Laparoscopic radical prostatectomy. preliminary pathologic evaluation

A Clinical Evaluation of Robotic-assisted Radical Prostatectomy (RARP) in Located Prostate Cancer: A Systematic Review and Network Meta-analysis

Prostate cancer (PCa) is a prevalent malignant tumor affecting the male reproductive system and there are mainly three widely accepted PCa surgery types in current clinical treatment: open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP). Here, we aimed to evaluate the clinical effect of RARP for PCa patients compared with ORP and LRP based on the context of PCa encompass two dimensions: oncological outcomes (biochemical recurrence (BCR) and positive surgical margin (PSM)) and functional outcomes (urinary continence and recovery of erectile function) in this network meta-analysis (NMA). PubMed, Embase and Cochrane databases were systematically searched in January 7, 2024. 4 randomized controlled trials (RCTs) and 72 non-RCTs were included. RARP displayed significant positive effect on lower BCR and better recovery of erectile function but no significant differences existed among three surgery types for PSM and urinary continence.

Development and application of Reverse Systematic Review on laparoscopic radical prostatectomy

CONTEXT

Evidence-based medicine was widely used in the context of diverse surgical treatments through several systematic reviews (SR). Despite the high level of evidence from these reviews, the specificity of the analyzed outcomes makes it difficult to establish the state of maturity of the analyzed technique neglecting significant bias.

OBJECTIVE

To describe a novel SR methodology based on a temporal population analysis in a Reverse Systematic Review utilizing the case of well-established laparoscopic radical prostatectomy (LRP).

EVIDENCE ACQUISITION

A systematized search was performed in order to obtain the primary studies feeding SR for the composition of a complete database, covering clinical-surgical and bibliometric variables. Quantitative, qualitative, and temporal correlations of studies variables were performed to determine trends regarding results, geographic distribution and bibliometrics to delineate the development and trends of LRP between 2000 and 2017.

EVIDENCE SYNTHESIS

Among a total of 353 SR found, 40 were included and provided 238 primary studies elected to the database composition. An accumulation of studies was found on the Europe-USA axis predominantly in 4 preeminent scientific journals, which scientifically influenced the profile of publications, mainly until 2011 when interest clearly migrates to robotic-assisted surgery reducing the influence of these centers in the development of LRP in an upfront reversal in the standard of publications with a clear shift between LRP and robotic-assisted surgery studies. Operative time, blood loss, and conversion to open surgery showed trend to reduction and only biochemical recurrence (among PENTAFECTA) positively correlated with the year of publication, all with stabilization throughout the period.

CONCLUSION

The Reverse Systematic Review proved to be feasible and effective in demonstrating the evolution of a surgical technique, outlining its "Natural History," which is not captured in the standard SR. In addition, it allowed to identify the presence of scientific influencers and potential biases in the composition of the best evidence in the literature, as well as to trace the curves of development until its technical-scientific maturity. Further studies to test the reproducibility of this methodology may aid in the comparison of diverse surgical techniques. Patient summary: This temporal study analyzed the variables inherent to the publications and the patients in the primary studies of SRs that approached a specific surgical technique. The results demonstrated the scientific maturity of the technique and the vulnerability to scientific influencers in the history of its development.

Incidence and location of positive surgical margin among open, laparoscopic and robot-assisted radical prostatectomy in prostate cancer patients: a single institutional analysis

Objective

To evaluate the positive surgical margin rates and locations in radical prostatectomy among three surgical approaches, including open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy.

Methods

We retrospectively reviewed clinical outcomes at our institution of 450 patients who received radical prostatectomy. Multiple surgeons were involved in the three approaches, and a single pathologist conducted the histopathological diagnoses. Positive surgical margin rates and locations among the three approaches were statistically assessed, and the risk factors of positive surgical margin were analyzed.

Results

This study included 127, 136 and 187 patients in the open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy groups, respectively. The positive surgical margin rates were 27.6% (open radical prostatectomy), 18.4% (laparoscopic radical prostatectomy) and 13.4% (robot-assisted radical prostatectomy). In propensity score-matched analyses, the positive surgical margin rate in the robot-assisted radical prostatectomy was significantly lower than that in the open radical prostatectomy, whereas there was no significant difference in the positive surgical margin rates between robot-assisted radical prostatectomy and laparoscopic radical prostatectomy. In the multivariable analysis, PSA level at diagnosis and surgical approach (open radical prostatectomy vs robot-assisted radical prostatectomy) were independent risk factors for positive surgical margin. The apex was the most common location of positive surgical margin in the open radical prostatectomy and laparoscopic radical prostatectomy groups, whereas the bladder neck was the most common location in the robot-assisted radical prostatectomy group. The significant difference of positive surgical margin locations continued after the propensity score adjustment.

Conclusions

Robot-assisted radical prostatectomy may potentially achieve the lowest positive surgical margin rate among three surgical approaches. The bladder neck was the most common location of positive surgical margin in robot-assisted radical prostatectomy and apex in open radical prostatectomy and laparoscopic radical prostatectomy. Although robot-assisted radical prostatectomy may contribute to the reduction of positive surgical margin, dissection of the bladder neck requires careful attention to avoid positive surgical margins.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: surgical, oncological, and functional outcomes: a systematic review

OBJECTIVES

Despite the wide diffusion of minimally invasive approaches, such as laparoscopic (LRP) and robot-assisted radical prostatectomy (RALP), few studies compare the results of these techniques with the retropubic radical prostatectomy (RRP) approach. The aim of this study is to compare the surgical, functional, and oncological outcomes and cost-effectiveness of RRP, LRP, and RALP.

METHODS

A systematic review of the literature was performed in the PubMed and Embase databases in December 2013. A 'free-text' protocol using the term 'radical prostatectomy' was applied. A total of 16,085 records were found. The authors reviewed the records to identify comparative studies to include in the review.

RESULTS

44 comparative studies were identified. With regard to the perioperative outcome, LRP and RALP were more time-consuming than RRP, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates were the most optimal in the laparoscopic approaches. With regard to the functional and oncological results, RALP was found to have the best outcomes.

CONCLUSION

Our study confirmed the well-known perioperative advantage of minimally invasive techniques; however, available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. On the contrary, cost comparison clearly supports RRP.

[Critic analysis of a comparative meta-analysis on the morbidity, functional and carcinologic results after radical prostatectomy according to surgical approach. Work of cancerology committee of the French urological association]

Surgical approach for radical prostatectomy is even today a subject of debate in the urologic community. Many comparative studies between retropubic and laparoscopic approach (robotic assisted or not) were reported since 10 years without being able to decide between the supporters of retropubic or laparoscopic approach. The committee of cancer research of the French urological association took hold this question after a recent meta-analysis publication on this subject. Although imperfect, this meta-analysis exists and permits to conclude partially on the advantages and the inconveniences supposed for each surgical approach. Regarding morbidity after radical prostatectomy, the only significant difference reported concerns the hemorrhagic risk in favour of the laparoscopic approach. Regarding oncologic results, the only exploitable data concern positive surgical margins rate, which is identical whatever surgical approach. Concerning the functional results, no difference was reported in the literature between different surgical approaches.

Laparoscopic radical prostatectomy: oncological and functional results of 126 patients with a minimum 3-year follow-up at a single Chinese institute

In this study we evaluate the oncological and functional results of the largest cohort of patients in China treated by laparoscopic radical prostatectomy (LRP) and with at least 3 years of follow-up. 126 inconsecutive patients (range 56-78 years, median 62.5) who had an LRP were retrospectively analyzed. The mean prostate specific antigen level and Gleason score was 13.4 ng mL(-1) and 6.4, respectively. Twenty-seven patients had unilateral or bilateral nerve preservation and 29 had pelvic lymphadenectomy. Multivariate analysis was used to adjust for differences in clinical and pathological features when comparing the risk for biochemical progression-free survival (bPFS). Urinary continence was assessed by incontinence questionnaire and erectile function by the Sexual Health Inventory for Men score. The mean operative duration was 250 min and blood loss 354 mL. Five patients received blood transfusion and nine had complications, including rectal injury (two), ureteral injury (one), active bleeding (one), bladder neck stenosis (two), paralytic ileus (one), subcutaneous hematoma (one) and port-site hernia (one). The overall positive surgical margin rate was 20.6% and correlated with pathological stage and Gleason score respectively (P = 0.03, P < 0.001 respectively). All patients had >or= 3 years of follow-up (range 3-6.75 years, mean 4.6, median 4.75). At 3 years of follow-up, the overall survival rate was 100% and the bPFS was 81.0% in all patients; 124 patients (98.4%) were continent; 22 of 27 patients (81.5%) who underwent nerve preservation retained erectile function. Our series confirms that LRP is an effective, safe and precise technique at Chinese institution.

3-year actuarial biochemical recurrence-free survival following laparoscopic radical prostatectomy: experience from a tertiary referral center in the United States

PURPOSE

We performed a prospective analysis of pathological and oncological outcomes following laparoscopic radical prostatectomy at a medical center in the United States.

MATERIALS AND METHODS

A total of 528 men underwent laparoscopic radical prostatectomy between April 2001 and August 2005. We excluded 4 open surgical conversions (0.8%) and 16 men (3.0%) without followup. The remaining 508 men had a mean preoperative prostate specific antigen of 6.0 ng/ml (range 0.3 to 27) and Gleason score of 6.3 (range 6 to 10). Stage was cT1b in 1 case (0.2%), cT1c in 350 (68.9%), cT2a in 135 (26.6%), cT2b in 21 (4.1%) and cT2c in 1 (0.2%). Of the patients 89% underwent cavernous nerve preservation. Biochemical recurrence was defined and timed at the first prostate specific antigen of 0.2 ng/ml or greater if at repeat testing it remained 0.2 ng/ml or greater.

RESULTS

Mean followup was 13.2 months (median 12, range 2 to 52). Pathological stage was pT0N0/Nx in 2 men (0.4%), pT2N0/Nx in 414 (81.5%), pT3aN0/Nx in 72 (14.2%), pT3bN0/Nx in 17 (3.3%) and pT2-3N1 in 3 (0.6%). Positive margin rates increased with higher stage (8.2% in pT2 and 39.3% in pT3 cases, p <0.0001). Three-year actuarial biochemical recurrence-free survival was 98.2% for pT2N0/Nx and 78.7% for pT3N0/Nx/N1 disease (p <0.0001), and it was 94.5% overall. Multivariate analysis controlling for age, preoperative prostate specific antigen, postoperative Gleason score and stage, and margin status showed that only Gleason score (greater than vs less than 7) and stage (pT3 or any N1 vs pT2) predicted biochemical progression.

CONCLUSIONS

Laparoscopic radical prostatectomy can provide excellent cancer control outcomes for clinically localized prostate cancer with high actuarial biochemical recurrence-free survival rates at 3 years.

Pathologic outcome of laparoscopic and open radical prostatectomy

OBJECTIVES

To compare the clinicopathologic data of 286 laparoscopic radical prostatectomies (LRPs) and 714 open radical prostatectomies (RRPs) performed at the Massachusetts General Hospital from 2001 to 2005.

METHODS

A total of 1000 radical prostatectomy procedures were analyzed for prostate weight, pathologic stage, Gleason score, surgical margin status, and positive margin location.

RESULTS

The mean patient age was 58.6 and 59.1 years for the LRP and RRP groups, respectively. The mean preoperative prostate-specific antigen level was 5.96 and 6.00 ng/mL, respectively. Clinical Stage T1c cancer was seen in 86.4% of the LRP and 90.5% of the RRP patients. Gleason score 7 or less disease was seen on biopsy in 97.5% of the LRP and 96.9% of the RRP patients. The average prostate weight was 46.8 g for LRP and 46.0 g for RRP. In the radical prostatectomy specimens, 94.4% of LRP and 93.3% of RRP patients had Gleason score 7 or less disease and 86.0% of LRP and 81.7% of RRP patients had pathologic Stage pT2 cancer. The rate of positive surgical margins was 15.0% and 17.4% for the LRP and RRP groups, respectively. The positive margins occurred mainly at the peripheral and apical regions in both groups. No significant difference was found in the preoperative variables or final pathologic findings between the two surgical groups.

CONCLUSIONS

With similar case selection, LRP and RRP achieve similar pathologic outcomes.

Comparison of operative and functional outcomes of laparoscopic radical prostatectomy and radical retropubic prostatectomy: Single surgeon experience

OBJECTIVES

To compare radical retropubic prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) outcomes in a contemporary series.

METHODS

A total of 70 LRP patients operated on between 2001 and 2002 with at least 18 months of follow-up were selected. These patients were compared with a matched cohort of 70 patients who had undergone RRP by the same surgeon from 1999 to 2001. The baseline patient characteristics, perioperative and histologic parameters, recovery time, complications, and 18-month functional data were compared.

RESULTS

No significant differences were found in the preoperative characteristics. The mean operative time was 181.8 +/- 18.7 minutes for RRP and 246.4 +/- 46.1 minutes for LRP (P <0.0001). The mean estimated blood loss was 563.2 mL for RRP and 275.8 mL for LRP (P <0.0001). The positive margin rate was 20% and 15.7% for the RRP and LRP groups, respectively (P = NS). The mean pain score on postoperative day 1 was 4.5 in the LRP group and 7.8 in the RRP group on an analog pain score of 0 to 10 (P = 0.02). Full recovery was achieved at 33 +/- 17 days and 45 +/- 20 days for the LRP and RRP groups, respectively (P <0.001). The total perioperative complication rate for LRP and RRP was comparable at 18.5% and 15.7%, respectively. The diurnal continence rate (no pads) for the LRP and RRP groups was 70%, 90%, and 92.8% and 71.4%, 87.6%, and 92% at 6, 12, and 18 months, respectively (P = NS). The potency rate after bilateral neurovascular preservation with or without sildenafil for the LRP and RRP group was 55%, 72.6%, and 79.5% and 43%, 58%, and 72.4% at 6, 12, and 18 months, respectively (P = NS).

CONCLUSIONS

LRP is well tolerated and provides short-term oncologic and functional results comparable to those of RRP.

Laparoscopic Radical Prostatectomy for Localized Prostate Cancer: A Systematic Review of Comparative Studies

PURPOSE

We compared the safety and efficacy of laparoscopic and open radical prostatectomy through a systematic assessment of the literature.

MATERIALS AND METHODS

Literature databases were searched from 1996 to December 2004 inclusive. Studies comparing transperitoneal laparoscopic radical prostatectomy, extraperitoneal endoscopic radical prostatectomy or robot assisted radical prostatectomy with open radical retropubic prostatectomy or radical perineal prostatectomy for localized prostate cancer were included. Comparisons between different laparoscopic approaches were also included.

RESULTS

We identified 30 comparative studies, of which none were randomized controlled trials. There were 21 studies comparing laparoscopic with open prostatectomy with a total of 2,301 and 1,757 patients, respectively, and 9 comparing different laparoscopic approaches with a total of 1,148 patients. In terms of safety there did not appear to be any important differences in the complication rate between laparoscopic and open approaches. However, blood loss and transfusions were lower for laparoscopic approaches. In terms of efficacy operative time was longer for laparoscopic than for open prostatectomy but length of stay and duration of catheterization were shorter. Positive margin rates and recurrence-free survival were similar. Continence and potency were not well reported but they appeared similar for the 2 approaches. There were no important differences between laparoscopic approaches.

CONCLUSIONS

Laparoscopic radical prostatectomy is emerging as an alternative to open radical prostatectomy but randomized, controlled trials considering patient relevant outcomes, such as survival, continence and potency, with sufficient followup are required to determine relative safety and efficacy.

Laparoscopic radical prostatectomy: minimum 3-year follow-up of the first 100 patients in the UK

OBJECTIVE

To present the results of the first 100 patients in the UK treated by laparoscopic radical prostatectomy (LRP) and with at least 3 years of follow-up, as LRP continues to develop as a minimally invasive alternative to open radical prostatectomy.

PATIENTS AND METHODS

In all, 100 patients (mean age 62 years, range 52-72) had a transperitoneal LRP by one surgeon during a 25-month period from 2000 to 2002. Most (78%) patients had a prostate-specific antigen level of 4-10 ng/mL, clinical stage T1 disease (62%), and Gleason 6 on biopsy (50%). Sixty-four patients had unilateral or bilateral nerve preservation and 14 had pelvic lymphadenectomy.

RESULTS

The mean operative duration was 245 min, with a 1% conversion rate. Three patients received a blood transfusion and three had major complications, including a rectal injury. The positive margin rate was 16% and correlated with pathological variables. At > or = 3 years of follow-up (mean 3.7) the overall survival rate was 99% and the biochemical progression-free survival was 88% in all patients, at 90% for pT2 and 75% for pT3. Ninety patients used 0-1 pads/day (84% pad-free) and 60 undergoing nerve preservation retained erectile function.

CONCLUSION

This series includes the first results for LRP with a > or = 3-year follow-up reported from the UK, with oncological control and morbidity comparable to those in previously published open and laparoscopic series. The history of open radical prostatectomy suggests that as the technique of LRP develops and experience with it increases, these results are likely to improve.

Nerve Sparing Laparoscopic Radical Prostatectomy: Our Technique

PURPOSE

To describe our technique of nerve sparing laparoscopic radical prostatectomy (LRP). We present the oncological and functional results (potency and urinary continence).

MATERIAL AND METHODS

LRP has become standard at our institution based on experience with more than 2800 consecutive cases operated on between 1997 and 2005. From May 2003 to March 2005 a total of 677 LRP were performed, 425 consecutive patients candidates for a nerve sparing technique have been operated using the intrafascial approach. The challenge of our technique is to remove the prostate without any thermic and mechanic traumatism, avoiding dissection of outer layer. Oncological data were assessed by pathological examination and post-operative PSA level. Functional results were assessed with a self questionnaire.

RESULTS

By pathological stage, 2 pT2a specimens (7.4%), 7 pT2b specimens (21%), 44 pT2c specimens (24%), 63 pT3a specimens (43%), 11 pT3b specimens (46%) were found to have positive surgical margins (SMs). In 86 specimen (59%) positive SMs were focal inframillimetric. Median follow-up was 11 months (range 1-22). The continence rate (no leakage/no pad) was 95% at 6 months, confirmed at 12 months among 202 patients. For 137 patients, potency rate was 58.5% at 12 months.

CONCLUSION

Intrafascial LRP provides satisfactory results in regard to recovery of continence and sexual function. Long-term progression and survival outcome are necessary before this procedure should be offered as a replacement for interfascial nerve sparing technique.

[Decreased number of R1-resections in radical retropubic prostatectomy. Use of a newly developed fast sectioning technique]

Therapeutic success and prognosis in RRP is determined by negative surgical margins. In order to minimize the proportion of positive surgical margins in the final histological evaluation, valid intraoperative control by means of frozen margin analysis is indispensable. We have developed and evaluated a new frozen margin procedure based on the Stanford method with transverse and sagittal cut directions. This technique facilitates comprehensive intraoperative evaluation of curved margin areas for the first time. Retrospective analysis of the results of the new frozen section technique revealed positive surgical margins in 2.7% of patients. The results obtained with this new technique were significantly superior to those obtained with two established techniques (10.3%, P < or =0.001; 17.2%, P < or =0.001). Our results demonstrate that the new frozen margin technique is clearly more sensitive for intraoperative detection of positive margins and thus leads to substantially higher rates of negative surgical margins.

LAPAROSCOPIC RADICAL PROSTATECTOMY

PURPOSE

After the pioneering period when only few teams were performing the procedure, the laparoscopic approach to radical prostatectomy has become widespread with several technical variations. A comprehensive review of the published literature on laparoscopic radical prostatectomy was performed to determine the current state of the art of this surgical innovation in terms of perioperative parameters, functional results and cancer control.

MATERIALS AND METHODS

English language, peer reviewed articles published before June 2004 concerning laparoscopic radical prostatectomy were found by MEDLINE query. All articles were analyzed and none were a priori excluded. Conclusions were drawn from series of 50 or more patients.

RESULTS

Laparoscopic radical prostatectomy is being performed at multiple centers worldwide using various surgical approaches and technologies. Analysis of perioperative parameters, including surgical blood loss, operative time, complications and convalescence, demonstrated low morbidity and showed a clear trend toward improvement with increased experience. The reported positive surgical margin rates were lower in more recent series. As measured by prostate specific antigen recurrence and disease-free intervals, oncological results and cancer control rates are difficult to ascertain in the immature series published to date. Functional results in terms of postoperative urinary and sexual function appear encouraging.

CONCLUSIONS

Overall the current operative, oncological and functional results of laparoscopic radical prostatectomy appear to approximate those of open radical retropubic prostatectomy. These results justify the considerable interest of the urological community in laparoscopy, as evidenced by its widespread application. Nevertheless, longer followup and more mature data are needed definitively to establish laparoscopic radical prostatectomy as an alternative to the retropubic approach.

Prostatectomía radical laparoscópica. ¿Sólo en Centros de excelencia?

OBJECTIVES

To present and evaluate our experience and initial results in radical laparoscopic prostatectomy which we have been using for two and an half years in our General Hospital (covering a total population of 200.000 inhabitants).

MATERIAL AND METHODS

Between December 2002 and August 2005, were selected 26 patients for radical laparoscopic prostatectomy (25 transperitoneal and 1 extraperitoneal). Mean age was 62.3 +/- 5.3 years (range 52-69). Mean PSA level was 9.16 +/- 4.20 ng/mL (range 5.26 to 24.3). Pre-operative classification was Tlc in 10 patients (38.4%), T2a in 8 (30.8%) and T2b in 8. Mean Gleason Score was 6 +/- 0.8 (range 4-7). Three patients had undergone preoperatively neo-adjuvant hormonal blockage (11.5%). Simultaneous bilateral inguinal lymphadenectomy was performed in two patients. In no case did we consider a nerve sparing approach.

RESULTS

The procedure was accomplished in 20 patients. Mean follow-up was 12.4 +/- 8.6 months (range 3 - 34). There was no perioperative mortality. Conversion to open surgery was required six times in the ten first cases but not thereafter. Mean operating time for the whole series was 303 +/- 95 minutes (range 150-540) but with a distinct difference between the first fourteen and the last six cases: 332 +/- 92.58 versus 236.6 +/- 66.5 (p<0.02). Mean blood loss was 90.25 +/- 46.5 ml. There were early postoperative complications in 4 patients (15.38%). Final pathological staging was: T2a in three patients (15%), T2b (50%) in 10, T3a (15%) in three and T3b (20%) in four. Positive margins were found in three cases (11.5%): T2b, T3a and T3b. Mean hospitalisation time was 4.7 +/- 3.1 days. Provided there was no urinary leakage, the urinary catheter was removed at 12.7 +/- 2.7 days. Full continence at three months was achieved in 17 of the patients (85%) who had undergone the full laparoscopic procedure.

CONCLUSIONS

Our previous experience in other major laparoscopic procedures has allowed us to perform radical laparoscopic prostatectomy with a fast learning curve even in a setting of a relatively low population. Initial long term results seem similar to those achieved with conventional surgery.

Comparison of Early Oncologic Results of Laparoscopic Radical Prostatectomy by Extraperitoneal versus Transperitoneal Approach

PURPOSE

Compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach.

METHODS

330 consecutive men underwent laparoscopic radical prostatectomy for localized prostate cancer, the first 165 by transperitoneal approach, and the last 165 by extraperitoneal approach. Clinical stage, serum PSA, Gleason score of biopsy were recorded, as well as operating time, surgical and medical complications, blood loss, length of hospital stay and catheterization time. The weight of the specimen, pathological stage (1997 TNM classification) and status of the surgical margins were noted. The Fisher test as well as the chi2-test were used for statistical analysis. Differences were considered significant when p < 0.05.

RESULTS

There were no significant differences between the two groups in terms of preoperative characteristics except for Gleason score of the biopsies which was higher in the extraperitoneal group (p < 0.0001). The operating time was longer with the transperitoneal approach (248.5 min vs. 220.0 min, p < 0.0001). There was no difference in transfusion rate (1.2% vs. 5.4%, transperitoneal vs. extraperitoneal, respectively, p = 0.6). There was no difference in hospital stay, medical and surgical complications. Respectively, in the transperitoneal and extraperitoneal groups, there were 108 and 88 pT2 tumors. There were no differences in terms of positive surgical margins between the two groups, 23% and 29.7% (p = 0.21) overall, 13.0% and 17.0% (p = 0.42) in pT2 tumors and 43.6% and 44.7% (p = 0.99) in pT3 tumors.

CONCLUSIONS

Extraperitoneal approach offers the same early oncological results as transperitoneal approach with a shorter operative time.

Impact of Learning Curve in Laparoscopic Radical Prostatectomy on Margin Status: Prospective Study of First 100 Procedures Performed by One Surgeon

PURPOSE

To describe the experience of a single surgeon with his first 100 laparoscopic radical prostatectomies and determine the impact of the learning curve on the surgical margin status according to the rate of nervesparing procedures.

PATIENTS AND METHODS

Between December 2000 and April 2002, 100 laparoscopic radical prostatectomies were performed by one surgeon without any selection of patients and without the help of any other surgeon. The procedures were divided in four groups of 25 consecutive cases. There was no significant difference among the groups in terms of age, clinical and pathological stage, or Gleason score. Nerve-sparing (NS) dissection was performed when the procedure was easy. Positive surgical margins (SM+) were measured and classified according to their location.

RESULTS

The overall rate of SM+ was 12.8% in pT2 and 31.8% in pT3 tumors. The SM+ rate was not significantly different among the groups. In contrast, the number of NS dissections (49 patients) increased from group 1 to group 4. Both the positive margin length and the rate of multiple positive margins were significantly lower in the 50 most recent patients.

CONCLUSION

Nerve-sparing surgery was performed with increasing frequency during this learning curve without compromising the surgical margins. The results suggest that experience could lead to a decrease of both the positive margin length and the rate of multiple positive margins. The impact on cancer control and potency is under evaluation.

Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? An analysis of peri-operative morbidity in two contemporary series in Italy

OBJECTIVE

To compare morbidity in two groups of patients who underwent retropubic or laparoscopic radical prostatectomy in the same period.

PATIENTS AND METHODS

The clinical and pathological data obtained in 50 consecutive patients who underwent retropubic radical prostatectomy (RRP) from January 2001 to December 2001 were compared to those obtained in 71 consecutive patients who were treated in the same year by extraperitoneal laparoscopic radical prostatectomy (LRP). The two groups were comparable in terms of mean pre-operative PSA and biopsy Gleason score. The peri-operative data included operative time, intra-operative and post-operative transfusion rates, complication rates, hospitalization length, and duration of catheterization. The following pathological parameters were considered: Gleason score, pathological stage, and positive surgical margin rate. A comparative evaluation of continence recovery (no pads and any leakage) was made only in patients with follow-up longer than 12 months.

RESULTS

The two groups were comparable in terms of pathological stage and definitive Gleason score. Operating times were significantly shorter in RRP (p<0.0001). LRP patients showed higher autologous (p<0.001) and eterologous transfusion (p=0.03). No significant difference was observed in terms of complication rates (p=0.07). The rectal injury rate was 2.8% in the laparoscopic group. The mean post-operative hospital stay was 10.2+/-2 days in the surgery group and 7.2+/-3.4 days in the laparoscopy group (p<0.001). Catheterization time was 8.4+/-0.9 days in the surgery group and 8+/-2.8 days in the laparoscopy group (p=0.27). After 12 months, complete continence was achieved in 64% of RRP and 40% of LRP patients, respectively (p=0.29).

CONCLUSION

The results of our non-randomized study show that up to now laparoscopic radical prostatectomy does not provide significant advantages in terms of peri-operative morbidity compared with the traditional retropubic approach.

Intraoperative Frozen Section Analysis During Nerve Sparing Laparoscopic Radical Prostatectomy: Feasibility Study

PURPOSE

Nerve sparing radical prostatectomy may allow preservation of potency but it can increase positive surgical margins. We used intraoperative frozen section (IFS) analysis to monitor the nerve sparing procedure in laparoscopic prostatectomy.

MATERIALS AND METHODS

A total of 100 patients with localized prostatic carcinoma underwent bilateral intrafascial nerve sparing laparoscopic prostatectomy with IFS. A wedge of tissue was cut from base to apex in the region of the neurovascular bundles (NVBs) and analyzed on frozen section. If carcinoma was detected at the inked margin, the corresponding NVB was resected. Definitive margin status was evaluated after permanent section analysis of IFS prostatectomy specimens and eventually NVB specimens.

RESULTS

IFS analysis was positive in 24 patients, as confirmed in all by permanent section of the wedges. Three of these patients had positive margins in the prostate specimen at another site. Of the 76 tumors with negative IFSs 1 had positive margins on permanent sections of the wedges and 8 had positive margins on the prostate specimen at another site. IFS led to a decrease in the overall positive margin status from 33% to 12% and from 26.1% to 7.9% in pT2 tumors. Tumor was found on NVB resection in 8 cases (33%).

CONCLUSIONS

These results suggest that IFS analysis is a reliable method by which to monitor nerve sparing during laparoscopic prostatectomy. IFS could allow the surgeon to offer a nerve sparing procedure more frequently without compromising cancer control.