Radical retropubic prostatectomy through a minimal incision with portless endoscopy: Our initial experience

Gasless single-port access endoscopic surgery in urology: minimum incision endoscopic surgery, MIES

Abstract Minimum incision endoscopic surgery (MIES) is a gasless, single-port access, cost-effective, and minimally invasive surgery that has been in development since the late 1990s. Use of MIES has steadily increased in Japan and Asia and has been introduced into Europe and the USA. In 2006, MIES was certified by the Japanese government as an advanced surgery and since 2008 it has been covered by the Japanese universal health insurance system as a new surgical technique. Briefly, MIES involves an initial minimum incision (a single port) that permits extraction of the target specimen. A wide working space through the port is then made by separating the anatomical plane extraperitoneally. This is maintained with special retractors instead of gas insufflation. All instruments including an endoscope are inserted through the port and the operation is completed. The size of the port can be tailored to the situation if necessary, which contributes to preclusion of patient selection. The procedure uses only two disposable devices that are inexpensive, resulting in low equipment costs. Surgeons have the benefits of magnified vision through endoscopy as well as stereovision and panoramic vision of naked eyes through the port, which reduces the technical demands of the procedure. Techniques for two basic MIES procedures allow MIES to be performed for most urological organs and in extraordinary cases by their modifications. Thus, the MIES system permits minimally invasive surgery without use of CO(2) gas, which is ideal from medical, environmental and economic perspectives, is cost-effective and minimizes patient selection.

Frequency of postoperative inguinal hernia after endoscope-assisted mini-laparotomy and conventional retropubic radical prostatectomies

OBJECTIVE

The objective of the present study was to compare the incidence of postoperative inguinal hernia between endoscope-assisted mini-laparotomy retropubic radical prostatectomy (mini-lap RRP) with conventional techniques to identify possible risk factors.

METHODS

From April 1998 to December 2006, 347 consecutive cases with localized prostate cancer were treated with conventional RRP (75 cases) and mini-lap RRP (272 cases) with pelvic lymphadenectomy. Mini-lap RRP was carried out with a 6-cm median incision. The charts were retrospectively reviewed, and the incidence of and risk factors for postoperative inguinal hernia were assessed.

RESULTS

There were no significant differences in age, initial prostate-specific antigen concentrations, clinical stage, Gleason score, body mass index, incidence of previous major abdominal surgery (cholecystectomy, gastrectomy, and colectomy), previous appendectomy, and previous inguinal hernia repair between the two groups. Postoperative inguinal hernia was observed in 29 cases (38.7%) in the conventional RRP group and in eight cases (2.9%) in the mini-RRP group during the mean follow-up period of 26.1 months (range: 3-105 months). The patients treated with mini-lap RRP had significantly higher hernia-free survival than those treated with conventional RRP (log rank test, P < 0.001). Multivariate analysis showed that surgical technique (conventional RRP) and previous major abdominal surgery were risk factors for inguinal hernia (P < 0.001 and P = 0.007, respectively).

CONCLUSIONS

Inguinal hernia was less frequent after mini-lap RRP than after conventional RRP. A history of a major abdominal surgery was an independent risk factor for this event.

Modified Pfannenstiel approach for radical retropubic prostatectomy: a 3-year experience

A modified Pfannenstiel approach for radical retropubic prostatectomy (RRP) has been described previously. We present our experience with this approach for performing a RRP over the past 3 years. Between January 2003 and July 2006, 544 consecutive RRPs by modified Pfannenstiel approach between January 2003 and July 2006 were performed. We analyzed blood loss, transfusions, use of drain, pain score, analgesia and hospital stay. Patients were followed up at 6 weeks, three monthly for a year and six monthly thereafter. All clinical and operative variables were entered into a database and analyzed. A total of 544 men underwent RRP with median follow-up of 11 (s.d.+/-10.5) months. The mean age was 60 (s.d.+/-7) years. About 83, 91 and 95% of patients had nerve sparing, bladder neck preservation and a lymph node dissection, respectively. Fifty-three patients had a concurrent inguinal hernia repair through the same incision. Mean estimated blood loss was 431 (s.d.+/-267) ml. The pathological staging distribution was T2, 82%; T3a, 9%; and T3b, 9%. The mean pain score at days 1 and 7 were 3.7 (s.d.+/-2.5) and 3.3 (s.d.+/-3), respectively. The median hospital stay was 36 h (s.d.+/-24). About 5.5% have had biochemical recurrence. At 12 months 97% were continent and 46% potent. RRP using a modified Pfannenstiel approach offers safety and efficacy. It facilitates repair of associated inguinal hernia through the same incision.