Insufficient utilization of care in male incontinence surgery: health care reality in Germany from 2006 to 2020 and a systematic review of the international literature

PURPOSE

Data suggest that the utilization of care in male incontinence surgery (MIS) is insufficient. The aim of this study was to analyse the utilization of care in MIS from 2006 to 2020 in Germany, relate this use to the number of radical prostatectomies (RP) and provide a systematic review of the international literature.

METHODS

We analysed OPS codes using nationwide German billing data and hospitals' quality reports from 2006 to 2020. A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).

RESULTS

MIS increased by + 68% from 2006 to 2011 (1843-3125; p = 0.009) but decreased by - 42% from 2011 to 2019 (3104-1799; p < 0.001). In 2020, only 1435 MISs were performed. In contrast, RP increased from 2014 to 2019 by 33% (20,760-27,509; p < 0.001). From 2012 to 2019, the number of artificial urinary sphincters (AUSs) changed minimally (- 12%; 1291-1136; p = 0.02). Sling/sling systems showed a decrease from 2011 to 2019 (- 68% 1632-523; p < 0.001). In 2019, 63% of patients received an AUS, 29% sling/sling systems, 6% paraurethral injections, and 2% other interventions. In 2019, few high-volume clinics [n = 27 (13%)] performed 55% of all AUS implantations, and few high-volume clinics [n = 10 (8%)] implanted 49% of retropubic slings.

CONCLUSION

MIS have exhibited a relevant decrease since 2011 despite the increase in RP numbers in Germany, indicating the insufficient utilization of care in MIS. The systematic review shows also an international deficit in the utilization of care in MIS.

[Acceptance and status of digitalization in clinics and practices : Current assessment in German urology]

BACKGROUND

Digitalization of patient documentation and introduction of the electronic patient record (ePA) pose challenges to everyday clinical practice.

OBJECTIVES

We investigated the acceptance and status of the digitalization of patient data and the introduction of the ePA among German urologists.

MATERIALS AND METHODS

A questionnaire with 30 questions about the acceptance and status of digitalization of patient documentation and ePA was sent out via the newsletter of the German Society of Urology.

RESULTS

A total of 80 urologists participated in the survey (response rate 2%). Digital platforms such as Urotube or Researchgate are used by 63% of participants. The complete implementation of digital patient documentation was reported by 72% of respondents working in medical practice and by 54% of those working in the hospital (p = 0.042). While 76% see the digitalization process as reasonable, 34% expressed partial or strong concerns about the complete digitalization of patient documentation. Only 14% of the participants offer video consultations. Advantages for ePA include better networking of the healthcare system (73%), improved diagnosis, indication (41%) and treatment quality (48%), and avoidance of medication errors (70%).

CONCLUSION

German urologists are open to the digitalization process and ePA. Especially younger urologists are using digital media. The advantages of digitalization are, in particular, an improvement in treatment processes. For a smooth introduction, a cross-departmental establishment and, if necessary, an adaptation of the treatment processes are necessary.

[Digital transformation in urology-opportunity, risk or necessity?]

Ultimately, new (digital) techniques and artificial intelligence (AI) applications are changing the working environment in urology. This can be an opportunity for further development, but also a change which is not desired. Adjustments to work processes may be necessary. So-called disruptive processes lead to fundamental changes. In the context of the digital transformation, our way of working is changing. Classic hierarchies, working hours, and working environments are dissolving in favor of creative and flexible working models and corporate structures. Clinics and practices in urology must prepare themselves for changing requirements and be able to provide answers.

[MRI/TRUS fusion-guided prostate biopsy : Value in the context of focal therapy]

BACKGROUND

Several systems for MRI/TRUS fusion-guided biopsy of the prostate are commercially available. Many studies have shown superiority of fusion systems for tumor detection and diagnostic quality compared to random biopsy. The benefit of fusion systems in focal therapy of prostate cancer (PC) is less clear.

OBJECTIVES

Critical considerations of fusion systems for planning and monitoring of focal therapy of PC were investigated.

MATERIALS AND METHODS

A systematic literature review of available fusion systems for the period 2013-5/2016 was performed. A checklist of technical details, suitability for special anatomic situations and suitability for focal therapy was established by the German working group for focal therapy (Arbeitskreis fokale und Mikrotherapie).

RESULTS

Eight fusion systems were considered (Artemis™, BioJet, BiopSee®, iSR´obot™ Mona Lisa, Hitachi HI-RVS, UroNav and Urostation®). Differences were found for biopsy mode (transrectal, perineal, both), fusion mode (elastic or rigid), navigation (image-based, electromagnetic sensor-based or mechanical sensor-based) and space requirements.

DISCUSSION

Several consensus groups recommend fusion systems for focal therapy. Useful features are "needle tracking" and compatibility between fusion system and treatment device (available for Artemis™, BiopSee® and Urostation® with Focal One®; BiopSee®, Hitachi HI-RVS with NanoKnife®; BioJet, BiopSee® with cryoablation, brachytherapy).

CONCLUSIONS

There are a few studies for treatment planning. However, studies on treatment monitoring after focal therapy are missing.

[Cancer control in focus insights and future perspectives for the focal treatment of prostate cancer]

Faced with the dilemma of choosing between the extremes of standard whole gland therapy and active surveillance, those affected by prostate cancer have recently been on the lookout for less invasive alternatives. Particularly the question of whether it would be possible in low risk cancer to treat only the tumour itself while sparing the organ has long been considered. This article discusses the pros and cons of focal treatment and elucidates the latest innovative technologies. High overtreatment rates in low-risk patients submitted to standard therapy and considerable technological advances in diagnosis (particularly multiparametric MRI) and therapy are regarded by the authors as key arguments for abandoning complete tumour eradication with its side effects in favour of sufficient local cancer control by focal treatment with better preserved quality of life in suitable cases.

[Active surveillance for renal cell carcinoma]

The incidence of renal cell carcinoma (RCC) and especially that of small RCCs is increasing. However, not all tumours are malignant and not all malignant tumours are RCCs. Although partial nephrectomy is the therapeutic standard of care, an increasing number of patients is being treated with cryoablation, radiofrequency ablation, or active surveillance. The latter options require a pretherapeutic tumour biopsy. Approximately 85% of all biopsies can distinguish benign from malignant tumours. In the case of a RCC, histological subtype and grading are correctly diagnosed in 85% and 65%, respectively. However, tumour growth and metastasis in patients undergoing active surveillance cannot be predicted. A later tumour growth is the main trigger to change to active therapy. In this paper the results of tumour biopsy and active surveillance of patients with a renal mass are presented.

Green light laser (KTP, 80 W) for the treatment of benign prostatic hyperplasia

AIM

An attractive alternative for the management of benign prostate hyperplasia (BPH) is the use of 80 W potassium titanyl phosphate (KTP). We evaluated the efficacy and safety of this procedure in patients with bladder outlet obstruction (BOO).

METHODS

A total of 171 patients with obstructive BPH underwent the 80 W potassium-titanyl-phosphate laser procedures. Preoperatively the international prostate symptom score (IPSS), the maximal urinary flow rate (Qmax), prostate volume and the post-void residual urine volume (PVR) were determined. Perioperative complications and postoperative blood loss, hospitalization, catheterization time, Qmax and PVR were also assessed.

RESULTS

From the 171 patients, who underwent KTP laser procedure, 143 have been evaluated. The mean preoperative prostate volume was 43.9+/-17.1 (15-76). Eighty-nine patients (62.2%) were on chronic oral anticoagulant therapy (Coumarin or Aspirin 100). The mean applied energy was 170+/-65 kJ (100-275). There was no significant blood loss or fluid absorption during the KTP procedure. The mean Qmax values preoperatively and postoperatively were 3.4+/-4.3 and 16.3+/-7.3, respectively. PVR decreased from 74+/-47.7 mL preoperatively, to 16.6+/-21.5 mL postoperatively. Catheteriza-tion time was 1.4+/-0.8 days (0-5).

CONCLUSION

KTP laser for the prostate represents a safe and effective treatment for patients with BPH. The procedure has a low rate of postoperative complications. It can be used for high risk patients especially for them who are receiving oral anticoagulation therapy.

Randomised prospective study of intermittent versus continuous androgen suppression in advanced prostate cancer

5015

Background: Based on results of animal experiments intermittent androgen blockade was suggested to delay progression of advanced prostate cancer to the hormone refractory stage. We conducted a prospective randomized study to compare intermittent with continuous androgen suppression. Methods: This was a multi-centre, randomised, two-arm study comparing treatment with goserelin + bicalutamide (intermittent, group A) vs. goserelin + bicalutamide (continuous, group B). The primary endpoint was time to clinical and/or biochemical progression of the disease despite androgen suppression. Secondary enpoints were survival time, patient’s quality of life (QoL) and toxicity. Patients eligibility criteria were: histologically confirmed adenocarcinoma of the prostate in clinical stage T1–4N1–3M0 or T1–4N0–3M1 (D1 oder D2). After an induction phase of 24 weeks with MAB, 335 patients whose PSA decreased under 4 ng/ml or = 90% from baseline were randomized. Results: About two-thirds of the patients of both the intermittent and the continuous therapy arm (65% versus 66%, ITT population) experienced a clinical and/or biochemical disease progression due to any reason during this study. The median time to disease progression was longer for patients randomised to the intermittent therapy arm (16.6 months) compared with patients randomised to the continuous therapy arm (11.5 months). This difference however was not statistically significant (log rank test, p=0.1758). The median time to death from any cause was 51.4 month in the intermittent arm compared and 53.8 months in the continuous therapy arm (p = 0.658). There were no differences in the incidence of patients with AEs or SAEs or in any other safety parameter between patients treated intermittently and patients treated continuously. Patients’ self-assessment of their overall health and of their sexual activity appeared to be favourable in the intermittent compared with the continuous therapy arm. 88% of all patients treated intermittently experienced more than 50% of the number of treatment days as treatment-free days. Conclusions: Intermittent therapy in D1 and D2 prostate cancer patients appears to be safe and feasible. Off treatment periods are > 40 % and attribute to patients quality of life.

No significant financial relationships to disclose.

Laparoscopic Radical Prostatectomy in Men Older than 70 Years of Age with Localized Prostate Cancer: Comparison of Morbidity, Reconvalescence, and Short-Term Clinical Outcomes between Younger and Older Men

OBJECTIVES

To analyze the safety and efficacy of extraperitoneal laparoscopic radical prostatectomy (eL-RPE) in elderly versus younger men with localized prostate cancer.

METHODS

Patients undergoing eL-RPE were retrospectively subdivided into group eL-RPE1 (72 men aged 71 yr and older) and group eL-RPE2 (132 men aged 59 yr and younger). Group eL-RPE1 was compared with a group of 70 contemporary, comparable patients aged 71 yr and older undergoing open retropubic radical prostatectomy (group OPEN-RPE).

RESULTS

Compared with group eL-RPE2, patients of group eL-RPE1 had a higher pathologic stage (45% vs. 32% stage pT3 or greater, p<0.001) and higher Gleason score (median 7 vs. 6, p<0.001). Prostate-specific antigen recurrence was significantly worse compared with age-matched controls for younger patients with high-stage or high-grade lesions (p<0.001). Importantly operative time, analgesic requirements, hospital stay, convalescence, and complication rates were comparable. Urinary continence rate was significantly better in group eL-RPE2 at 6 mo (67% vs. 91%, respectively, p<0.001). Group eL-RPE1 and group OPEN-RPE patients had statistically similar pathologic stage and Gleason score (each p>0.05), similar operative time (p=0.12), but less blood loss (p<0.001), shorter hospital stay (p<0.001), and more rapid convalescence (p<0.001) occurred in eL-RPE1.

CONCLUSIONS

eL-RPE is feasible and efficacious even in elderly patients with unfavorable, large-volume disease. eL-RPE offers the advantages of decreased blood loss, shorter hospital stay, and more rapid recovery over OPEN-RPE. However, the elderly patient must be informed preoperatively about the observed higher incontinence rate.

Vesicourethral anastomosis during endoscopic extraperitoneal radical prostatectomy: A prospective comparison between the single-knot running and interrupted technique

OBJECTIVES

To determine the safety and efficacy of the single-knot running versus interrupted technique for urethrovesical anastomosis during endoscopic extraperitoneal radical prostatectomy.

METHODS

A total of 250 consecutive patients who underwent endoscopic extraperitoneal radical prostatectomy were prospectively divided into two groups of 125 patients each who underwent urethrovesical anastomosis using the single-knot running technique (group 1) or the interrupted suture technique (group 2). Surgical data, operative time, difficulty scores, extravasation rate, catheterization time, occurrence of anastomotic strictures, and the early and late continence rates were analyzed statistically.

RESULTS

Regarding the clinical and pathologic findings, extravasation rate, catheterization time, and occurrence of anastomotic strictures, no significant differences were found between the two groups (P >0.05). The strongest independent predictors for extravasation were the integrity of the dorsal wall of the anastomosis and the degree of bladder neck opening (P <0.001). Overall, the continence rate at 3 and 6 months was 76% and 91.5% for group 1 and 77.6% and 93% for group 2, respectively (all P >0.05). The anastomosis technique had no impact on extravasation or continence status (all P >0.05). The only significant differences (P <0.001) in favor of the single-knot technique were the mean operative time and difficulty score (16 versus 24 minutes and 1 versus 3, respectively).

CONCLUSIONS

Both techniques provide satisfactory and similar functional results. However, because of its simplicity and shorter operative time, the single-knot running technique appears preferable.

Induction of spermatogenesis in men with azoospermia or severe oligoteratoasthenospermia after antegrade internal spermatic vein sclerotherapy for the treatment of varicocele

AIM

To evaluate the treatment outcome of antegrade internal spermatic vein sclerotherapy in men with non-obstructive azoospermia or severe oligoteratoasthenospermia (OTA) as a result of varicocele.

METHODS

Between September 1995 and January 2004, 47 patients (mean age 33.8 +/- 6.3 years) underwent antegrade internal spermatic vein sclerotherapy for the treatment of varicocele with azoospermia (14 patients) or severe OTA (33 patients). Testicular core biopsy was also performed in complete azoospermic patients who provided informed consent. The outcome was assessed in terms of improvement in semen parameters and conception rate.

RESULTS

Forty-two (89.4%) of 47 patients had bilateral varicocele. Serum follicle stimulating hormone (FSH) did not differ between patients with azoospermia and severe OTA. After the follow-up of 24.8 +/- 9.2 months, significant improvement was noted in mean sperm concentration, motility and morphology in 35 patients (74.5%). Comparison between groups during the follow-up revealed significantly higher values of sperm concentration, motility and normal morphology in the severe OTA group. Pregnancy was achieved in 14 cases (29.8%). Testicular histopathology of the azoospermic patients with postoperative induction of spermatogenesis revealed maturation arrest at spermatid stage, Sertoli-cell-only (SCO) with focal spermatogenesis or hypospermatogenesis. None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage achieved spermatogenesis after the treatment. Preoperative serum FSH levels didn't relate to treatment outcome.

CONCLUSION

Antegrade internal spermatic vein sclerotherapy is an easy and effective treatment for symptomatic varicocele. It can significantly reverse testicular dysfunction and improve spermatogenesis in men with severe OTA, as well as induce sperm production in men with azoospermia, improving pregnancy rates in subfertile couples.

Extracorporeal shockwave therapy for Peyronie's disease: an alternative treatment?

AIM

To determine retrospectively the safety and efficacy of extracorporeal shock wave therapy (ESWT) in patients with Peyronie's disease.

METHODS

Fifty-three patients with stable Peyronie's disease underwent ESWT (group 1). Fifteen patients matched with the baseline characteristic of the patients in group 1, who received no treatment, were used as the control (group 2). The patients' erectile function (International Index of Erectile Function [IIEF-5] score), pain severity (visual analog scale), plaque size and degree of penile angulation were assessed before and after the treatment in group 1 and during the follow-up in group 2.

RESULTS

The mean follow-up time was 32 months (range: 6-64 months) in group 1 and 35 months (range: 9-48 months) in group 2. All the patients were available for the follow-up. Considering erectile function and plaque size, no significant changes (P > 0.05) were observed in group 1 before or after the ESWT. A total of 39 patients (74%) reported a significant effect in pain relief in group 1 after ESWT. However, regarding improvement in pain, IIEF-5 score and plaque size, no significant differences were observed between the two groups. In 21 patients (40%) of group 1, the deviation angle was decreased more than 10 degrees with a mean reduction in all patients of 11 degrees (range: 6-20 degrees). No serious complications were noted considering ESWT procedure.

CONCLUSION

ESWT is a minimally invasive and safe alternative procedure for the treatment of Peyronie's disease. However, the effect of ESWT on penile pain, sexual function and plaque size remains questionable.

Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: A comparison study

OBJECTIVES

To compare the postoperative quality of life (QOL) and reconvalescence in patients with clinical Stage I nonseminomatous germ cell tumor (NSGCT) after laparoscopic retroperitoneal lymph node dissection (L-RPLND) and the open procedure (O-RPLND).

METHODS

Twenty-one patients with NSGCT who underwent transperitoneal L-RPLND were matched and compared with 29 patients who underwent O-RPLND. The operative, QOL, and recovery data and complications and cure rates were analyzed for both groups.

RESULTS

The mean follow-up time for the L-RPLND and O-RPLND groups was 14 months (range 6 to 20) and 26 months (range 8 to 38), respectively. No major complication requiring open surgical revision or prolongation of hospitalization was observed intraoperatively or postoperatively in either group. However, the early and late minor postoperative complications were significantly greater in the O-RPLND group than in the L-RPLND group (P <0.001). The L-RPLND patients had a significantly shorter hospitalization, greater QOL scores, and a faster return to normal activities than did the O-RPLND patients (all P <0.001).

CONCLUSIONS

L-RPLND for patients with clinical Stage I NSGCT is a safe and efficacious procedure, with a faster reconvalescence and greater postoperative QOL than after O-RPLND.

Intensive laparoscopic training: the impact of a simplified pelvic-trainer model for the urethrovesical anastomosis on the learning curve

We prospectively evaluated the learning curve (LC) for laparoscopic urethrovesical anastomosis (L-UVA) in an operator-training model and program using an innovative simplified pelvic-trainer model. Over a period of 12 months, 30 LRP were performed by one urologist skilled in open surgery but inexperienced in laparoscopy. During the first 15 procedures no systematic training was done. Consequentially, a systematic simplified daily program was performed on the pelvic trainer with a videolaparoscopic unit. The training lesson consisted of intracorporal knotting and suturing, linear and circular interrupted suture anastomosis. At the end of each lesson, time and performance error scores were recorded and progression curve was plotted for each task. The performances of each training tasks were plotted against the performance of L-UVA during the LRP. The significance of progression was evaluated using logarithmic regression analysis. A steady improvement in time and accuracy of performance skill was shown during the first 20 lessons (p<0.001). These improved skill acquisitions were proportionally correlated with the time and the accuracy (water-tight) of L-UVA performance during the last 15 L-RPE. Compared to the first 15 L-RPE, where no systematic training was performed, time and accuracy of L-UVA performance in the last 15 L-RPE were improved from a mean 51 (median 48, range: 38-75) to 26 (median 24, range 18-33) min (p<0.001) and from 10 to 15 watertight anastomoses (p<0.001), respectively. Using a continuing, systematic, simplified training model the LC of L-UVA can be improved significantly in a short time.

Tension-Free Vaginal Tape (TVT) in Morbidly Obese Patients with Severe Urodynamic Stress Incontinence as Last Option Treatment

OBJECTIVES

To determine the safety and efficacy of tension-free vaginal tape (TVT) in morbidly obese women with severe urodynamic stress incontinence (USI) as last option treatment.

METHODS

Thirty-one patients with body mass index (BMI) >40 kg/m2, who had undergone the TVT procedure for urodynamically-confirmed USI were matched with 52 patients with BMI <30 kg/m2 who underwent the same procedure. BMI was calculated at the time of the surgery. Patients' characteristics and surgical data, complications and cure rates were analyzed for both groups.

RESULTS

After a mean follow-up of 18.5 (range: 12-24) months the continence rates were 87% and 92% for morbidly obese women and control group, respectively (p = 0.103). No serious intraoperative complications were noted in both groups. However, the early postoperative complications were significantly higher (p < 0.05) in morbidly obese patients. In 4 patients from both group long term postoperative catheterization was necessary for 4 weeks. In one patient (2%) from the control group dilatation of urethra took place. No defect in healing or rejection of the tape occurred.

CONCLUSIONS

TVT is a minimal invasive and safe procedure for morbidly obese patients suffering from severe USI with good outcome. Preoperative morbid obesity does not seem to be a risk factor for failure of this procedure.

Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients

AIM

To identify possible risk factors for erectile dysfunction (ED) after transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH).

METHODS

Between March 1999 and March 2004, 629 patients underwent TURP in our department for the treatment of symptomatic BPH. All patients underwent transrectal ultrasound examination. In addition, the flow rate, urine residue, International Prostate Symptom Score (IPSS) and quality of life (QOL) were recorded for those who presented without a catheter. Finally, the erectile function of the patient was evaluated according to the International Index of Erectile Function Instrument (IIEF-5) questionnaire. It was determined that ED existed where there was a total score of less than 21. The flow rate, IPSS and QOL assessment were performed at 3 and 6 months post-treatment. The IIEF-5 assessment was repeated at a 6-month follow-up. A logistic regression analysis was used to identify potential risk factors for ED.

RESULTS

At baseline, 522 (83%) patients answered the IIEF-5 questionnaire. The mean patient age was (63.7+/-9.7) years. The ED rate was 65%. After 6 months, 459 (88%) out of the 522 patients returned the IIEF questionnaire. The rest of the group was excluded from the statistical analysis. Six months after TURP, the rate of patients reporting ED increased to 77%. Statistical analysis revealed that the only important factors associated with newly reported ED after TURP were diabetes mellitus (P = 0.003, r = 3.67) and observed intraoperative capsular perforation (P = 0.02, r = 1.12).

CONCLUSION

The incidence of postoperative, newly reported ED after TURP was 12%. Risk factors for its occurrence were diabetes mellitus and intraoperative capsular perforation.

Laparoscopic Radical Prostatectomy Using an Extraperitoneal Approach: Nordwest Hospital Technique and Initial Experience in 255 Cases

PURPOSE

We report on our modifications in technique and initial experience with 255 extraperitoneal laparoscopic radical prostatectomy (eLRP).

PATIENTS AND METHODS

Using significant surgical modifications, our laparoscopic method replicates the steps of the retropubic descending RP. We evaluated 255 consecutive patients who underwent an eLRP with pelvic lymph-node dissection.

RESULTS

The mean operative time was 136 minutes (range 84-266 minutes). Because of technical difficulty, the first three patients were converted to open surgery. One major complication, myocardial infarction, and one surgical reintervention in a case of secondary rectourethral fistula after open surgical repair of a laparoscopic rectal injury were observed. The blood transfusion rate was 1.2%. The pathologic stage was pT2a in 56 patients (22%), pT2b in 50 (20%), pT2c in 74 (29%), pT3a in 42 (16%), pT3b in 29 (11%), and pT4 in 3 (2%). Positive margins were found in 7% of patients (13/180) with pT2 tumors and 27% of patients (19/71) with pT3 tumors. The mean catheterization time was 7 days. The continence rates (no pads at all) at 3, 6, and 12 months were 73.7% (146/198), 89.6% (112/125), and 92.7% (38/41), respectively. After a nerve-sparing procedure, the total potency rates at 3 and 6 months were 37.5% (21/56) and 48.8% (21/43), respectively.

CONCLUSION

The eLRP seems to be safe with short-term oncologic and functional results at least as favorable as those of open radical prostatectomy and classical transperitoneal LRP. The operative times are shorter, and the complication rate appears to be lower.

Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence

OBJECTIVES

To determine whether retroperitoneoscopic radical nephrectomy for large renal cell carcinoma in stage cT2 or cT3a is a feasible, safe and effective therapy option and if it shows any advantage regarding quality of life in comparison to open procedure.

METHODS

23 patients who underwent RPNx for tumor size greater than 7 cm (group 1) were matched and compared with 25 patients, who underwent ONx (group 2) for tumor with similar size characteristics. Patient and surgical data, QoL variables and complications were statistically analyzed.

RESULTS

The median followup was 12 (range: 6-18) months for both groups. Group 1 had significantly (p < 0.001) less blood loss, shorter hospital stay, and shorter postoperative analgesic requirements. No conversion to open surgery was necessary, and no major complications requiring an invasive intervention occurred. Retroperitoneoscopic patients had significantly better QoL and pain scores postoperatively to 6 months (p < 0.001) and they return to baseline QoL status faster (p < 0.001).

CONCLUSIONS

RPNx for large RCC in stage cT2 or cT3a is a safe and efficacious procedure with good short-term outcome results and significantly shorter recovery of QoL variables.

Laparoscopic Radical Prostatectomy: The Value of Intraoperative Frozen Sections

OBJECTIVE

To examine the clinical and pathological value of intraoperative frozen section (IFS) in patients undergoing laparoscopic radical prostatectomy (L-RPE) for clinically localized prostate cancer.

METHODS

The study includes 198 consecutive cases of L-RPE. After removal of the prostate, a 2-3mm circumferential specimen was obtained from the apical and bladder neck soft-tissue margin and submitted for IFS examination. In cases suspicious for capsular incision (n=57), IFS were taken from the neurovascular bundle/lateral pedicle.

RESULTS

The IFS diagnosis from the apical, bladder neck, and neurovascular bundle/lateral pedicle soft-tissue margins was adenocarcinoma in 12 (6%), 1 (0.5%), and 2 (1%) cases, respectively. Patient age, clinical stage, and mean specimen weight were not associated with cancer at the apical IFS. The accuracy, sensitivity, specificity, positive and negative predictive value of the apical IFS to predict cancer in the permanent section of the apical soft-tissue margin was 96%, 70%, 97%, 58%, and 98%, respectively. All the patients (n=15) with cancer at IFS had wide resections of additional tissue in the area of positive soft-tissue margin and all had no cancer in the additional resected tissue. Especially at the apex, IFS decreases the overall PSM status on surgical specimen by 5.1% (apical PSM from 8.6% to 3.5%).

CONCLUSION

Because of the low predictive value of IFS of bladder neck and neurovascular bundle/lateral pedicle their use is not recommended. IFS of the apex should be performed to reduce the PSM rate.