Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy

Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies

BACKGROUND

Due to the lack of sufficient evidence, it is not clear whether robotic-assisted radical prostatectomy (RARP) or laparoscopic radical prostatectomy (LRP) is better for prostate cancer. The authors conducted this study by separately pooling and analysing randomised controlled trials (RCTs) and non-randomised studies to compare the perioperative, functional, and oncologic outcomes between RARP and LRP.

METHODS

A systematic literature search was performed in March 2022 using Cochrane Library, Pubmed, Embase, Medline, Web of Science, and China National Knowledge Infrastructure. Two independent reviewers performed literature screening, data extraction and quality assessment according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Subgroup analysis and sensitivity analysis were performed.

RESULTS

A total of 46 articles were included, including 4 from 3 RCTs and 42 from non-randomised studies. For RCTs, meta-analysis showed that RARP and LRP were similar in blood loss, catheter indwelling time, overall complication rate, overall positive surgical margin and biochemical recurrence rates, but quantitative synthesis of non-randomised studies showed that RARP was associated with less blood loss [weighted mean difference (WMD)=-71.99, 95% CI -99.37 to -44.61, P <0.001], shorter catheterization duration (WMD=-1.03, 95% CI -1.84 to -0.22, P =0.010), shorter hospital stay (WMD=-0.41, 95% CI -0.68 to -0.13, P =0.004), lower transfusion rate (OR=0.44, 95% CI 0.35-0.56, P <0.001), lower overall complication rate (OR=0.72, 95% CI 0.54-0.96, P =0.020), and lower biochemical recurrence rate (OR=0.78, 95% CI 0.66-0.92, P =0.004), compared with LRP. Both meta-analysis of RCTs and quantitative synthesis of non-randomised studies showed that RARP was associated with improved functional outcomes. From the results of the meta-analysis of RCTs, RARP was higher than LRP in terms of overall continence recovery [odds ratio (OR)=1.60, 95% CI 1.16-2.20, P =0.004), overall erectile function recovery (OR=4.07, 95% CI 2.51-6.60, P <0.001), continence recovery at 1 month (OR=2.14, 95% CI 1.25-3.66, P =0.005), 3 (OR=1.51, 95% CI 1.12-2.02, P =0.006), 6 (OR=2.66, 95% CI 1.31-5.40, P =0.007), and 12 months (OR=3.52, 95% CI 1.36-9.13, P =0.010) postoperatively, and potency recovery at 3 (OR=4.25, 95% CI 1.67-10.82, P =0.002), 6 (OR=3.52, 95% CI 1.31-9.44, P =0.010), and 12 months (OR=3.59, 95% CI 1.78-7.27, P <0.001) postoperatively, which were consistent with the quantitative synthesis of non-randomised studies. When sensitivity analysis was performed, the results remained largely unchanged, but the heterogeneity among studies was greatly reduced.

CONCLUSION

This study suggests that RARP can improve functional outcomes compared with LRP. Meanwhile, RARP has potential advantages in perioperative and oncologic outcomes.

Versatility of 3D laproscopy for radical prostatectomy: A single tertiary cancer center experience

Objective

The objective of this study is to compare our institutional outcomes of 3D laparoscopic when compared with open radical prostatectomy in terms of functional and oncological outcomes.

Methods

This is a retrospective study of patients who underwent radical prostatectomy during the period January 2016 to September 2019 at our institute. Out of 49 patients who underwent radical prostatectomy, 23 were done by open approach and 25 were operated by 3D laparoscopy. One patient was lost to follow-up and was excluded from the study. Data were collected from medical records, and functional evaluation was done by telephonic interview. Data analysis was done by SPSS software to calculate overall and disease-free survival.

Results

Laparoscopic arm patients had lesser blood loss, postoperative pain, hospital stay and wound-related issues although they had a longer operating time. Functional outcomes in terms of erectile dysfunction and incontinence were almost similar in both open and 3D laparoscopic approach. No statistically significant difference was observed for overall survival or disease-free survival. All shortcomings with the laparoscopic arm were improved as our experience increased with 3D laparoscopic prostatectomy. The outcomes of 3D laparoscopic radical prostatectomy were comparable to previously published data of robotic radical prostatectomy.

Conclusions

3D LRP is a feasible technique with similar oncological or functional outcomes and better perioperative outcomes as compared to ORP. Being cost-effective and with comparable outcomes it is a suitable alternative to RRP in resource-limited settings.

A Historical Perspective of The Evolution of Laparoscopic Surgeries in Urology

Recent decades have seen the rapid progression of minimally invasive surgery in urology with continuing developments in robotic technology paving ways into a new era. In addition to these technological innovations, interests from urologists in developing and embracing new techniques have become a forefront in the ongoing evolution of the field allowing for improvement intraoperative experience as well as morbidity and mortality outcomes. This article aims to provide an overview of the historical development of laparoscopic surgery in urology whilst also providing a brief look into its future.

Factors influencing self-esteem after radical prostatectomy in older adult patients

Older adult patients with prostate cancer experience symptoms such as uncontrolled sexual and urinary dysfunction after radical prostatectomy, which lowers self-esteem. Lack of access to information about the illness increases uncertainty, requiring interventions from healthcare providers. This study aimed to identify factors affecting the self-esteem of older adult patients who underwent prostate cancer surgery and provided data for establishing nursing strategies to promote healthy lifespans. This cross-sectional study examined participants over 65 years old who underwent radical prostatectomy at two university hospitals in 2017. The results indicated that the most influential factor for self-esteem was inconsistency-related uncertainty, followed by postoperative symptom experience and healthcare provider support. These variables explained 43% of the variance in self-esteem. To improve self-esteem among older adult patients who undergo radical prostatectomy, integrated programs that include sexual-related symptom management, such as erectile dysfunction and incontinence, and healthcare provider support should be developed to reduce inconsistency-related uncertainty.

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.

Extraperitoneal Laparoscopy in Severe Intra-abdominal Adhesions: A Safe Alternative to Laparotomy

Surgery in a frozen abdomen can be difficult and dangerous with a significant risk of visceral injuries. We report a case of a 26-year-old lady with chronic pelvic pain diagnosed to have large bilateral adnexal cysts on magnetic resonance imaging with normal tumor markers. She had previous two laparotomies for benign conditions. Laparoscopy was planned, but pneumoperitoneum could not be created due to dense intraperitoneal adhesions. Direct entry was done into the preperitoneal space followed by insufflation of gas in this space. Blunt and sharp dissection of this space was done without breaching the peritoneum to reach the adnexa. The adnexal cyst was found to be encysted collection due to adhesions from previous surgeries. Deroofing was done followed by the visualization of pelvic structures intraperitoneally. Extraperitoneal laparoscopy may be used as a safe alternative to laparotomy in patients with dense intra-abdominal adhesions with the advantage of faster postoperative recovery.

Laparoscopic radical prostatectomy: a single surgeon’s experience in 80 cases after 2 years of formal training

Background

To assess the learning curve in laparoscopic radical prostatectomy (LRP) performed by a single surgeon who had a healthcare career as a surgical first assistant for 2 years in high-volume centers treating > 150 cases per year.

Methods

The records of 80 LRP cases performed between October 2017 and August 2018 by a single surgeon were consecutively divided into four groups (groups A = first 20 cases, B = second 20 cases, C = third 20 cases, and D = last 20 cases). The groups were compared in terms of surgical and functional outcomes with a minimum follow-up of 6 months.

Results

Clinical and surgical stages of the four groups were similar between groups. The operative time (126.8 ± 5.48 min; P = 0.001) and time of removal of the drain (1.65 ± 0.93 days; P = 0.029) were significantly lower in group D; however, hospitalization, catheterization time, and blood loss were similar between groups. The complication rate was low. No patient had a visceral injury, and there were no procedures needed to open conversion. The positive surgical margin (PSM) rates were similar between groups. In terms of continence and potency, all groups were similar at the 6th-month follow-up after surgery.

Conclusions

Our results showed that prior experience in laparoscopic surgery as a surgical first assistant in a high-volume center improves the learning curve and oncological and functional outcomes, and helps to minimize the complication rate

Embarking with laparoscopic radical prostatectomy and dealing with the complications and collateral problems: A single-center experience

OBJECTIVE

The aim of the present study was to report our single-center initial experience in laparoscopic radical prostatectomy (LRP) with special emphasis on the complications and collateral problems and their management.

MATERIAL AND METHODS

A total of 48 patients (mean age 64 years) underwent LRP in our institution between August 2014 and July 2018. Two surgeons completed a fellowship training program for LRP before. Mentored operations started after the first 10 cases. The patients were divided in two groups of 30 (group I) and 18 (group II) patients. Demographic, preoperative, peroperative, and postoperative data were collected prospectively. Anesthesiology and nurses' team performances, as well as problems and their management, were reviewed.

RESULTS

The demographic data for both groups (group I vs. group II) were similar. Estimated blood loss (695.5±139.23 vs. 398±339.39 mL) and intraoperative complication rates (36.66% vs. 5.55%) were significantly (p<0.05) higher in group I. Conversion to open surgery occurred in 7 (20%) patients in group I and in 1 (5.55%) patient in group II. Continence rates at 12 (83%) months were similar in both groups. Positive surgical margins were 8.33% for pT2 and 27.1% for pT3 stages.

CONCLUSION

A validated fellowship program before starting LRP and performing the first cases under mentorship are helpful. The complication and conversion rates decrease after 30 cases in addition to the improved experience also with improved cooperation with the anesthesiologist and scrub nurse.

Robot-assisted and laparoscopic vs open radical prostatectomy in clinically localized prostate cancer: perioperative, functional, and oncological outcomes: A Systematic review and meta-analysis

BACKGROUND

To perform a systematic review and meta-analysis evaluating the perioperative, functional, and oncological outcomes and cost of robot-assisted radical prostatectomy (RARP), or laparoscopic radical prostatectomy (LRP) comparing with open radical prostatectomy (ORP) in men with clinically localized prostate cancer through all prospective comparative studies.

METHODS

A comprehensive literature search was performed in August 2018 using the Pubmed, Medline, Embase, and Cochrane databases. Only randomized controlled trials (RCTs) and prospective studies including patients with clinically localized prostate cancer were eligible for study inclusion. Cumulative analysis was conducted using Review Manager v. 5.3 software.

RESULTS

Two RCTs and 9 prospective studies were included in this systematic review. There were no significant differences between RARP/LRP and ORP in overall complication rate, major complication rate, overall positive surgical margin (PSM) rate, ≤pT2 tumor PSM rate, ≥pT3 tumor PSM rate. Moreover, RARP/LRP and ORP showed similarity in biochemical recurrence (BCR) rate at 3, 12, 24 months postoperatively. Urinary continence and erectile function at 12 months postoperatively between RARP and ORP are also comparable. RARP/LRP were associated with significantly lower estimated blood loss [mean difference (MD) -749.67, 95% CI -1038.52 to -460.82, P = .001], lower transfusion rate (OR 0.17, 95% CI 0.10 to 0.30, P < .001) and less hospitalization duration (MD -1.18, 95% CI -2.18 to -0.19, P = .02). And RARP/LRP required more operative time (MD 50.02, 95% CI 6.50 to 93.55, P = .02) and cost.

CONCLUSION

RARP/LRP is associated with lower blood loss, transfusion rate and less hospitalization duration. The available data were insufficient to prove the superiority of any surgical approach in terms of postoperative complications, functional and oncologic outcomes.

Anaesthesia for Robotic-Assisted Radical Prostatectomy: Considerations for Laparoscopy in the Trendelenburg Position

Two cases of anaesthetic complications after robotic-assisted laparoscopic radical prostatectomy using the da Vinci Remote-Controlled Surgical System are presented. Case 1 describes a patient with post-extubation respiratory distress requiring reintubation and subsequent ventilation in an intensive care unit. This was attributed to laryngeal oedema, which was most likely due to the reduction in venous outflow from the head caused by the pneumoperitoneum and prolonged, extreme Trendelenburg position. Case 2 describes a patient with mild brachial plexus neurapraxia, which was most likely due to compression by shoulder braces (to prevent cephalad sliding) during the exaggerated head-down tilt. For this procedure, the authors recommend limiting the duration and extent of head-down tilt as much as possible, avoiding excessive intravenous fluids and careful positioning of the patient with avoidance of shoulder braces whenever possible.

Bidirectional Barbed Only vs Poliglecaprone Suture with Rhabdosphincter Reconstruction for Urethrovesical Anastomosis During Robotic Radical Prostatectomy: Does It Make Any Difference?

OBJECTIVES

We investigated the use of bidirectional barbed suture only vs poliglecaprone suture with posterior rhabdosphincter reconstruction for urethrovesical anastomosis (UVA) during robot-assisted radical prostatectomy (RARP) on cystographic leakage, duration of catheterization, and early urinary continence.

MATERIALS AND METHODS

Bidirectional double-armed barbed suture only was used for UVA (n = 50) in Group 1. Two 3/0 poliglecaprone 25 sutures were tied to each other to form a double-armed suture used for UVA with posterior rhabdosphincter reconstruction in Group 2 (n = 50). Groups were similar regarding patient demographics and operative parameters. Groups were compared regarding leakage on cystography, duration of urethral catheterization after RARP, immediate urinary continence (continence at the time of urethral catheter removal), and continence rates at first and third-month follow-up.

RESULTS

Leakage on cystography was detected in 4 (8%) and 10 (20%) of the patients in Group 1 and 2, respectively (p = 0.08). Urinary catheter removal duration was 7.8 and 8.5 days in Group 1 and 2, respectively (p = 0.1). Immediate urinary continence was achieved in 38 (76%) and 20 (40%) of the patients in Group 1 and 2, respectively (p = 0.002). Urinary continence in first-month follow-up was achieved in 46 (92%) and 38 (76%) of the patients in Group 1 and 2, respectively (p = 0.02). Urinary continence in third-month follow-up was achieved in 48 (96%) and 47 (94%) of the patients in Group 1 and 2, respectively (p = 0.64). Mean UVA time was 16.8 and 21.2 minutes, respectively, in Group 1 and 2 (p < 0.001).

CONCLUSIONS

Because of our experience, use of a barbed suture for UVA during RARP seems to lead to better immediate and early (first month) urinary continence rates and a shorter UVA time.

Laparoscopic radical prostatectomy in 2018: 20 years of worldwide experiences, experimentations, researches and refinements

INTRODUCTION

After the first feasibility report in 1997, a growing interest has risen in the urologic community for laparoscopic radical prostatectomy (LRP) and several authors have contributed to the evolution of the technique. We attempt a review of the available evidences and provide a broad framework of different technical refinements considering their impact on pentafecta.

EVIDENCE ACQUISITION

The PubMed/Medline database was searched. Duplicates and "Expert opinion" papers were removed. Studies were included according to the aim of the present paper to present a selected review on LRP and report our personal experience.

EVIDENCE SYNTHESIS

In 1999 Guillonneau et al. codified their transperitoneal-posterior-antegrade technique for LRP. Since then, several modifications of the transperitoneal approach were published and the extraperitoneal route was also proposed. Sparing the bladder neck and reconstructing the posterior muscolofascial plate were proven to improve continence rate. Nerve-sparing LRP were performed in order to maximize postoperative recovery of the sexual function. Novel techniques to ligate the Santorini plexus and sew the urethrovesical anastomosis provided improvement in operative time, intraoperative blood loss and reduced the incidence of postoperative urinary-leakages. In the recent years, the single-site approach as pushed the limits of LRP and three-dimensional (3D) systems for endoscopic surgery were developed.

CONCLUSIONS

Thanks to several technical improvements, LRP provides brilliant oncologic and functional outcomes and it is now considered the treatment of choice in many institutions worldwide. Although it is a technically demanding procedure, the recent introduction of 3D systems will reduce the steepness of its learning curve.

Robot-Assisted Radical Prostatectomy Is More Beneficial for Prostate Cancer Patients: A System Review and Meta-Analysis

Background

Robot-assisted radical prostatectomy (RARP) is increasingly used worldwide, but comparisons of perioperative, functional, and oncologic outcomes among RARP, laparoscopic radical prostatectomy (LRP), and open radical prostatectomy (ORP) remain inconsistent.

Material/Methods

Systematic literature searches were conducted using EMBASE, PubMed, the Cochrane Library, CNKI, and Science Direct/Elsevier up to April 2017. A meta-analysis was conducted using Review Manager and Stata software.

Results

We included 33 studies. Meta-analysis revealed that blood loss, transfusion rate, and positive surgical margin (PSM) rate were significantly lower following RARP compared with LRP (SMD (95% confidence interval [CI]) 0.31 [0.01, 0.61]; combined ORs (95% CI) 5.32 [1.29, 21.98]; 1.27 [1.10, 1.46]) and ORP (SMD (95% CI) 0.75 [0.30, 1.21]; and combined ORs (95% CI) 3.44 [1.21, 9.79]); positive surgical margin (PSM) rates were significantly lower following RARP compared with LRP (combined ORs (95% CI) 1.27 [1.10, 1.46]), but not ORP. Operation time was also shorter for RARP than for LRP. The rates of nerve-sparing, recovery of complete urinary continence, and recovery of erectile function were significantly higher following RARP compared with LRP (combined ORs (95% CI) 0.55 [0.31, 0.95]; 0.66 [0.55, 0.78]; 0.46 [0.30, 0.71]) and ORP (combined ORs (95% CI) 0.36 [0.21, 0.63]; 0.33 [0.15, 0.74]; 0.65 [0.37, 1.14]).

Conclusions

This meta-analysis demonstrates that RARP results in better overall outcomes than LRP and ORP in terms of blood loss, transfusion rate, nerve sparing, urinary continence and erectile dysfunction recovery, and suggests that RARP offers better results than LRP and ORP in treatment of prostate cancer. However, studies with larger sample sizes and long-term results are needed.

Laparoscopic Surgery in Urologic Oncology

Background

Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy.

Methods

We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies.

Results

All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States.

Conclusions

When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.

An observational study: Effects of tenting of the abdominal wall on peak airway pressure in robotic radical prostatectomy surgery

Background:

Robotic radical prostatectomy (RRP) is associated with various anesthetic challenges due to pneumoperitoneum and deep Trendelenburg position. Tenting of the abdominal wall done in RRP surgery causes decrease in peak airway pressure leading to better ventilation. Herein, we aimed to describe the effects of tenting of the abdominal wall on peak airway pressure in RRP surgery performed in deep Trendelenburg position.

Methods:

One hundred patients admitted for RRP in Kokilaben Dhirubhai Ambani Hospital of American Society of Anesthesiologists 1 and 2 physical status were included in the study. After undergoing preanesthesia work-up, patients received general anesthesia. Peak airway pressures were recorded after induction of general anesthesia, after insufflation of CO₂, after giving Trendelenburg position, and after tenting of the abdominal wall with robotic arms.

Results:

Mean peak airway pressure recording after induction in supine position was 19.5 ± 2.3 cm of H₂O, after insufflation of CO₂ in supine position was 26.3 ± 2.6 cm of H₂O, after giving steep head low was 34.1 ± 3.4 cm of H₂O, and after tenting of the abdominal wall with robotic arms was 29.5 ± 2.5 cm of H₂O. P value is highly statistically significant (P = 0.001).

Conclusion:

Tenting of the abdominal wall during RRP is beneficial as it decreases peak airway pressure and helps in better ventilation and thus reduces the ill effects of raised peak airway pressure and intra-abdominal pressures.

4-Ports endoscopic extraperitoneal radical prostatectomy: preliminary and learning curve results

INTRODUCTION

There is a lack of studies in our national scenario regarding the results obtained by laparoscopic radical prostatectomy technique (LRP). Except for a few series, there are no consistent data on oncological, functional, and perioperative results on LRP held in Brazil. As for the LRP technique performed by extraperitoneal access (ELRP), when performed by a single surgeon, the results are even scarcer.

OBJECTIVE

To analyze the early perioperative and oncologic results obtained with the ELRP, throughout the technical evolution of a single surgeon.

PATIENTS AND METHODS

A non-randomized retrospective study was held in a Brazilian hospital of reference. In the 5-year period, 115 patients underwent the ELRP procedure. Patients were divided into two groups, the first 57 cases (Group 1) and the following 58 cases, (Group 2). A comparative analysis between the groups of efficacy results and ELRP safety was carried out.

RESULTS

The average age of patients was 62.8 year-old and the PSA of 6.9ng/dl. The total surgery time was 135.8 minutes on average, and the urethral-bladder anastomosis was 21.9 min (23.3 min versus 20.7 min). The positive surgical margins (PSM) rate was 17.1%, showing no difference between groups (16.4% versus 17.9%; p=0.835). There was statistical difference between the groups in relation to the anastomosis time, estimated blood loss and the withdrawal time of the urinary catheter.

CONCLUSION

The ELRP technique proved to be a safe and effective procedure in the treatment of prostate cancer, with low morbidity.

Endoscopic extraperitoneal radical prostatectomy: An initial report following the first 30 cases

Introduction

To present initial observations after the first 30 cases of endoscopic extraperitoneal radical prostatectomy carried out at our department, which so far has had no experience with this surgical procedure.

Material and methods

In the period of 15 months a group of 30 patients with organ confined prostate cancer, underwent endoscopic extraperitoneal radical prostatectomy using Montsouris technique. All procedures were performed by the same team of two urologists and one resident.

Results

The mean age of the patients was 65.3 years (43–73 years), the mean preoperative prostate specific antigen (PSA) was 7.2 ng/ml (4–9.8 ng/ml), the mean prostate volume measured in TRUS was 41 cm³ (25–80 cm³). The mean operative time was 3 h 55 min (3 h 15 min – 5 h 30 min). The negative margin was achieved in 26 patients (86%). In seven patients (23%) blood transfusion was required. Three patients had intraoperative rectal injury. In two cases trauma was supplied laparoscopically, and in one case it was decided to perform diverting colostomy. The majority of patients (65%) were discharged home on the fifth day after surgery. Two months postoperatively 13 patients (43%) were continent, 16 (35%) presented moderate stress incontinence with occasional urine leakage during normal activity and 1 patient (3%) presented severe stress incontinence.

Conclusions

Endoscopic extraperitoneal radical prostatectomy during the early phase of learning is technically difficult, requiring from the operator the laparoscopic skills, determination and a thorough knowledge of the theoretical basis of the subsequent stages of the procedure. Urologists who start performing this procedures must be aware of possible intra as well as postoperative complications.

Comparison of functional outcomes between laparoscopic radical prostatectomy and robot-assisted laparoscopic radical prostatectomy: a propensity score-matched comparison study

AIM

To compare the functional outcomes after laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

Between September 2008 and January 2016, 712 patients underwent radical prostatectomy (RP; 614 LRP and 98 RARP). Recovery of incontinence was evaluated through a 24-h pad test. Urinary and erectile function was evaluated using the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function-5. Follow-up interval was 1, 3, 6 and 12 months after the surgery. The propensity score matching was used to balance the preoperative characteristics.

RESULTS

The recovery of incontinence was similar to the two groups at 6 and 12 months after the surgery. However, patients underwent RARP restored the continence sooner than those in the LRP group in 1 and 3 months after the surgery (P < 0.001 and 0.001). For the multivariable analysis, the type of RP procedure was a uniquely meaningful contributing factor (P = 0.001, HR = 1.925; 95% CI, 1.299-2.851). In the case of urinary function, the RARP groups showed a better IPSS score than LRP groups at the 1-, 3- and 6-month visits, respectively (P = 0.008, 0.026, 0.001), and the RARP groups early improved compared with LRP groups at the 3-month visit in the case of erectile function (P = 0.018).

CONCLUSION

The RARP tended toward getting back the urinary continence earlier than the LRP. In addition, urinary and erectile function recovered more quickly in the RARP group than in the LRP group.

Transarterial embolization for pelvic hematoma following laparoscopic radical prostatectomy: A case report and review of the literature

The present study reports a case of hemorrhage from branches of the right obturator artery following laparoscopic radical prostatectomy. On post-operative day 9, the patient complained of lower abdominal pain, and the hemoglobin and hematocrit levels had decreased. Emergency computed tomography angiography showed a large pelvic hematoma suggesting active bleeding. Transarterial embolization (TAE) was performed using microcoils. There were no post-procedure complications. At 3 months post-surgery, using computed tomography, the pelvic hematoma was shown to have been absorbed. To the best of our knowledge, TAE for a hemorrhage from the obturator artery following laparoscopic prostatectomy has not previously been described. TAE is a safe and minimally invasive treatment compared with surgical intervention, and should be considered as a treatment for post-operative arterial hemorrhage.

Robotic and minimal access surgery: technology and surgical outcomes of radical prostatectomy for prostate cancer

Since the 1990s, minimal access surgery has been utilized in urology. In the past 15 years, robotic surgery has evolved and become a natural part of minimal access surgery. The dissemination has been fast and the opportunity of prospective trials has been missed. Nevertheless, robotic surgery has obvious benefits for the surgeon and patient. Even though the scientific evidence is not strong, robotic surgery is here to stay. However, there are lessons to learn from the implementation of the da Vinci system with regards to patient safety and prospective evaluation of the new technology. The future of surgery will include technologies derived from robotic surgery.

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.

Health-related quality of life in the first year after laparoscopic radical prostatectomy compared with open radical prostatectomy

OBJECTIVE

To assess health-related quality of life in the first year after laparoscopic radical prostatectomy compared with that after open radical prostatectomy.

METHODS

The subjects were 105 consecutive patients with localized prostate cancer treated with laparoscopic radical prostatectomy between January 2011 and June 2012. Health-related quality of life was evaluated using the International Prostate Symptom Score, Medical Outcome Study 8-Items Short Form Health Survey (SF-8) and Expanded Prostate Cancer Index Composite at baseline and 1, 3, 6 and 12 months after surgery. Comparisons were made with data for 107 consecutive patients treated with open radical prostatectomy between October 2005 and July 2007.

RESULTS

The International Prostate Symptom Score change was similar in each group. The laparoscopic radical prostatectomy group had a better baseline Medical Outcome Study 8-Items Short Form Health Survey mental component summary score and a better Medical Outcome Study 8-Items Short Form Health Survey physical component summary score at 1 month after surgery. In Expanded Prostate Cancer Index Composite, obstructive/irritative symptoms did not differ between the groups, but urinary incontinence was worse until 12 months after surgery and particularly severe after 1 month in the laparoscopic radical prostatectomy group. The rate of severe urinary incontinence was much higher in the laparoscopic radical prostatectomy group in the early period. Urinary bother was worse in the laparoscopic radical prostatectomy group at 1 and 3 months, but did not differ between the groups thereafter. Urinary function and bother were good after nerve sparing procedures and did not differ between the groups. Bowel and sexual function and bother were similar in the two groups.

CONCLUSION

Urinary function in the first year after laparoscopic radical prostatectomy is worse than that after open radical prostatectomy.

Does transperitoneal minimally invasive radical prostatectomy increase the amount of small bowel receiving salvage radiation?

INTRODUCTION

Transperitoneal minimally invasive radical prostatectomy (MIRP) has become first choice for several urologists and patients dealing with localized prostate cancer. We evaluate the effect of postoperative radiation on the small bowel in patients who underwent extraperitoneal open versus transperitoneal MIRP.

METHODS

We reviewed all patients who received postoperative radiation from 2006 to 2010. Planning target volume (PTV) and surrounding organs, including the small bowel, were delineated. The presence of the small bowel in PTV and its volume in receiving each dose level were analyzed.

RESULTS

A total of 122 patients were included: 26 underwent MIRP and 96 underwent open prostatectomy. The median age of patients was 66 years, with median body mass index 27 kg/m(2). The total PTV dose was 66 Gy, with the minimum and maximum doses received by the small bowel 0.4 and 66.4 Gy, respectively. The maximum volume of small bowel that received the safe limit of 40 Gy was 569 cm(3). Of the 26 patients who underwent MIRP, 12 (46%) had small bowel identified inside the PTV compared to 57 (59%) among patients who underwent open prostatectomy (p = 0.228). The mean volume of the small bowel receiving 40 Gy was 26 and 67 cm(3) in open and MIRP groups, respectively (p = 0.006); the incidence of acute complications was the same in both groups.

CONCLUSIONS

Higher volumes of the small bowel are subjected to significant radiation after MIRP procedures compared to open procedures; however, we could not demonstrate any impact on acute complications. Whether there is a difference in late complications remains to be evaluated.

A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1:2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤ 65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.

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.

Laparoscopic radical prostatectomy: the learning curve of a low volume surgeon

OBJECTIVE

Analyze the learning curve for laparoscopic radical prostatectomy in a low volume program.

MATERIALS AND METHODS

A single surgeon operated on 165 patients. Patients were consecutively divided in 3 groups of 55 patients (groups A, B, and C). An enhancement of estimated blood loss, surgery length, and presence of a positive surgical margin were all considered as a function of surgeon's experience.

RESULTS

Operative time was 267 minutes for group A, 230 minutes for group B, and 159 minutes for group C, and the operative time decreased over time, but a significant difference was present only between groups A and C (P < 0.001). Mean estimated blood loss was 328 mL, 254 mL, and 206 mL (P = 0.24). A conversion to open surgery was necessary in 4 patients in group A. Positive surgical margin rates were 29.1%, 21.8%, and 5.5% (P = 0.02). Eight patients in group A, 4 patients in group B, and one in group C had biochemical recurrence.

CONCLUSION

Significantly less intraoperative complications were evident after the first 51 cases. All other parameters (blood loss, operative time, and positive surgical margins) significantly decreased and stabilized after 110 cases. Those outcomes were somehow similar to previous published series by high-volume centers.

Complications of laparoscopic radical prostatectomy--a single institute experience

Laparoscopic radical prostatectomy (LRP) is a demanding procedure that requires surgical skill, a long learning curve and significant laparoscopic expertise. We report herein our initial experience with 41 laparoscopic radical prostatectomies to assess all perioperative complications in our initial 5-year experience. We reviewed retrospectively the case records of 41 patients who underwent laparoscopic radical prostatectomy for clinically localized prostate cancer from 2005 to 2010 at our institution. All abnormal symptoms were developed during the 30 days after the operation. Complications were noted as well as their severity according to the Clavien grading system. No conversion to open surgery was necessary in all cases. The median postoperative hospital stay was 10 days (range 9-16). The median duration of bladder catheterization was 8 days (range 7-35). There was no case of multiple-organ dysfunction or death. Minor complications constituted 82.6% of all complications. The incidence of severe complications was 17.4%. LRP displayed some advantages over open surgery in the perioperative period. Our complication rates were significantly higher than those indicated in the series previously reported. We found that most complications occurred in the first 30 patients who underwent LRP. We suggest that the surgeons should pay more attention to the difficulties of the procedure.

Oncological and functional results of extraperitoneal laparoscopic radical prostatectomy

The oncological and functional results of 329 cases in a population treated with extraperitoneal laparoscopic radical prostatectomy (ELRP) were evaluated retrospectively. A total of 329 inconsecutive patients with prostate cancer (PCa) who underwent ELRP were retrospectively analyzed. The median initial prostate-specific antigen (PSA) level was 17.35 ng/ml. The median biopsy Gleason score was 7.77. Patients with a T2 or T3a clinical stage had received preoperative neoadjuvant hormonal therapy (NHT) for 3 to 9 months prior to ELRP. No conversion or re-intervention were observed. The median time for anastomosis, surgery time and postoperative catheterization time were 13.0 min, 90.0 min and 6 days, respectively. The median estimated blood loss was 75 ml. There were 12 temporary urinary leakages requiring prolonged catheterization to 14 days. There was 1 case of deep vein thrombosis, 1 case of alimentary tract hemorrhage and 7 cases of anterior urethral stricture. The median follow-up time was 27 months. A total of 17 patients were lost during the follow-up period. No rectal injury, lymphocele, incision hernia, postoperative persistent urinary leak or anastomotic stricture occurred. Younger patients (≤67 years of age) had a more rapid recovery of continence and a better postoperative potency. The overall positive surgical margin rate was 16.7%, which correlated with the pathological stage and Gleason score, respectively (both P<0.001). A total of 89 (28.6%) patients were diagnosed with biochemical recurrence. The initial PSA value, PSM, pathological stage and Gleason score were identified as independent prognostic factors for biochemical recurrence-free survival using multivariate analysis. Our results demonstrated that preoperative NHT had significant effects on the pathological Gleason score (P<0.001) and surgical margin (P=0.027), but no significant impact on biochemical recurrence (P=0.202). The reproducibility of ELRP has been proven as a reliable curative treatment in Western countries during the last 15 years. Due to the increase in PCa patients, the results of our study may aid surgeons who use ELRP for the first time.

[Radical prostatectomy - pro laparoscopic]

Recent publications have failed to demonstrate significant differences in perioperative oncological and functional outcomes between laparoscopic radical prostatectomy (LRPE) and R-LRPE. Reports suggesting better functional results, in particular better potency rates for R-LRPE, are rare. However, to date no large prospective, randomized, multicenter studies have compared the two methods. With an experienced operator both methods produce comparably good results. The monopoly of the intuitive system with extremely high cost of purchase and maintenance are the major disadvantages of R-LRPE.

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.

Comments on the extraperitoneal approach for standard laparoscopic radical prostatectomy: what is gained and what is lost

Laparoscopic extraperitoneal radical prostatectomy (LERP) is considered the standard care treatment option for the management of localized and locally advanced prostatic cancer (PCa) in many institutes worldwide. In this work, the main advantages and disadvantages of LERP approach are reviewed with regard to its outcomes, the complication management, the learning curve, and the extend of pelvic lymph node dissection (PLND). It is concluded that LERP demonstrates comparable cancer control, urinary continence, and potency outcomes with the open and the robot-assisted radical prostatectomy, while offering advantages in complication management in comparison to the transperitoneal approach. Learning curve of LERP is considered long and stiff and significantly affects perioperative outcomes and morbidity, cancer control, and functional results. Thus, close mentoring especially in the beginning of the learning curve is advised. Finally, LERP still has a role in the limited or modified PLND offered in intermediate risk PCa patients.

Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy

Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors' RALP technique, and concludes with tips to overcome the learning curve.

Laparoscopic radical prostatectomy: A European virus

The evolution of prostate cancer treatment has now incorporated the principles of minimally invasive surgery. Laparoscopic radical prostatectomy, just like a virus, infected first Europe and three years ago the United States. This European virus has nowadays a potentially widespread application. Oncological efficacy and ability to preserve and improve continence and potency are the factors that will ultimately determine the role of laparoscopic radical prostatectomy and thus the future of this virus infection. This article reviews the current published experience with minimally invasive prostatectomy and provides comparisons to published data on radical retropubic prostatectomy to increase awareness about viability. Some prospective and retrospective non-randomized comparative studies of the two approaches are also included in the present review. The current practice patterns regarding urological laparoscopic surgery and the tendency of the urologic community in Europe and in the United States to establish minimally invasive radical prostatectomy in more urological departments are described.