[Endoscopic extraperitoneal radical prostatectomy. Results after 300 procedures]

Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE): technique and outcome

Endoscopic extraperitoneal radical prostatectomy (EERPE) is a well-established and standardized technique for treating patients with localized prostate cancer. Nevertheless, the procedure is continuously being refined with the expansion of anatomical knowledge. The development of a nerve-sparing approach and improvements in currently used equipment are expected to yield better results in cosmesis and convalescence without sacrificing the procedure's established benefits in terms of potency, continence and oncological management. In this study, the technique and its evolution are presented in detail, along with an analysis of its clinical efficacy. We also consult the literature to compare EERPE to transperitoneal laparoscopic radical prostatectomy, and we also discuss new technical advancements regarding the use of robotic assistance during EERPE.

Laparoskopische Chirurgie in der Urologie

Relatively long learning curves and, therefore, initially longer operating times compared to conventional procedures are still a matter of debate. Today, there are numerous possibilities for learning laparoscopic techniques and establishing one's own laparoscopic programs, including various pelvitrainers and virtual reality computer programs. One useful and realistic way involves "wet lab" training programs for ablative and reconstructive procedures using the pig model. Today, laparoscopic urological surgery includes procedures with low (e.g. laparoscopy for undescended testicles), intermediate (laparoscopic pyeloplasty) and high level (laparoscopic/endoscopic prostatectomy) complexity. Therefore, laparoscopy should be an integral part of training in urology. A defined number of possibly multi-institutional training centers with well structured educational programs are needed. The main goal should be the standardization of surgical procedures as well as educational training programs in order to shorten individual learning curves and generate common quality standards.

Laparoskopische Beckenchirurgie

Laparoscopic radical prostatectomy has become an equivalent alternative to the open retropubic approach, offering the advantages of minimally invasive surgery. It is being applied increasingly in Germany and the rest of Europe. Whether the surgical robot da Vinci will be used for this procedure to the same extent as in the United States is unpredictable because of high investment and maintenance costs. Similarly, laparoscopic sacrocolpopexy has proven to be a viable option compared to open transabdominal or transvaginal surgery, showing a significant reduction in postoperative morbidity. The value of radical cystectomy is controversial despite proven feasability. On one hand, the technical difficulties of purely laparoscopic urinary diversion result in very long operating times, and in the case of the laparoscopically assisted creation of a neobladder, the advantage of this approach has to be questioned. On the other hand, a maximum rate of 30% of local recurrences and distant metastases indicates at least poor patient selection. In conclusion, this procedure should be limited to a few experienced centers.

Laparoscopic Radical Prostatectomy Using an Extraperitoneal Approach: Nordwest Hospital Technique and Initial Experience in 255 Cases

PURPOSE

We report on our modifications in technique and initial experience with 255 extraperitoneal laparoscopic radical prostatectomy (eLRP).

PATIENTS AND METHODS

Using significant surgical modifications, our laparoscopic method replicates the steps of the retropubic descending RP. We evaluated 255 consecutive patients who underwent an eLRP with pelvic lymph-node dissection.

RESULTS

The mean operative time was 136 minutes (range 84-266 minutes). Because of technical difficulty, the first three patients were converted to open surgery. One major complication, myocardial infarction, and one surgical reintervention in a case of secondary rectourethral fistula after open surgical repair of a laparoscopic rectal injury were observed. The blood transfusion rate was 1.2%. The pathologic stage was pT2a in 56 patients (22%), pT2b in 50 (20%), pT2c in 74 (29%), pT3a in 42 (16%), pT3b in 29 (11%), and pT4 in 3 (2%). Positive margins were found in 7% of patients (13/180) with pT2 tumors and 27% of patients (19/71) with pT3 tumors. The mean catheterization time was 7 days. The continence rates (no pads at all) at 3, 6, and 12 months were 73.7% (146/198), 89.6% (112/125), and 92.7% (38/41), respectively. After a nerve-sparing procedure, the total potency rates at 3 and 6 months were 37.5% (21/56) and 48.8% (21/43), respectively.

CONCLUSION

The eLRP seems to be safe with short-term oncologic and functional results at least as favorable as those of open radical prostatectomy and classical transperitoneal LRP. The operative times are shorter, and the complication rate appears to be lower.

Modular surgical training for endoscopic extraperitoneal radical prostatectomy

OBJECTIVE

To develop a modular training scheme which enabled the use of individual steps of laparoscopic radical prostatectomy (RP) for teaching and training surgeons with varied experience, including residents with no experience in open RP, as in extending laparoscopic surgery to more complex operations like RP, the proper training of urologists is crucial.

SUBJECTS AND METHODS

The technique of endoscopic extraperitoneal RP (EERP) was divided into 12 individual steps of differing complexity. The levels of difficulty were called "modules" and graded according to their requisite skills from module 1 (lowest level of difficulty) to module 5 (highest level). Based on this modular system we established a training programme whereby the trainee learns the procedure in a mentor-initiated schedule. During each training operation the trainee only performs the modules (steps) of the operation, which correspond with his or her actual skill level. The mentor performs all the other steps, with the trainee assisting. Four trainees with different surgical experience participated in the study.

RESULTS

After a phase of assisting and camera holding during EERP, the trainees entered the modular training programme and required 32-43 procedures until they were considered to be competent. An analysis of the first 25-50 procedures done independently by the trainee showed mean operative times of 176-193 min and a transfusion rate of 1.3%. Complications during and after EERP requiring re-intervention were one each of recto-urethral fistula, haemorrhage, symptomatic lymphocele and anastomotic leak. The positive margin rate for pT2 disease was 12.2% and for pT3 tumours 37%.

CONCLUSION

The modular concept for teaching EERP is an attractive concept, which overcomes many of the problems involved in complex laparoscopic procedures. Based on a highly standardized technique, this concept offers a short learning curve; it enables training on different sites in cooperation with a high-volume centre, and it makes it possible to start with this complex procedure as a beginner or with no experience in open RP.

Laparoscopic radical prostatectomy a review of the literature and comparison with open techniques

BACKGROUND

The development of laparoscopic radical prostatectomy (LRP) has been one of the surgical advances in the treatment of localized prostate cancer. The procedure aims to combine the advantages of minimal access surgery with resection based on established oncological principles with cure rates and functional results that are at least comparable to open radical prostatectomy (ORP).

OBJECTIVES

This review compares the advantages and disadvantages of the LRP to the ORP with regard to the real benefits to the patient. The impact on the urological practice was also addressed by the review.

METHODS

A comprehensive literature review of the published series/cases of both open and laparoscopic radical prostatectomy was performed.

RESULTS

LRP is a feasible and reproducible procedure for the treatment of localized prostate cancer. Although its technique is standardized, LRP is technically demanding and it takes longer time than ORP.

CONCLUSION

The current published results of LRP show no advantages over that of the ORP. If long-term data shows better results in terms of functional and oncological outcomes, LRP may challenge or even replace the standard ORP in the treatment of localized prostate cancer.