Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? An analysis of peri-operative morbidity in two contemporary series in Italy

Impact of open and minimally invasive surgery on postoperative wound complications in patients undergoing prostate surgery: A meta-analysis

In this article, we analysed the therapeutic efficacy of open radical prostatectomy (ORP) and minimally invasive surgery (MIS) after operation for the treatment of post-operation complications. In summary, because of the broad methodology of the available trials and the low number of trials, the data were limited. The investigators combined the results of six of the 211 original studies. We looked up 4 databases: PubMed, EMBASE, Web of Science and the Cochrane Library. A total of six publications were selected. The main result was the rate of post-operation wound complications. Secondary results were the time of operation and the duration of hospitalization. Our findings indicate that the minimal invasive operation can decrease the incidence of wound infections (OR, 0.61; 95% CI: 0.42,0.90, p = 0.01), bleeding (MD, -293.09; 95% CI: -431.48, -154.71, p < 0.0001), and length of stay in the hospital compared with open surgery (MD, -1.85; 95% CI: -3.52, -0.17, p = 0.03), but minimally invasive surgery increased patient operative time (MD, 51.45; 95% CI: 40.99, 61.92, p < 0.0001). Compared with the open operation, the microinvasive operation has the superiority in the treatment of the wound complications following the operation of radical prostatic carcinoma. But the operation time of the microinvasive operation is much longer. Furthermore, there is a certain amount of bias among the various studies, so it is important to be cautious in interpretation of the findings.

Incidence of Rectal Injury After Radical Prostatectomy: A Systematic Review and Meta-analysis

Context

Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe infection/sepsis, and late sequelae, such as a rectourethral fistula (RUF). Considering its traditionally low incidence, uncertainty remains as to predisposing risk factors and management.

Objective

To examine the incidence of RI after RP in contemporary series and to propose a pragmatic algorithm for its management.

Evidence acquisition

A systematic literature search was performed using the Medline and Scopus databases. Studies reporting data on RI incidence were selected. Subgroup analyses were conducted to assess the differential incidence by age, surgical approach, salvage RP after radiation therapy, and previous benign prostatic hyperplasia (BPH)-related surgery.

Evidence synthesis

Eighty-eight, mostly retrospective noncomparative, studies were selected. The meta-analysis obtained a pooled RI incidence of 0.58% (95% confidence interval [CI] 0.46-0.73) in contemporary series with significant across-study heterogeneity (I² = 100%, p < 0.00001). The highest RI incidence was found in patients undergoing open RP (1.25%; 95% CI 0.66-2.38) and laparoscopic RP (1.25%; 95% CI 0.75-2.08) followed by perineal RP (0.19%; 95% CI 0-276.95) and robotic RP (0.08%; 95% CI 0.02-0.31). Age ≥60 yr (0.56%; 95% CI 0.37-06) and salvage RP after radiation therapy (6.01%; 95% CI 3.99-9.05), but not previous BPH-related surgery (4.08%, 95% CI 0.92-18.20), were also associated with an increased RI incidence. Intraoperative versus postoperative RI detection was associated with a significantly decreased risk of severe postoperative complications (such as sepsis and bleeding) and subsequent formation of a RUF.

Conclusions

RI is a rare, but potentially devastating, complication following RP. RI incidence was higher in patients ≥60 yr of age, and in those who underwent open/laparoscopic approach or salvage RP after radiation therapy. Intraoperative RI detection and repair apparently constitute the single most critical step to significantly decrease the risk of major postoperative complications and subsequent RUF formation. Conversely, intraoperatively undetected RI can lead more often to severe infective complications and RUF, the management of which remains poorly standardised and requires complex procedures.

Patient summary

Accidental rectum tear is a rare, but potentially devastating, complication in men undergoing prostate removal for cancer. It occurs more often in patients aged 60 yr or older as well as in those who underwent prostate removal via an open/laparoscopic approach and/or prostate removal after radiation therapy for recurrent disease. Prompt identification and repair of this condition during the initial operation are the key to reduce further complications such as the formation of an abnormal opening between the rectum and the urinary tract.

Neuraxial anesthesia versus general anesthesia in patients undergoing three-dimensional laparoscopic radical prostatectomy: Preliminary results of a prospective comparative study

Objective

Neuraxial anesthesia (NA) showed to reduce both morbidity and mortality in patients undergoing laparoscopic surgery. We aimed to investigate the use of NA in patients undergoing transperitoneal three-dimensional laparoscopic radical prostatectomy (t-3DLRP) and compare the intraoperative and postoperative outcomes with a control group of patients undergoing t-3DLRP under general anesthesia (GA).

Methods

A prospective, double-center, double-surgeon study cohort of 84 consecutive patients undergoing t-3DLRP between June 2019 and June 2021 was analyzed. A study group of 42 patients undergoing t-3DLRP under NA was compared with a control group of 42 patients undergoing t-3DLRP under GA.

Results

The two group were similar in all demographic, clinical, and pathological variables. Postoperative blood gas parameters were within physiologic limits in both groups. Muscle relaxation was adequate for surgery during both NA and GA. Median length of stay was 1 day shorter for NA group than GA group (5 days vs. 6 days, p=0.05). t-3DLRP under NA had a statistically lower rate of minor complications (4.8% vs. 19.0%, p=0.03) and less postoperative pain (median numeric rating scale 3 vs. 4, p=0.01) compared to GA. No major complications were observed in both groups. Significantly more patients were willing to undergo a similar intervention under NA than GA (p=0.04).

Conclusion

t-3DLRP under NA is a feasible and safe procedure, with less postoperative pain and fewer minor complications than the same procedure under GA. NA allows the maintenance of muscle relaxation and respiratory excursions without interfering with surgery.

Laparoscopic Radical Prostatectomy in Patients with High-Risk Prostate Cancer: Feasibility and Safety. Results of a Multicentric Study

INTRODUCTION

In Western countries about 25% of prostate cancer (PCa) are high-risk tumors at presentation and its treatment is still a matter of debate among urologists. When a surgical approach is preferred the use of a mininvasive tecnique is still difficult due to the lack of data supporting it in literature. The aim of this study is to evaluate feasibility and safety of laparoscopic radical prostatectomy (LRP) for high-risk PCa.

MATERIALS AND METHODS

The study included 1114 patients with high-risk PCa submitted to LRP between 1998 and 2014. High-risk patients were defined according to D'Amico classification. We collected functional and oncological long-term outcomes and evaluated with univariate and multivariate analyses the role of predictive factors for survival and biochemical recurrence (BR).

RESULTS

Mean age at treatment was 62 ± 8 years; mean follow-up was 74 ± 50 months. We obtained an overall survival (OS) of 96.6% at a mean follow-up of 74 months (1076 patients) and a disease-free survival of 66.2% (737 patients). Age (p = 0.0006), pT (p < 0.0001), pN (p = 0.0018), and surgical margins (p = 0.0076) resulted as independent predictors for BR in multivariate analysis. pN (p = 0.0025) and Gs (p = 0.0003) are independent predictors for OS and cancer-specific survival in a univariate analysis; just the Gs results significant in the multivariate model.

CONCLUSIONS

According to our encouraging data about oncological and functional outcomes we believe that radical prostatectomy represents an effective treatment for patients with high-risk PCa and that laparoscopy is a safe approach offering a mini-invasive alternative to open surgery.

Transperitoneal versus extraperitoneal approach in laparoscopic radical prostatectomy: A meta-analysis

BACKGROUND

To compare the transperitoneal approach with extraperitoneal approach in laparoscopic radical prostatectomy (LRP) (including pure and robotic-assisted LRP) using meta-analytic techniques.

METHODS

Medline (PubMed), Embase, Ovid, CMB, and Cochrane databases were searched for studies that compared the transperitoneal and extraperitoneal approaches in LRP from January 2000 to January 2017. Outcomes included were operative time, operative bloods joss (milliliters), rate of transfusion, rate of open conversion, rate of intraoperative complications, rate of postoperative complications, and time of postoperative catheterization.

RESULTS

Thirteen studies including 1674 patients were selected for the meta-analysis. 850 (50.8%) cases had undergone transperitoneal LRP (TLRP) and 824 (49.2%) cases had undergone the extraperitoneal LRP (ELRP). Comparison of operative time between the TLRP group and the ELRP group showed no significant differences (weighted mean difference [WMD] = 21.21,95%CI = -1.16-43.57, P = .06). No significant differences were observed in blood loss (WMD = -6.04, 95%CI = -43.38-31.29, P = .75) and the rate of transfusion (odds ratio [OR] = 1.03, 95%CI = 0.55-1.96, P = .92) between the 2 groups. No significant differences were observed for the rate of intraoperative complications (OR = 1.25, 95%CI = 0.57-2.21, P = .75) and the rate of open conversion (OR = 1.12, 95%CI = 0.32-4.97, P = .75). Significant differences were observed in the TLRP group compared with the ELRP group (OR = 1.69, 95%CI: 1.23-2.32, P = .001) regarding the rate of postoperative complications.

CONCLUSIONS

Our meta-analysis findings revealed that the TLRP group showed no significant differences in most important indicators compared with ELRP. Moreover, TLRP showed higher rate of postoperative complications compared with ELRP.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: surgical, oncological, and functional outcomes: a systematic review

OBJECTIVES

Despite the wide diffusion of minimally invasive approaches, such as laparoscopic (LRP) and robot-assisted radical prostatectomy (RALP), few studies compare the results of these techniques with the retropubic radical prostatectomy (RRP) approach. The aim of this study is to compare the surgical, functional, and oncological outcomes and cost-effectiveness of RRP, LRP, and RALP.

METHODS

A systematic review of the literature was performed in the PubMed and Embase databases in December 2013. A 'free-text' protocol using the term 'radical prostatectomy' was applied. A total of 16,085 records were found. The authors reviewed the records to identify comparative studies to include in the review.

RESULTS

44 comparative studies were identified. With regard to the perioperative outcome, LRP and RALP were more time-consuming than RRP, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates were the most optimal in the laparoscopic approaches. With regard to the functional and oncological results, RALP was found to have the best outcomes.

CONCLUSION

Our study confirmed the well-known perioperative advantage of minimally invasive techniques; however, available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. On the contrary, cost comparison clearly supports RRP.

Practicalities of using a modified version of the Cochrane Collaboration risk of bias tool for randomised and non-randomised study designs applied in a health technology assessment setting

We describe our experience of using a modified version of the Cochrane risk of bias (RoB) tool for randomised and non-randomised comparative studies.

OBJECTIVES

To assess time to complete RoB assessment. To assess inter-rater agreement. To explore the association between RoB and treatment effect size

METHODS

Cochrane risk of bias assessment was performed on a sample of full text primary reports included in a systematic review comparing operative techniques for radical prostatectomy. Inter-rater agreement was assessed using the kappa statistic.

RESULTS

Twenty-four studies were judged as high overall RoB, 13 were judged as low RoB and 11 were unclear. The weighted Kappa value was 0.35 indicating fair agreement. The median (range) time taken to rate each study was 30 min (10-49). The effect estimate for all studies was 0.61 (95% credible interval (CrI) 0.46-0.83) and 0.73 (95% CrI 0.29-1.75) for low risk studies.

CONCLUSIONS

Although the process was time consuming, using a modified version of the RoB tool proved useful for demonstrating conservative effect estimates. That we only achieved a fair agreement between reviewers demonstrates the urgent need for further validation to improve inter-rater agreement. We suggest additional RoB levels could improve inter-rater reliability.

Laparoscopic versus open bilateral intrafascial nerve-sparing radical prostatectomy after TUR-P for incidental prostate cancer: surgical outcomes and effect on postoperative urinary continence and sexual potency

OBJECTIVE

To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRPT) and nerve-sparing retropubic radical prostatectomy (nsRRPT) after TUR-P for incidental prostate cancer.

MATERIALS AND METHODS

Between January 2003 and August 2011, 125 nsLRPT and 128 nsRRPT for incidental prostate cancer diagnosed after TUR-P were performed at our clinic. Demographic data, peri- and postoperative measurements and functional outcomes were compared.

RESULTS

The mean operative time was 153.1 ± 35.4 min for nsLRPT and 122.5 ± 67.5 min for nsRRPT (p = 0.03). The mean catheterization time was 8 ± 1 days in the laparoscopic group and 11 ± 2 days in the open group (p = 0.02). Also, the length of hospitalization presents statistical significant difference in the two groups. Positive margins were detected in 2.4 and 4.7% of patients with pT2c tumours in the laparoscopic and open groups, respectively (p = 0.09). At a mean follow-up of 26.9 ± 9.3 months for the nsLRPT group and of 27.8 ± 9.7 months for the nsRRPT group, all patients were alive with no evidence of tumour recurrence. Twelve months postoperatively, complete continence was reported in 96.8% of patients who underwent an nsLRPT and in 89.4% of patients in the nsRRPT group (p = 0.02). At that time, 74.4% of patients in the nsLRPT group and 53.1% in the nsRRPT group reported the ability to engage in sexual intercourse (p = 0.0004).

CONCLUSION

nsLRPT after TUR-P, performed by expert surgeons, results to be a safe procedure with excellent functional outcomes with regard to the urinary continence and sexual potency.

Comparison of oncological and functional outcomes of pure versus robotic-assisted laparoscopic radical prostatectomy performed by a single surgeon

OBJECTIVE

The aim of this study was to compare oncological and functional outcomes of pure laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALRP) performed by a single surgeon.

MATERIAL AND METHODS

In total, 327 consecutive patients with prostate cancer who underwent radical prostatectomy (144 with LRP and 183 with RALRP) were enrolled. No significant differences were found in prostate-specific antigen level, biopsy Gleason score, clinical T stage or D'Amico risk stratification between the two groups. The operating time was longer in the LRP group (p < 0.001). The RALRP group patients had significantly lower postoperative pain numerical rating scale (NRS) (p = 0.016) and catheter duration (p < 0.001). There were no differences in pathological Gleason score, pathological T stage or positive surgical margin rate. No differences were found in biochemical recurrence-free survival. Postoperative pad-free continence rates revealed a more rapid recovery in the RALRP group, but rates at 12 months were not significantly different. Multivariate analysis showed that the type of surgery was a strong independent factor to predict early postoperative pad use. Postoperative potency rates were not significantly different at 3, 6 and 12 months in patients who underwent nerve-sparing procedures.

CONCLUSIONS

LRP and RALRP performed by a single surgeon yielded similar results in terms of safety and oncological outcomes. More favorable outcomes were noted in operating time, pain NRS and catheter duration, as well as urinary continence recovery time. Therefore, RALRP showed more favorable components in terms of postoperative quality of life than LRP.

Radical perineal prostatectomy: An outdated procedure?

OBJECTIVES

Radical perineal prostatectomy (RPP) is an alternative to the retropubic, laparoscopic or robotic prostatectomy approaches. This study reports the experience with RPP of a single surgeon at a single institution; the technical aspects, oncological outcome, and complications, such as urinary incontinence and erectile dysfunction, were investigated.

METHODS

A total of 212 consecutive patients with a mean age of 63 (range 45-74) years and clinically localised prostate cancer were monitored. Between January 2001 and December 2010, all patients underwent RPP that was performed by a single experienced surgeon at one institution. All data were introduced into a database focussing on the intra-operative and post-operative complications, continence rate, potency and oncological outcome.

RESULTS

The mean follow-up was 48 (6-117) months. Intra-operative complications, both early and late, occurred in 19% of the patients. The average length of in-hospital stay was 9 (3-45) days, and the mean period of time spent with a urethral catheter in place was 9 (4-45) days. The continence rate was 81%, and the potency rate, without any pharmacological aid, was 27%. The overall PSA-free survival rate was 86%. There was one cancer-specific death.

CONCLUSION

On the basis of our prospective data, we conclude that RPP provides satisfactory oncological results with an acceptable outcome in terms of quality of life. RPP can be considered to be mini-invasive and achieves results that are equivalent to those of the alternative surgical approaches.

Rectourinary fistula after radical prostatectomy: review of the literature for incidence, etiology, and management

Although rectourinary fistula (RUF) after radical prostatectomy (RP) is rare, it is an important issue impairing the quality of life of patients. If the RUF does not spontaneously close after colostomy, surgical closure should be considered. However, there is no standard approach and no consensus in the literature. A National Center for Biotechnology Information (NVBI) PubMed search for relevant articles published between 1995 and December 2010 was performed using the medical subject headings “radical prostatectomy” and “fistula.” Articles relevant to the treatment of RUF were retained. RUF developed in 0.6% to 9% of patients after RP. Most cases required colostomy, but more than 50% of them needed surgical fistula closure thereafter. The York-Mason technique is the most common approach, and closure using a broad-based flap of rectal mucosa is recommended after excision of the RUF. New techniques using a sealant or glue are developing, but further successful reports are needed.

Robotic surgery in urologic oncology: gathering the evidence

In less than a decade, the widespread application of robotic technology to the field of urologic oncology has permanently altered the way urologists approach malignancy. The short-term benefits of minimally invasive surgery using robotic assistance (i.e., decreased blood loss, improved convalescence and ergonomic appeal), as well as a broad marketing campaign, have helped the technology gain traction in the field of urology. Although the long-term benefits of its use in urologic surgery are less clear and the costs of robotic surgery are consistently greater than those of other approaches, the numbers of prostate, kidney and bladder cancer cases continue to rise. Identifying transferable surgical processes of care that matter most for each of the robotic cases in urologic oncology (e.g., prostatectomy, cystectomy and partial nephrectomy) is a next step toward broadly improving the quality of urologic cancer care. To this end, urologic professional societies and their surgeons should aim to identify underwriters for and participate in large clinical registries and surgical quality collaboratives.

Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients

Study Type - Therapy (case series).

LEVEL OF EVIDENCE

 4. What's known on the subject? and What does the study add? Bilateral nerve-sparing radical prostatectomy still represents an issue for urologists as the indications to perform it depend oft from the personal clinical experience. Moreover, until now data concerning bilateral and unilateral laparoscopic nerve-sparing radical prostatectomy have been limited. This study states that bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes when compared with unilateral nsLRP and it suggests to prefer a bilateral nerve-sparing technique in younger patients with low-risk, organ-confined prostate cancer.

OBJECTIVE

To evaluate the surgical and functional outcomes in bilateral and unilateral nerve-sparing laparoscopic radical prostatectomy (nsLRP).

PATIENTS AND METHODS

Between January 2005 and May 2009, 457 nsLRP were performed at our clinic. In all, 250 patients underwent a bilateral nsLRP and 207 patients underwent an unilateral nsLRP. One surgeon performed all the operations. All patients presented at biopsy a localized prostate cancer. Demographic data and perioperative and postoperative measurements and outcomes were compared.

RESULTS

The operative times for bilateral nsLRP and unilateral nsLRP were 165 ± 45 min and 130 ± 25 min, respectively. The mean intra-operative blood loss was 450 ± 300 mL and 270 ± 160 mL in the bilateral and unilateral nsLRP groups with a transfusion rate of 3% and 1%, respectively (P = 0.013). Conversion to open surgery was never deemed necessary. Postoperatively, the mean Gleason Score after nsLRP and distribution of tumour stages was similar in the two groups, and the frequency of positive margins in both groups did not present any statistically significant difference. At 12 months, a complete continence was reported in 97% of patients who underwent a bilateral nsLRP and in 88% of patients of the unilateral nsLRP group. At that time, 69% in the bilateral nsLRP and 43% in the unilateral nsLRP groups reported the ability to engage in sexual intercourse.

CONCLUSION

The bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes with regard to urinary continence and sexual potency, when compared with unilateral nsLRP, reporting similar oncological outcomes.

Trends in the care of radical prostatectomy in the United States from 2003 to 2006

OBJECTIVE

• o determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy.

PATIENTS AND METHODS

• We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach.

RESULTS

• Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P = 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P = 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P = 0.049), miscellaneous surgical complications (3.6 to 2.3%, P = 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P = 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P = 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period.

CONCLUSION

• The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control.

Management of anaemia in prostate cancer

Anaemia is a frequent complication of prostate cancer and of its treatments. In Europe prostate cancer accounts for the 10.8% of all malignant neoplasms. Iatrogenic hypogonadism and age-related physiologic changes along with nutritional deficits contribute to increase prevalence of prostate cancer related anaemia. The reason of the present review is to provide clinicians with all aspects of a frequent and multifactorial co-morbidity, whose effects are often underestimated. Erythropoiesis pathology and causes of anaemia in prostate cancer are reviewed. Critical issues of clinical management of anaemia in prostate cancer are discussed.

Laparoscopic radical prostatectomy: a review

INTRODUCTION

We offer an overview of the intra-, peri- and postoperative outcomes of laparoscopic radical prostatectomy (LRP) with the endpoint to evaluate potential advantages of this approach.

MATERIALS AND METHODS

We conducted an extensive Medline literature search (search terms "laparoscopic radical prostatectomy" and "radical prostatectomy") from 1990 until 2007. Only full-length English language articles identified during this search were considered for this analysis. A preference was given to the articles with large series with more than 100 patients. All pertinent articles concerning localized prostate cancer were reviewed.

CONCLUSION

Pure LRP has shown to be feasible and reproducible but it is difficult to learn. Potential advantages over open surgery have to be confirmed by longer-term follow-up and adequately designed clinical studies.

Laparoscopic vs open retropubic intrafascial nerve-sparing radical prostatectomy: surgical and functional outcomes in 300 patients

OBJECTIVE

To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRP) and retropubic nsRP (nsRRP).

PATIENTS AND METHODS

Between January 2005 and November 2007, 150 nsLRP and 150 nsRRP were performed at our clinic. Demographic data, variables before and after surgery, and outcomes, were compared.

RESULTS

The operative duration was 165 min for nsLRP and 120 min for nsRRP. Although the nsLRP group had a lower frequency of positive margins, the difference was not statistically significant. At 1 year after surgery, complete continence was reported in 97% of patients who had nsLRP and in 91% who had nsRRP (P= 0.03). At that time, 66% of patients in the nsLRP and 51% in the nsRRP group reported being able to engage in sexual intercourse (P < 0.05). There were no statistical differences in surgical trauma in both groups.

CONCLUSION

Our study showed that nsLRP performed by expert surgeons results in better functional outcomes for continence and potency than for nsRRP. There was no significant difference between the surgical techniques in surgical trauma.

[Urinary incontinence following open prostatectomy or laparoscopy for local prostate cancer. A review of relevant literature]

AIM

Evaluate urinary continence after radical prostatectomy.

MATERIALS AND METHOD

Recent series about urinary continence were studied.

RESULTS

In seven articles analyzed, continence fluctuated between 63.6 and 91.9%. Evaluation benchmarks were depending on study. Unlike self-questionnaires, objective criteria (pad test) should be more reliable. Carcinologic prognostic factors were not implicated directly. The most frequently preoperative risk factors of incontinence were: age, BMI. Peroperative parameters, attesting of surgical difficulties could have a functional impact. Bladder neck preservation could affect the recovery velocity but not functional results. Length of catheterization and lack of urinary rehabilitation could be influent. The mean of continence evaluation after radical prostatectomy was different for each study.

CONCLUSION

Comparability was difficult because operative technique, group's features and mean of functional evaluation were different from study to study. Several risk factors were found but without consensus. It would be necessary to separate carcinologic and functional risk factors.

Laparoscopic radical prostatectomy: A European virus

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

Minimal invasiveness of radical laparoscopic prostatectomy: dreams or reality?

To determine the systemic response to extraperitoneal laparoscopic (eLRP) and open retropubic radical prostatectomy (RRP).

Materials and Methods.

In all, 430 patients who had eLRP (200) or open RRP (230) were recruited; patients in both groups had similar preoperative staging. In addition to peri-operative variables (operative duration, complications, blood loss, transfusion rate, hospitalization, catheterization), oncological data (Gleason score, pathological stage, positive margins) were also compared. The extent of the systemic response to surgery-induced tissue trauma was measured in all patients, by assessing the levels of acute-phase markers C-reactive protein (CRP), serum amyloid A (SAA), interleukin-6 (IL-6) and IL-10 before, during and after RP.

Results.

The duration of surgery, transfusion rate, hospital stay and duration of catheterization were comparable with those of previous studies. There was an increase in IL-6, CRP and SAA but no change in IL-10, and no differences between eLRP and RRP over the entire period assessed.

Conclusion.

The invasiveness of eLRP could not be substantiated objectively on the basis of the variables measured in this study. The surgical trauma and the associated invasiveness of both methods were equivalent.

Management of complications of prostate cancer treatment

Prostate cancer is the most commonly diagnosed noncutaneous cancer in men in the United States. Treatment of men with prostate cancer commonly involves surgical, radiation, or hormone therapy. Most men with prostate cancer live for many years after diagnosis and may never suffer morbidity or mortality attributable to prostate cancer. The short-term and long-term adverse consequences of therapy are, therefore, of great importance. Adverse effects of radical prostatectomy include immediate postoperative complications and long-term urinary and sexual complications. External beam or interstitial radiation therapy in men with localized prostate cancer may lead to urinary, gastrointestinal, and sexual complications. Improvements in surgical and radiation techniques have reduced the incidence of many of these complications. Hormone treatment typically consists of androgen deprivation therapy, and consequences of such therapy may include vasomotor flushing, anemia, and bone density loss. Numerous clinical trials have studied the role of bone antiresorptive therapy for prevention of bone density loss and fractures. Other long-term consequences of androgen deprivation therapy may include adverse body composition changes and increased risk of insulin resistance, diabetes, and cardiovascular disease. Ongoing and planned clinical trials will continue to address strategies to prevent treatment-related side effects and improve quality of life for men with prostate cancer.

[Study of urinary continence after radical prostatectomy. Comparison between laparoscopic and retropubic prostatectomy based on a series of 251 cases]

INTRODUCTION

The objective of this study was to compare the results in terms of continence and quality of life between retropubic radical prostatectomy and laparoscopic radical prostatectomy, performed according to the same principle of retrograde dissection from the apex.

MATERIAL AND METHOD

The series was composed of 120 patients undergoing retropubic radical prostatectomy and 131 patients undergoing laparoscopic radical prostatectomy performed in the Limoges hospital, urology and andrology department, between January 2002 and September 2005. Continence was evaluated by anonymous self-administered questionnaire sent to the patient's home. Pain was evaluated by visual analogue scale and narcotic consumption. Predictive factors of continence were analysed.

RESULTS

The two groups were comparable in terms of pathological stage, Gleason score and age. The laparoscopy group comprised more patients with a history of transurethral resection of the prostate and more obese patients. No significant difference was observed between laparoscopy and laparotomy for degree of continence (71% versus 76%; p>0.05), time to return of continence (13 weeks versus nine weeks; p>0.05) and rate of mild (14% versus 13%), moderate (7% versus 6%) and severe (7% versus 5%) urinary incontinence. The anastomosis secondary stenosis rate was also identical in the two groups. Age was found to be a predictive factor for continence, especially for the mean time to return periods of continence. The patient's weight, prostate weight and TNM stage were not predictive factors for incontinence. The incontinence rate was 40% for salvage prostatectomies after radiotherapy. The mean duration of bladder catheterization was 6.9 days in the laparoscopy group and 7.2 days in the laparotomy group. Narcotic consumption was significantly lower in the laparoscopy group (21 mg versus 36 mg; p<0.05).

CONCLUSION

Laparoscopic radical prostatectomy appears to give the same results in terms of continence as retropubic radical prostatectomy. However, these procedures were the first laparoscopic prostatectomies performed in the department, suggesting that, with greater experience, the results of laparoscopy could become superior to those of laparotomy. The laparoscopic technique also appeared to provide better patient comfort by decreasing postoperative pain.

[Oncological and functional results of total prostatectomy: an objective open analysis versus laparoscopy]

Based on a systematized literature analysis, laparoscopic radical prostatectomy is associated with less peroperative blood loss than open surgery. Operative time is shorter using an open approach. In terms of cancer control and functional results, no difference was found between both approaches.

Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter?

The treatment of prostate cancer has undergone a fundamental change in the last decade. New surgical and nonsurgical minimal invasive methods have evolved. As the methodology of the different treatments is commonly known to urologists, this article focuses on oncological and functional outcome of open retropubic (ORP), trans- or extraperitoneal endoscopical (LRP), and robot-assisted radical prostatectomy (RALP), based on personal experience and review of the literature. A MEDLINE search was performed to review the literature on LRP and RALP between 1982 and 2007 with special emphasis on oncological and functional results, technical considerations, comparison of LRP and RALP to ORP, laparoscopic training, historical aspects, and cost-efficiency of the techniques. Based on diligent training and proctoring programs, a continuous dissemination of laparoscopic techniques takes place. There is a trend towards the extraperitoneal access in most of the minimal invasive programs at least in the European community. Mid-term outcomes of LRP and short-term outcomes of RALP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower transfusion rates, shorter convalescence, and better cosmetics. In contrast to RALP, LRP reaches cost-equivalence with open surgery in selected centers. LRP and RALP reproduce the short-term results of open surgery while providing the advantages of a minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow, but the discussion about the longer learning curve for laparoscopy handling remains. The future will show if European centers adopt the use of robots comparable to the United States.

Head-to-head comparison of retropubic, perineal and laparoscopic radical prostatectomy

OBJECTIVE

As more patients are diagnosed with prostate cancer at an early stage, it is becoming increasingly important to refine the technique of surgical excision. For this purpose we have generated objective data comparing three different surgical approaches used by three experienced surgeons.

METHODS

We prospectively compared three contemporary personal series of 50 consecutive radical prostatectomy (RP) patients. The health-related quality of life was evaluated preoperatively and in months 1, 3, 6, 12 and 24.

RESULTS

Considering in turn the patients undergoing retropubic, perineal and laparoscopic RP, the median procedure time was 2 h and 27 min, 1 h and 50 min and 4 h, with a transfusion rate of 2, 0 and 8%, respectively. In the perineal group there were more wound infections. Median catheter drainage was 7, 10 and 7 days and zero, 13 and one patients needed reinsertion of a catheter. Early continence varied considerably, with 57.4, 11.4 and 6.3% of patients pad-free after 1 month, but there were no differences in social continence (zero or one pad) with 97.8, 97.8 and 91.9% after 2 years. The Litwin score for incontinence (preoperative minus postoperative) was -24, -41 and -63% after 1 month and -13, +3 and -29% after 2 years. Twenty-nine, five and 15 patients had a preoperative five-item version of International Index of Erectile Function (IIEF-5) score of > or = 17 points and a nerve-sparing procedure. After 2 years, 48.1, 0 and 0% had an IIEF-5 score of > or = 17 points without the use of phosphodiesterase type 5 (PDE-5) inhibitors, but when including patients using inhibitors there were no significant differences.

CONCLUSIONS

A comparison of morbidity, short-term convalescence and long-term side-effects of different surgical techniques is strongly biased by both the preoperative status of patients and the skill of the surgeons. Overall, we found some differences in the short-term results (e.g. early continence) and comparable long-term results.

Prostatectomía radical laparoscópica versus abierta

INTRODUCTION

To evaluate the differences between laparoscopic (LRP) and open radical prostatectomy (ORP).

MATERIAL AND METHODS

From 2004 to 2005 180 Radical prostatectomies (RP) were performed, 105 laparoscopical and 75 by an open approach. Different urologists have acted as first surgeon; 51% of them, fully experienced ones in OPR, and 56% in LRP. Differences in operative time, estimated blood loss (difference of pre and post operative hematocrite), and duration of hospitalization were compared. Additionally, we have also analysed surgical and oncologic control of the specimen defined by the following variables: Malignant margins (MM) (positive margin in a pT3 specimen), and benign/malign surgical incision (BSI/MSI).

RESULTS

Groups were similar concerning age, clinical stage and Gleason score, and there are only differences in PSA. Mean operative time was significantly higher in LRP (172 minutes) versus ORP (145 minutes) (p < 0.001). Difference of pre and post operative hematocrite was also higher in the open group (10.7 vs 9.2) (p = 0.03), together with hospital stay, which was one day longer in the ORP group (p = 0.001). ORP group had a higher rate of benign surgical incisions (48.7% vs 26.7%) (p = 0.001). Regarding oncologic results, LRP presented a 5.4% of positive margins, which compared significantly with a 16.9% rate in the open group (p = 0.023). However, no differences concerning malignant surgical incisions were observed.

CONCLUSION

With no differences in clinical and pathological stage, LRP offers a significant reduction of surgical aggressiveness on the specimen, together with a better MM control. We also observe a clear decrease in blood loss and hospital stay. Therefore, we conclude that LRP in our environment is a valid approach of surgical prostate cancer treatment in spite of a longer operative time (27 minutes) and a steep learning curve.

Laparoscopic Radical Prostatectomy for Localized Prostate Cancer: A Systematic Review of Comparative Studies

PURPOSE

We compared the safety and efficacy of laparoscopic and open radical prostatectomy through a systematic assessment of the literature.

MATERIALS AND METHODS

Literature databases were searched from 1996 to December 2004 inclusive. Studies comparing transperitoneal laparoscopic radical prostatectomy, extraperitoneal endoscopic radical prostatectomy or robot assisted radical prostatectomy with open radical retropubic prostatectomy or radical perineal prostatectomy for localized prostate cancer were included. Comparisons between different laparoscopic approaches were also included.

RESULTS

We identified 30 comparative studies, of which none were randomized controlled trials. There were 21 studies comparing laparoscopic with open prostatectomy with a total of 2,301 and 1,757 patients, respectively, and 9 comparing different laparoscopic approaches with a total of 1,148 patients. In terms of safety there did not appear to be any important differences in the complication rate between laparoscopic and open approaches. However, blood loss and transfusions were lower for laparoscopic approaches. In terms of efficacy operative time was longer for laparoscopic than for open prostatectomy but length of stay and duration of catheterization were shorter. Positive margin rates and recurrence-free survival were similar. Continence and potency were not well reported but they appeared similar for the 2 approaches. There were no important differences between laparoscopic approaches.

CONCLUSIONS

Laparoscopic radical prostatectomy is emerging as an alternative to open radical prostatectomy but randomized, controlled trials considering patient relevant outcomes, such as survival, continence and potency, with sufficient followup are required to determine relative safety and efficacy.

Technology Insight: surgical robots--expensive toys or the future of urologic surgery?

There is an increasing demand for minimally invasive surgery, despite any controversy over whether patients benefit from minimally invasive procedures rather than undergoing open surgery. In the field of urology, the performance of more complicated procedures is still a challenge even for experienced laparoscopic surgeons. Recently, robots have been introduced to enhance operative performance, increase applicability and precision of laparoscopy, and improve the learning curve for complicated minimally invasive procedures. With the introduction of master-slave systems where the surgeon is seated remotely from the robot and uses controls to maneuver the mechanical arms placed inside the patient, a new development in robot-assisted surgery has commenced. Several authors have suggested that surgical robots similar to the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA), which have three-dimensional (3D) vision and wristed instruments thus giving a greater degree of freedom than rigid laparoscopic instruments, will facilitate the outcome of these more challenging laparoscopic procedures. Whether these features will translate into better functional and oncological results remains to be evaluated. Data published so far clearly suggest that the patient will benefit from less postoperative pain, decreased bleeding and a shorter hospital stay compared with open surgery, and that the surgeon benefits from a faster learning curve than for conventional laparoscopy. For the benefit of our patients and for the development of urology it is vital that we understand both the limitations of telerobotics and when it is appropriate to incorporate these new techniques in day-to-day urologic surgery.

Laparoscopic and Robotic Assisted Radical Prostatectomy – Critical Analysis of the Results

OBJECTIVE

To evaluate the role of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RLRP) based on personal experience and a review of the literature.

MATERIAL AND METHODS

Own experience at one European and one American LRP-center includes more than 2000 cases. We performed a MEDLINE search reviewing the literature on LRP and RLRP between 1992 and 2005 with special emphasis on historical aspects, technical considerations, comparison to open retropubic (RRP) and perineal radical prostatectomy (PRP), laparoscopic training, and the cost-efficiency of the techniques.

RESULTS

Based on sophisticated training programs a continuous dissemination of the technique took place. In the United States, this process was accelerated by the use of the daVinci-robot. There is a trend towards the extraperitoneal access. Mid-term outcomes of LRP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower rate of complications, shorter convalescence, and better cosmesis. In contrast to RLRP, LRP may reach cost-equivalence with open surgery (i.e. by reduction of OR-time, use of multi-usable instruments).

CONCLUSIONS

LRP reproduces the excellent results of open surgery providing the advantages of minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow. In contrast the United States, the use of robots is likely to remain limited in Europe.

Intra- and peri-operative outcomes comparing radical retropubic and laparoscopic radical prostatectomy: results from a prospective, randomised, single-surgeon study

OBJECTIVES

To prospectively compare intra- and peri-operative outcomes of open radical retropubic prostatectomy (RRP) and laparoscopic prostatectomy (LRP) by a single surgeon.

PATIENTS AND METHODS

One-hundred-twenty, consecutive, age-matched patients diagnosed with clinically localized prostate cancer were eligible for surgery. Sixty patients underwent RRP and 60, LRP. Intra- and peri-operative parameters, pathologic findings and early complications were recorded. A validated visual analogue scale was used to assess pain in the recovery room, 3 h after the operation and on post-operative days 1, 2 and 3. A cystogram was performed on post-operative day 5.

RESULTS

Operating time was significantly shorter in the RRP group versus the LRP group (mean+/-SD, 170+/-34. 2 vs 235+/-49.9 min, p<0.001). Blood loss was significantly less in the LRP group versus the RRP group (mean+/-SD, 853.3+/-485 vs 257.3+/-177 ml, p<0.001), but no patient in either group underwent early re-intervention for bleeding. The RRP group showed a trend for higher use of analgesia. A watertight anastomosis was shown at cystourethrography and the catheter removed in 86% and 66% of LRP and RRP patients, respectively. The overall percentage of post-operative complications and positive margins were comparable.

CONCLUSION

Laparoscopic prostatectomy is an attractive alternative to open prostatectomy, offering the advantages of reduced blood loss and safe early catheter removal. Furthermore, the laparoscopic procedure proved to be safe oncologically. Long-term follow-up is required to compare functional results in terms of continence and potency.