Endoscopic Extraperitoneal Radical Prostatectomy Research Articles

A comprehensive comparison between mpMRI of the prostate, MR-US fusion biopsy and whole mount histopathology.

To compare multiparametric magnetic resonance imaging (mpMRI) findings, US-MR fusion prostate biopsy results and whole-mount thin-section histopathology after radical prostatectomy. Overall 259 patients,who had undergone mpMRI with lesions reported as PI-RADS 3-5, underwent a MR-US fusion biopsy between 2018 and 2020.Overall 186 biopsies yielded prostate cancer and 104 patients subsequently underwent endoscopic extraperitoneal radical prostatectomy. Histopathology of biopsies was compared to the final histopathology in whole mount thin sections after radical prostatectomy by means of descriptive statistics, and further, the lesions from mpMRT were compared to whole mount histology. Prostate cancer was diagnosed in 186 (71.8%) of 259 patients (median age 69.2 y, range 42-82 y, median PSA 7.8ng/ml, range 2.1-31.3ng/ml). Of those, 95 (51,1%) underwent radical endoscopic prostatectomy, and 80 (43%) chose radiotherapy or active surveillance. In 52/95 (54,7%) with RPE additional lesions were found in the final histological whole mount sections not described at mpMRI. 22/95 (23,2%) of RPE patients had ≥ 1 additional Gleason score ≥ 7 lesions, 23 /259 (8,4%) of biopsies, respectively. The Gleason score after surgery was upgraded in 37/95 (38,9%) and downgraded in 18/95 (18,9%) patients. If we compare all 259 performed biopsies with the final histological whole mount sections which showed additional lesions with Gleason ≥ 7 (23,2%), it can be assumed that up to 10% ofclinical significant carcinomas are missed during primary assessment via mpMRI. The majority of additional findings after RP were intermediate/high risk tumors. Upgrades from low-risk to intermediate or high-risk occurred.

Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access

IntroductionRectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. Material and methodsBetween 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. ResultsThe mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 min (140–210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30–60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. ConclusionsThe interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.

Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal

IntroductionRectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. Material and methodsBetween 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. ResultsThe mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 minutes (140-210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30-60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. ConclusionsThe interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy.

Extended pelvic lymph node dissection during extraperitoneal laparoscopic or robotic assisted radical prostatectomy

Objective: Extraperitoneal access in endoscopic (laparoscopicic or robotic assisted) radical prostatectomy is a standard approach in the management of prostatic cancer with well-established advantages over transperitoneal access. Still, traditionally, extraperitoneal endoscopic radical prostatectomy (EERP) has been associated with an inability to offer an extended pelvic lymph node dissection (PLND). The former is due to the fact that in the extraperitoneal space, peritoneal folding covers the majority of common iliac vessels and as a result in extraperitoneal PLND, lymph nodes (LNs) located above the bifurcation of common iliac vessels cannot be dissected. We herein present a simple and easy technique to offer an extended PLND during EERP. Methods: After a conventional extraperitoneal PLND, a peritoneal fenestration cranially to extrernal iliac vessels is performed bilaterally exposing the common iliac vessels. Results: Upon peritoneal fenestration, PLND can be continued in a standard fashion as in transperitoneal approach until the uppermost limit of the extended PLND template which is the ureteral crossing over common iliac vessels. Following LN dissection, both peritoneal fenestrations are left open at both sides, as this approach has been found to decrease the incidence of postoperative lymphocele formation. Conclusions: Peritoneal fenestration over common iliac vessels during extraperitoneal PLND is an easy approach that allows surgeon to reach the uppermost limit of extended PLND template. The latter peritoneal dissection is not time consuming and is expected to decrease the morbidity of the operation reducing the incidence of postoperative lymphocele formation.

Review of the article “Earl y removal of urethral catheter after endoscopic extr aperitoneal radical prostatectomy”

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Early removal of urethral catheter after endoscopic extraperitoneal radical prostatectomy

Background. Extraperitoneal radical prostatectomy (RP) in patients with prostate cancer is useful when there are no oncological indications to lymph node dissection (e.g. in low and intermediate-low risk of the disease), and allows to perform precise anastomosis and facilitates the early postoperative period. However, even minimally invasive approach does not avoid such factors as a urinary catheter that may disturb patients.Objective. We assessed the possibility to remove the urinary catheter as early as possible.Materials and methods. 28 patients with low (n = 22) and low-intermediate (n = 6) prostate cancer risk (according to NCCN (National Comprehensive Cancer Network) criteria) underwent an extraperitoneal laparoscopic RP from March 2017 to November 2018. All operations were performed by the same surgeon (A. Nosov). The inclusion criteria were the following: localized prostate cancer, prostate specific antigen (PSA) <10 ng/ml, ISUP group 1–2, life expectancy of more than 10 years and preoperative patient’s counseling (awareness about early catheter removal and discharge). All patients were continent before surgery. During surgery, the prostate and seminal vesicles were removed extraperitoneally without peritoneal cavity opening and conversion. Bladder neck sparing was performed in all cases but nerve-vascular bundles were spared according to indication (preoperative International Index of Erectile Function (IIEF), oncological reasons). Vesicourethral anastomosis was performed by two V-Loc circular sutures. No drainage tubes were inserted to control bleeding/urinary leakage. A urinary catheter Foley 20 Fr was inserted into the bladder after anastomosis completion. No other urinary drainage (suprapubic tubes, etc) was used. Anastomosis resistance and completeness were checked at the end of surgery by filling the bladder with 150 ml of saline through the catheter. Except for cases with macroscopic hematuria, urinary catheters were removed on the 1st postoperative day’s morning (<24 hours) with an active followup (daily voiding assessment, pelvic ultrasound and postvoided residual volume assessment) on Day 1. Immediately after the catheter removal, alpha-blockers (for urination alleviation) and PDE-5 inhibitors (in patients with neurovascular sparing) were prescribed. All patients were available for a 3-month follow-up. During the follow-up, a monthly combined assessment was performed, including IPSS, QoL, PSA analysis, pelvic ultrasound and urofloumetry.Results. The average patient’s age was 63 years (52–71 years). The median preoperative PSA level was 7.6 ng/ml. The intraoperative technique was unremarkable with no blood transfusion or conversion. All early postoperative complications were classified as minor – grade I, II and IIIa in 2 (7.2 %), 5 (17.8 %) and 1 (3.6 %) patients, respectively. Related to the early catheter removal complications included 1 (3.6 %) patient with urinary leakage (resolved by repeated prolonged urinary catheter insertion) and 4 (14.3 %) with urinary obstruction – resolved by single catheterization (n = 2), percutaneous suprapubic cystostomy (n = 2). No major complications were noticed during the follow-up. Totally, 22 (78.6 %) patients were discharged on the next day after the catheter removal – on the 2nd postoperative day. All discharged patients did not need readmission during the follow-up. Remained 6 (21.4 %) patients stayed at the hospital for 5–18 days. The pathological investigation showed upgrading in 9 (32.1 %) patients with low risk and in 1 (3.6 %) patient with low-intermediate risk. Upstaging to locally advanced forms was noticed in 6 (21.4 %) patients. All patients had the PSA level of <0.2 ng/ml 30–90 days after surgery. Postoperative assessment showed improvement in urinary function and erectile function sparing in selected patients, with no compromising functional results due to the early catheter removal.Conclusion. Despite the common widespread of minimally invasive RP, there is no consensus on the terms of a urinary catheter removal. According to our data, we suggested it might be of some benefit to remove a urinary catheter early in selected and well-informed patients. A thorough vesicourethral anastomosis pursuance, nerve-sparing, bladder neck sparing and Retzius sparing procedure, intraand postoperative assessment is necessary in all cases.

Endoscopic extraperitoneal radical prostatectomy: An initial report following the first 30 cases.

IntroductionTo present initial observations after the first 30 cases of endoscopic extraperitoneal radical prostatectomy carried out at our department, which so far has had no experience with this surgical procedure.Material and methodsIn the period of 15 months a group of 30 patients with organ confined prostate cancer, underwent endoscopic extraperitoneal radical prostatectomy using Montsouris technique. All procedures were performed by the same team of two urologists and one resident.ResultsThe mean age of the patients was 65.3 years (43–73 years), the mean preoperative prostate specific antigen (PSA) was 7.2 ng/ml (4–9.8 ng/ml), the mean prostate volume measured in TRUS was 41 cm³ (25–80 cm³). The mean operative time was 3 h 55 min (3 h 15 min – 5 h 30 min). The negative margin was achieved in 26 patients (86%). In seven patients (23%) blood transfusion was required. Three patients had intraoperative rectal injury. In two cases trauma was supplied laparoscopically, and in one case it was decided to perform diverting colostomy. The majority of patients (65%) were discharged home on the fifth day after surgery. Two months postoperatively 13 patients (43%) were continent, 16 (35%) presented moderate stress incontinence with occasional urine leakage during normal activity and 1 patient (3%) presented severe stress incontinence.ConclusionsEndoscopic extraperitoneal radical prostatectomy during the early phase of learning is technically difficult, requiring from the operator the laparoscopic skills, determination and a thorough knowledge of the theoretical basis of the subsequent stages of the procedure. Urologists who start performing this procedures must be aware of possible intra as well as postoperative complications.

Endoscopic extraperitoneal radical prostatectomy after radical resection of pT1-pT2 rectal cancer: a report of thirty cases.

IntroductionEndoscopic extraperitoneal radical prostatectomy (EERPE) has gained popularity for the treatment of localized prostate cancer. However, prior complex lower abdominal or pelvic surgery can complicate subsequent EERPE. To date, there have been few reports on patients who underwent EERPE after radical resection of pT1-pT2 rectal cancer.AimTo present our experience with EERPE in patients after radical resection of pT1-pT2 rectal carcinoma and introduce a simple and effective way to create an extraperitoneal working space.Material and methodsThirty patients after radical resection of pT1-pT2 rectal carcinoma were treated with EERPE for biopsy-proven localized prostate cancer. Operation time, estimated blood loss, conversion to open surgery rate, transfusion rate and transurethral catheter time were recorded. Meanwhile, functional outcome (continence and potency) and oncological outcome were reviewed.ResultsThe average operative time was 168 min. Mean blood loss was 195 ml. There was no need for conversion to open surgery or transfusion. The catheter was removed on postoperative day (POD) 7.8. After a mean follow-up time of 53.1 months, 3 patients had a prostate-specific antigen level relapse over 0.1 ng/ml. At the follow-up time, 26 patients were completely continent, and 4 needed 1–2 pads/day. Of the 6 patients who underwent neurovascular bundle preservation, none have experienced return of erections at the last follow-up time.ConclusionsEndoscopic extraperitoneal radical prostatectomy after radical resection of rectal carcinoma appears promising, with feasibility in experienced hands. The operative data, postoperative urinary incontinence and oncological outcomes appear encouraging, but the rate of erectile dysfunction seems to be disappointing.

Striated Muscle in Radical Prostatectomy Specimens: A Marker of Apical Dissection Quality and an Independent Predictor of Urinary Continence after Endoscopic Extraperitoneal Radical Prostatectomy

Introduction: The study aimed to determine if the presence and amount of striated muscle on the apical sections of the cruciate sections of laparoscopic radical prostatectomy (LRP) specimens predict early and long-term urinary continence outcomes. Patients and Methods: We conducted a retrospective review of our prospectively collected single surgeon LRP database. We identified patients based on their continence outcomes (continent (0 pads) or incontinent at 12 months), with an approximate even spread early continent and incontinent patients). An uropathologist separate from the urology team was blinded to outcome and assessed each patients' apical cruciate sections (H&E stained) for the presence, percentage and maximal diameter of muscle and extraprostatic tissue on these sections. Specifically 2 scoring systems were used: (1) semi-quantitative estimation of percentage of muscle on the apical cruciate sections (low <5% and high >5%) and (2) percentage of total extraprostatic tissue on cruciate section (low <10% and high >10%). Logistic regression and classification and regression tree analyses were performed to identify the predictors of urinary incontinence (UI). Results: In total 80 patients were analyzed, 38 were continent and 42 were incontinent at 12 months follow-up. The percentage of extraprostatic tissue/muscle being an independent predictor of being wet at 12 months (p = 0.002) on multivariate regression along with age (p = 0.04). Using percentage of extraprostatic tissue in cruciate section (high >10%) to predict UI at 12 months, it yielded 71% sensitivity, 82% specificity, 81% PPV, 72% NPV and 76% accuracy. Conclusion: The use of simple additional reporting of muscle and extraprostatic tissue on the apical sections of RP specimens can help to better predict the likelihood of continence return.

42 - Economic benefits of endoscopic extraperitoneal radical prostatectomy at medical center in Poland - single institution experience

42 - Economic benefits of endoscopic extraperitoneal radical prostatectomy at medical center in Poland - single institution experience

4-Ports endoscopic extraperitoneal radical prostatectomy: preliminary and learning curve results.

ABSTRACTIntroduction There is a lack of studies in our national scenario regarding the results obtained by laparoscopic radical prostatectomy technique (LRP). Except for a few series, there are no consistent data on oncological, functional, and perioperative results on LRP held in Brazil. As for the LRP technique performed by extraperitoneal access (ELRP), when performed by a single surgeon, the results are even scarcer.Objective To analyze the early perioperative and oncologic results obtained with the ELRP, throughout the technical evolution of a single surgeon.Patients and methods A non-randomized retrospective study was held in a Brazilian hospital of reference. In the 5-year period, 115 patients underwent the ELRP procedure. Patients were divided into two groups, the first 57 cases (Group 1) and the following 58 cases, (Group 2). A comparative analysis between the groups of efficacy results and ELRP safety was carried out.Results The average age of patients was 62.8 year-old and the PSA of 6.9ng/dl. The total surgery time was 135.8 minutes on average, and the urethral-bladder anastomosis was 21.9 min (23.3 min versus 20.7 min). The positive surgical margins (PSM) rate was 17.1%, showing no difference between groups (16.4% versus 17.9%; p=0.835). There was statistical difference between the groups in relation to the anastomosis time, estimated blood loss and the withdrawal time of the urinary catheter.Conclusion The ELRP technique proved to be a safe and effective procedure in the treatment of prostate cancer, with low morbidity.

Switching from Endoscopic Extraperitoneal Radical Prostatectomy to Robot-Assisted Laparoscopic Prostatectomy: Comparing Outcomes and Complications

Objective: Endoscopic extraperitoneal radical prostatectomy (EERPE) and robot-assisted laparoscopic prostatectomy (RALP) are minimally invasive surgical techniques to treat localized prostate cancer. We report the outcome and complications of these two techniques conducted by one individual surgeon. Patients and Methods: 86 patients underwent EERPE between January 2008 and June 2011, and 100 patients underwent RALP between August 2011 and October 2012. All surgeries were performed by one single surgeon. Results: The patients of the EERPE and RALP groups had similar clinical characteristics in PSA, prostate volume and D'Amico classification, and were significantly different in their age and BMI as well as in the number of prior surgeries. RALP surgeries were significantly slower (183 vs. 157 min) but also involved lower blood loss (147 vs. 245 ml). Pathological stages and positive surgical margins were similar in both groups. Complications were assessed by the Clavien-Dindo classification. 6 patients in the EERPE group and 3 patients of the RALP group suffered major complications (IIIb-IV). Conclusion: Altogether our results indicate that the learning curve for RALP was short after experience with EERPE. We hypothesize that this is more a result of the surgical experience of the surgeon with the EERPE than on the robotic technique.

Robot-assisted laparoscopic total extraperitoneal hernia repair during prostatectomy: technique and initial experience.

IntroductionTo describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes.Material and methods12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure.ResultsSac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data.ConclusionsRobot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

What should be the correct indications for laparoscopic inguinal hernia repair?

I appreciate the comments of Sabuncuoglu et al. [1] about my article [2]. They raised several important issues regarding indications for laparoscopic hernia repair, primary end points of hernia surgery, and the difficulties of urologic surgery after laparoscopic and endoscopic hernia repair. The historical studies on laparoscopic and open hernia repair techniques presented by Sabuncuoglu et al. do not analyze the different hernia types (e.g., medial and lateral inguinal hernias, scrotal hernias, incarcerated hernias, hernias after radical prostatectomy and recurrences following TAPP and TEP). Therefore, the statements of the Hernia Trialists Collaboration study are restricted [3]. Nevertheless, the data suggested less persistent postoperative pain and numbness following laparoscopic repair and the patients were able to return to their usual activities more quickly. According to the study, there was no apparent difference in recurrence rate between laparoscopic and open mesh methods of hernia repair. However, the transferability of the results is limited. The European Hernia Society (EHS) has recommended TAPP and TEP as standard procedures for repairing bilateral and recurrent hernias after anterior repair, and inguinal hernias in females [4]. In addition, the International Endohernia Society (IEHS) recommended TAPP and TEP as treatment options for complicated hernias (scrotal hernias, incarcerated hernias, hernias after radical prostatectomy, and recurrent hernias after TAPP and TEP procedures), if the repair is performed by a surgeon experienced in laparoscopic and endoscopic hernia repair [5]. Besides the recurrence rate, a high level of patient satisfaction with the outcome of their repair is an important primary end point in hernia surgery. According to my retrospective study, 96.9 % of all patients were satisfied with the result of their modified TAPP. Only 1.5 % was dissatisfied due to hernia recurrence, persistent pain, or postoperative complications. A radical prostatectomy after a bilateral laparoscopic or endoscopic hernia repair and a TAPP or TEP after a radical prostatectomy are challenging and time-consuming interventions. A modification of the surgical repair technique is necessary. There is necessarily a steep learning curve for these procedures. The repair should be done only by surgeons who have extensive experience in laparoscopic and endoscopic hernia repair [5]. According to single-case reports [6, 7], the fibrotic reaction of the implanted mesh after endoscopic and laparoscopic hernia repair makes urologic cancer surgery complicated. According to these reports, the preparation of the preperitoneal space should be nearly impossible [1]. In contrast, Stolzenburg et al. [8] presented a large series of 2,000 endoscopic extraperitoneal radical prostatectomy (EERPE) procedures, including 50 patients who had had a prior endoscopic/laparoscopic hernioplasty, with no conversions to an open procedure and the rates of intraand postoperative complications were not increased. We agree with these authors that EERPE after TAPP and TEP is a safe and effective procedure when port placement and the preparation of the retropubic space are modified. For this procedure, a surgeon experienced not only in laparoscopic hernia repair but also in laparoscopic radical prostatectomy is needed. Replying to the question of how to manage hernia repair in patients with risk factors for pelvic surgery, to our W. K. J. Peitsch (&) Klinik fur Allgemeinund Viszeralchirurgie, Katholisches Krankenhaus St. Josef, Kliniken Essen Sud, Propsteistr. 2, 45239 Essen, Germany e-mail: wkjpeitsch@t-online.de

Step-by-step illustrated endoscopic extraperitoneal radical prostatectomy (EERP): tips and tricks to trifecta outcomes.

INTRODUCTION Laparoscopic prostatectomy has become a widely accepted and applied surgical method of localized prostate cancer treatment. The pearls of critical anatomical and technical features to optimal oncological and functional outcomes on radical prostatectomy are illustrated. Several aspects with respect to that must be recognized in the early phases of training to optimize trifecta outcomes: disease recurrence free, urinary continence and sexual functions preservation.

Analysis of the pentafecta learning curve for laparoscopic radical prostatectomy

Laparoscopic radical prostatectomy (LRP) has a long learning curve; however, little is known about the pentafecta learning curve for LRP. We analysed the learning curve for a fellowship trained surgeon with regard to the pentafecta with up to 6-year follow-up. A retrospective review was performed in 550 cases, by dividing these cases into 11 groups of 50 patients. Outcomes analysed were the following: (1) the pentafecta (complication rate, positive surgical margin (PSM) rate, continence, potency and biochemical recurrence); (2) operative time and blood loss; and (3) overall pentafecta attainment. The mean complication rate for the entire series was 9 %; this plateaued after 150 cases. The overall PSM rate for the series was 23.5 %, 16.3 % for pT2 and 40.5 % for pT3. PSM plateaued after 200 cases. Excluding the first 100 cases, the overall PSM rate for pT2 was 10.9 % and 37.8 % for pT3. The continence rate stabilised after approximately 250 cases. The rate of male sling/artificial urinary sphincter plateaued after 200 cases. The potency learning curve continues to improve after 250 cases of nerve-sparing (ns) endoscopic extraperitoneal radical prostatectomy (EERPE) as does the pentafecta learning curve which closely follows the pattern of the potency learning curve. The last group of nsEERPE achieved pentafecta in 63 %. This study shows multiple learning curves: an initial for peri-operative outcomes, then stabilisation of oncologic outcomes and the final for stabilisation of functional outcomes. In this series over 250 cases were required to achieve the learning curve.

C100 Endoscopic extraperitoneal radical prostatectomy and its complications – analysis of the first 300 procedures

C100 Endoscopic extraperitoneal radical prostatectomy and its complications – analysis of the first 300 procedures

Five-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) for prostate cancer: results from a medium-volume UK centre

To determine the 5-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) from a medium-volume centre, thereby providing much needed data on outcomes from the UK.From January 2006 to January 2012, 575 patients underwent EERPE for localized prostate cancer, performed by a single surgeon who had completed a modular training programme. Follow-up was as per local hospital policy and data were collected in our prospective database. A retrospective review of patient demographics, prostate-specific antigen (PSA) levels, pathological T stages, Gleason scores, surgical margin status and biochemical recurrence (BCR) data was performed. BCR was defined as PSA >0.2 μg/L.The mean (range) patient age was 62 (40.3-76.5) years and the mean (range) follow-up was 30 (12-72) months. The median (interquartile range [IQR]) operating time was 135 (120-170) min and the median (IQR) blood loss was 200 (100-250) mL. Of the 575 patients, 135 (23.5%) had positive surgical margins (PSMs). The PSM rate for pT2 disease was 66/406 patients (16.3%) and for pT3 disease it was 68/168 patients (40.5%). Overall BCR-free survival at 5-years was 81.5%. Multivariate Cox analysis showed that PSMs, Gleason score, D'Amico risk category and pT stage were independent predictors of BCR-free survival.This assessment of the oncological results of EERPE, which included the surgical learning curve, shows that the adoption of EERPE after mentored fellowship training translates into mid-term oncological outcomes in line with those of retropubic/transperitoneal laparoscopic approaches and with large-volume centres worldwide which have pioneered laparoscopic radical prostatectomy. The study shows that EERPE in a medium-volume second generation laparoscopic centre (that introduced EERPE after adequate training in pioneering centres) produces results with good 5-year oncological outcomes, similar to those of other major series, for patients in the UK.

Midterm oncological outcome and clinicopathological characteristics of anterior prostate cancers treated by endoscopic extraperitoneal radical prostatectomy

The purpose of the study is to characterise the clinicopathological characteristics of anterior prostate cancer (APC) compared to posterior prostate cancer (PPC)s and to determine the midterm oncological outcomes of patients with APCs undergoing endoscopic extraperitoneal radical prostatectomy (EERPE). A retrospective review was carried out on all EERPEs performed in 2009. Pathology reports (transrectal ultrasound biopsy and surgical specimen), specimen photographs, demographic details and oncological outcome data from a prospectively maintained database were reviewed. Unpaired t test, chi-squared test and Kaplan-Meier curves were used for the analysis. Of 139 patients identified, 53 were APCs (38 %) and 86 were PPCs (62 %). Significantly, greater number of repeat biopsies were required to diagnose APCs (p = 0.02) and they had significantly fewer positive biopsy cores (p = 0.0005). The APC group had a significantly higher PSA density (PSAd) with (<5 and 5-25 %) tumour involvement in positive cores compared to PPCs (p = 0.036 and 0.024, respectively). APCs had higher positive surgical margin (PSM) rates (p = ns), the apical margin more likely positive than PPCs (p = 0.0006). Biochemical recurrence-free survival (BRFS) for APCs at 1, 2 and 3 years was lower than PPCs, although not statistically significant (p = 0.16). In our study, APCs proved more difficult to diagnose and stage, had a higher PSM rate and a trend towards a worse bRFS than PPCs. Additionally, the use of PSAd low core involvement biopsies might aide clinicians to investigate this cohort of patients more thoroughly before advising active surveillance.

The deep vein thrombosis caused by lymphocele after endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection.

Pelvic lymphocele is a postoperative complications than can result after endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection. Radical prostatectomy have many risk factors of deep vein thrombosis including location of target organ, malignancy, old age, Trendelenburg position, pelvic lymph node dissection, and long procedure time. A 57-year-old man with a localized prostate cancer was treated with endoscopic extraperitoneal radical prostatectomy and pelvic lymph node dissection. Deep vein thrombosis was detected as a first sign of pelvic lymphocele. Lymphocele was managed with a percutaneous drainage without sclerosant. We report a case of deep vein thrombosis due to pelvic lymphocele after endoscopic extraperitoneal radical prostatectomy.