Oncologic Outcome after Extraperitoneal Laparoscopic Radical Prostatectomy: Midterm Follow-up of 1115 Procedures

Evaluating the Oncological and Functional Outcomes in 167 Patients Undergoing Laparoscopic Radical Prostatectomy: Could Laparoscopy Still be a Viable Option in Suitable Patients?

Aim: To evaluate the oncological and functional outcomes of 167 patients who underwent laparoscopic radical prostatectomy (LRP). Materials and Methods: The retrospective study included 167 patients who were treated with LRP due to clinically localized prostate cancer between January 2007 and April 2012. Most of the patients were treated with the extraperitoneal approach. Preoperative evaluations included age, serum prostate-specific antigen (PSA) level, and biopsy Gleason score. Perioperative evaluations included duration of operative time and anastomosis time, blood loss (milliliter), and complications. Postoperative evaluations included length of hospital stay and catheterization time. Continence and erectile function were evaluated both pre- and postoperatively. The patients who used no pads or no more than one pad daily and the ones who had only a few urine leakages on effort or exertion were accepted as continent. Postoperative potency was defined as the ability to achieve sexual intercourse with or without the use of PDE-5 inhibitors. Results: Mean age and mean operative time were 62.4 ± 6.0 years and 220.5 ± 45.6 minutes, respectively. Mean anastomosis time was 35.6 ± 9.8 minutes. Mean serum PSA level and mean Gleason score were 17.5 ± 9.97 ng/mL and 6.16 ± 0.42, respectively. Pelvic lymphadenectomy was performed in 94 patients and nerve-sparing procedures in 61 patients. The pathological analysis revealed positive surgical margin in 35 patients (20.9%). Bilateral and unilateral nerve-sparing LRP procedures were performed in 51 (30.5%) and 10 (6%) patients, respectively. At 12 months after surgery, 3 (1.8%) patients were using 2 or more pads per day, 19 (26.4%) patients were satisfied with erection, hardness, and duration of intercourse, and 9 (12.5%) patients had an erection with insufficient hardness and duration. Conclusion: LRP is an acceptable method in localized prostate cancer due to its perioperative and early postoperative results.

Annual nationwide analysis of costs and post-operative outcomes after radical prostatectomy according to the surgical approach (open, laparoscopic, and robotic)

OBJECTIVE

Annual countrywide data are scarce when comparing surgical approaches in terms of hospital stay outcomes and costs for radical prostatectomy (RP). We aimed to assess the impact of surgical approach on post-operative outcomes and costs after RP by comparing open (ORP), laparoscopic (LRP), and robot-assisted (RARP) RP in the French healthcare system.

PATIENTS AND METHODS

Data from all patients undergoing RP in France in 2020 were extracted from the central database of the national healthcare system. Primary endpoints were length of hospital stay (LOS including intensive care unit (ICU) stay if present), complications (estimated by severity index), hospital readmission rates (at 30 and 90 days), and direct costs of initial stay.

RESULTS AND LIMITATIONS

A total of 19,018 RPs were performed consisting in ORP in 21.1%, LRP in 27.6%, and RARP in 51.3% of cases. RARP was associated with higher center volume (p < 0.001), lower complication rates (p < 0.001), shorter LOS (p < 0.001), and lower readmission rates (p = 0.004). RARP was associated with reduced direct stay costs (2286 euros) compared with ORP (4298 euros) and LRP (3101 euros). The main cost driver was length of stay. The main limitations were the lack of mid-term data, readmission details, and cost variations due to surgery system.

CONCLUSIONS

This nationwide analysis demonstrates the benefits of RARP in terms of post-operative short-term outcomes. Higher costs related to the robotic system appear to be balanced by patient care improvements and reduced direct costs due to shorter LOS.

Oncological and functional outcomes of extraperitoneal laparoscopic radical prostatectomy: An 18-years, single-center experience

OBJECTIVE

To present a retrospective analysis on the oncological and functional outcomes of a single-center experience on a large series of extraperitoneal laparoscopic radical prostatectomies (eLRP) with an extended follow-up.

MATERIALS AND METHODS

Herein we present a retrospective review of patients who underwent eLRP. Oncological and functional follow-up data were collected by means of outpatient visits and telephone interviews, assessing overall mortality and biochemical recurrence-free survival. Patients with clinical T4 stage prostate cancer (PCa), previous surgery for benign prostatic hyperplasia (BPH), previous androgen deprivation, radiotherapy, concomitant chemotherapy and/or experimental therapies, and with insufficient follow-up data were excluded. Preoperative data recorded were age, body mass index, ultrasound prostate volume, preoperative PSA and clinical stage of PCa. Operative data (operative time, nerve sparing technique and any perioperative complication) and pathological findings were obtained by consulting the surgical and pathological reports. Oncological and functional follow-up were collected during follow-up visits and telephone interview.

RESULTS

Between January 2001 and December 2019, overall 938 eLRP were performed at our Institution. The median follow-up was 132 months. 69.7% of the patients had complete dataset. The estimated overall biochemical recurrence (BCR)-free survival was 71.4% at 5 years and 58.9% at 10 years. Cancer specific survival was 84,5%. Erectile function was preserved in the most of patients as postoperative IIEF-5 score within 12 months after surgery was > 12 in the 82.1%. About the urinary incontinence, 0.76% of the patients presented severe incontinence (continued and persistent loss of urine) and 7.0% were mildly incontinent (using up to one pad per day). Conclusions; eLRP has shown oncological and functional results comparable to other minimally invasive techniques and to open radical prostatectomy (ORP), with favorable perioperative outcomes than the open technique and a reduced complication rate.

The CAPRA-S score versus subtypes of minimal residual disease to predict biochemical failure after radical prostatectomy

Objective

The objective of this study was to compare the CAPRA-S score (based on clinicopathological findings) and the subtypes of minimal residual disease (MRD) (based on the biological properties of cancer cells) to predict biochemical failure (BF) after prostatectomy radical.

Patients and methods

This was a prospective single-centre study of men who underwent radical prostatectomy. One month after surgery, the blood and bone marrow were taken for circulating prostate cell (CPC) and micrometastasis detection, identified using anti-PSA immunocytochemistry and defined as positive or negative. Patients were classified as Group A: CPC and micrometastasis negative, Group B: micrometastasis positive and CPC negative and Group C: CPC positive. CAPRA-S scores were classified as low, intermediate and high risk. Kaplan–Meier curves for biochemical failure-free survival (BFFS) and restricted mean survival time (RMST) to biochemical failure were determined and compared for up to 10 years.

Results

347 men participated with a median follow-up of 7 years, BFFS decreased proportionally with increasing CAPRA-S score and HR 1.13 and 1.65 for intermediate and high risk, respectively. After 10 years, the BFFS and RMST were 68%, 47% and 16% and 9, 7 and 6 years, respectively. The BFFS curves for MRD were not proportional; Group A and B BFFSs were similar up to 5 years, and then, there was an increasing failure in Group B patients After 10 years, the BFFS and RMST were 95%, 57% and 27% and 10, 9 and 6 years respectively. The CAPRA-S score failed to distinguish between Groups A and B, and one-third of high-risk Group C had low-risk CAPRA-S scores. MRD hazard ratios were Group B 1.76 and Group C 4.03.

Conclusions

The MRD prognostic classification was superior to the CAPRA-S score in predicting BFFS and differentiated between early and late BF. The results need to be confirmed in larger studies.

Indwelling Urinary Catheter-Related Problems After Laparoscopic Radical Prostatectomy

PURPOSE

The purpose of this study was to determine occurrence rates of catheter-related problems and their association to pertinent clinical characteristics in men with indwelling urinary catheters following laparoscopic radical prostatectomy.

STUDY DESIGN

Descriptive, correlational study.

SUBJECTS AND SETTING

One hundred twelve men who underwent laparoscopic radical prostatectomy between December 2010 and December 2012 at the Leiden University Medical Centre in the Netherlands were included in this study. After surgery, a Charriere 20 (20F) silicone catheter was left indwelling for 1 week.

METHODS

Data were gathered from 2 sources; we reviewed participants' medical records, and participants completed a questionnaire designed for this study. Pearson χ tests were used to analyze associations between dichotomous and ordinal variables and catheter-related problems. Univariate logistic regression analyses were used to analyze the relationships between continuous factors and catheter-related problems.

RESULTS

Seventy-five percent of participants reported at least 1 catheter-related problem. Univariate regression analyses revealed correlations between body weight and experiencing catheter-related problems (odds ratio [OR] = 1.050; P = .028) and between body mass index and experiencing catheter-related problems (OR = 1.159; P = .049).

CONCLUSION

Indwelling catheter-related problems after laparoscopic radical prostatectomy are prevalent, and they may occur at any time during the entire period of catheter use. High body mass index and high body weight were associated with an increased likelihood of catheter-related problems following radical prostatectomy.

Prediction model for early biochemical recurrence after radical prostatectomy based on the Cancer of the Prostate Risk Assessment score and the presence of secondary circulating prostate cells

OBJECTIVE

To establish a prediction model for early biochemical recurrence based on the Cancer of the Prostate Risk Assessment (CAPRA) score and the presence of secondary circulating prostate cells (CPCs).

PATIENTS AND METHODS

We conducted a prospective single-centre study of men who underwent radical prostatectomy as monotherapy for prostate cancer. Clinicopathological findings were used to calculate the CAPRA score. At 90 days after surgery, blood was taken for CPC detection, mononuclear cells were obtained using differential gel centrifugation, and CPCs were identified using immunocytochemistry. A CPC was defined as a cell expressing prostate-specific antigen (PSA) but not CD45. The CPC test results were defined as positive or negative. Patients were followed up for up to 5 years and biochemical recurrence was defined as a PSA level >0.2 ng/mL. The validity of the CAPRA score was calibrated using partial validation, and Cox proportional hazard regression to build three models: a CAPRA score model, a CPC model and a CAPRA/CPC combined model.

RESULTS

A total of 321 men, with a mean age of 65.5 years, participated in the study. After 5 years of follow-up the biochemical recurrence-free survival rate was 98.55%. For the model that included CAPRA score there was a hazard ratio (HR) of 7.66, for the CPC model there was an HR of 34.52 and for the combined model there were HRs of 2.60 for CAPRA score and 22.5 for CPC. Using the combined model, 23% of men changed from the low-risk to the high-risk category, or vice versa.

CONCLUSION

The incorporation of CPC detection significantly improved the model's discriminative ability in establishing the probability of biochemical recurrence; patients in the high-risk group according to CAPRA score who are negative for CPCs have a much better prognosis. The addition of CPC detection gives clinically significant information to aid the decision on who may be eligible for adjuvant therapy.

Long-Term Oncologic Outcome of an Initial Series of Laparoscopic Radical Prostatectomy for Clinically Localized Prostate Cancer After a Median Follow-up of 10 Years

INTRODUCTION

When laparoscopic radical prostatectomy (LRP) was introduced as a novel treatment option for prostate cancer, it had to compete with the established open techniques. The short- and intermediate-term oncologic and functional outcomes were encouraging and comparable to those with retropubic radical prostatectomy. However, the long-term oncologic safety for LRP has yet to be fully elucidated. We evaluated the long-term oncologic outcomes of an initial series of patients who had undergone LRP.

PATIENTS AND METHODS

An initial unselected and consecutive series of 100 patients who had undergone LRP for clinically localized prostate cancer from 1999 to 2001 was identified. The pre-, intra-, and postoperative data were collected. Biochemical recurrence (BCR) was defined as a prostate-specific antigen (PSA) value of ≥ 0.2 ng/mL. The outcome measures were cancer control (CC), BCR-free survival (BCRFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

The mean patient age was 64 ± 7 years, and the mean preoperative PSA level was 9.6 ± 8.3 ng/mL. Of the 100 patients, 79 (79%) had stage pT2 and 15 (15%) had stage pT3 disease. Positive surgical margins were found in 25 patients (25%; 16.4% for pT2 and 40% for pT3). The median follow-up time was 126 months (range, 60-176 months). The 5-year CC rate was 82%. The estimated 10-year BCRFS was 83% and 80% for patients with stage pT2 and pT3 tumors, respectively. The median time to BCR was 52 months (range, 6-144 months). The estimated 10-year CSS and OS was 98% and 93%, respectively.

CONCLUSION

Our long-term follow-up data from an initial unselected patient cohort have indicated that LRP offers excellent long-term oncologic control for patients with localized prostate cancer.

Laparoscopic Radical Prostatectomy Alone or With Laparoscopic Herniorrhaphy

BACKGROUND AND OBJECTIVES

Prostate cancer and inguinal hernia are common health issues in men aged more than 50 years. Recently, more data are accumulating that laparoscopic radical prostatectomy (LRP) and laparoscopic inguinal hernia repair (LIHR) can be performed in the same operation. The purpose of this study was to compare patients who underwent simultaneous extraperitoneal LRP (E-LRP) and LIHR with control patients who underwent only E-LRP in a matched-pairs design.

METHODS

Medical records of 215 patients were evaluated, and 20 patients who underwent E-LRP+LIHR were compared with 40 patients who underwent only E-LRP in a matched-pairs analysis. Preoperative clinical parameters (age, body mass index, prostate-specific antigen, clinical stage, Gleason score of the prostate biopsy, and prostate volume) and operative data (operation time, duration of catheterization, length of hospital stay, estimated blood loss, time to perform the anastomosis and its quality, and the percentage of patients with bilateral lymphadenectomy) were evaluated, as well as postoperative parameters (pathological stage, Gleason score, specimen weight, follow-up duration, biochemical recurrence, complication rates, and duration of postoperative analgesic treatment).

RESULTS

No statistically significant differences were found in the preoperative and operative parameters between the 2 study groups. Pathological parameters and the follow-up period and complication rates were similar between the 2 groups.

CONCLUSION

Performing LIHR and E-LRP during the same operation is safe and feasible in the treatment of patients with prostate cancer and inguinal hernia.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies

OBJECTIVES

To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients.

RESULTS

The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation.

CONCLUSIONS

The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.

Clinical value of ERG, TFF3, and SPINK1 for molecular subtyping of prostate cancer

BACKGROUND

In view of the marked molecular heterogeneity of prostate cancer (PCa), clinical and pathologic parameters alone may be unreliable for predicting disease outcomes after surgical intervention. The development of biomarkers may be helpful to estimate tumor heterogeneity and stratify patients in terms of their risk of progression. Levels of v-ets avian erythroblastosis virus E26 oncogene homolog (ERG), trefoil factor 3 (TFF3), and serine peptidase inhibitor, Kazal type 1 (SPINK1) are commonly elevated in PCa, but it is unclear whether the evaluation of these 3 markers can help to discriminate patients who will have different clinical outcomes. The authors investigated whether assessment of ERG, TFF3, and SPINK1 expression could help to define clinically relevant, distinct subsets of patients with PCa.

METHODS

The cohort consisted of 279 men with PCa who underwent radical prostatectomy at Henri Mondor Hospital. Expression levels of ERG, TFF3, and SPINK1 were evaluated immunohistochemically in the prostatectomy specimens. Potential associations of ERG, TFF3, and SPINK1 with age, prostate-specific antigen (PSA), tumor stage, Gleason score, and biochemical recurrence, defined by PSA failure, were investigated.

RESULTS

Although prognostic significance was not observed for ERG or TFF3, an exclusive pattern of expression was demonstrated for TFF3 and ERG. SPINK1 expression was observed exclusively in a subgroup of cancers that expressed TFF3 (41 of 175 tumors). Moreover, SPINK1 positivity was identified as predictive of biochemical recurrence in univariate (P = .0009) and multivariate (P = .0003) analyses.

CONCLUSIONS

The current results suggest that ERG and TFF3 characterize 2 distinct subsets of PCa, with a more aggressive subgroup of TFF3-expressing tumors that express SPINK1. Together, these findings support a rationale of screening for these biomarkers for prognostic purposes and molecular subtyping of the disease.

Clinical value of extended pelvic lymph node dissection in patients subjected to radical prostatectomy

Introduction

Extended pelvic lymph node dissection (ePLND) is advised to complement radical prostatectomy (RP) in intermediate and high risk prostate cancer patients.

Aim

To assess the risk of nodal involvement in patients subjected to laparoscopic radical prostatectomy and to characterize the group of patients with lymph node (LN) metastases.

Material and methods

Data of patients subjected to laparoscopic radical prostatectomy with ePLND between February 2011 and June 2013 were analyzed. The LN that were removed included presacral nodes, common, external and internal iliac nodes and obturator ones.

Results

Mean number of removed LNs was 19. Metastases within LN were found in 13 (16.6%) patients. In comparison to those without LN involvement, patients who were found to have LN metastases had a greater number of positive biopsy cores (3.7 vs. 5.3, p < 0.01), maximum percentage of cancer in biopsy core (47.0 vs. 67.6, p < 0.01), greater biopsy and specimen Gleason scores (7.0 vs. 7.7 and 7.0 vs. 7.8) and more frequently advanced clinical and pathological stage. The most frequent landing sites of prostate cancer were obturator and presacral nodes (100% and 38%). Eleven patients (85%) among those with positive LN had locally advanced disease.

Conclusions

The risk of LN metastases in intermediate and high risk prostate cancer patients is significant. Therefore, if radical prostatectomy is chosen, ePLND should be performed. The majority of patients with involvement of pelvic LN have locally advanced disease which would refer them to adjuvant radiation if managed without nodal dissection.

[Prostate cancer surgical margin: review by the CCAFU (Oncology Committee of the French Association of Urology)]

OBJECTIVE

Literature showed the impact of surgical margin status on prognosis after radical prostatectomy (mostly on biochemical survival). Margin status is an easy self-evaluation of surgical practice to assess. The aim of this paper was to define what a positive surgical margin (PSM) is and how to prevent the occurrence, to precise the impact on survival and how to treat.

METHOD

A literature analysis with Pubmed has been performed to 2012, furthermore conclusions of the main congresses with selection committee and review publication have also been studied.

RESULTS

PSM is defined as "tumor cells touching the ink on the specimen edge". The most frequent reported incidence is between 15 to 20%. Margin status remains one of the major criteria to determine the need of adjuvant radiotherapy after surgery. Quality of life is not or only lightly modified by radiotherapy with the current techniques. Adjuvant radiotherapy improves biological survival but is synonymous with overtreatment in many times. Salvage radiotherapy has to be quickly performed after Prostate Specific Antigen (PSA) relapse (PSA<1 ng/mL even<0.5 ng/mL).

CONCLUSION

This literature review did not allow to suggest superiority of one surgical technique over another. In the same way, the kind of dissection i.e. bladder neck or neurovascular bundle preservation does no clearly modify PSM rate. However, it seems logical to "customize" dissection according to prostate cancer characteristics (D'Amico criteria for instance) guided with multiparametric MRI. Intrafascial dissection has to be applied only to low risk. Lastly, the debate between adjuvant or salvage radiotherapy is always ongoing.

Five-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) for prostate cancer: results from a medium-volume UK centre

OBJECTIVE

To determine the 5-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) from a medium-volume centre, thereby providing much needed data on outcomes from the UK.

PATIENTS AND METHODS

From January 2006 to January 2012, 575 patients underwent EERPE for localized prostate cancer, performed by a single surgeon who had completed a modular training programme. Follow-up was as per local hospital policy and data were collected in our prospective database. A retrospective review of patient demographics, prostate-specific antigen (PSA) levels, pathological T stages, Gleason scores, surgical margin status and biochemical recurrence (BCR) data was performed. BCR was defined as PSA >0.2 μg/L.

RESULTS

The mean (range) patient age was 62 (40.3-76.5) years and the mean (range) follow-up was 30 (12-72) months. The median (interquartile range [IQR]) operating time was 135 (120-170) min and the median (IQR) blood loss was 200 (100-250) mL. Of the 575 patients, 135 (23.5%) had positive surgical margins (PSMs). The PSM rate for pT2 disease was 66/406 patients (16.3%) and for pT3 disease it was 68/168 patients (40.5%). Overall BCR-free survival at 5-years was 81.5%. Multivariate Cox analysis showed that PSMs, Gleason score, D'Amico risk category and pT stage were independent predictors of BCR-free survival.

CONCLUSIONS

This assessment of the oncological results of EERPE, which included the surgical learning curve, shows that the adoption of EERPE after mentored fellowship training translates into mid-term oncological outcomes in line with those of retropubic/transperitoneal laparoscopic approaches and with large-volume centres worldwide which have pioneered laparoscopic radical prostatectomy. The study shows that EERPE in a medium-volume second generation laparoscopic centre (that introduced EERPE after adequate training in pioneering centres) produces results with good 5-year oncological outcomes, similar to those of other major series, for patients in the UK.

Evaluating PSA Density as a Predictor of Biochemical Failure after Radical Prostatectomy: Results of a Prospective Study after a Median Follow-Up of 36 Months

Purpose. To evaluate the predictive ability of PSA density for biochemical relapse after radical prostatectomy in patients operated for clinically localized disease and to compare its predictive strength with preoperative PSA and Gleason score. Patients and Methods. The study evaluated 244 patients with localized disease who underwent an open retropubic radical prostatectomy between February 2007 and April 2011. PSA was measured every 3 months after surgery with a mean follow-up period of 36 months. Two consecutive rises >0.2 ng/mL were considered as biochemical relapse. Results. Biochemical recurrence was observed in 71 (29.1%). A great correlation was found between relapse and PSA (P = 0.005), PSA density (P = 0.002), Gleason score (P = 0.015), pathological stage (P = 0.001), positive surgical margins (P = 0.021), and invasion of seminal vesicles (P < 0.001) and lymph nodes (P < 0.001). We also found that PSA density was associated with adverse pathological findings. In univariate and multivariate analysis both PSA (P = 0.006) and PSA density (P = 0.009) were found to be significant predictors for relapse in contrast to tumor grade. Conclusion. PSA density is a valuable parameter in estimating the danger of biochemical failure and it may increase predictive potential through the incorporation in preoperative nomograms.

Long-term oncological and functional results of extraperitoneal laparoscopic radical prostatectomy: one surgical team's experience on 1,600 consecutive cases

PURPOSE

To determine the oncologic and functional outcomes of ELRP on a single surgical team's series.

METHODS

A total of 1,600 consecutive ELRP patients were recorded with a 2-year follow-up. In 778 patients, a 5-year follow-up was available.

RESULTS

The mean operative time was 125,6 min (PLND not included) and 150,9 min (PLND included). Postoperative stage was pT2a in 282 patients (17.6 %), pT2b in 877 (54.8 %), pT2c in 18 (1.1 %), pT3a in 241 (15 %), and pT3b in 182 (11.3 %). Positive margins were detected in 7.4 and 13.4 % of pT2 and pT3 tumors, respectively. Overall complication rate was 4 %. PSA levels resulted in <0.2 ng/mL in 96.4, 94.9, 92, 90.9, and 81.5 % of the cases at 3, 12, 24, 36, and 60 months after surgery, respectively. BCRFS rates 5 years after ELRP were 88.7 % for patients staged as pT2, 73.9 % for pT3a, and 62.4 % for pT3b. Complete urinary continence rate resulted in 39 and 92 % after 1 and 12 months, respectively, with a further increase from 92 to 98.4 % at 24-month follow-up. A nerve-sparing procedure was performed in 45 % of patients. The overall potency rate at 12-month follow-up was 38.67 % for UNSS patients and 75 % for BNSS patients. Potency recovery was age-dependent, with patients aged <55 years who resulted potent in 46.8 % of UNSS and 95.8 % of BNSS after 24 months.

CONCLUSIONS

ELRP is a standardized and safe procedure that implies advantages of both minimally invasive and extraperitoneal approaches with elevated standards for oncologic and functional outcomes obtained at long-term follow-up.

Extraperitoneal robot-assisted laparoscopic radical prostatectomy: a single-center experience beyond the learning curve

OBJECTIVES

To report our surgical technique and outcomes after extraperitoneal robot-assisted laparoscopic radical prostatectomy (RALRP).

MATERIALS AND METHODS

At Henri Mondor's Hospital, we performed the first RALRP in 2001 and started to perform routinely RALRP since 2006. Preoperative characteristics, perioperative parameters, functional and oncological outcomes were collected in a prospective database and studied. All parameters were tested in patients undergoing RALRP beyond the learning curve of each surgeon. The overall cohort included 792 patients.

RESULTS

RALRP offers interesting results in terms of hospital stay, operative time, and blood loss. The overall rate of complications was low, especially concerning the rates of anastomosis' complications. An extraprostatic extension was seen in 42.8 % of specimens. The overall rate of positive margins was 30.7 % of specimens. In our cohort, after a mean follow-up of 19 months, 8.7 % of PSA failure has been reported. The rate of continence was 77.4 % at 6 months and 96.8 % at 2 years. The rate of potency was 17 % at 3 months and 60.9 % at 2 years. The 2-year rate was 86.7 % in case of intrafascial dissection. A trifecta outcome was achieved in 44 and 53 % of men at 12 and 24 months, respectively.

CONCLUSIONS

The extraperitoneal approach confers interesting results in terms of perioperative parameters as previously described in series using a transperitoneal approach. Functional outcomes in terms of continence and potency recovery after extraperitoneal seem equivalent to those reported after transperitoneal RALRP. Longer follow-up is warranted to confirm our favorable mid-term oncologic outcomes.

Dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy

Objectives

To describe a novel dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and to evaluate its postoperative outcomes.

Methods

A total of 109 patients who underwent laparoscopic radical prostatectomy by a single surgeon were evaluated, including 44 patients with dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy, 20 patients with conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and 45 patients with non-nerve-sparing laparoscopic radical prostatectomy. Functional outcomes were evaluated using a self-administered questionnaire (Expanded Prostate Cancer Index Composite). Continence was defined as zero to one security pad per day. Oncological outcomes were evaluated based on positive surgical margin.

Results

In the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group, the continence rate was 57%, 77% and 95% at 1, 3 and 12 months, respectively. The continence rate in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy group was 37%, 63% and 90%, and in the non-nerve-sparing laparoscopic radical prostatectomy group it was 23%, 57% and 82% at 1, 3, and 12 months, respectively. The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group showed a significantly earlier recovery from incontinence compared with that in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and non-nerve-sparing laparoscopic radical prostatectomy groups (log–rank test, P = 0.044 and P < 0.001). Similarly, the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group tended to show a more early recovery in relation to urinary function of the Expanded Prostate Cancer Index Composite. Regarding sexual function, there were no significant differences between the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and conventional intrafascial nerve-sparing laparoscopic radical prostatectomy groups. In pT2 patients, the positive surgical margin rate of the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group (11%) was similar to that of the other two groups (conventional intrafascial nerve-sparing laparoscopic radical prostatectomy 7%; non-nerve-sparing laparoscopic radical prostatectomy 11%).

Conclusions

The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome.

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.

Oncologic outcomes of asian men with clinically localized prostate cancer after extraperitoneal laparoscopic radical prostatectomy: a single-institution experience

Purpose. To evaluate the midterm oncologic results of extraperitoneal laparoscopic radical prostatectomy (EPLRP) for Asian men with localized prostate cancer. Methods. Between 2004 and 2009, 218 men underwent EPLRP at an Asian tertiary hospital. The mean preoperative prostate-specific antigen (PSA) was 15.5 ng/ml and mean Gleason score was 6.6. Stage distributions were cT1a-b in 21 cases, cT1c in 139, cT2 in 48 and cT3 in 10. Disease recurrence was defined as PSA ≥ 0.2 ng/mL in 2 consecutive measurements or initiation of secondary therapy. Results. Postoperative pathological stage was pT2a-b in 33 patients, pT2cN0 in 10, pT3a in 27, pT3b in 36, pT4 in 9 and pN1 in 10. Positive surgical margins occurred in 14.6% and 48.6% for pT2 and pT3 diseases, respectively (P < .001). The overall PSA recurrence-free survival at 3 and 5 years was 82.1% and 74.5%. By the pathological stages, 3-year recurrence-free survival was 92.4% (pT2), 81.1% (pT3a), 62.6% (pT3b-4) and 55.6% (pN1), respectively (P < .001). Conclusions. EPLRP is curative even for some locally advanced prostate cancers in a midterm follow-up. Even at an Asian center of low volume of radical prostatectomy EPLRP still provides oncologic outcomes similar to that of high volume centers.

Five-year progression-free survival in 577 patients operated on with laparoscopic radical prostatectomy for localized prostate cancer

OBJECTIVE

Laparoscopic radical prostatectomy (LRP) was introduced in the Department of Urology, Oslo University Hospital, in 2002. The aim of this study was to report mid-term oncology results and survival data.

MATERIAL AND METHODS

From February 2002 to November 2007, 582 consecutive patients with localized prostate cancer underwent LRP. Data were collected prospectively into a database.

RESULTS

Mean and median follow-up after LRP was 30.3 months (± 15.5) and 36.0 months (range 3-72). Five patients (1%) were lost during follow-up. Two patients died of prostate cancer during the study period and 10 patients died of other causes. The overall positive surgical margin (PSM) rate was 29% and decreased to 13% for the last 100 patients. The overall PSA progression-free survival (PFS) was 85% at 3 years and 73% at 5 years. Gleason score in the tumour specimen, pT stage and surgical margins were statistical significant independent predictors of biochemical PFS.

CONCLUSION

These oncology results and 5-year PFS data after LRP are in line with other reports.

Effectiveness of postgraduate training for learning extraperitoneal access for robot-assisted radical prostatectomy

PURPOSE

To determine the effectiveness of postgraduate training for learning extraperitoneal robot-assisted radical prostatectomy (EP-RARP) and to identify any unmet training needs.

MATERIALS AND METHODS

The training resources used were live surgery observations, digital video disc instruction, postgraduate courses, and literature review. Modifications to the transperitoneal (TP) setup in equipment, patient positioning, port placement, and access technique were identified. A surgeon who had previous experience with 898 TP robot-assisted radical prostatectomies (TP-RARPs) performed EP-RARP in 30 patients. We evaluated setup results, emphasizing access-related difficulties, and compared the EP cohort with a nonrandomized, concurrent TP cohort of 62 patients for short-term outcomes.

RESULTS

The median setup time for EP was 26 minutes (range 15-65 min) for EP compared with 14 to 17 minutes for the comparable TP setup and dropping the bladder. During EP setup and dissection, peritoneal entry occurred in 37%, incorrect port spacing in 10%, epigastric vessel injury in 10%, and other minor pitfalls in 10%. No significant differences were found between EP and TP in postsetup operative times, hospital stay, complications, surgical margin status with organ-confined disease, or lymph node dissection yield. EP had significantly higher estimated blood loss (300 vs 200 mL, P=0.001) and more symptomatic lymphoceles when extended pelvic lymph node dissection was performed (3/16 vs 0/47, P=0.001).

CONCLUSIONS

Using postgraduate education resources, an experienced TP-RARP surgeon successfully transitioned to EP-RARP, achieving the major objectives of safety and equivalent outcomes. We identified several minor nuances in the setup that need further refinement in future education models.