cells (seminomatous and non-seminoma germ cell testicular cancer), and more than 50% of patients are diagnosed with stage I disease. Epidemiological, pathological and clinical risk factors are well established. The tumour, node, metastasis (TNM) staging system is endorsed, and for metastatic disease a recently devised prognostic-factor-based staging system has proven to be useful. Staging assessment includes pre- and post-orchiectomy marker levels, pathology of the testis, and nodal and visceral status. Following orchiectomy, treatment depends on the tumour type, pathological risk factors for stage I disease and clinical prognostic factors for advanced disease. The cure rate is excellent for disease stages I and II, irrespective of the treatment adopted. However, the pattern of relapse (rate, timing and site) is highly influenced by therapeutic policy. For metastatic disease, survival depends on clinical prognostic factors and treatment. Follow-up schedules are tailored according to stage, tumour type and post-orchiectomy treatment schedules.

CONCLUSIONS

Excellent cure rates are achieved for early-stage germ cell testis tumours following accurate staging at diagnosis. Satisfactory survival rate can be achieved in advanced metastatic disease using a multidisciplinary therapeutic approach. Follow-up schedules vary, depending on the pathology and stage of the primary tumour and on the treatment policy adopted following orchiectomy.

Efficacy and safety of the new high-energy 30-minute transurethral microwave thermotherapy: results of 1-year follow-up in a multicenter study

PURPOSE

To assess the efficacy and durability of a new 30-minute algorithm for high-energy transurethral microwave thermotherapy (TUMT, Prostasoft 3.5) in the treatment of men with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 167 men (mean age 67 years) with bothersome LUTS were treated with the new TUMT protocol. Evaluation included assessment of the short- and long-term objective and subjective outcome measures of this treatment.

RESULTS

The treatment is well tolerated. The International Prostate Symptom Score improved from a mean of 19.2 at baseline to 7.9 at 12 months after treatment. Maximum urinary flow improved from 8.9 to 16.4 mL/s at 12 months. Mean duration of catheterization was 16.1 days. Urodynamic evaluation showed a change from the obstructed to the nonminimally obstructed zone. There were no serious complications.

CONCLUSION

High-energy TUMT using the new high-dose Prostasoft 3.5 protocol appears to be a safe, effective, and durable treatment. The faster procedure improves tolerance of the treatment. Subjective and objective improvements were significant and the treatment-related morbidity low.

Microwave thermotherapy: historical overview

The application of heat with curative aim is an old and very well-known principle in medicine. A review of the history of heat use in the treatment of prostatic disease is presented. The article is based on bibliographic research (MEDLINE Search and PubMed) and focuses on treatment of benign prostatic hyperplasia (BPH) since the first clinical documentation of transrectal hyperthermia for this condition. Then, in a chronological sequence, not only the evolution toward thermotherapy but also enhancements of the latest techniques are presented. The new advances in the field of patient selection, indications, and outcome predictors, as well as new trends in treatment are briefly considered.

[Percutaneous suprapubic bladder lithotripsy]

The authors present a case of multiple bladder stones in a patient with severe ankylosis of the lower extremities, treated via percutaneous suprapubic approach. The suprapubic tract was created with Teflon-coated dilators and an Amplatz tube and the stones were fragmented with the nephroscope and a pneumatic lithotriptor. The simplicity of the procedure and the ease of the manoeuvre accelerated the stone fragmentation process while avoiding unnecessary trauma of the urethra.

[Treatment of prostate benign hyperplasia (BPH) with visually controlled laser, assessment at 2 years, and anatomopathologic findings]

The endoscopically-guided lateral discharge laser (VLAP) has been considered an alternative in the management of benign prostate hyperplasia (BPH). The purpose of this paper is to describe the technique, results obtained in 20 treated patients, and pathoanatomical findings in those later treated with prostate transurethral resection. Four patients were carriers of an indwelling catheter, while IPSS/QL mean values in the other 16 patients were 23/4. Mean maximum flow was 7.01 mL/s. Assessment after one and two years shows a fall of mean IPSS/QL to 5/1 and mean maximum flow to 15.2 mL/s and 21 mL/s, respectively, but the difference is not significant. This paper also describes the morbidity affecting 65% patients, which is comparable to the retreatment rate (15%) obtained in other series published. The results are similar to those described in the literature although, in our view, the high rate of complications undermines this choice as an alternative in BPH management.

[Gastrocystoplasty for renal insufficiency in adults]

Vesical substitution or augmentation with various segments from the gut is a frequent occurrence in urology. In the presence of normal renal function there are few or no metabolic disorders. In the presence of renal failure the most suitable gut segment is the stomach due to its characteristics of Cl- and ammonium excretion, smaller mucus formation, acid pH provided to the urine and because it allows easy ureteral regrafting. This article contributes one case of gastrocystoplastia in a patient with trigonal bladder and chronic renal failure, presenting reno-vesical TB.

[Acute colonic pseudo-obstruction (Ogilvie syndrome) after nephrectomy for renal carcinoma: persistence after decompressive colonoscopy and spontaneous remission]

A 65-year-old male patient presented acute dilatation in the ascendant colon on the third post-operative day following nephrectomy due to renal adenocarcinoma. No changes in colonic diameter were seen after decompressive colonoscopy and, while the patient was asymptomatic, conservative therapy was instituted and the picture was resolved in just a few days. The case is used to review the issue of acute colonic pseudo-obstruction and its relationship to urological operations.

Carcinoma in situ as a prognostic factor for G3pT1 bladder tumours

G3pT1 bladder cancer has traditionally been regarded as a superficial tumour with a high risk of progression. We have studied 37 patients with initial G3pT1 bladder tumours treated between January 1981 and December 1985. They were divided into 2 groups according to the association with carcinoma in situ (Cis) at the time of diagnosis. Clinical behaviour was analysed at 5 years. The first group (without Cis) showed progression and recurrence rates similar to those of low grade, low stage bladder tumours. The second group (with Cis) had a similar rate of recurrence but their progression rate was 65%.