Surgical treatment of high-risk prostate cancer

High-risk prostate cancer (HRPC) currently comprises 17-35% of newly diagnosed cases and has the highest rate of metastasis and cancer-related death, making its management a top priority for improving prostate cancer outcomes. The definition of HRPC is not consensual and several risk stratification criteria have been used, which hinders the interpretation of data and the comparison of different studies. All classifications include prostate-specific antigen (PSA) level, biopsy Gleason score and clinical stage as criteria, but others have been added in an attempt to make stratification more accurate and clinically useful, to enable identification of the patients that can be cured by local treatment of the disease. HRPC was traditionally treated with radiotherapy (RT) and/or androgen deprivation therapy (ADT), but radical prostatectomy (RP) has slowly gained more importance in this context. This article aims to discuss the role of surgery in HRPC, highlighting the advantages of RP as primary treatment option: the ability to provide a definitive stage and grade of the cancer; allowing an early detection of treatment failure by having an undetectable PSA as treatment target; providing excellent local control of the disease; reducing the risk of metastatic progression to a greater extent than does RT. We will try to show the benefits and risks of a "surgery first" approach, keeping in mind that, despite the curative intent, a significant number of patients will still need adjuvant or salvage RT and/or ADT.

Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer

BACKGROUND

Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.

OBJECTIVE

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.

DATA SOURCES

MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.

RESULTS

The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.

LIMITATIONS

The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.

CONCLUSIONS

This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100-150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Laparoscopic Pyeloplasty: Status and Review of Literature

The ideal treatment for ureteropelvic junction (UPJ) obstruction should have the highest success rate, enable treatment of all types of obstruction, allow removal coexisting renal stones, and be minimally invasive. Open pyeloplasty offers all these features except the last (minimal invasiveness), whereas endourology techniques guarantee only the last one. Different techniques of pyeloplasty can be applied laparoscopically, although the best results are seen with dismembered pyeloplasty (Anderson-Hynes technique). Various methods of tissue approximation have been devised to avoid the difficult-to-master, time-consuming conventional suturing technique. Laparoscopic (antegrade) stenting is preferred by some surgeons, but we consider retrograde stenting is superior, as this rules out the presence of associated distal-ureteral obstruction. The transperitoneal approach has the advantages of a larger working space and readily identifiable anatomic landmarks. However, access to the renal pelvis requires considerable mobilization and retraction of the overlying loops of bowel. The retroperitoneal approach has the perceived disadvantage of a somewhat limited working space and absence of readily identifiable intra-abdominal anatomic structures such as the liver and spleen. However, the retroperitoneal approach has the advantage of greater familiarity, better detection of crossing vessels, direct and rapid access to the UPJ, and less risk of ileus. The robot-assisted technique has made suturing easier and may allow expansion of advanced laparoscopic procedures to surgeons without expertise in advanced laparoscopic surgery. The optimal length of follow-up after pyeloplasty is still unclear. Although most failures occur within the first 2 years, failures continue to appear after 5 and 10 years.

Laparoscopic pyeloplasty: Evolution of a new gold standard

OBJECTIVES

To report our series of laparoscopic dismembered pyeloplasty for the treatment of primary and secondary ureteropelvic junction obstruction and to review the current status of this procedure.

METHODS

A total of 170 consecutive cases of laparoscopic pyeloplasty (156 for primary and 14 for secondary ureteropelvic junction obstruction) were performed or supervised by a single surgeon (C.G.E). A four-port extraperitoneal approach was used in all but 3 cases, which were performed transperitoneally.

RESULTS

The median operative time was 140 minutes. The complication rate was 7.1%, and the conversion rate was 0.6%, with no conversion in the last 161 cases. The median postoperative hospital stay was 3 nights. Crossing vessels were encountered in 42% of cases, and in 11 patients, coexisting renal calculi were successfully removed. At a median follow-up of 12 months, the success rate was 96.2%.

CONCLUSIONS

Laparoscopic dismembered pyeloplasty produces functional results comparable to that of open surgery with the advantages of a minimally invasive procedure. Our results are consistent with previous series and support the view that laparoscopic pyeloplasty is moving rapidly toward replacing open surgery as the gold standard in the treatment of ureteropelvic junction obstruction.

The impact of prostate size in laparoscopic radical prostatectomy

OBJECTIVES

Large prostates can be challenging to remove during open or laparoscopic radical prostatectomy (LRP). Our objective was to critically analyse the impact of prostate volume in LRP.

METHODS

400 cases of LRP were performed. Three hundred and fourteen patients had a small prostate (weight < 75 g) and 86 patients had a large prostate (weight > or = 75 g) on final histology. The following outcomes were assessed: operative time; estimated blood loss (EBL); transfusion rate; length of hospital stay (LOS); length of catheterisation; perioperative and postoperative complications (including incontinence and erectile dysfunction); surgical margin status; and early biochemical recurrence rates.

RESULTS

Patients' age, PSA, Gleason sum and clinical stage were all similar. Larger prostates were associated with a 14 minutes longer mean operating time (p < 0.001), but fewer positive surgical margins (p = 0.01). Blood loss, blood transfusion rate, length of hospital stay, length of catheterisation and complication rate were all similar in both groups.

CONCLUSIONS

Prostate size should not be a factor determining a patient's suitability for LRP. Further follow-up is needed to assess the effect of prostate size on long-term functional and oncological results.

The Impact of Prostate Size in Laparoscopic Radical Prostatectomy

OBJECTIVES

Large prostates can be challenging to remove during open or laparoscopic radical prostatectomy (LRP). Our objective was to critically analyse the impact of prostate volume in LRP.

METHODS

400 cases of LRP were performed. Three hundred and fourteen patients had a small prostate (weight < 75 g) and 86 patients had a large prostate (weight > or = 75 g) on final histology. The following outcomes were assessed: operative time; estimated blood loss (EBL); transfusion rate; length of hospital stay (LOS); length of catheterisation; perioperative and postoperative complications (including incontinence and erectile dysfunction); surgical margin status; and early biochemical recurrence rates.

RESULTS

Patients' age, PSA, Gleason sum and clinical stage were all similar. Larger prostates were associated with a 14 minutes longer mean operating time (p < 0.001), but fewer positive surgical margins (p = 0.01). Blood loss, blood transfusion rate, length of hospital stay, length of catheterisation and complication rate were all similar in both groups.

CONCLUSIONS

Prostate size should not be a factor determining a patient's suitability for LRP. Further follow-up is needed to assess the effect of prostate size on long-term functional and oncological results.

TRANSPERITONEAL OR EXTRAPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY: DOES THE APPROACH MATTER?

PURPOSE

: The greater accuracy of apical dissection and reconstruction in our first 100 patients undergoing transperitoneal laparoscopic radical prostatectomy (TLRP) was not matched by a proportionate increase in the rate of return to normal continence compared with our prior open prostatectomy experience. We postulated that greater bladder dysfunction due to the almost total bladder dissection mandated by TLRP might be responsible and this might be rectified by the adoption of laparoscopic radical prostatectomy using an extraperitoneal approach (ELRP).

MATERIALS AND METHODS

: A total of 100 patients undergoing TLRP were compared with 100 undergoing ELRP. The groups were subdivided into halves to investigate the influence of any learning curve effect. All patients had clinical stage T3aN0M0 or less prostate cancer and they were operated on by a single surgeon.

RESULTS

: Mean operative time (238.9 vs 190.6 minutes), blood loss (310.5 vs 201.5 ml), postoperative hospitalization (3.8 vs 2.6 nights) and catheterization duration (11.3 vs 10.1 days) were significantly greater in the TLRP group. After the first 50 cases were excluded in each group statistical significance persisted only for operative time (218.3 vs 184.2 minutes) and hospitalization (3.5 vs 2.5 nights). The pad-free rate was significantly lower 3 months following ELRP (80% vs 56%, p = 0.02). The overall 12-month pad-free rate for TLRP and ELRP was 90% and 96%, respectively. The overall 12-month erection rate for TLRP and ELRP was 61% and 82%, respectively.

CONCLUSIONS

: ELRP is superior to TLRP with respect to operative time, hospitalization and early continence.

Laparoscopic radical prostatectomy: the initial UK series

OBJECTIVE

To test the reproducibility of other series of laparoscopic radical prostatectomy (LRP) for safety, efficacy and early oncological and functional results.

PATIENTS AND METHODS

One hundred consenting patients with clinically localized adenocarcinoma of the prostate and a Gleason sum of < or = 8 opting for surgery underwent LRP undertaken by one surgeon. Their mean (range) age was 62.2 (52-72) years, weight 78.8 (65-100) kg, prostate specific antigen (PSA) level 8.0 (2-32) ng/mL, and Gleason sum 6.0 (4-8). A five-port antegrade transperitoneal technique was used in all cases.

RESULTS

The mean (range) operative duration was 245 (145-600) min, blood loss 313 (50-1300) mL, parenteral morphine sulphate administration 20.2 (0-160) mg and hospital stay after LRP 4.2 (3-13) nights. Bilateral neurovascular bundle preservation was attempted in 58% of patients. The transfusion rate was 3%. The conversion and re-intervention rates were 1% and 2%, respectively. There were eight complications, six of which were in the initial 26 cases, i.e. bladder neck stenosis (two), and rectal injury, laparotomy for bleeding, premature drain removal leading to urinary peritonitis, ulnar nerve neuropraxia, port-site hernia and paralytic ileus in one each. The positive surgical margin rate was 16%. All patients had a PSA level of < or = 0.1 ng/mL at 3 months. By 1 year 90% of patients were pad-free and 62% operated on using a bilateral nerve-sparing technique had erections. There were no biochemical failures. The mean (range) follow-up was 9.8 (1-24) months.

CONCLUSION

The present results are similar to those reported by other centres with greater experience and confirm that LRP is an effective, safe and precise technique. Once intial experience has been gained it offers advantages over open surgery in the form of a dry and magnified operative site, and a lower likelihood of blood transfusion, in addition to the generic advantages of laparoscopy.

Big-screen laparoscopic surgery

Significant advances in fiberoptic and digital technology for laparoscopic surgery have been made over the past decade. One area that appears to be overlooked in this field is the advancement in the display of the image during laparoscopic surgery. The authors describe the use of digital video-cinema equipment as a simple and effective technique that enhances the projection of the surgical view. This method has been found to be visually more comfortable, aiding the surgical procedure, and extremely useful as a teaching tool.

Laparoscopic dismembered pyeloplasty: 50 consecutive cases

OBJECTIVE

To test the hypothesis that laparoscopic dismembered pyeloplasty offers the same good results as open pyeloplasty, but without the disadvantages of the loin incision (which is painful, prolongs hospitalization and prevents a return to normal activities for several weeks) in the treatment of pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Fifty consecutive consenting patients presenting with PUJ obstruction underwent laparoscopic dismembered pyeloplasty carried out by one surgeon using an extraperitoneal approach.

RESULTS

Two (4%) procedures were converted to open surgery. The mean (range) operative duration was 164 (120-240) min. Fifteen (30%) of the patients had their ureter transposed anterior to a crossing lower-pole vessel; 22 (44%) patients had a separate renal pelvic suture line. The mean (range) postoperative parenteral analgesic requirement was 19.1 (0-111) mg of morphine sulphate. The mean (range) hospitalization was 2.6 (2-7) days. Two (4%) patients had complications. After a mean (range) follow-up of 18.8 (3-72) months all but one patient, who had failed endopyelotomy, had a normal renogram and were symptom-free.

CONCLUSION

These results suggest that a loin wound is not necessary for a successful outcome after dismembered pyeloplasty, and that in expert hands laparoscopic dismembered pyeloplasty should now be considered the standard of care.

Intracorporeal or extracorporeal lithotripsy for distal ureteral calculi? Effect of stone size and multiplicity on success rates

Over a period of 57 months, 404 patients with distal ureteral calculi were treated by in situ SWL on a Storz Modulith SL 20 lithotripter and 163 by ureteroscopy (URS) and Swiss Lithoclast stone fragmentation. The case notes on these patients were reviewed for comparison of the initial stone number and individual length and for the calculation of the stone-free, treatment, retreatment, secondary procedure, and complication rates. Complete data were available on 447 patients. The median stone length was 7.0 (range 4-25) mm in the SWL group and 8.0 (range 5-13) mm in the URS group. The single-treatment stone-free rates for the SWL and URS groups were 74.8% and 89.7%, respectively, for single stones and 50.0% and 88.9%, respectively, for multiple (>1) stones. The mean treatment rates for the SWL and URS groups were 1.97 and 1.03, respectively, for single stones and 2.83 and 1.00, respectively, for multiple stones. The mean treatment rate for single stones subjected to SWL increased with increasing stone length (1.57 for stones <8 mm and 2.38 for stones >8 mm), whereas this was not the case for patients submitted to URS (1.20 and 1.27, respectively). The re-treatment rate for each group showed a reciprocal trend. Of the SWL group, 25.9% of the patients eventually required URS to render them stone-free. Nearly all (96%) of the patients undergoing SWL were treated as outpatients. The mean hospitalization in the URS group was 1.1 days. Three patients who underwent URS sustained a ureteral perforation, which was managed successfully by double-J stent insertion. The ideal primary treatment for small (<8 mm) distal ureteral calculi is in situ SWL, with URS plus Lithoclast fragmentation being reserved for failed SWL, single stones >8 mm in length, and multiple stones.

Extraperitoneal laparoscopic dismembered fibrin-glued pyeloplasty: medium-term results

OBJECTIVE

To assess the feasibility and results of performing retroperitoneoscopic dismembered fibrin-glued pyeloplasty in a clinical series of patients with pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

A balloon-dissecting four-port extraperitoneal laparoscopic approach was used in each of nine patients (aged 21-60 years) to dismember the PUJ over a previously placed double-pigtail stent, insert stay sutures to appose the urothelium and complete the pelvi-ureteric anastomosis using fibrin glue. Anastomoses were assessed by diuresis renography 3 months after surgery and at yearly intervals thereafter.

RESULTS

Eight of the nine attempted procedures were completed successfully in a median (range) operating time of 180 (150-230) min. The median (range) post-operative parenteral opiate requirement was 0 (0-80) mg morphine sulphate and the post-operative hospitalization was 2 (2-4) nights. A shortened fibrotic ureter prevented the laparoscopic completion of the second case, which was converted to an open procedure. Follow-up imaging after 1-2 years showed satisfactory upper tract drainage in those cases completed successfully. One patient developed a renal pelvic calculus that was treated by extracorporeal shock wave lithotripsy.

CONCLUSION

This technique is associated with a significantly shorter operating time than historical laparoscopic controls, and with a significantly lower post-operative opiate analgesic requirement and shorter post-operative hospitalization than in a contemporaneous series of patients undergoing open pyeloplasty. However, longer term follow-up is needed to fully assess the performance of these anastomoses.

Assessment of alternative tissue approximation techniques for laparoscopy

OBJECTIVE

To investigate the feasibility and results of applying alternative techniques of tissue approximation for experimental urothelial re-anastomosis in an open and laparoscopic setting.

MATERIALS AND METHODS

The study was carried out in two phases; in phase 1, an open porcine ureteric re-anastomosis was performed using gelatin/resorcin/ formaldehyde (GRF) glue, fibrin glue or potassiumtitanyl-phosphate laser tissue-welding with a fluorescein-doped human albumin solder. The anastomoses were assessed both immediately, by leak pressure, and by the operating time, upper tract urodynamic studies and light and scanning electron microscopy, 6 weeks after surgery. In phase 2 the best technique from phase 1 was compared with sutured controls for porcine retroperitoneoscopic dismembered pyeloplasty, using the same assessment criteria.

RESULTS

In phase 1, GRF glue produced adhesion which was insufficiently flexible to withstand rotation of the anastomosis and this technique was therefore abandoned. Fibrin-glued anastomoses withstood leak pressures equal to those from laser-welding (P = 0.91) and gave similar changes in maximum pressure with a Whitaker test at 6 weeks (P = 0.30), but were superior in requiring a shorter operating time (P = 0.02) and in their electron and light microscopic appearances. In phase 2, fibrin glue gave similar changes in maximum pressure with a Whitaker test to those from polyglactin 910 sutures (P = 0.51) but withstood higher leak pressures (P = 0.01), had a shorter operating time (P = 0.01) and had superior electron and light microscopic appearances.

CONCLUSION

Fibrin glue produced effective experimental laparoscopic pelvi-ureteric anastomoses within less operating time than did sutured controls. Such anastomoses withstood supra-physiological pressures, with no evidence of functional obstruction and with a more favourable histological result after 6 weeks. Laparoscopic evaluation of this modality in a clinical setting is now justified.

Malignant mesothelioma of the tunica vaginalis

Malignant mesothelioma is a rare, often aggressive tumor of the tunica vaginalis. We report 2 cases and review the literature concerning current management strategies. It appears that, although adjuvant chemotherapy and radiotherapy have little value, local and nodal recurrence may be successfully treated by local excision.

Alternative techniques for laparoscopic tissue anastomosis in the retroperitoneum

The scope of reconstructive laparoscopy is currently limited by the difficult and time-consuming nature of laparoscopic suturing. Alternative methods to suturing, such as the use of biocompatible glues and laser tissue welding, have the potential to produce anastomoses which are immediately water-tight, achieved with less tissue trauma and reduce operating times.

Alternative endoscopic access techniques to the retroperitoneum

Operative retroperitoneoscopy provides a less traumatic alternative to transperitoneal laparoscopy for the minimal access surgery of retroperitoneal structures. Although open and closed techniques have been described for achieving access, the former allows the creation of a larger initial retroperitoneal workspace with a greater margin of safety and in a shorter space of time.

Laparoscopic nephrectomy results in better postoperative pulmonary function

The pulmonary response to nephrectomy was studied in 16 patients undergoing laparoscopic (n = 8) or open (n = 8) nephrectomy using a standardized anesthetic technique. Although there was no significant difference between the two groups at 24 hours, postoperative pulmonary function measures (P = 0.02-0.03) and oxygenation (P = 0.03) were significantly better in the laparoscopic surgery group at 48 hours. The median opiate analgesic requirement (P = 0.02) and the number of nights spent in the hospital (P = 0.003) also were significantly lower in this group. The results of this study suggest that laparoscopic nephrectomy offers a real biological advantage in terms of postoperative preservation of lung function and that this might therefore be the safest technique for nephrectomy in patients with limited respiratory reserves.

A consumer's guide to laparoscopic equipment for urology

The ever increasing amount of laparoscopic instrumentation and the lack of any objective comparison make choosing the most appropriate equipment a difficult task for the urological neo-laparoscopist. All major manufacturers of laparoscopic equipment were invited to submit as much of their equipment as possible for inspection. A selection of ports, hand instruments, haemostatic devices and imaging systems was then tested in a laboratory and clinical setting. Costings are provided for evaluated ports, hand instruments and imaging systems. Vessels with a diameter greater than 7 mm, such as renal artery and vein, should be secured with a linear stapler-cutter. The optics of the Olympus OTV-S4, CLV-10 light source, Olympus light cable and A5254A telescope are superior to the other imaging systems tested. Laparoscopic equipment is diverse in specification, performance and cost. Due consideration must be given to these factors when purchasing equipment to avoid disappointment and wastage of resources, particularly with regard to disposable instruments and imaging systems.

Duodenal perforation after laparoscopic cholecystectomy

A case is reported of duodenal perforation complicating laparoscopic cholecystectomy performed by laser dissection. The importance of investigating a patient with persistent shoulder-tip pain following this technique to exclude a subphrenic abscess is emphasised.

Treatment of desmoid tumours in Gardner's syndrome

A 24 year old woman with Gardner's syndrome developed a massive chest wall desmoid tumour, which required radical excision and prosthetic reconstruction. In view of the local aggressiveness of this tumour and the fact that it does not metastasize a policy of radical surgery when possible is recommended.

Penetration of enoxacin into lung tissue

For a study of penetration of enoxacin into lung, patients undergoing pneumonectomy were given 400 mg by mouth the night before and again approx 2 h before operation. A blood sample was taken as the lung was excised. Lung and serum enoxacin concentrations were assayed by high pressure liquid chromatography. Results from 15 patients showed that enoxacin was concentrated in the lung. Enoxacin lung concentrations were 3.2-13.1 mg/l, and ratios of lung to serum concentrations were 3-6 (mean, 4.2).