Endoscopic Extraperitoneal Radical Prostatectomy: The University of Leipzig Experience of 2000 Cases

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

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

Robot-assisted versus three-dimensional laparoscopic radical prostatectomy: 12-month outcomes of a randomised controlled trial

OBJECTIVES

To compare functional and oncological outcomes of robot-assisted laparoscopic prostatectomy (RALP) to three-dimensional laparoscopic radical prostatectomy (3D-LRP) at 12 months after surgery.

PATIENTS AND METHODS

Prospective randomised single-centre study of 145 consecutive men referred to radical prostatectomy in a tertiary referral centre in Finland. Patients were randomised 1:1 to the RALP (N = 75) and 3D-LRP (N = 70) groups. The primary outcome was urinary continence evaluated with the Expanded Prostate Cancer Index Composite 26-item version (EPIC-26) incontinence domain score at 12 months after surgery. Secondary outcomes included the use of protective pads at 12 months after surgery, EPIC-26 domain scores of irritative/obstructive, bowel, sexual and hormonal symptoms, positive surgical margin (PSM) rate, and biochemical recurrence (BCR). Complication frequency within the 3-month period after surgery was evaluated according to Clavien-Dindo classification. Statistical significance between groups was analysed using Mann-Whitney, chi-square and Fisher's exact tests. The trial was terminated after interim analysis based on no statistically significant difference in EPIC-26 urinary incontinence domain scores. Altogether 145 patients of the target accrual of 280 patients were recruited.

RESULTS

Postoperative continence at 12 months after surgery according to the EPIC-26 incontinence domain was 79.25 in both groups (P = 0.4). Between group difference was -5.8 (95% confidence interval -15.2 to 3.6). There was no statistically significant difference in the rates of PSM or BCR between the two surgical modality groups.

CONCLUSION

We were unable to demonstrate a difference between the RALP and 3D-LRP groups for functional and oncological outcomes at 12 months after surgery.

3D laparoscopic prostatectomy: A prospective single-surgeon learning curve in the first 200 cases with oncologic and functional results

BACKGROUND

Studies for 3D-laparoscopic prostatectomy (3D-LRP) learning curve and surgical results are lacking. Combining 3D vision to LRP attenuates differences compared to Robotic assisted laparoscopic prostatectomy (RALP) with similar mini-invasiveness but lower costs.

MATERIALS AND METHODS

Two hundred consecutive men with localized prostate cancer underwent 3D-LRP at Seinäjoki central hospital between 2013 and 2018. Oncological and functional results were documented. Long-term functional evaluation was done using EPIC-26 survey. Clavien-Dindo classification was used to assess complications during first 3 months. All operations were performed by a single surgeon (M.R.) with no experience of LRP or 3D-LRP. The learning curve was assessed by evaluating urethral anastomosis- and total operative time. Perioperative and postoperative data was collected prospectively during surgery and at subsequent control visits up to minimum of 1 year.

RESULTS

A plateau in anastomosis time was reached after 30 cases and in operative time after 60 cases. Median operative time was 114 min (78-258 min) and median time for anastomosis was 25 min (11-90 min). Median blood loss was 150 ml (10-800 ml); 93.5% of the patients were discharged within the first 3 days. Clavien-Dindo ≥3a complications occurred in 6.5%. Positive surgical margins occurred in 23%. One-year after the operation, 93.3% had PSA ≤ 0.1; 91.9% of the patients were dry or used one daytime pad. EPIC-26 scores were as follows: Urinary incontinence 79.25 (14.5-100), urinary irritative/obstructive 93.75 (31.25-100), bowel 100 (33.33-100), sexual 36.17 (0-100) and hormonal 95 (37.5-100).

CONCLUSION

The learning curve for 3D laparoscopic prostatectomy is comparable to RALP, which makes it a cost-effective alternative with comparable oncological and functional results.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy

Introduction:

This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP.

Patients and Methods:

110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used.

Results:

The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad).

Conclusions:

The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

Endoscopic extraperitoneal radical prostatectomy after radical resection of pT1-pT2 rectal cancer: a report of thirty cases

INTRODUCTION

Endoscopic extraperitoneal radical prostatectomy (EERPE) has gained popularity for the treatment of localized prostate cancer. However, prior complex lower abdominal or pelvic surgery can complicate subsequent EERPE. To date, there have been few reports on patients who underwent EERPE after radical resection of pT1-pT2 rectal cancer.

AIM

To present our experience with EERPE in patients after radical resection of pT1-pT2 rectal carcinoma and introduce a simple and effective way to create an extraperitoneal working space.

MATERIAL AND METHODS

Thirty patients after radical resection of pT1-pT2 rectal carcinoma were treated with EERPE for biopsy-proven localized prostate cancer. Operation time, estimated blood loss, conversion to open surgery rate, transfusion rate and transurethral catheter time were recorded. Meanwhile, functional outcome (continence and potency) and oncological outcome were reviewed.

RESULTS

The average operative time was 168 min. Mean blood loss was 195 ml. There was no need for conversion to open surgery or transfusion. The catheter was removed on postoperative day (POD) 7.8. After a mean follow-up time of 53.1 months, 3 patients had a prostate-specific antigen level relapse over 0.1 ng/ml. At the follow-up time, 26 patients were completely continent, and 4 needed 1-2 pads/day. Of the 6 patients who underwent neurovascular bundle preservation, none have experienced return of erections at the last follow-up time.

CONCLUSIONS

Endoscopic extraperitoneal radical prostatectomy after radical resection of rectal carcinoma appears promising, with feasibility in experienced hands. The operative data, postoperative urinary incontinence and oncological outcomes appear encouraging, but the rate of erectile dysfunction seems to be disappointing.

Laryngeal tube suction II or endotracheal intubation for laparoscopic radical prostatectomy in a head down position: A randomised controlled trial

BACKGROUND

The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration.

OBJECTIVES

To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy.

DESIGN

Randomised, controlled, blinded and single-centre study.

SETTING

Academic tertiary care centre in Leipzig from April 2014 to May 2015.

PATIENTS

It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway.

INTERVENTIONS

All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation.

MAIN OUTCOME MEASURES

The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy.

RESULTS

In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group.

CONCLUSION

Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy.

TRIAL REGISTRATION

DRKS00008985 (German Clinical Trials Register).

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

[Intermediate and high risk prostate cancer patients. Clinical significance of extended lymphadenectomy]

INTRODUCTION

We examined the quantity and localization of pelvic lymph node (LN) metastases in patients undergoing extended pelvic lymphadenectomy (ePLND).

MATERIALS AND METHODS

A total of 174 patients with intermediate and high-risk prostate cancer underwent radical prostatectomy (RP) and ePLND. We analyzed the relationship between the number of LNs removed and the number, frequency and topography of LN metastases.

RESULTS

In group 1 (intermediate risk patients, n=115) the average number of LNs removed was 20.5, LN metastases were found in 15 patients (13 %) and the localizations were in the external iliac artery 19 %, the internal iliac artery 32 %, the obturator foramen 36 %, the common iliac artery 7 %, Marcille's triangle 3 % and sacral regions 3 %. In group 2 (high-risk patients, n=59) the average number of LNs removed was 23.9, LN metastases were found in 19 patients (32 %) and the localizations were the external iliac artery 15 %, the internal iliac artery 26 %, the obturator foramen 19 %, the common iliac artery 29 %, Marcille's triangle 6 % and sacral regions 5 %. The full number of metastases was detected only if more than 15 LNs were removed in group 1 and 18 LNs in group 2.

CONCLUSIONS

At least 15 LNs in the intermediate risk group and at least 18 LNs in high risk group should be removed. The ePLND should include the common iliac artery, the internal iliac artery, Marcille's triangle and sacral regions.

Transurethral marking incision of the bladder neck: a helpful technique in robot-assisted laparoscopic radical prostatectomy involving post-transurethral resection of the prostate and cancers protruding into the bladder neck

Background

Bladder neck transection is one of the most difficult procedures for robot-assisted laparoscopic radical prostatectomy (RALP), particularly in patients who have undergone previous transurethral resection of the prostate (TUR-P), and in those with large median lobes or prostate cancer protruding into the bladder neck. To ensure negative surgical margins and safely preserve the ureteral orifices during bladder neck transection, we propose the use of the transurethral resectoscope for making the incision in the bladder neck before initiating RALP. Thus, we developed a technique for bladder neck transection to facilitate this operation in such patients.

Case presentation

Two Japanese men, aged 61 and 63 years, who were diagnosed with prostate cancer, received a transurethral marking incision of the bladder neck before starting RALP; prostate cancer developed in one patient after TUR-P and the other patient had cancer protruding into the bladder neck. A transurethral resectoscope was used to closely observe the ureteral orifices and bladder necks; the bladder necks were marked to indicate the depth from the mucosa to the muscular layer. During the RALP, the bladder necks were dissected to indicate the depth of the marking incision. The surgical margins were negative and perioperative complications did not occur. The Foley catheters were removed on postoperative day 6, according to the usual protocol. No urinary leakage from the anastomosis sites was observed.

Conclusion

This technique, involving the use of an ordinary transurethral resectoscope, may be an easy procedure to ensure negative surgical margins, safely preserve the ureteral orifices, avoid increasing the bladder neck diameter, and achieve a good quality vesicourethral anastomosis that prevents the risk of suture-related tissue tears.

Study of predictive factors for complications after percutaneous nephrolithotomy according to the Clavien classification

OBJECTIVE

Set predictors of complications in percutaneous nephrolithotomy (PCNL) using the modified Clavien system.

MATERIAL AND METHODS

Retrospective study included 172 PCNL in Galdakao position made in the La Ribera Hospital between January 2005 and December 2011. They classified the complications of these procedures using the modified Clavien system. We performed a univariate analysis (Chi(2) Test and Cramer's V) and multivariate (logistic regression) of predictors of these complications (P < .05).

RESULTS

In 49 of the 172 procedures complications were detected (28.5%).The most frequent complications were grade 1 (9.9%), 12 complications (6.9%) were classified as grade 2 by requiring additional medical treatment, 6 as grade 3A (3.5%), 7 as grade 3B (4.1%), 2 and 4A (1.1%), 4 and 4B (2.3%) and one and 5 (0.6%). In the univariate analysis, positive urine culture before surgery, the stones complex and larger than 40 mm of the same, showed a statistically significant association with the occurrence of complications (P < .05). The positive culture (OR: 2.96) and complex stones (OR: 3.03) proved to be independent variables predicting complications in multivariate analysis.

CONCLUSIONS

Clavien system allows a common language for classifying complications, expressing the degree of the same as the complexity of treatment required for resolution. The preoperative urine culture positivity and complex stone proved predictors of these complications in our serie.

An ectopic ureter of a duplicated system presenting as a pelvic collection following laparoscopic radical prostatectomy

Radical prostatectomy remains the gold-standard surgical treatment for clinically localized prostate cancer. Contrast imaging of the upper urinary tract is not part of the routine work-up of the patient before radical prostatectomy. This may lead to rare, albeit serious complications when anatomical anomalies are present. This article reports a case of delayed anastomotic leakage following radical prostatectomy due to an unrecognized duplex system on the left side and inclusion of the ureteric orifice draining the upper moiety in the anastomosis, which caused failure of healing and persistent leakage.

[Radical prostatectomy - pro robotic]

Anatomical radical prostatectomy was introduced in the early 1980s by Walsh and Donker. Elucidation of key anatomical structures led to a significant reduction in the morbidity of this procedure. The strive to achieve similar oncological and functional results to this gold standard open procedure but with further reduction of morbidity through a minimally invasive access led to the establishment of laparoscopic prostatectomy. However, this procedure is complex and difficult and is associated with a long learning curve. The technical advantages of robotically assisted surgery coupled with the intuitive handling of the device led to increased precision and shortening of the learning curve. These main advantages, together with a massive internet presence and aggressive marketing, have resulted in a rapid dissemination of robotic radical prostatectomy and an increasing patient demand. However, superiority of robotic radical prostatectomy in comparison to the other surgical therapeutic options has not yet been proven on a scientific basis. Currently robotic-assisted surgery is an established technique and future technical improvements will certainly further define its role in urological surgery. In the end this technical innovation will have to be balanced against the very high purchase and running costs, which remain the main limitation of this technology.

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.

Complications of Percutaneous Nephrolithotomy Classified by the Modified Clavien Grading System: A Single Center's Experience over 16 Years

PURPOSE

To stratify complications of percutaneous nephrolithotomy (PCNL) in a single, tertiary hospital by use of the modified Clavien system.

MATERIALS AND METHODS

From May 1987 to December 2010, 1,236 cases of PCNL were performed at our institute. Medical records were available for 826 cases of PCNL from 698 patients, from February 1995 to December 2010. Using multiple factors, we retrospectively reviewed and analyzed 698 patients for complication rates classified by the modified Clavien grading system, along with success rates.

RESULTS

In 698 patients, staghorn stone patients accounted for 33.8% (236 patients). Initial and overall stone-free rates were 69.9% and 88.8%. A total of 297 complications were documented in 282 patients. According to the modified Clavien classification, grade I, II, IIIa, IIIb, IVa, IVb, and V complications were observed in 88 (12.6%), 145 (20.8%), 31 (4.4%), 5 (0.7%), 6 (0.9%), 4 (0.6%), and 3 (0.4%) patients, respectively. Transient peri-nephrostomy catheter urine leakage (15.2%) was the most common complication, followed by transient fever >38° (11%) and transfusion (6.9%). Other individual complications occurred in less than 1.5% of cases. In patients with staghorn stones, grade I, II, IIIb, and IVa complications were significantly more common, and all grade IVb and V complications occurred in patients with staghorn stones.

CONCLUSIONS

The modified Clavien classification provides a standardized grading system for complications of PCNL, although consensus on specific complications would prompt better comparison between centers. A shorter operation time is imperative to achieve less bleeding. Previous stone-related fever and staghorn stones are significant contributing factors for developing postoperative fever.

Experience of 100 laparoscopic radical prostatectomies performed by a single surgeon: an analysis of surgical and functional outcomes

PURPOSE

We analyzed the surgical and functional outcomes of 100 consecutive laparo-scopic radical prostatectomies (LRP) performed by a single surgeon.

MATERIALS AND METHODS

Between October 2007 and May 2010, a total of 100 consecutive patients underwent LRP for prostate cancer at our institution. We retrospectively reviewed the medical records of these patients to determine surgical and functional results. We compared surgical and functional outcomes between three groups divided on the basis of operation period (Group 1; first 40 cases; Group 2; next 30 cases; Group 3; last 30 cases).

RESULTS

The operative time decreased significantly as the surgeon's experience increased over time (P<0.01). The learning curve for operative time was surpassed after approximately 40 cases. The overall positive surgical margin (PSM) rate was 17.5% in Group 1, 16.7% in Group 2, and 10% in Group 3. For organ-confined disease, the PSM rate was 2.5%, 6.7%, and 3.3% in Groups 1, 2, and 3, respectively. The continence rate (absence of a pad) was 73.2% and the social continence rate was 94.7% at 12 months after surgery. There was a significant difference in continence (absence of pad) between the early (Group 1) and late group (Group 3) at 1, 3, and 6 months (P<0.0001). The continence rate was not affected by whether the pubic bone-anchoring procedure or the Rocco suture method was used. The overall potency rate was 16.7% and 48.6% at 6 and 12 months, respectively. For bilateral nerve-sparing cases, the potency rate was 20% and 57.1% at 6 and 12 months, respectively.

CONCLUSIONS

Our surgical and functional outcomes indicate that even in this 'robotic era', LRP is still an attractive treatment option for patients with localized prostate cancer, especially in areas with limited access to surgical robots.

Overcoming the challenges of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of laparoscopic radical prostatectomy (LRP). However, robotic surgery is still fraught with potential difficulties and avoiding complications while on the steepest part of the learning curve is critical. Furthermore, as surgeons progress there is a tendency to take on increasingly complex cases, including patients with difficult anatomy and prior surgery, and these cases present a unique challenge. Significant intra-abdominal adhesions may be identified following open surgery, or dense periprostatic inflammation may be encountered following TURP; large prostate gland size and median lobes may alter bladder neck anatomy, making difficult subsequent urethro-vesical anastomosis. Even experienced robotic surgeons will be challenged by salvage RARP. Approaching these problems in a structured manner allows many of the problems to be overcome. We discuss some of the specific techniques to deal with these potential difficulties and highlight ways to avoid making serious mistakes.

The deep vein thrombosis caused by lymphocele after endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection

Pelvic lymphocele is a postoperative complications than can result after endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection. Radical prostatectomy have many risk factors of deep vein thrombosis including location of target organ, malignancy, old age, Trendelenburg position, pelvic lymph node dissection, and long procedure time. A 57-year-old man with a localized prostate cancer was treated with endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection. Deep vein thrombosis was detected as a first sign of pelvic lymphocele. Lymphocele was managed with a percutaneous drainage without sclerosant. We report a case of deep vein thrombosis due to pelvic lymphocele after endoscopic extraperitoneal radical prostatectomy.

Current status of laparoendoscopic single-site surgery in urology

PURPOSE

Laparoendoscopic single-site surgery (LESS) uses single incisions for the introduction of instruments through a specially designed multi-lumen single port (multi-port) for the performance of several urologic procedures.

METHODS

Literature review regarding the LESS approach took place on May 2009 and the experiences of our institutions were also included.

RESULTS

Almost all urologic intra-abdominal and pelvic procedures have been successfully and safely performed with the LESS approach. Nevertheless, current experience is limited and there are significant technical challenges to the performance of LESS techniques.

CONCLUSIONS

Wider adaptation of the approach requires refinement of LESS instrumentation to overcome the technical challenges of the approach. The improved outcome should also be documented with further clinical evaluation.

Early continence in patients with localized prostate cancer. A comparison between open retropubic (RRPE) and endoscopic extraperitoneal radical prostatectomy (EERPE)

OBJECTIVE

The study examined and compared continence rates in prostate cancer patients who had undergone either open retropubic prostatectomy (RRPE) or endoscopic extraperitoneal radical prostatectomy (EERPE). The core question was whether the surgical approach had an effect on the patients' continence status 3 months after surgery.

METHODS

We conducted a multicentric, longitudinal study in 7 German hospitals. Three hundred fifty prostate cancer patients (166 EERPE, 184 RRPE) were asked to self-assess symptoms associated with urinary incontinence (UI) 1 day before and 3 months after prostatectomy. Symptoms of UI were assessed using the EORTC QLQ-PR25 questionnaire. Urinary continence was defined according to (1) the use of no protective pad, (2) the use of up to a single protective pad in a 24-hour period, and (3) according to the patient's self-assessment. A binary regression model was employed to predict early continence status.

RESULTS

Three months after prostatectomy, 44% of patients who underwent EERPE and 40% of patients who underwent RRPE were completely continent. Patients who underwent nerve-sparing prostatectomy and patients younger than 65 years had a better chance of regaining urinary continence earlier. The surgical approach had no significant impact on the patients' continence status. Limitations of the study are a drop-out rate of 39% and sociodemographic and clinical differences between both treatment groups.

CONCLUSIONS

Three months after prostatectomy, there were no significant differences between both treatment groups regarding urinary continence. The surgical approach had no significant effect on the patients' continence status. Higher age and non-nerve-sparing surgery are associated with a longer period of convalescence.

Extended lymphadenectomy "step by step" in patients undergoing radical prostatectomy

OBJECTIVES

To describe a surgical technique of pelvic lymph node dissection (PLND) in prostate cancer patients. The idea was to standardize the procedure of PLND and to increase the significance of lymphadenectomy as a part of radical prostatectomy (RP). The best ways to achieve this are (1) to describe the surgical procedure in detail, (2) to improve the knowledge of metastatic spread, and (3) to improve the management of complications.

METHODS

One-hundred six patients with localized prostate carcinoma were treated with RP, including extended PLND. The number of removed lymph nodes (LNs) was correlated with histology and compared with that reported in the literature. Our aim was to observe technical differences that probably accrue in clinical outcomes. We proposed a conceptual schema of PLND.

RESULTS

LN metastases were detected in 15 of 106 patients (14.15%). Positive sentinel LNs were detected in 11 of these 15 patients (73.3%). The average number of removed LNs was 20.5 (range +5). In 4 of 15 patients (26.5%), positive LNs were found in the fossa obturatoria; in 4 patients (26.5%) in the region of the external iliac artery; in 3 patients (20%) in the internal LN region; in 2 patients (13%) in the region of the common iliac artery; in 1 patient (7%) in the presciatic area; and in 1 patient (7%) in the sacral region.

CONCLUSIONS

The standard routine was: (1) dissection of LN tissue along the common iliac artery, (2) dissection of LN tissue in the presciatic area, (3) dissection of LN tissue parasacral, and (4) peritoneal fenestration.

The modified Clavien classification system: a standardized platform for reporting complications in transurethral resection of the prostate

Purpose

The aim of the study was to evaluate the applicability of the modified Clavien classification system (CCS) in grading perioperative complications of transurethral resection of the prostate (TURP).

Methods

All patients with benign prostatic hyperplasia submitted to monopolar TURP from January 2006 to February 2008 at a non-academic center were evaluated for complications occurring up to the end of the first postoperative month. All complications were classified according to the modified CCS independently by two urologists, and the final decision was based on consensus. If multiple complications per patient occurred, categorization was done in more than one grade. Results were presented as complication rates per grade.

Results

Forty-four complications were recorded in 31 out of 198 patients (overall perioperative morbidity rate: 15.7%), and their grading was generally easy, non-time-consuming and straightforward. Most of them were classified as grade I (59.1%) and II (29.5%). Higher grade complications were scarce (grade III: 2.3% and grade IV: 6.8%, respectively) There was one death (grade V: 2.3%) due to acute myocardial infarction (overall mortality rate: 0.5%). Negative outcomes such as mild dysuria during this early postoperative period or retrograde ejaculation were considered sequelae and were not recorded. Nobody was complicated with severe dysuria. There was one re-operation due to residual adenoma (0.5%).

Conclusions

The modified CCS represents a straightforward and easily applicable tool that may help urologists to classify the complications of TURP in a more objective and detailed way. It may serve as a standardized platform of communication among clinicians allowing for sound comparisons.

Endoscopic extraperitoneal radical prostatectomy after previous transurethral resection of prostate: oncologic and functional outcomes of 100 cases

OBJECTIVES

To study radical prostatectomy that has been reported to be more challenging and associated with complications in patients with history of transurethral resection of prostate (TURP).

METHODS

In our series, 100 of 2300 patients had undergone endoscopic extraperitoneal radical prostatectomy (EERPE) after previous TURP. All patients included in the study had at least 1-year follow-up. Patient demographics, mean blood loss, mean catheterization time, complications, functional and oncologic outcome were reviewed.

RESULTS

In all, 100 patients underwent EERPE and 26 of these patients were treated by nerve-sparing EERPE. Lymphadenectomy was performed in 45 patients. Operative time and mean blood loss were similar to previous EERPE series. The transfusion rate and mean time of catheterization were slightly higher than general EERPE population. Positive surgical margin rates were 7% for pT2 and 36% for pT3/4. At 12-month follow-up, 94% of the patients did not experience prostate-specific antigen level>or=0.1 ng/mL. The overall complication rate was 14%. At 12 months, 93% of patients were continent, 4% used 1-2 pads/day and 3% needed >2 pads/day. The potency rates for the 26 patients who underwent nerve-sparing EERPE were 52.6% and 66.7% at 6 and 12 months, respectively.

CONCLUSIONS

Patients who had previously undergone TURP should be considered for radical treatment with EERPE. The procedure is safe even though technically more demanding. Perioperative, functional, and short-term oncologic outcome is promising and directly comparable to existing EERPE experience. Potency results were lower in comparison with existing EERPE series.

Association of HLA class I antigen abnormalities with disease progression and early recurrence in prostate cancer

Defects in HLA class I antigen processing machinery (APM) component expression often have a negative impact on the clinical course of tumors and on the response to T cell-based immunotherapy. Since only scant information is available about the frequency and clinical significance of HLA class I APM component abnormalities in prostate cancer, the APM component expression pattern was analyzed in 59 primary prostate carcinoma, adjacent normal tissues, as well as in prostate carcinoma cell lines. The IFN-gamma inducible proteasome subunits LMP2 and LMP7, TAP1, TAP2, calnexin, calreticulin, ERp57, and tapasin are strongly expressed in the cytoplasm of normal prostate cells, whereas HLA class I heavy chain (HC) and beta(2)-microglobulin are expressed on the cell surface. Most of the APM components were downregulated in a substantial number of prostate cancers. With the exception of HLA class I HC, TAP2 and ERp57 not detectable in about 0.5% of tumor lesions, all other APM components were not detected in at least 21% of lesions analyzed. These APM component defects were associated with a higher Gleason grade of tumors and an early disease recurrence. Prostate carcinoma cell lines also exhibit a heterogeneous, but reduced constitutive APM component expression pattern associated with lack or reduced HLA class I surface antigens, which could be upregulated by IFN-gamma. Our results suggest that HLA class I APM component abnormalities are mainly due to regulatory mechanisms, play a role in the clinical course of prostate cancer and on the outcome of T cell-based immunotherapies.

Neuroanatomy of the male pelvis in respect to radical prostatectomy including three-dimensional visualization

The neuroanatomical structures of the radical prostatectomy (RP) are extensively discussed for their existence, localization and function. Especially structures, e.g. the so-called neurovascular bundle (NVB) that are points of debate in numerous anatomical studies. We review the literature and present our observations in cadaveric specimens, to reconstruct neuroanatomical structures in three dimensions (3D) with the use of appropriate computer applications and produce images of operative fields. We used an internet PubMed survey (http://www.ncbi.nlm.nih.gov) to review recent publications and included back copies of historical neuroanatomical studies from our own library. Our own experimental cadaveric (specimens preserved in Thiel's solution) studies of the autonomic nerve supply of the lower urinary tract were also reviewed. Visualization of the pelvic anatomy and neuroanatomy was done using computer-based software packages. No unified terminology for the structures of the NVBs can be presented to date. The innervation of the smooth muscular structures of the urethra and the complex morphology of urethral sphincter remain unclear. Our cadaveric studies showed that nerves are located on the lateral aspect of the prostate in addition to the NVBs described at the dorsolateral side of the prostate. The neuroanatomical investigations of the male pelvis and visualization of the structures in 3D enable the presentation of operative sites as seen intraoperatively. Moreover, dynamic depiction of the pelvic floor is also possible.