Cases Of Laparoscopic Radical Prostatectomy Research Articles

Comparative evaluation of continence and potency after radical prostatectomy: Robotic vs. laparoscopic approaches, validating LAP-01 trial

BackgroundMinimally invasive techniques have demonstrated several advantages over the open approach. In the field of prostate cancer, the LAP-01 trial demonstrated the superiority of robotic-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) when comparing continence at 3-month after surgery, with no statistically significant differences at 6 and 12 months of follow-up. ObjectivesExternally validate the LAP-01 study and compare functional outcomes between the two minimally invasive approaches. Material and methodsThis retrospective study, conducted by a single surgeon (MRB), utilized data from a prospectively collected database, which included patients who underwent both RARP or LRP. Data regarding baseline characteristics, continence (assessed through the 24-h Pad test and ICIQ questionnaire) and potency were collected at multiple time points: 1 and 6 weeks after catheter removal, 3-, 6-, and 12-months post-surgery. ResultsThe study encompasses 601 patients, 455 who underwent LRP and 146 RARP. The median age at diagnosis was 64 for LRP and 62 for RARP, while the median PSA levels at diagnosis were 6.7 ng/mL for LRP and 6.5 ng/mL for RARP. Bilateral nerve-sparing procedures were performed in 34.07 % of LRP cases and 51.37 % of RARP cases.RARP exhibited a significant advantage over LRP both in continence and potency. Continence rates at 3-, 6- and 9-month after radical prostatectomy (RP) were 36.43 %, 61.86 % and 79.87 % for LRP, compared to 50.98 %, 69.87 % and 91.69 % for RARP. Potency rates at the same intervals were 0.90 %, 3.16 % and 6.39 % for LRP, and 6.19 %, 9.16 % and 18.96 % for RARP. These rates were more pronounced in patients with bilateral nerve-sparing. ConclusionOur study demonstrates that RARP results in significantly better continence recovery and superior potency outcomes throughout the entire follow-up period compared to LRP, even at the beginning of the robotic approach learning curve.

LAPAROSCOPIC RADICAL PROSTATECTOMY: SINGLE CENTER CASE SERIES.

Laparoscopic radical prostatectomy (LRP) is traditionally characterized as a technically difficult procedure with a long learning curve but it is successfully performed worldwide. The aim of this paper was to assess the initial learning curve and clinical outcomes for LRP in our center. We performed a retrospective study including 63 LRP cases, in the course of 22 months, performed by 2 urologists, with no previous LRP experience. All patients were previously assessed by a multidisciplinary team and were selected on the basis of low and intermediate risk disease attributes according to the classification of prostate cancer risk groups of the European Association of Urology. The main outcomes of follow-up are procedure duration, estimated blood loss, complications, positive surgical margins, biochemical relapse and urinary continence. The median follow-up was 19.6 months. The median procedure duration was 196.8 minutes and median blood loss 257.1 mL. Significant decrease in both outcomes was observed when comparing first and last cases in the series. There were 5 (7.9%) Clavien Dindo grade II complications. Undetectable prostate specific antigen (PSA) was observed in 59 (93.6%) patients, and fifty-five patients (87.3%) were continent. Following a methodical learning approach, LRP can be safely mastered with favorable outcomes.

Laparoscopic radical prostatectomy: a single surgeon\u2019s experience in 80 cases after 2\xa0years of formal training

BackgroundTo assess the learning curve in laparoscopic radical prostatectomy (LRP) performed by a single surgeon who had a healthcare career as a surgical first assistant for 2 years in high-volume centers treating > 150 cases per year.MethodsThe records of 80 LRP cases performed between October 2017 and August 2018 by a single surgeon were consecutively divided into four groups (groups A = first 20 cases, B = second 20 cases, C = third 20 cases, and D = last 20 cases). The groups were compared in terms of surgical and functional outcomes with a minimum follow-up of 6 months.ResultsClinical and surgical stages of the four groups were similar between groups. The operative time (126.8 ± 5.48 min; P = 0.001) and time of removal of the drain (1.65 ± 0.93 days; P = 0.029) were significantly lower in group D; however, hospitalization, catheterization time, and blood loss were similar between groups. The complication rate was low. No patient had a visceral injury, and there were no procedures needed to open conversion. The positive surgical margin (PSM) rates were similar between groups. In terms of continence and potency, all groups were similar at the 6th-month follow-up after surgery.ConclusionsOur results showed that prior experience in laparoscopic surgery as a surgical first assistant in a high-volume center improves the learning curve and oncological and functional outcomes, and helps to minimize the complication rate

Risk Factors for Recurrence in Patients with Pathological Lymph Node-Positive Prostate Cancer after Extended Lymph Node Dissection in Laparoscopic and Robotic-Assisted Radical Prostatectomy

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.

Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques.

BACKGROUNDRoutinely, after receiving prostate specific antigen (PSA) testing and digital rectum examination, patients with suspected prostate cancer are required to undergo prostate biopsy. However, the ability of ultrasound-guided prostate biopsy to detect prostate cancer is limited. Nowadays, a variety of diagnostic methods and more sensitive diagnostic methods, such as multi-parameter prostate magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) can be applied clinically. Furthermore, laparoscopic/robot-assisted prostatectomy is also a safe and effective procedure for the treatment of benign prostatic hyperplasia. So maybe it is time to reconsider the necessary to perform prostate biopsy before radical prostatectomy.AIMTo explore the feasibility of radical prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques.METHODSFrom June 2014 to November 2018, 11 cases of laparoscopic radical prostatectomy without prostate biopsy were performed at the three tertiary medical centers involved in this study. All patients received prostate magnetic resonance imaging and prostate cancer was suspected, including six patients with positive 68Ga-PSMA PET/CT results. Laparoscopic radical prostatectomy and pelvic lymph node dissection were performed for all patients.RESULTSAll surgeries were accomplished successfully. The mean age was 69 ± 7.7 year, the mean body mass index was 24.7 ± 1.6 kg/m2, the range of serum PSA was 4.3 to >1000 ng/mL, and the mean prostate volume was 40.9 ± 18.3 mL. The mean operative time was 96 ± 23.3 min, the mean estimated blood loss was 90 ± 90.9 mL, and the median duration of catheter placement was 14 d. The final pathology confirmed that all specimens were prostate cancer except one case of benign prostatic hyperplasia. No major complications occurred in 90 d postoperatively.CONCLUSIONThe current practice of mandating a prostatic biopsy before prostatectomy should be reconsidered in the era of new imaging technology and minimally invasive techniques. Radical prostatectomy could be carried out without the evidence of malignancy. Large-sample randomized controlled trials are definitely required to confirm the feasibility of this new concept.

The Study of Surgical Outcome for Robotic-Assisted Laparoscopic Radical Prostatectomy : Experience of a Single Surgeon with 70 Initial Cases

We investigated the surgical outcome for robotic-assisted laparoscopic radical prostatectomy (RALP) withinitial 70 prostate cancer cases performed by a single surgeon between June 2014 and May 2016. The surgeon had a previous experience of more than 400 cases of laparoscopic radical prostatectomy (LRP). Comparative study of the surgical outcome was made between the first 35 patients (group 1) and the second 35 patients (group 2). The console time without lymph node dissection significantly decreased from group 1 to 2 (193 min vs 158 min, p=0.002). Among specific 3 parts of the console operation (part 1 : until the bladder neck transection, part 2 : until the prostate removal and part 3 : urethrovesical anastomosis), duration of parts 1 and 2 similarly decreased witha significant difference of 0. 001 and 0. 002, respectively. Continence recovery rates 1 month after RALP were significantly higher in group 2 than in group 1 (group1 : 48.5% vs group 2 : 74.2%, p=0.02). Between groups 1 and 2, the positive surgical margin rates of both pT2 and pT3 were similar (group 1 : 20. 8 and 50. 0%, group 2 : 17. 2 and 50. 0%, respectively). The perioperative 8 complications (11.4%) were classified into Clavien-Dindo grades 1 and 2. Our surgical outcome of initial 70 RALP cases was considered as comparable to that reported from the high volume centers.

The Australian laparoscopic radical prostatectomy learning curve.

International estimates of the laparoscopic radical prostatectomy (LRP) learning curve extend to as many as 1000 cases, but is unknown for Fellowship-trained Australian surgeons. Prospectively collected data from nine Australian surgeons who performed 2943 consecutive LRP cases was retrospectively reviewed. Their combined initial 100 cases (F100, n = 900) were compared to their second 100 cases (S100, n = 782) with two of nine surgeons completing fewer than 200 cases. The mean age (61.1 versus 61.1 years) and prostate specific antigen (7.4 versus 7.8 ng/mL) were similar between F100 and S100. D'Amico's high-, intermediate- and low-risk cases were 15, 59 and 26% for the F100 versus 20, 59 and 21% for the S100, respectively. Blood transfusions (2.4 versus 0.8%), mean blood loss (413 versus 378 mL), mean operating time (193 versus 163 min) and length of stay (2.7 versus 2.4 days) were all lower in the S100. Histopathology was organ confined (pT2) in 76% of F100 and 71% of S100. Positive surgical margin (PSM) rate was 18.4% in F100 versus 17.5% in the S100 (P = 0.62). F100 and S100 PSM rates by pathological stage were similar with pT2 PSM 12.2 versus 9.5% (P = 0.13), pT3a PSM 34.8 versus 40.5% (P = 0.29) and pT3b PSM 52.9 versus 36.4% (P = 0.14). There was no significant improvement in PSM rate between F100 and S100 cases. Perioperative outcomes were acceptable in F100 and further improved with experience in S100. Mentoring can minimize the LRP learning curve, and it remains a valid minimally invasive surgical treatment for prostate cancer in Australia even in early practice.

Antibiotic Prophylaxis in Radical Prostatectomy: Comparison of 2-Day and More than 2-Day Prophylaxis.

The efficacy of antibiotic prophylaxis in radical prostatectomy (RP) remains to be established. We retrospectively compared the occurrence of perioperative infections after RP between the 2 different antibiotic protocols. This study involved 428 cases of laparoscopic radical prostatectomy (LRP). After excluding patients who had no perioperative urine culture data, 313 consecutive patients who underwent LRP for prostate carcinoma were classified into 2 groups according to the duration of antimicrobial prophylaxis. To group 1 (153 patients), a second-generation cephalosporin was administered for less than 2 days, whilst the remaining 160 patients in group 2 were administered the drug for more than 2 days. The overall incidence of postoperative bacteriuria was 50.8%, being significantly higher in group 1 (56.9%) than in group 2 (45%). The incidence of surgical site infection (SSI) was significantly higher in group 1 (5.2%) than in group 2 (0.6%). Multivariate analysis revealed that old age, duration of antibiotics for more than 2 days, and duration of Foley catheter placement were independently associated with postoperative infectious complications (all, P < 0.05). Multivariate analysis revealed that duration of antibiotics for more than 2 days, duration of Foley catheter placement, and duration of surgical drain placement were independently associated with postoperative SSI (all, P < 0.05). The incidence of postoperative bacteriuria and SSI were higher in patients who received antibiotics for a short duration. Based on our results, we demonstrated that the outcome of postoperative infectious complications is dependent on old age, short antibiotic administration duration, and prolonged Foley catheterization. Prolonged drain placement is associated with SSI, whilst a longer duration of antibiotics use and prolonged Foley catheterization are associated with a decrease in the incidence of SSI.

The Australian laparoscopic non robotic radical prostatectomy experience - analysis of 2943 cases (USANZ supplement).

To analyse the Australian experience of high-volume Fellowship-trained Laparoscopic Radical Prostatectomy (LRP) surgeons. 2943 LRP cases were performed by nine Australian surgeons. The inclusion criteria were a prospectively collected database with a minimum of 100 consecutive LRP cases. The surgeons' LRP experience commenced at various times from July 2003 to September 2009. Data were analysed for demographic, peri-operative, oncological and functional outcomes. The mean age of patients were 61.5years and mean preoperative PSA 7.4ng/ml. Mean operating time was 168minutes with conversion to open surgery in 0.5% and a blood transfusion rate of 1.1%. Overall mean length of stay was 2.5days. 73.6% of pathological specimens were pT2 and 86.3% had Gleason Score >7. Overall positive surgical margins (PSM) occurred in 15.9% with pT2 PSM 9.8%, pT3a PSM 30.8% and pT3b PSM 39.2%. Mean urinary continence at 12months was 91.4% (data available from five surgeons). Mean 12months potency after bilateral nerve spare was47.2% (data available from four surgeons). Biochemicalrecurrence occurred in 10.6% (mean follow up 17months). The Australian experience of Fellowship trained surgeons performing LRP demonstrates favourable peri-operative, oncological and functional outcomes in comparison to published data for open, laparoscopic and robotic assisted radical prostatectomy. In our Australian centres, LRP remains an acceptable minimally invasive surgical treatment for prostate cancer despite the increasing use of robotic assisted surgery.

Establishing a teaching unit in laparoscopic radical prostatectomy: An Australian experience

Objective: The aim of this project was to examine the role of surgical mentorship on the perioperative and oncological outcomes of patients undergoing laparoscopic radical prostatectomy (LRP) performed by two urologists inexperienced in the procedure. Methods: Forty-one (41) consecutive LRP cases were performed for clinically localised prostate cancer between December 2006 and June 2008 at a single centre. The surgical mentor approach was used with an experienced LRP surgeon being present for all cases that were performed by two urologists training in LRP. Data was retrospectively reviewed to assess morbidity and oncological outcomes of patients undergoing LRP by the team of trainees. Results: No LRP cases were converted to open and no major intraoperative complications were noted. Mean intraoperative blood loss was 493 ml (range 150–1000 ml) with the mean operative time being 220 minutes (range 100–315 minutes). The overall positive margin rate was only 12% (five out of 41 cases). Conclusion: LRP teaching units can be established with appropriate mentor supervision and can result in good oncological outcomes and minimal morbidity that compares favourably to robotic-assisted radical prostatectomy (RARP).

Robotic-assisted radical prostatectomy learning curve for experienced laparoscopic surgeons: does it really exist?

ABSTRACTBackground Robotic-assisted radical prostatectomy (RALP) is a minimally invasive procedure that could have a reduced learning curve for unfamiliar laparoscopic surgeon. However, there are no consensuses regarding the impact of previous laparoscopic experience on the learning curve of RALP. We report on a functional and perioperative outcome comparison between our initial 60 cases of RALP and last 60 cases of laparoscopic radical prostatectomy (LRP), performed by three experienced laparoscopic surgeons with a 200+LRP cases experience.Materials and Methods Between January 2010 and September 2013, a total of 60 consecutive patients who have undergone RALP were prospectively evaluated and compared to the last 60 cases of LRP. Data included demographic data, operative duration, blood loss, transfusion rate, positive surgical margins, hospital stay, complications and potency and continence rates.Results The mean operative time and blood loss were higher in RALP (236 versus 153 minutes, p<0.001 and 245.6 versus 202ml p<0.001). Potency rates at 6 months were higher in RALP (70% versus 50% p=0.02). Positive surgical margins were also higher in RALP (31.6% versus 12.5%, p=0.01). Continence rates at 6 months were similar (93.3% versus 89.3% p=0.43). Patient’s age, complication rates and length of hospital stay were similar for both groups.Conclusions Experienced laparoscopic surgeons (ELS) present a learning curve for RALP only demonstrated by longer operative time and clinically insignificant blood loss. Our initial results demonstrated similar perioperative and functional outcomes for both approaches. ELS were able to achieve satisfactory oncological and functional results during the learning curve period for RALP.

Impact of learning curve on perioperative complications in laparoscopic radical prostatectomy: a single center experience of 200 consecutive cases

Objective To assess the impact of learning curve on perioperative complications in laparoscopic radical prostatectomy (LRP) by a series of consecutive 200 cases in a single center. Methods Two hundred patients who were biopsy proved prostatic carcinoma and underwent LRP were retrospectively evaluated.All the operations were performed by professor Ma Lulin.The patients were divided into 4 groups according the time of operation.All the clinical data, including age, body mass index (BMI), preoperative PSA level, biopsy Gleason score, and clinical stage were collected.Operative parameters and peri–operative complications were evaluated, including operative time, blood loss, transfusion rate, and perioperative complications.The complications were evaluated by Clavien classification system. Results Age, BMI, PSA, prostate volume, biopsy Gleason score and clinical stage had no significant difference among the 4 groups (P>0.05). The operative time was gradually lowered from group one to group four.Significantly less blood loss occurred after every 50 cases of LRP (P<0.001). The complication rates were 15.5% in this series, 28.0%, 18.0%, 12.0% and 4.0% for group one to group four respectively.The complication rate reduced as experience was gained(P=0.008). The rates of mild complications were 24.0%, 14.0%, 6.0% and 4.0%, and severe complication rates were 4.0%, 4.0%, 6.0% and 0, respectively. Conclusion With experience was gained and technique was improved, the operative time and blood loss of LRP decreased and complication rate reduced substantially. Key words: Prostatic neoplasms; Learning curve; Prostatectomy; Laparoscopes; Complications

Impact of barbed suture in controlling the dorsal vein complex during laparoscopic radical prostatectomy

Objective: To compare applications of unidirectional knotless barbed suture and traditional two single polyglactin sutures for dorsal vein complex (DVC) control during laparoscopic radical prostatectomy (LRP). Material and methods: This was a non-randomized, prospective matched-pair pilot study. Thirty-one LRP cases with barbed suture (V-Loc®) were match-paired with 31 LRP cases in which traditional two single polyglactin stitches according to patient’s prostate volume and body mass index (BMI) were used. Time needed for DVC ligation, DVC control and operation time were recorded. Peri- and postoperative parameters were noted. Statistical analyses were performed. Results: Mean age was 65.4±6.3 years. Mean follow-up was 20.2±3.3 months. Mean BMI and prostate volume were similar in both groups. Mean preoperative clinical stage, Gleason score, and PSA were comparable between both groups. Mean DVC ligature time and mean DVC controlling time in group 1 were statistically shorter than in group 2 (p=0.04, p<0.001). Continence rates were significantly higher in group 1 than in group 2 in early follow-up (p=0.005).

MP58-12 COMPARISON OF SURGICAL-RELATED COMPLICATIONS BETWEEN ROBOTIC ASSISTED AND LAPAROSCOPIC RADICAL PROSTATECTOMY AS CONSECUTIVE CASES STUDY

You have accessJournal of UrologyProstate Cancer: Localized VI1 Apr 2014MP58-12 COMPARISON OF SURGICAL-RELATED COMPLICATIONS BETWEEN ROBOTIC ASSISTED AND LAPAROSCOPIC RADICAL PROSTATECTOMY AS CONSECUTIVE CASES STUDY Katsumi Shigemura, Kazushi Tanaka, Junya Furukawa, Nobuyuki Hinata, Takeshi Ishimura, Mototsugu Muramaki, Hideaki Miyake, and Masato Fujisawa Katsumi ShigemuraKatsumi Shigemura More articles by this author , Kazushi TanakaKazushi Tanaka More articles by this author , Junya FurukawaJunya Furukawa More articles by this author , Nobuyuki HinataNobuyuki Hinata More articles by this author , Takeshi IshimuraTakeshi Ishimura More articles by this author , Mototsugu MuramakiMototsugu Muramaki More articles by this author , Hideaki MiyakeHideaki Miyake More articles by this author , and Masato FujisawaMasato Fujisawa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1828AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic assisted radical prostatectomy (RARP) has been spread to undergo but following adverse events (AEs) were not fully examined in this situation. The purpose of this study is to compare operation-related adverse events AEs between RARP under the classification of laparoscopic radical prostatectomy (LRP)- naive or experienced surgeons and LRP as consecutive cases study especially in order to examine if LRP-experience may help RARP leaning. METHODS We retrospectively investigated intra- and peri (before discharge)-operative complications in the RARP cases and comparative LRP cases which were performed in our institution and compared them especially according to the Clavien-Dindo classifications. RARP groups were divided to 2 groups: 1) LRP naive and 2) LRP experienced surgeons for the purpose of evaluating the merit of LRP experience for RARP learning. RESULTS We had consecutive 167 RARP, 133 RARP (LRP naive), and 260 LRP cases in this study. Median surgical time and estimated blood loss for RARP, RARP (LRP naive) and LRP were 254 ± 53.1, 257 ± 57.4 and 300 ± 59.3 minutes (p<0.0001), respectively, and 248 ± 358, 236 ± 365, and 880 ± 630 ml (p<0.0001), respectively. Of the RARP, RARP (LRP naive) and LRP patients, 5 (2.99 %), 5 (3.79 %) and 16 (6.15 %) had intraoperative complications, respectively (p>0.05), and 24 (14.3 %), 19 (14.3 %) and 51 (19.2 %) had peri-operative complications, respectively (p>0.05). Importantly, RARP had less severe AEs (Grade IIIa+IIIb) than LRP (p=0.0401). CONCLUSIONS Our comparison cases data showed that RARP offered less severe peri-operative complication rates, shorter operative time and less estimated blood loss compared to LRP. LRP naive surgeons did not comprise AEs compared to those surgeons with LRP-experienced surgeons. Further investigation will be undertaken with longer observed periods for late AEs. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e662 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Katsumi Shigemura More articles by this author Kazushi Tanaka More articles by this author Junya Furukawa More articles by this author Nobuyuki Hinata More articles by this author Takeshi Ishimura More articles by this author Mototsugu Muramaki More articles by this author Hideaki Miyake More articles by this author Masato Fujisawa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic versus robot-assisted bilateral nerve-sparing radical prostatectomy: comparison of pentafecta rates for a single surgeon

This study aimed to compare the pentafecta rates between laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RALP) and to identify prognostic factors predicting the pentafecta for each technique. This prospective comparative study enrolled 248 consecutive male patients 70 years of age or younger with clinically localized prostate cancer [PCa: age ≤ 70 years, prostate-specific antigen (PSA) ≤ 10 ng/ml, biopsy Gleason score ≤ 7] who were fully continent, potent, and candidates for bilateral nerve-sparing (BNS) LRP or RALP. The pentafecta rates between LRP and RALP were compared. A logistic regression model was created to evaluate independent factors for achieving pentafecta. In the final analysis, 91 LRP and 136 RALP patients were evaluated. The median follow-up period was 21 months for the 91 LRP patients and 18 months for the 136 RALP patients (p = 0.07). Of the 227 patients, 87 reached pentafecta [25 LRP patients (27.5 %) vs 62 RALP patients (45.6 %), p = 0.006]. Of the 140 patients who failed pentafecta, 90 (64.3 %) missed a single parameter. In these cases, erectile deficit was the leading cause of pentafecta failure, with a significant [corrected] difference between groups (80 % LRP cases that missed potency recovery [corrected] vs 53.3 % RALP, p = 0.007). Lower age, lower pathologic stage, and RALP are significantly associated with pentafecta as independent factors. For the pT3 disease, the two techniques did not differ significantly. Patients submitted to BNS RP have low possibilities of achieving pentafecta. Use of the robotic platform by a single surgeon significantly enhances the possibility of achieving pentafecta independently of age and pathologic stage. Potency was the most difficult outcome to reach after surgery, and it was the main factor leading to pentafecta failure. LRP and RALP provide equivalent pentafecta rates for the pT3 disease and similar "tetrafecta" outcomes when potency recovery is not included among the postoperative expectations of the patient.

Preliminary results of robot‐assisted laparoscopic radical prostatectomy (RALP) after fellowship training and experience in laparoscopic radical prostatectomy (LRP)

• To ascertain whether prior experience in laparoscopic radical prostatectomy (LRP) shortens the 'learning curve' and therefore improves early patient outcomes when transitioning to robot-assisted laparoscopic RP (RALP). • Retrospective analysis of prospectively collected data of the most recent 87 cases of LRP compared with the initial 73 cases of RALP. • LRP was performed via a five-port extraperitoneal approach, while transperitoneal RALP was performed using a four-arm da Vinci S unit. • The median operative duration for RALP (skin-to-skin, including docking time) rapidly reduced, although never exceeded 3.5 h, for each consecutive set of 10 cases. • Oncological outcomes were preserved with no cases of pT2 positive surgical margins (PSMs) in any group. pT3 PSM rates were not significantly different at 50% and 38% for LRP and RALP, respectively. • Penetrative intercourse rates at 3 months for bilateral nerve-sparing procedures in preoperatively potent patients were similar, at 50% for LRP (median Sexual Health Inventory for Men [SHIM] 17) and 48.1% for RALP (median SHIM 18). The pad-free rate at 3 months was significantly better for RALP at 59.7%, compared with 39.8% for LRP (P= 0.043). • Complications were minimal and comparable for the two groups except for a higher LRP radiological anastomotic leak rate of 16 vs 1% (P= 0.004). • In this comparative series fellowship training and prior experience in LRP resulted in no significant RALP learning curve with regards to oncological and functional outcomes, while maintaining a low complication rate. • A short learning curve existed for operative duration but this improved rapidly and there were no prolonged cases. • Differences in early continence and radiological leaks may reflect changing from an interrupted anastomosis (LRP) to a continuous anastomosis with posterior rhabdosphincter reconstruction (RALP).

A Case of Laparoscopic Radical Prostatectomy for a Prostatic Stromal Tumor of Uncertain Malignant Potential

Prostatic stromal tumor of uncertain malignant potential (STUMP) is a rare neoplasm with distinctive clinical and pathological characteristics. Here we report a case of laparoscopic radical prostatectomy performed in a patient with prostatic STUMP.

A cost-analysis comparison of laparoscopic radical prostatectomy versus open radical prostatectomy:the McMaster Institute of Urology experience

The objective of this study was to identify and compare the costs of laparoscopic radical prostatectomy (LRP) and radical retropubic prostatectomy (RRP) at our centre. We conducted a retrospective chart review of our first 70 consecutive LRP cases and 70 consecutive RRP cases at St. Joseph's Healthcare in Hamilton, Ontario, Canada. We performed cost analysis, including operating room costs, disposable instruments, blood transfusions, analgesic requirements and length of hospital stay. Overall expenses were then analyzed and compared. Preoperative patient demographics and disease stages were comparable between the LRP and RRP groups. On a per procedure basis, large discrepancies were found in mean disposable instrument costs (LRP = $659.18 vs. RRP = $236.59), operating room costs (LRP = $4278.00 vs. RRP = $3139.00), mean cost of blood transfusions (LRP = $21.00 vs. RRP = $394.34), mean analgesia requirements (LRP = $12.94 vs. RRP = $41.06) and mean hospital stay bed costs (LRP = $3690.00 vs. RRP = $5027.14). Overall, costs for all patients in the LRP and RRP groups, respectively, were $606 307.29 and $618 721.57 with a cost saving of $12 414.28 in favour of the LRP arm. At our institution, we found that LRP costs are slightly less than those for RRP. Higher operative time and disposable instrument expenses are offset by the shorter hospital stays, fewer blood transfusions and less analgesic requirements for the LRP group. Further financial advantages for LRP will likely be achieved with additional reduction of operating room time and by minimizing disposables.

Operator is an Independent Predictor of Detecting Prostate Cancer at Transrectal Ultrasound Guided Prostate Biopsy

We investigated whether interoperator differences exist in the setting of prostate cancer detection by transrectal ultrasound guided prostate biopsy. Our secondary aim was to investigate whether a learning curve exists for prostate cancer detection. A prospective database from 2000 to 2008 including 9,072 transrectal ultrasound guided prostate biopsies at our institution was limited to 4,724 done at initial presentation. Biopsies were performed by 4 uroradiologists. The OR for detecting cancer on transrectal ultrasound guided prostate biopsy was calculated for likely independent prognostic variables, including operator. We also examined the rate of biopsy positivity in increments, comparing the first and last cohorts. The senior radiologist (AT) with the most biopsies (75%) was considered the referent for prostate cancer detection. Univariate and multivariate logistic regression modeling was used to determine significant covariates with p <0.05 deemed relevant. Prostate cancer was detected in 2,331 men (49.3%). Operators performed a median of 514 transrectal ultrasound guided prostate biopsies (range 187 to 3,509) with a prostate cancer detection rate of 43.8% to 52.4% (p = 0.001). Other significant covariates were prostate specific antigen, suspicious lesions on ultrasound, nodule on digital rectal examination, smaller prostate volume and increasing patient age. Operator was a significant multivariate predictor of cancer detection (OR 0.67 to 0.89, p = 0.003). No learning curve was detected and biopsy rates were consistent throughout the series. Significant differences in prostate cancer detection exist among operators who perform transrectal ultrasound guided prostate biopsy even in the same setting. The volume of previously performed transrectal ultrasound guided prostate biopsies does not appear to influence the positive prostate cancer detection rate, nor could a learning curve be identified. Differences in prostate cancer detection among operators are likely related to unknown differences in expertise or technique. Further research is needed.

The first 1000 cases of laparoscopic radical prostatectomy in the UK: evidence of multiple ‘learning curves’

To report the initial experience of one surgeon, with contemporary experience of both open radical prostatectomy (ORP) and reconstructive laparoscopy, in laparoscopic radical prostatectomy (LRP) in 1000 patients, and to investigate the rate of change of various outcome variables for this procedure with time. Between March 2000 and December 2007, 1000 consecutive patients with clinical stage T < or = 3aN0M0 prostate cancer underwent LRP, either supervised (17%) or performed (83%), by one surgeon. The median prostate-specific antigen (PSA) level was 7.0 (1-50) ng/mL and median Gleason sum 6 (4-10); the clinical stage was T1 in 46.9%, T2 in 49.8% and T3 in 3.3%. The median (range) operative duration was 177 (78-600) min. There was one conversion (patient 8) to open surgery. The median blood loss was 200 (10-1300) mL and four patients were transfused (0.4%). The median postoperative hospital stay was 3.0 (3-28) nights. The median catheterization time was 10.0 (0.8-120) days. There were 48 complications (4.8%) requiring surgical intervention in 33 (3.3%) patients, 58% of these as a day-case admission. The positive margin rates according to d'Amico risk groups were: low, 9.1%; intermediate, 20.3%; and high, 36.8%. The overall positive margin rate was 13.3%. The PSA level was < or =0.1 mg/L at 3 months in 99.1% of patients. At a mean follow-up of 27.7 (3-72) months, 96.1% of patients were free of biochemical recurrence. In patients with a follow-up of > or =24 months potency rates peaked in the series at 86% for all men and 94% for men aged < or =65 years, and continence rates at 98% before declining thereafter in men with a shorter follow-up. The learning curve for operating time and blood loss was overcome within the first 100-150 cases, but complication and continence rates took 150-200 cases to reach a plateau. The longest learning curve was for potency, which did not stabilize until 700 cases. These learning curves are likely to be considerably shorter when surgeons are taught in departments with a high throughput of cases but both surgeons and patients should be aware of them. In view of these findings, the authors recommend that LRP should not be self-taught and should be learned within an immersion teaching programme. Even then, a large surgical volume is likely to be needed to maintain clinical outcomes at the highest level.