Assessment of surgical technique and perioperative morbidity associated with extraperitoneal versus transperitoneal laparoscopic radical prostatectomy

State of art of robotic prostatectomy: the way we do it in Catalonia, Spain

INTRODUCTION AND OBJECTIVE

Robotic-assisted laparoscopic prostatectomy (PLAR) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the PLAR "state of art" in Catalonia, Spain.

MATERIAL AND METHODS

This was a cross-sectional survey-based study conducted among urologists across Catalonia, Spain. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v20.

RESULTS

59 urologists completed the survey, revealing PLAR as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the Airseal technology. The intraperitoneal approach is performed in >90% of cases. Endopelvic fascia preservation is not routinely performed. 34.5% of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. 34% performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95%CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95%CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95%CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized.

CONCLUSIONS

The study provides an overview of the state of PLAR in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Comparison of Perioperative, Functional, and Oncological Outcomes of Transperitoneal and Extraperitoneal Laparoscopic Radical Prostatectomy

Purpose

This study aimed to compare the oncological, functional, and perioperative outcomes of localized and locally advanced prostate cancer treated with intraperitoneal or extraperitoneal laparoscopic radical prostatectomy (LRP).

Methods

From April, 2008, through December, 2020, 266 patients underwent laparoscopic radical prostatectomy, 168 cases with an extraperitoneal approach (E-LRP) and 98 cases using a transperitoneal approach (T-LRP). The clinical, perioperative, functional, and oncological outcomes were collected and compared between these groups. At the 3-, 12- and 24-monthfollow-ups, the functional outcomes tested were urinary function (urinary domain of EPIC) and sexual function (sexual domain of EPIC). The oncological outcomes of biochemical recurrence, biochemical recurrence-free survival, and positive surgical margin status were evaluated. Univariable and multivariable Cox regression analyses were used to identify factors predictive for biochemical recurrence. All statistical analyses used the R program.

Results

The patient characteristics were similar between the E-LRP and T-LRP groups except for higher prostatic-specific antigen (PSA) in the T-LRP group. The T-LRP had lower overall operative time (222.5 min vs. 290 min, p 0.001), decreased blood loss (400 ml vs. 800 ml, p < 0.001), and shorter hospital stays (4 days vs. 7 days, p < 0.001) compared to the E-LRP. Early sexual intercourse with penetration at 3 months was higher in the T-LRP group (36.7% vs. 15.5%, p 0.001). Urinary continence (no pads) was not different between the T-LRP and E-LRP groups at 3 and 24 months after surgery but higher in the E-LRP group at 12 months (1% vs. 3%; p=0.419, 85.1 vs. 83.7%; p=0.889, 47.4% vs. 34.6%; p=0.028, respectively). The EPIC questionnaire was used to assess functional outcomes at 3, 12, and 24 months after surgery and found that urinary function was significantly higher in the T-LRP group at 3 and 12 months (p < 0.001) but did not show a difference at 24 months (p=0.734), and sexual function scores were higher in the T-LRP group at 12 and 24 months (p=0.001). The positive surgical margin rate was higher in the E-LRP (38.7% vs. 21.4%; p=0.006). The BCR rate was not different between the groups (36.3% in the E-LRP group and 27.6% in the E-LRP group; p=0.184).

Conclusion

Transperitoneal laparoscopic radical prostatectomy (T-LRP) was found to be superior to extraperitoneal radical prostatectomy (E-LRP) in perioperative outcomes such as decreased operative time, decreased blood loss, shorter hospital stay, lower positive surgical margin, and improved early sexual intercourse and sexual function. The urinary functional outcome was better in the T-LRP group at 3 and 12 months. These findings support the use of transperitoneal laparoscopic radical prostatectomy, as our study patients exhibited significant benefits from this procedure.

Extraperitoneal Laparoscopic Versus Transperitoneal Robot-Assisted Laparoscopic Approaches for Extended Pelvic Lymph Node Dissection During Radical Prostatectomy

Background: We aim to directly compare the feasibility and safety of extended pelvic lymph node dissection (PLND) during transperitoneal robotic-assisted radical prostatectomy (Tp-RARP) and extraperitoneal laparoscopic radical prostatectomy (Ep-LRP). Materials and Methods: We retrospectively identified the prospectively maintained database records of 162 patients diagnosed with prostate cancer (PC) who underwent Ep-LRP or Tp-RARP with extended PLND. Patients with risk of nodal metastases over 5% according to Briganti nomogram received extended PLND. All data analyzed in this study were based on the documentation in our PC database including age, body mass index, Charlson comorbidity index score, preoperative prostate-specific antigen, history of abdominal surgery, biopsy Gleason score, total operation time, postoperative pelvic drainage time, pathological results, lymph node yield (LNY), percentage lymph node involvement (%LNI), and perioperative complications. Patients were followed up for biochemical recurrence in the postoperative period. Results: Eighty-two of the 162 enrolled patients were in group 1 (Ep-LRP+PLND) and 80 were in group 2 (Tp-RARP+PLND). There were no statistically significant differences between the groups regarding preoperative demographics and clinical characteristics. The median LNY was 17 (range 8-27) and 17.5 (range 10-29) in groups 1 and 2, respectively, and no statistically significant difference was found. There was no significant difference between the groups in terms of biochemical recurrence-free survival with mean follow-up of 44.8 months after radical surgery. Conclusion: Our results support the view that extended PLND through the Ep-LRP approach is a feasible and safe procedure without compromising oncological efficacy compared with a similar template attempted during Tp-RARP. Clinical Trial Registration number is 01/21-2.

Predictors of Prolonged Laparoscopic Radical Prostatectomy and the Creation of a Scoring System for the Duration

Purpose

To identify the relevant factors, and create and validate a predictive scoring system for the duration of laparoscopic radical prostatectomy (LRP).

Patients and Methods

We retrospectively analyzed clinicopathological data from 436 patients who underwent LRP between January 2014 and January 2019, of whom 304 cases were used as a model creation group and 132 were used as a validation group. Uni/multivariate linear regression analysis was performed to determine the predictors of the duration of the procedure and a novel scoring system was created using these predictors. External validation of the scoring system was performed. The Hosmer–Lemeshow test was used to determine the goodness-of-fit of the model and calibration plots were created for visual assessment.

Results

“Prolonged duration” was defined as a duration of the procedure that was longer than the mean (>150 min) duration. Multivariate analysis showed that body mass index (BMI), prostate volume, intravesicular protrusion of the prostate (IPP), the ratio of the cross-sectional areas of the prostate and the Retzius space (P/R), pelvic lymph node dissection, and neurovascular bundle (NVB) preservation were significant predictors of prolonged duration. A scoring system that included these six parameters was created and the area under the curve achieved during receiver operating characteristic analysis using this scoring system was 0.874 (95% confidence interval [CI]: 0.836–0.913). The Hosmer–Lemeshow test showed that the scoring system was well calibrated (X²=5.339, P=0.376). The external validation showed that the model had high predictive accuracy (AUC=0.835, 95% CI: 0.764–0.906) and goodness-of-fit (X²=4.401, P=0.493).

Conclusion

The following factors were significantly associated with prolonged duration of laparoscopic radical prostatectomy: BMI, prostate volume, IPP, P/R, pelvic lymph node dissection, and NVB preservation. The novel scoring system created can be used to accurately predict the duration of the procedure, assess the difficulty of surgery, and improve perioperative efficiency.

Transperitoneal versus extraperitoneal robot-assisted laparoscopic radical prostatectomy on postoperative hepatic and renal function

Background

In this retrospective study, we evaluated the effect of two approaches of robotic-assisted laparoscopic radical prostatectomy (RALP). The first approach was pneumoperitoneum via transperitoneal (TP-RALP), and the second approach was extraperitoneal (EP-RALP) on visceral function. We aimed to provide clinical evidence for the perioperative safety with RALP and to help the surgical team choose an appropriate approach for those with hepatic or renal insufficiency.

Methods

One hundred and fifty-seven eligible prostate cancer patients from 2015 to 2019 were included in this study. The postoperative related laboratory tests were compared between transperitoneal and extraperitoneal. The primary endpoint was hepatic and renal function. We also evaluate the intraoperative amount of bleeding, the length of postoperative hospital stays, the occurrence of postoperative complications (lymphatic leakage, bleeding, and infection), and the prostate-specific antigen (PSA).

Results

Postoperative total bilirubin and bound bilirubin in both groups were significantly increased, while total protein, albumin, globulin, urea, and uric acid were significantly decreased (P<0.05). The total protein, albumin, and globulin are significantly higher in the EP-RALP group than in the TP-RALP group (P<0.05) postoperatively. There are no statistical differences in estimated glomerular filtration rate (eGFR) and creatinine clearance (CCR) between these two groups, postoperatively.

Conclusions

RALP had a significant effect on hepatic function after both TP-RALP and EP-RALP approaches, while the latter showed a lesser extent. Our results suggested that pneumoperitoneal pathways have significant effects on protein consumption. Thus, we should require a more cautious choice of surgical approaches when it comes to patients with impaired hepatic function or under risk of hepatic malfunction.

Transperitoneal versus extraperitoneal approach in laparoscopic radical prostatectomy: A meta-analysis

BACKGROUND

To compare the transperitoneal approach with extraperitoneal approach in laparoscopic radical prostatectomy (LRP) (including pure and robotic-assisted LRP) using meta-analytic techniques.

METHODS

Medline (PubMed), Embase, Ovid, CMB, and Cochrane databases were searched for studies that compared the transperitoneal and extraperitoneal approaches in LRP from January 2000 to January 2017. Outcomes included were operative time, operative bloods joss (milliliters), rate of transfusion, rate of open conversion, rate of intraoperative complications, rate of postoperative complications, and time of postoperative catheterization.

RESULTS

Thirteen studies including 1674 patients were selected for the meta-analysis. 850 (50.8%) cases had undergone transperitoneal LRP (TLRP) and 824 (49.2%) cases had undergone the extraperitoneal LRP (ELRP). Comparison of operative time between the TLRP group and the ELRP group showed no significant differences (weighted mean difference [WMD] = 21.21,95%CI = -1.16-43.57, P = .06). No significant differences were observed in blood loss (WMD = -6.04, 95%CI = -43.38-31.29, P = .75) and the rate of transfusion (odds ratio [OR] = 1.03, 95%CI = 0.55-1.96, P = .92) between the 2 groups. No significant differences were observed for the rate of intraoperative complications (OR = 1.25, 95%CI = 0.57-2.21, P = .75) and the rate of open conversion (OR = 1.12, 95%CI = 0.32-4.97, P = .75). Significant differences were observed in the TLRP group compared with the ELRP group (OR = 1.69, 95%CI: 1.23-2.32, P = .001) regarding the rate of postoperative complications.

CONCLUSIONS

Our meta-analysis findings revealed that the TLRP group showed no significant differences in most important indicators compared with ELRP. Moreover, TLRP showed higher rate of postoperative complications compared with ELRP.

Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis

Objectives

To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP).

Methods

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be ≥6 months.

Results

In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of −0.30 days (95% confidence interval [CI] −0.35, −0.24) for the laparoscopic group and 1.09 days (95% CI −1.47, −0.70) for the robotic group (P < 0.001). Early continence rates favoured the E-RP group, although this was statistically significant only in the laparoscopic group (odds ratio [OR] 2.52, 95% CI 1.72, 3.70; P < 0.001). There was no statistically significant difference between the E-RP and T-RP cohorts for 12-month continence rates for both the laparoscopic (OR 1.55, 95% CI 0.89, 2.69; P = 0.12) and robotic groups (OR 3.03, 95% CI 0.54, 16.85; P = 0.21). The overall complication and ileus rates were significantly lower in the E-RP cohort for both the laparoscopic and robotic groups. The symptomatic lymphocele rate favoured the T-RP cohort, although this was statistically significant only in the laparoscopic group (OR 8.69, 95% CI 1.60, 47.17; P = 0.01).

Conclusion

This review suggests that the extraperitoneal approach is associated with a shorter hospital stay, lower overall complication rate, and earlier return to continence when compared to the transperitoneal approach. The transperitoneal approach has a lower lymphocele rate.

Comparison of antegrade and retrograde laparoscopic radical prostatectomy techniques

We evaluated the effect of antegrade and retrograde approaches on functional recovery and surgical outcomes of extraperitoneal laparoscopic radical prostatectomy (LRP). We analyzed 135 patients who underwent extraperitoneal LRP, with the retrograde technique performed on 42 (31%; Group 1) and the antegrade technique on 93 (69%; Group 2). Both groups were statistically similar with respect to age, clinical stage, preoperative prostate-specific antigen (PSA) and American Society of Anesthesiologists (ASA) scores, prostate volume, and previous surgical history. Mean operative time was significantly longer in Group 1 (244±18.3 vs. 203.3±18.4 min, p<0.001), whereas mean anastomosis times for both groups were similar (35.8±7.2 vs. 34.7±5.8 min, p=0.155). Estimated blood loss and transfusion rates were significantly lower in Group 2. A significant difference was observed for both hospitalization (6.79±3.3 vs. 5.46±3.08 days, respectively; p=0.026) and catheterization times (12.24±2.1 vs. 11±1.08 days, respectively; p=0.001) for Group 2. The total complication rate was 47.6% in Group 1, and 11.8% in Group 2 (p<0.01). Rates of positive surgical margins were 14.2% and 15% for Groups 1 and 2, respectively. At the 12-month interval from operation, similar recoveries in urinary continence were obtained for both groups (81% in Group 1; 91% in Group 2). Upon comparison of the two LRP techniques, we found that both were effective; however, the latter resulted in lower minor complication rate, lower blood loss, shorter operation time, and shorter length of hospital stay.

Extraperitoneal robot-assisted laparoscopic radical prostatectomy: Initial experience

OBJECTIVES

To report our initial experience and technique of performing robot-assisted laparoscopic radical prostatectomy (RALP) with the extraperitoneal approach.

MATERIALS AND METHODS

Twenty-seven patients, between September 2010 to January 2012, were included in the study. All patients underwent extraperitoneal robot-assisted radical prostatectomy. Patients were placed supine with only 10-15(0) Trendelenburg tilt. The extraperitoneal space was developed behind the posterior rectus sheath. A five-port technique was used. After incision of endopelvic fascia and ligation of the deep venous complex, the rest of the procedure proceeded along the lines of the transperitoneal approach.

RESULTS

The mean patient age, prostate size and Gleason score were 67 ± 1.8 years, 45 ± 9.55 g and 6, respectively. The mean prostate-specific antigen (PSA) was 6.50 ng/mL. The mean time required for creating extraperitoneal space, docking of robot and console time were 22, 7 and 94 min, respectively. The mean time to resume full oral feeds was 22 ± 3.45 h. There were no conversions from extraperitoneal to transperitoneal or open surgery in our series. Pathological stage was pT1, pT2a and pT3b in 11 (40.74%), 14 (51.85%) and two (7.4%) patients, respectively. Two patients had positive surgical margins and two had biochemical recurrence at the last follow-up. Our mean follow-up was 12 ± 3.30 (2-17) months. The overall continence rate was 83.33% and 92.4% at 6 and 12 months, respectively.

CONCLUSIONS

Extraperitoneal RALP is an efficacious, minimally invasive approach for patients with localized carcinoma of the prostate.

Robotic-assisted radical prostatectomy after the first decade: surgical evolution or new paradigm

Early studies indicate that robotic-assisted radical prostatectomy (RARP) has promising short-term outcomes; however, RARP is beyond its infancy, and the long-term report cards are now beginning. The important paradigm shift introduced by RARP is the reevaluation of the entire open radical prostatectomy experience in surgical technique by minimizing blood loss and complications, maximizing cancer free outcomes, and a renewed assault in preserving quality of life outcomes by many novel mechanisms. RARP provides a new technical “canvas” for surgical masters to create upon, and in ten years, has reinvigorated a 100-year-old “gold standard” surgery.

A comparison of extraperitoneal and intraperitoneal approaches for robotic prostatectomy

OBJECTIVES

This study compared oncologic and health-related quality-of-life outcomes among patients undergoing intraperitoneal or extraperitoneal robotic prostatectomy.

METHODS

Of 215 patients undergoing robotic prostatectomy, the approach was intraperitoneal in 48 and extraperitoneal in 167. Cancer control was evaluated using margin status. Recovery after surgery and functional health was assessed using the convalescence and recovery evaluation and expanded prostate cancer index composite questionnaires, respectively.

RESULTS

Positive surgical margin rates were similar between approaches (14% extraperitoneal, 10% intraperitoneal; P = .63). Functional outcomes were slightly improved for those with the extraperitoneal approach (i.e., higher urinary irritation/obstruction scores at 3 months). The extraperitoneal group demonstrated higher activity (91.8 vs 83.3, P = .03) and cognitive scores (94.9 vs. 91.7, P = .04) at 6 weeks as well as higher gastrointestinal scores at 2 weeks (94.2 vs. 90.8, P = .05).

CONCLUSIONS

These data support efforts to broaden the adoption of the extraperitoneal approach for robotic prostatectomy.

Transperitoneal versus extraperitoneal laparoscopic radical prostatectomy during the learning curve: does the surgical approach affect the complication rate?

PURPOSE

To compare the perioperative complication rate obtained with the transperitoneal laparoscopic radical prostatectomy (TLRP) and with the extraperitoneal LRP (ELRP) during the learning curve (LC).

MATERIALS AND METHODS

Data of the initial 40 TLRP (Group 1) were retrospectively compared with the initial 40 ELRP (Group 2). Each Group of patients was operated by two different surgeons.

RESULTS

The overall surgical time (175 min x 267.6 min; p < 0.001) and estimated blood loss (177.5 mL x 292.4 mL; p < 0.001) were statistically better in the Group 1. Two intraoperative complications were observed in Group 1 (5%) represented by one case of bleeding and one case of rectal injury, whereas four complications (10%) were observed in Group 2, represented by two cases of bleeding, one bladder and one rectal injuries (p = 0.675). Open conversion occurred once in each Group (2.5%). Overall postoperative complications were similar (52.5% x 35%; p = 0.365). Major early postoperative complications occurred in three and in one case in Group 1 and 2, respectively. Group 1 had two peritonitis (fecal and urinary), leading to one death in this group.

CONCLUSIONS

No statistical differences in overall complication rates were observed. The transperitoneal approach presented more serious complications during the early postoperative time and this fact is attributed to the potential chance of intraperitoneal peritonitis not observed with the extraperitoneal route.

Comparison of oncological results, functional outcomes, and complications for transperitoneal versus extraperitoneal robot-assisted radical prostatectomy: a single surgeon's experience

BACKGROUND AND PURPOSE

To compare the oncologic results, functional outcomes, and complications of transperitoneal (TP) and extraperitoneal (EP) robotic radical prostatectomy.

PATIENTS AND METHODS

From June 2007 to April 2009, 105 patients underwent TP robotic radical prostatectomy, and 155 patients underwent EP robotic radical prostatectomy. Clinicopathological and perioperative data were compared between the two groups. Postoperative complications and functional outcomes including potency and incontinence were assessed.

RESULTS

Patient demographics were similar in the TP and EP groups. No significant differences in positive surgical margins were noted between the groups. The total operative time, number of lymph nodes removed, and estimated blood loss were also not significantly different. However, the robot console time was shorter for the EP group than for the TP group (89.1 vs. 107.8 minutes, p = 0.03). Postoperative pain scale scores were lower in the EP group than in the TP group (2.7 vs. 6.3, p < 0.001). The incidence of ileus and hernia were lower in the EP group; however, the incidence of lymphocele was higher in the EP group. Postoperative potency and continence rates were similar between the groups; however, the EP group had a faster recovery of continence compared with the TP group.

CONCLUSIONS

The EP approach has similar oncological and perioperative results, less postoperative pain, less bowel-associated complication, and better functional outcomes than those of the TP approach. The EP approach may be an important alternative in robotic radical prostatectomy.

How do young residents practice laparoscopic surgical skills?

OBJECTIVES

To investigate whether a training system using a dry box is feasible for training young urologists. Despite laparoscopic surgery being widely indicated for several urological diseases, a laparoscopic training system for young urologists has not been fully established yet. However, the learning curve for laparoscopic surgery has not yet been ascertained.

METHODS

We continued to test 11 sixth-year residents (postgraduate year: PGY6) and third-year residents (PGY3) in our department in terms of surgical skills using a dry box. We gave them several tasks (cutting and suturing) and let them practice until task completion. We continued to test all participants by these tasks for 16 weeks.

RESULTS

At the beginning of the present study, the PGY6 residents achieved significantly better scores than the PGY3 residents. However, the difference between the 2 groups became insignificant over time. Furthermore, statistical analysis revealed that a practice time of 100 minutes per week was the only significant factor affecting the last test score. For the final test, the mean practice time for all participants was 79.1 minutes per week.

CONCLUSIONS

These results suggest that laparoscopic surgical skills can definitely be polished by adequate voluntary practice.

Oncological and Functional Results of Laparoscopic Radical Prostatectomy after 100 Procedures: Our Experience

Laparoscopic radical prostatectomy plays an emerging role in the surgical management of prostatic tumors. We present our experience of the first 100 cases of extraperitoneal laparoscopic radical prostatectomy. Our results about continence, erectile function and surgical margins are reported.

Materials and Methods

Between January 2005 and December 2007, 100 laparoscopic radical prostatectomies were performed by one surgeon. We retrospectively reviewed margins status, operative time, blood transfusion rates, time of catheterization, length of hospital stay, continence and potency rates.

Results

The operative time decreased during the learning curve. The mean duration of surgery was 240 minutes (in the first 25 procedures the median time was 320 minutes, while in the last 25 cases the mean duration was 200 minutes). Five conversions to open surgery were required owing to failure to progress. The overall rate of positive surgical margins was 15% in pT2 and 35% in pT3a tumors. We had 3 minor complications (two anastomotic leakage and one hemorrhage from the anastomosis) and 2 major complications (recto-urethral fistula). The mean intraoperative blood loss was 450 ml (range 200–1500). With regard to transfusion, 25 patients (25%) received their autologous units, while 2% of the patients required homologous units. The mean duration of catheterization was 7.8 days. The continence rate at 12 months was 85%; the potency rate was 55% at 12 months.

Conclusions

The results of the present study show that by using a rational approach to training, a general urologist with low experience in laparoscopy is able to safely perform laparoscopic radical prostatectomy, and with oncological and functional results comparable to those of other published series.

Selective versus standard ligature of the deep venous complex during laparoscopic radical prostatectomy: effects on continence, blood loss, and margin status

BACKGROUND

Continence after laparoscopic radical prostatectomy is critical to patients and to surgeons. In this setting, the management of deep venous complex (DVC) without involvement of the sphincter fibres could be an important step of the procedure.

OBJECTIVE

To evaluate the effects of a personal selective suture of the plexus (selective ligature of the deep venous complex [SLDVC]) on continence, blood loss, and surgical margin status during laparoscopic radical prostatectomy (LRP).

DESIGN, SETTING, AND PARTICIPANTS

We planned a prospective randomised study. Sixty consecutive patients with clinically localised prostate cancer were involved in the study and were divided into two groups: group A (30 patients) underwent LRP with extraperitoneoscopic approach with standard management of DVC; group B (30 patients) underwent LRP with SLDVC.

INTERVENTION

In group A, a standard ligature of DVC was performed (ligature and subsequent section); in group B, a selective ligature of DVC after its section was performed.

MEASUREMENTS

Continence was evaluated during follow-up visits at catheter removal, and after 1, 3, 6, and 12 mo, perioperative variables and pathologic features of specimens were recorded.

RESULTS AND LIMITATIONS

The two groups were comparable in terms of age, body mass index (BMI), prostate-specific antigen (PSA) values, and Gleason score at biopsy. No differences were found between the two groups in terms of operative times, blood loss, catheterisation time, and postoperative stay or histologic status. As far as continence rate is concerned, a significant difference was recorded between the groups (53% in group A vs 80% in group B) after 3 mo.

CONCLUSIONS

This selective ligature of the DVC after its section can contribute to early recovery of continence. Our data suggest that SLDVC compromises neither the safety of the procedure nor its oncologic effectiveness.

Laparoscopic radical prostatectomy after transurethral resection of the prostate: surgical and functional outcomes

OBJECTIVES

To compare the morbidity and functional results after laparoscopic radical prostatectomy with and without previous transurethral resection of the prostate (TURP).

METHODS

From May 1998 to January 2005, 640 patients underwent laparoscopic radical prostatectomy, of whom 46 (7.2%) had previously undergone TURP. The perioperative and postoperative data were compared between group 1 (with previous TURP) and group 2 (without previous TURP). The functional results were assessed by self-administered questionnaires at 12 and 24 months after surgery.

RESULTS

In group 1, the operative time, hospital stay, and bladder catheterization duration was increased by 31 minutes, 1.9 days, and 2.9 days, respectively. The positive margin rate was not significantly different statistically between the two groups (P = .62). The 5-year actuarial freedom from biochemical recurrence rate was similar between the two groups (P = .86). Surgical complications occurred in 15.2% of group 1 and 5.7% of group 2 (P = .02). The risk of anastomotic stricture was 6.5% and 1.2% in groups 1 and 2, respectively (P = .02). Two years after surgery, the continence rate was 86.9% in group 1 and 95.8% in group 2 (P = .77), and the potency rate was 63.8% and 70.9%, respectively, after bilateral neurovascular bundle preservation (P = .61). However, neurovascular bundle preservation was performed after previous TURP in only 56.5% of group 1 vs 78.9% in group 2 (P = .02). The median follow-up was 50.8 months (range 30-107).

CONCLUSIONS

Laparoscopic radical prostatectomy can be performed after TURP without compromising the oncologic results. However, patients should be informed that the procedure is associated with worse intraoperative and postoperative outcomes. Although the urinary continence rate was not hampered by previous TURP, neurovascular bundle preservation is technically more difficult and compromises postoperative erectile function.

Prevention and management of perioperative complications in laparoscopic and endoscopic radical prostatectomy

INTRODUCTION

Laparoscopic transperitoneal radical prostatectomy (LRP) and endoscopic extraperitoneal radical prostatectomy (EERPE) are established techniques for the management of localized prostate cancer in numerous specialized urologic centers worldwide.

RESULTS

The complication rates of LRP and EERPE are ranging between 2 and 17%. Rare but possible complications are vascular injuries, bowel injury, lymphocele formation, port-site hernia, anastomotic leakage, gas embolism and catheter obstruction and other rare events.

CONCLUSION

Prevention and management of complications requires high surgical expertise and adequate standardization of the technique.

MATERIALS AND METHODS

We herein review our experience with the endoscopic extraperitoneal radical prostatectomy in a series of 1,800 consecutive patients regarding the appearance of complications and their management.

Extraperitoneal v intraperitoneal robotic prostatectomy: analysis of operative outcomes

BACKGROUND AND PURPOSE

Robotic prostatectomy can be performed either via an extra- or intraperitoneal approach. The extraperitoneal approach has advantages similar to those of an extraperitoneal open radical prostatectomy, but the potential disadvantages of a small working space. We report our experience using both approaches.

METHODS

From July 2003 to June 2004, 55 patients underwent a robot-assisted laparoscopic prostatectomy. During the first 6 months, 21 prostatectomies were performed using an intraperitoneal approach (group 1); 34 were performed using an extraperitoneal approach (group 2) during the next 6 months. Clinicopathologic parameters and perioperative complications were compared in both groups. All patients were categorized as intent-to-treat analysis.

RESULTS

Median surgery time was significantly shorter in the extraperitoneal compared with the intraperitoneal approach (3 hours and 34 minutes v 4 hours and 1 minute, respectively, P = 0.017). This was because of the shorter time interval between the skin incision and incision of the endopelvic fascia in the extraperitoneal v the intraperitoneal approach (55 minutes v 74 minutes, respectively, P < 0.0001). There was no significant difference in terms of patient age, clinical and pathologic stage, length of hospital stay, and perioperative complications between the two approaches.

CONCLUSION

Extraperitoneal robot-assisted laparoscopic prostatectomy offers a similar clinical outcome as the intraperitoneal approach. However, the extraperitoneal approach avoids potential bowel injury or complications related to an intraperitoneal urine leak.

[Extraperitoneal laparoscopic radical prostatectomy. First 50 cases in a middle sized hospital. Evaluation of the learning curve]

OBJECTIVE

Report our experience in the first 50 cases of laparoscopic radical prostatectomy performed in our Hospital. We describe the surgical technique and the modifications that we have applied. Time consumptions and technical difficulties are reviewed.

METHODS

From January 2005 to September 2006 we indicated 52 extraperitoneal laparoscopic radical prostatectomies. Two of them were done with the advice of a master and won't be included in our series. We followed the Brussels technique with some modifications.

RESULTS

We completed integrally by laparoscopy the 78% of the cases (39/50). The 11 converted cases were done within the 25 first ones. Mean operating time for the pure laparoscopic cases was 280 minutes. We divide surgery in six steps with the following mean times in minutes: Trocars placement (30), seminal vessels dissection (95), Santorini (25), specimen in endobag (55), anasthomosis (55) and final (15). After case 25, the results improve. The most challenging step was seminal vessels dissection. Transfusion rate has been 7%. The mean hospitalization time has been 4 days with a 30% of patients discharged 48 hours after surgery. Positive surgical margins were observed in 12%. Two of our patients presented major complications (4%).

CONCLUSIONS

Extraperitoneal laparoscopic radical prostatectomy is feasible in an institution like ours if it has the aim of invest a big effort, especially regarding operating time. The most demanding steps are the dissection of the vesicoprostatic plane and the anasthomosis. There is a clear progression after case 25.

Choices for Surgery

Surgical treatment of prostate cancer has seen many improvements in the past two decades, including laparoscopy, robotic surgery, and better assessment of quality of life and functional results. The limits of surgery for locally advanced disease and after failure of radiotherapy have been better defined, together with the roles of neoadjuvant and adjuvant treatment. Patients with clinically organ-confined prostate cancer, reasonable life expectancy, and little or no co-morbidity are the best candidates for radical prostatectomy. This chapter reviews the different technical options for the treatment of prostate cancer, with their respective indications and functional and oncological results.

Anatomical Landmarks of Radical Prostatecomy

INTRODUCTION

In the present study, we review current literature and based on our experience, we present the anatomical landmarks of open and laparoscopic/endoscopic radical prostatectomy.

METHODS

A thorough literature search was performed with the Medline database on the anatomy and the nomenclature of the structures surrounding the prostate gland. The correct handling of puboprostatic ligaments, external urethral sphincter, prostatic fascias and neurovascular bundle is necessary for avoiding malfunction of the urogenital system after radical prostatectomy.

RESULTS

When evaluating new prostatectomy techniques, we should always take into account both clinical and final oncological outcomes. The present review adds further knowledge to the existing "postprostatectomy anatomical hazard" debate. It emphasizes upon the role of the puboprostatic ligaments and the course of the external urethral sphincter for urinary continence. When performing an intrafascial nerve sparing prostatectomy most urologists tend to approach as close to the prostatic capsula as possible, even though there is no concurrence regarding the nomenclature of the surrounding fascias and the course of the actual neurovascular bundles. After completion of an intrafascial technique the specimen does not contain any periprostatic tissue and thus the detection of pT3a disease is not feasible. This especially becomes problematic if the tumour reaches the resection margin.

DISCUSSION

Nerve sparing open and laparoscopic radical prostatectomy should aim in maintaining sexual function, recuperating early continence after surgery, without hindering the final oncological outcome to the procedure. Despite the different approaches for radical prostatectomy the key for better results is the understanding of the anatomy of the bladder neck and the urethra.

Prostatectomía radical extraperitoneal Da Vinci

OBJECTIVE

To report the outcomes of 100 robotically assisted laparoscopic radical prostatectomies (RALPs), a minimally invasive alternative for treating prostate cancer.

PATIENTS AND METHODS

In all patients was used RALP with an extraperitoneal approach assisted by the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Prospective data collection included quality-of-life questionnaires, basic demographics (height, weight and body mass index), prostate specific antigen (PSA) levels, clinical stage and Gleason grade. Variables assessed during RALP were operative duration, estimated blood loss (EBL) and complications, and after RALP were hospital stay, catheter time, pathology, PSA level, return of continence and potency.

RESULTS

The mean (range) duration of RALP was 180 (140-295) min; all procedures were successful, with no intraoperative transfusions or deaths. The mean EBL was 300 mL (40-1100); 97% of patients were discharged home on the first day after RALP with a mean haematocrit of 36%. The mean duration of catheterization was 7 (5-21) days. The positive margin rate was 14% for all patients. The overall biochemical recurrence free (PSA level < 0.1 ng/mL) survival was 95% at mean follow-up of 9.7 months. There was complete continence at 6 months in 95% of patients. At 1 year 78% of patients were potent (with or without the use of oral medications), 15% were not yet able to sustain erections capable of intercourse, and another 7% still required injection therapy.

CONCLUSION

RALP is a safe, feasible and minimally invasive alternative for treating prostate cancer. Our initial experience with the procedure shows promising short-term outcomes.

Progression of laparoscopic radical prostatectomy: improved outcomes with the extraperitoneal approach and a running anastomosis

PURPOSE

To compare the operative and perioperative outcomes of patients undergoing either a transperitoneal or an extraperitoneal laparoscopic radical prostatectomy (TLRP or ELRP) with either an interrupted or a running urethrovesical anastomosis (IUVA or RUVA).

PATIENTS AND METHODS

From January 2003 through December 2004, 265 patients underwent LRP by one surgeon at the Lahey Clinic Medical Center. They were divided into three groups according to the operative approach (TLRP or ELRP) and the suture anastomosis (IUVA or RUVA): group 1 = TLRP and IUVA (N = 58; 21.6%), group 2 = TLRP and RUVA (N = 35; 13.1%), and group 3 = ELRP and RUVA (N = 172; 64.2%).

RESULTS

Group 3 had statistically better outcomes, as judged by operative time (222, 191, and 170 minutes for groups 1, 2, and 3, respectively; P < 0.0001), postoperative analgesic use (39.6, 30.4, and 18.9 mg of narcotic; P < 0.0001), length of stay (3.76, 2.74 days, and 1.67 days; P < 0.0001), leak on postoperative cystogram (17.9%, 11.4%, and 3.5%; P = 0.001), and complication rate (32.8%, 11.4%, and 9.9%; P < 0.0001). The groups had similar estimated blood loss (168, 145, and 176 mL) and positive surgical-margin rates (15.5%, 14.3%, and 14.5%).

CONCLUSIONS

We demonstrate improved surgical outcome for ELRP with RUVA in regard to operative time, analgesic use, length of stay, leak rate, and complication rate. Long-term follow-up will determine whether a difference exists in disease recurrence, continence, and erectile function.

Complications of endoscopic extraperitoneal radical prostatectomy (EERPE): prevention and management

Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of laparoscopic (transperitoneal) RPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. Endoscopic extraperitoneal radical prostatectomy has many advantages but is not without complications. The aim of this review article is to describe the most common complications of this procedure. Complications associated with endoscopic extraperitoneal radical prostatectomy are: vascular injury--bleeding--haematoma, bowel injury, lymphocele, injury to the bladder--ureter, port site hernia, anastomotic leakage--stricture, obturator nerve injury--paralysis, gas embolism, catheter blockage, and miscellaneous like perineal pain, pubic osteitis, infection- urosepsis. The present review paper focuses on the identification and management of these complications The incidence of most complications directly correlates with the surgeons' experience, and the various complications are related to technical errors rather than to the technique itself. The laparoscopist performing endoscopic/ laparoscopic radical prostatectomy should be aware of all these complications. He should be able to recognise promptly, treat efficiently, and ideally prevent these complications.

Laparoscopic Radical Prostatectomy in Patients following Transurethral Resection of the Prostate

OBJECTIVES

Previous transurethral resection of the prostate (TURP) was reported to impose difficulties during open radical prostatectomy. We describe our experience in laparoscopic radical prostatectomy (LRP) following transurethral resection of the prostate.

PATIENTS AND METHODS

The series included 35 patients: 22 patients underwent transperitoneal LRP (tpLRP) and 13 underwent extraperitoneal LRP (epLRP). The minimal interval between TURP and laparoscopy was 3 months. Patients' charts were reviewed for their preoperative characteristics, intraoperative difficulties and complications, and outcome.

RESULTS

Patients' mean age was 67.5+/-4.4 years. 12 patients were cT1a,b and 23 patients were cT1c/T2. Twenty-two patients underwent tpLRP and 13 underwent epLRP. No statistical difference was found between the preoperative characteristics and the pathological results of cT1a,b vs. T1c/cT2 patients, or tpLRP vs. epLRP patients. Thirty-three procedures were completed laparoscopically and 2 were converted to open surgery. Perioperative complications included two leaking anastomoses, prolonged lymph drainage in 1 case, atelectasis (n=1) and duodenal ulcer (n=1). Twelve positive margins were noted, half of them in pT2 tumors. The mean follow-up was 28.5 months. Twenty-five of 35 patients had more than 12 months of follow-up. Among them 19 patients were completely continent (76%) and 6 (24%), reported mild stress incontinence.

CONCLUSIONS

Although LRP following TURP is sometimes more technically difficult, simple modifications in the operative strategy help facilitate surgery. LRP following TURP favorably compares to open radical prostatectomy after TURP and laparoscopy in non-TURP patients.

Extraperitoneal laparoscopic radical prostatectomy

A total of 28 patients with clinically localized prostate cancer (PCa) underwent extraperitoneal laparoscopic radical prostatectomy (EP-LRP). The mean operative duration was 309 (287-600) minutes. Estimated blood loss ranged from 380 to 1000 (mean 480) ml. At 3 to 5 days postoperatively, the catheter was removed. No open conversion was required and no patient presented postoperative complications. PSA level was less than 0.1 ng/ml at 3 months after surgery in all patients. At a mean follow-up of 10 (6-16) months, there were no biochemical failures. The extraperitoneal technique potentially decreased the risk of intra-abdominal complications and better approximated than open retropubic radical prostatectomy. In conclusion, EP-LRP is an effective, safe and precise technique.

Anaesthetic considerations for endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy

We focus on the anaesthesiology and requirements for minimally invasive procedures for treating localized prostate cancer. The management of anaesthesia for laparoscopic and endoscopic radical prostatectomy (RP) can be more complex than expected. Numerous groups, especially early in their experience, have had problems (e.g. hypercarbia) with the anaesthesiology of the procedure. Co-operation between the surgeon and the anaesthesiologist is of paramount importance for a safe and effective laparoscopic or endoscopic RP. Nevertheless, the relative anaesthetic equipment and trained personnel should be available before embarking on such technically proficient procedures.

Transperitoneal versus extraperitoneal laparoscopic radical prostatectomy: Experience of a single center

OBJECTIVES

To analyze, in a consecutive study, the perioperative, postoperative, and functional results of the transperitoneal and extraperitoneal approaches for laparoscopic radical prostatectomy.

METHODS

A total of 160 patients underwent radical prostatectomy and were subdivided into two groups. Group 1 underwent the transperitoneal approach and group 2, the extraperitoneal approach. The preoperative parameters, age, prostate-specific antigen level, biopsy Gleason score, American Society of Anesthesiologists class, body mass index, and clinical stage, were considered. The perioperative parameters evaluated were the operative time, blood loss, blood transfusion, hospital stay, catheterization time, complications, histopathologic findings, TNM stage, Gleason score, prostate and tumor volumes, and functional results.

RESULTS

The patients in both groups had comparable preoperative data. No differences were observed between the two groups in the intraoperative data, except for the mean operative time (179 +/- 54.6 for group 1 versus 133.7 +/- 27 minutes for group 2). Also, no differences were observed between the two groups in terms of the postoperative data. The proportion of complications was 21.25% in group 1 and 22.5% in group 2. We recorded symptomatic lymphocele requiring treatment with a drain or reoperation in 8 patients (10%) in group 2 and 0% in group 1 (P <0.001) of all the patients who underwent lymphadenectomy. The rate of positive surgical margins was 25% for group 1 and 21.25% for group 2 (P = NS). For those with Stage pT2, the positive margin rate was 7.3% and 10% for groups 1 and 2, respectively. The recovery of continence at 3 months was faster in group 2 (75% of patients versus 50.9% in group 1; P <0.01).

CONCLUSIONS

The extraperitoneal approach required less operative time and enabled faster recovery of continence and the transperitoneal approach prevented the formation of lymphocele.

Minimally Invasive Approaches to Localized Prostate Carcinoma

Prostate cancer is an increasing medical problem. Radical prostatectomy and radiation therapy are effective treatments, but have the risk of significant morbidity. Clinicians have strived to develop new modalities of treatment that can maintain the excellent treatment outcomes of radical prostatectomy, but diminish the morbidity. Improved instrumentation, optics, and robotic technology have allowed the application of laparoscopic techniques to radical prostatectomy. Patients can have less blood loss and expect more rapid recovery. Intermediate oncologic outcomes appear similar to radical prostatectomy with good functional results. Cryotherapy and HIFU are tissue ablative approaches rather than extirpative approaches to prostate cancer treatment. They attempt to use nonsurgical methods to treat prostate cancer with the hope of providing oncologic control comparable to surgery and radiation while minimizing morbidity.

Methods of training using pelvic trainers

During the past decade, the clinical applications of laparoscopic surgery in urology have been growing steadily. The laparoscopic version of various procedures, such as nephrectomy, is becoming the standard of care. This has led to an increased need for laparoscopic training in urology and focused the attention on the various modalities for laparoscopic skill acquisition. The common training modalities for laparoscopy are box trainers, animal and cadaveric laparoscopy, and virtual reality simulators. Each modality carries its own benefits to the practicing surgeon. The box trainers are the first practiced and are basic training simulators. They were first designed to help with training in basic laparoscopic skills and to assist surgeons in getting acquainted with instruments. However, these simple boxes are being upgraded constantly by tissue- and organ-specific models, allowing the surgeon to train in a convenient and cost-effective environment. This article describes the ways to work with box trainers, from basic skills to advanced laparoscopic tasks, and discusses the contribution of these trainers to real surgery as well as their role in defining criterion levels of surgical performance.

Laparoscopic and Robotic Assisted Radical Prostatectomy – Critical Analysis of the Results

OBJECTIVE

To evaluate the role of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RLRP) based on personal experience and a review of the literature.

MATERIAL AND METHODS

Own experience at one European and one American LRP-center includes more than 2000 cases. We performed a MEDLINE search reviewing the literature on LRP and RLRP between 1992 and 2005 with special emphasis on historical aspects, technical considerations, comparison to open retropubic (RRP) and perineal radical prostatectomy (PRP), laparoscopic training, and the cost-efficiency of the techniques.

RESULTS

Based on sophisticated training programs a continuous dissemination of the technique took place. In the United States, this process was accelerated by the use of the daVinci-robot. There is a trend towards the extraperitoneal access. Mid-term outcomes of LRP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower rate of complications, shorter convalescence, and better cosmesis. In contrast to RLRP, LRP may reach cost-equivalence with open surgery (i.e. by reduction of OR-time, use of multi-usable instruments).

CONCLUSIONS

LRP reproduces the excellent results of open surgery providing the advantages of minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow. In contrast the United States, the use of robots is likely to remain limited in Europe.

Robotic extraperitoneal radical prostatectomy: an alternative approach

PURPOSE

Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy.

MATERIALS AND METHODS

A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded.

RESULTS

Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured.

CONCLUSIONS

The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Long-term functional and oncological results after retroperitoneal laparoscopic prostatectomy according to a prospective evaluation of 550 patients

The objective of the study was to evaluate the long-term results of retroperitoneal laparoscopic radical prostatectomy (LRP). From 2001 to 2005, 550 consecutive patients underwent a laparoscopic extraperitoneal prostatectomy in our department. Continence and erectile function were analysed prospectively by a self-administrated questionnaire. Mean operating time was 188 min, mean bladder catheterisation time 5.9 days, mean hospital stay 4.6 days Pathological stage was pT2 in 55.8%, pT3a in 29.6%, pT3b in 9.1% and pT4a in 5.4% tumours. Positive surgical margins were 17.9% for pT2, 44.8% for pT3 tumours and 71.4% for pT4a tumours. Five years survival without biochemical progression was 78.8%. After 24 months of follow-up, diurnal continence rate was 91%, and potency rate was 64% when both neurovascular bundles were preserved, 78.6% when the patients were younger than 60 years. LRP is now a standardised procedure. An extraperitoneal approach combines the advantages of a laparoscopic procedure with those of an extraperitoneal approach.