Extraperitoneal Laparoscopic Radical Prostatectomy Research Articles

Prediction of Postprostatectomy Biochemical Recurrence Using Quantitative Ultrasound Shear Wave Elastography Imaging.

Objectives: To determine the prognostic significance of tissue stiffness measurement using transrectal ultrasound shear wave elastography in predicting biochemical recurrence following radical prostatectomy for clinically localized prostate cancer.Patients and Methods: Eligible male patients with clinically localized prostate cancer and extraperitoneal laparoscopic radical prostatectomy between November 2013 and August 2017 were retrospectively selected. Information of potential biochemical recurrence predictors, including imaging (ultrasound shear wave elastography and magnetic resonance imaging), clinicopathological characteristics, and preoperative prostate specific antigen (PSA) levels were obtained. Recurrence-free survival (Kaplan–Meier curve) and a multivariate model were constructed using Cox regression analysis to evaluate the impact of shear wave elastography as a prognostic marker for biochemical recurrence.Results: Patients experienced biochemical recurrence in an average of 26.3 ± 16.3 months during their follow-up. A cutoff of 144.85 kPa for tissue stiffness measurement was estimated for recurrence status at follow-up with a sensitivity of 74.4% and a specificity of 61.7%, respectively (p < 0.05). In univariate analysis, shear wave elastography performed well in all preoperative factors compared to biopsy Gleason Score, PSA and magnetic resonance imaging; in multivariate analysis with postoperative pathological factors, shear wave elastography was statistically significant in predicting postoperative biochemical recurrence, which improved the C-index of predictive nomogram significantly (0.74 vs. 0.70, p < 0.05).Conclusions: The study revealed that quantitative ultrasound shear wave elastography-measured tissue stiffness was a significant imaging marker that enhanced the predictive ability with other clinical and histopathological factors in prognosticating postoperative biochemical recurrence following radical prostatectomy for clinically localized prostate cancer.

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) &lt;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 (&lt;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 &lt;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.

Pain Control after Laparoscopic Radical Prostatectomy: Comparison between Unilateral Transversus Abdominis Plane Block and Wound Infiltration

Background and Objectives: To determine the efficacy of unilateral transversus abdominis plane (TAP) block versus wound local infiltration for postoperative pain following laparoscopic radical prostatectomy (LRP). Methods: Data of consecutive patients who underwent extraperitoneal LRP and received either wound infiltration or unilateral TAP block for analgesia were retrospectively analyzed. The patients were divided into 2 groups based on the technique used. We compared pain intensity scores and on-demand analgesic use both during the hospital stay and post-discharge between the 2 groups. Results: A total of 48 patients were included, 27 received unilateral TAP blocks (group 1) and 21 were managed with wound infiltration (group 2). The unilateral TAP block group showed lower median pain scores on postoperative days (POD) 1 with pain scores being 0.2 (0–4) and 0.8 (0–4), respectively (p < 0.05). On POD2, the median pain intensity was 0.9 (0–5) and 1.6 (0–6) in groups 1 and 2, respectively (p < 0.05). The median number of on-demand analgesic doses during the POD1 was 0.2 (0–2) and 0.4 (0–2) in groups 1 and 2, respectively (p = 0.19). On POD2, the patients received 0.5 (0–2) and 1.1 (0–3) on-demand doses in groups 1 and 2, respectively (p < 0.05). Conclusion: Unilateral TAP block might improve pain control more pronounced after LRP than wound infiltration.

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.

238 A case series of patients underwent laparoscopic extra-peritoneal radical prostatectomy with simultaneous implant of penile prosthesis: focus on penile length preservation

There are many grey zones in the field of penile rehabilitation after radical prostatectomy. One of the most important aspect for improve the patient’s compliance to the treatment is the preservation of the full dimensions of the penis after surgery. We show the first cases series of patients treated by laparoscopic extra-peritoneal radical prostatectomy (RP) and simultaneous penile prostheses implantation (PPI), in order to preserve the full length of the penis and improve patients' satisfaction. From June 2013 to June 2014, 10 patients underwent simultaneous PPI (AMS “inibizone”), how shown in Figure 1 and RP by the same surgeon at the same Centre. Patients were evaluated with urological visits, dedicated questionnaires and instrumentation before surgery, at the hospital discharge and on day 21-28, each 3 months for the first year and each 6 months after. The main outcome measures were oncological (biochemical recurrence free rate), functional (penile length) and QoL.

Quantitative transrectal shear wave elastography undergoing salvage extraperitoneal laparoscopic radical prostatectomy following failed radiotherapy.

To evaluate pre-surgical quantitative transrectal shear wave elastography (SWE) in the detection and characterisation of radioresistant prostate cancer. Twelve men with recurrent prostate cancer following external beam radiotherapy were included in a prospective protocol-driven study. All underwent MR imaging and quantitative shear wave elastographic assessment of recurrent disease prior to salvage laparoscopic radical prostatectomy procedures. Images were used to construct 3D mold printing and histopathological processing of surgical specimen. Statistical analyses including ROC were generated using software programmes. There were 48 cancer foci identified on final histopathology using patient-specific mold-based approach in 12 patients. Mean number of lesion was 3.4 (range 2-4). Quantitative transrectal SWE showed a sensitivity and specificity 0.77 (95% CI 0.627-0.880) and 0.82 (95% CI 0.642-0.942), respectively. The diagnostic accuracy increased with increasing size of the lesions with overall AUC of 0.89. In our series, quantitative transrectal SWE showed a good diagnostic accuracy in the detection and characterisation of recurrent prostate cancer following failed radiotherapy treatment. These findings may help in targeting biopsies or future focal treatment options.

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.

Oncological and functional results of laparoscopic radical prostatectomy after 100 procedures: our experience

Laparoscopic radical prostatectomy plays an emerging role in the surgical management of prostatic tumors. We present our experience of the first 100 cases of extraperitoneal laparoscopic radical prostatectomy. Our results about continence, erectile function and surgical margins are reported. MATERIALS AND METHODS. Between January 2005 and December 2007, 100 laparoscopic radical prostatectomies were performed by one surgeon. We retrospectively reviewed margins status, operative time, blood transfusion rates, time of catheterization, length of hospital stay, continence and potency rates. RESULTS. The operative time decreased during the learning curve. The mean duration of surgery was 240 minutes (in the first 25 procedures the median time was 320 minutes, while in the last 25 cases the mean duration was 200 minutes). Five conversions to open surgery were required owing to failure to progress. The overall rate of positive surgical margins was 15% in pT2 and 35% in pT3a tumors. We had 3 minor complications (two anastomotic leakage and one hemorrhage from the anastomosis) and 2 major complications (recto-urethral fistula). The mean intraoperative blood loss was 450 ml (range 200-1500). With regard to transfusion, 25 patients (25%) received their autologous units, while 2% of the patients required homologous units. The mean duration of catheterization was 7.8 days. The continence rate at 12 months was 85%; the potency rate was 55% at 12 months. CONCLUSIONS. The results of the present study show that by using a rational approach to training, a general urologist with low experience in laparoscopy is able to safely perform laparoscopic radical prostatectomy, and with oncological and functional results comparable to those of other published series.

The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging.

ABSTRACTIntroduction and objectiveTo determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP).Materials and MethodsFrom 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP.ResultsThe mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin.ConclusionsThe findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.

A Case Series of Patients Who Underwent Laparoscopic Extraperitoneal Radical Prostatectomy with the Simultaneous Implant of a Penile Prosthesis: Focus on Penile Length Preservation.

PurposeThere are many grey areas in the field of penile rehabilitation after radical prostatectomy (RP). The preservation of the full dimensions of the penis is an important consideration for improving patients' compliance for the treatment. We present the first case series of patients treated by laparoscopic extraperitoneal RP and simultaneous penile prosthesis implantation (PPI) in order to preserve the full length of the penis and to improve patients' satisfaction.Materials and MethodsFrom June 2013 to June 2014, 10 patients underwent simultaneous PPI (with an AMS InhibiZone prosthesis) and RP. Patients were evaluated by means of urological visits, questionnaires, and objective measurements before surgery, at discharge from the hospital, on postoperative days 21 to 28, each 3 months for the first year, and each 6 months thereafter. The main outcome measures were biochemical recurrence-free rate, penile length, and quality of life.ResultsTen patients (mean age of 61 years; completed the study follow-up period (median, 32.2 months). No difference was found between the time of surgery and the 2-year follow-up evaluation in terms of penile length. The pre-surgery 36-Item Short Form Health Survey (SF-36) median score was 97. Patients were satisfied with their penile implants, and couples' level of sexual satisfaction was rated median 8. The median postoperative SF-36 score was 99 at 3 months follow-up.ConclusionsLaparoscopic extraperitoneal RP surgery with simultaneous PPI placement seems to be an interesting possibility to propose to motivated patients for preserving the length of the penis and improving their satisfaction.

Day case laparoscopic radical prostatectomy.

To evaluate the feasibility of performing laparoscopic radical prostatectomy (LRP) as a day case procedure while maintaining patient satisfaction and safety. Herein we report our experience, selection criteria, and discharge criteria for day case LRP. We performed a prospective study with 32 patients undergoing extraperitoneal LRP. These patients were counselled before the procedure that they would go home the same evening of the procedure. Pain scores and quality of life data were recorded day 1 postoperatively via a telephone consultation. The patients underwent routine blood tests on day 2 and an outpatient review on day 7 and regularly thereafter via an assigned key worker. Socio-demographic data, comorbidities, and outcomes were collected for analysis. All patients were successfully discharged the same day of surgery. Mean patient age was 62 years with a mean body mass index of 25. Mean operative time was 147 minutes, and estimated blood loss was 101 ml. Three patients were treated for post operative urinary tract infections; two patients developed infected lymphoceles which required percutaneous drainage and one patient required re-catheterisation due to a burst catheter balloon. Of these six complications four patients required re-admission. Post-operative pain, nausea and vomiting were low whilst patient satisfaction scores were unanimously high in all patients surveyed. The early experience with extraperitoneal LRP as a same day surgery is promising although patients who are at high risk of lymphocele should be excluded. Preoperative patient counselling and selection is paramount. Patient satisfaction is not adversely affected by the shortened stay. Surgeon experience, a well-motivated patient, meticulous attention to detail through an integrated pathway, a multidisciplinary team and adequate postoperative assessment are essential.

EXTRAPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY: INITIAL EXPERIENCE AND LEARNING CURVE OF A VERY LOW VOLUME CENTER

Objective: This study is aimed to report and evaluate the experience and learning curve of extraperitoneal Laparoscopic Radical Prostatectomy (LRP) performed in Cipto Mangunkusumo General Hospital Jakarta. Material &amp; method: We collected all data of patients that had been performed extraperitoneal LRP from June 2013 until February 2016, retrospectively. We divided those data into 3 groups with equal number in each group. We compared the preoperative (age, prostate volume, PSA level and prostate cancer staging), intraoperative (surgery time, total blood loss, conversion to open surgery and other organ injury), and postoperative (postoperative length of stay) variables between those 3 groups using ANOVA and Kruskal-Wallis test. Results: We performed 15 extraperitoneal LRP from June 2013 until February 2016 with patient’s mean age was 64.40 (SD ± 5.30) years old and mean prostate volume was 42.39 (SD ± 29.21). In this study, we found significant differences in surgery time, total blood loss, and postoperative length of stay (LOS) in all group with decrease on each intraoperative and postoperative variables. We also found no conversion to open surgery or other organ injury in all patients. Conclusion: The increase of surgeon’s experience and the number of surgery, and the consistency undergo the procedure of LRP demonstrate a decrease in surgery time, intraoperative blood loss and LOS in LRP patients.

Midterm outcomes of four-port extraperitoneal laparoscopic radical prostatectomy for high-risk prostate cancer within Asian population

ObjectiveAsian patients tend to have higher stage prostate cancer at diagnosis compared with patients of other races. This article aims to investigate the use of four-port extraperitoneal laparoscopic radical prostatectomy (EPLRP) as the first step in a multimodality treatment strategy for Asian patients with high-risk prostate cancer (HRPC). Materials and methodsA cohort of 202 patients underwent EPLRP between January 2006 to January 2016, of whom 122 (60.3%) had HRPC as defined by D'Amico classification: clinical T stage ≥ cT2c or PSA level ≥ 20 ng/mL or biopsy Gleason sum ≥ 8). All patients underwent proper preoperative staging. The median age was 68 years (48–82), PSA level 17.8 ng/mL (3.3–191.1), and biopsy Gleason sum 7 (6–10). All patients underwent pelvic lymphadenectomy, and some underwent neurovascular bundle preservation according to their risk category. ResultsPerioperative outcomes included a median operative time of 185 min (65–380), total blood loss 150 ml (30–500), postoperative hospitalization 10 days (6–25), and urethral catheterization time 7 days (4–22). No patient was converted to open surgery. Median specimen weight was 42 g (19–124), lymph node yield was 10 (0–35) with 11.5% positivity and a positive surgical resection margin rate of 28.7%. The median follow-up period was 37 months (6–129). 96.7% of patients achieved continence and 53.8% of the 39 potent patients prior to surgery maintained their sexual potency at one year after EPLRP. The 5-year cancer-specific, overall, and biochemical recurrence-free survival rates were 98.8%, 92.2%, and 68.7%, respectively. ConclusionExtraperitoneal laparoscopic radical prostatectomy has low morbidity, and can provide fair functional and oncological outcomes as the first step of a multimodality treatment strategy for high-risk prostate cancer in Asian.

Comparison of antegrade and retrograde laparoscopic radical prostatectomy techniques

We evaluated the effect of antegrade and retrograde approaches on functional recovery and surgical outcomes of extraperitoneal laparoscopic radical prostatectomy (LRP). We analyzed 135 patients who underwent extraperitoneal LRP, with the retrograde technique performed on 42 (31%; Group 1) and the antegrade technique on 93 (69%; Group 2). Both groups were statistically similar with respect to age, clinical stage, preoperative prostate-specific antigen (PSA) and American Society of Anesthesiologists (ASA) scores, prostate volume, and previous surgical history. Mean operative time was significantly longer in Group 1 (244±18.3 vs. 203.3±18.4 min, p<0.001), whereas mean anastomosis times for both groups were similar (35.8±7.2 vs. 34.7±5.8 min, p=0.155). Estimated blood loss and transfusion rates were significantly lower in Group 2. A significant difference was observed for both hospitalization (6.79±3.3 vs. 5.46±3.08 days, respectively; p=0.026) and catheterization times (12.24±2.1 vs. 11±1.08 days, respectively; p=0.001) for Group 2. The total complication rate was 47.6% in Group 1, and 11.8% in Group 2 (p<0.01). Rates of positive surgical margins were 14.2% and 15% for Groups 1 and 2, respectively. At the 12-month interval from operation, similar recoveries in urinary continence were obtained for both groups (81% in Group 1; 91% in Group 2). Upon comparison of the two LRP techniques, we found that both were effective; however, the latter resulted in lower minor complication rate, lower blood loss, shorter operation time, and shorter length of hospital stay.

037 - Is it possible to draw a risk map for obturator nerve injury during pelvic lymph node dissection? The Heilbronn experience and a review of the literature

Abstract Objective: Obturator nerve injury (ONI) is a rare complication during pelvic lymph node dissection (PLND), in extraperitoneal laparoscopic radical prostatectomy (e-LRP), and/or extraperitoneal robotic-assisted laparoscopic radical prostatectomy (e-RALP). It is important to recognize ONI during the initial operation, maximizing the feasibility of simultaneous repair. Here we report our experience with ONI during e-LRP/e-RALP procedures and draw an injury risk map. Materials and Methods: Between December 1999 and November 2014, 2531 e-LRPs and 1027 e-RALPs were performed. Five patients (3 during e-LRP, 2 during e-RALP) experienced ONI in the proximal part of the nerve. Obturator nerves were clipped during the 3 e-LRP cases. Clips were immediately removed, and patients received physiotherapy with medical treatments in the postoperative period. During e-RALP, two obturator nerves were transected and subsequently repaired using the robotic Da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale...

AB010. “Total reconstruction” of the urethrovesical anastomosis contributes to early urinary continence in laparoscopic radical prostatectomy

BackgroundTo improve early recovery of continence after radical prostatectomy, we present our experience with total reconstruction in urethrovesical anastomosis after extraperitoneal laparoscopic radical prostatectomy (ELRP).MethodsELRP was performed using a standard urethrovesical anastomosis in 79 consecutive patients (group A) from June 2011 to October 2012, and using a total reconstruction procedure in 82 consecutive patients (group B) from June 2012 to June 2013. The primary outcome measure was urinary continence assessed at 1, 2, 4, 12, 24 and 52 weeks after catheter removal. Other data recorded were patient age, body mass index (BMI) (kg/m2), International Prostate Symptoms Score (IPSS), prostate volume, preoperative PSA, Digital Rectal Examination (DRE) for T stage evaluation, Gleason score, neurovascular bundle preservation, operation time, blood loss, complications and positive margin rate.ResultsIn group A the continence rates at 1, 2, 4, 12, 24 and 52 weeks were 7.59%, 20.25%, 37.97%, 58.22%, 81.01% and 89.87% respectively. In group B the continence rates were 13.41%, 32.92%, 65.85%, 81.71%, 90.24% and 95.12% respectively. Group B had significantly higher continence rates at 4 and 12 weeks after ERLP (P<0.001 and P=0.001). There were no significant differences between the groups with respect to patients age, BMI, prostate-specific antigen level, prostate volume, IPSS, estimated blood loss, number of nerve-sparing procedures and postoperative complications.ConclusionsTotal reconstruction of the urethrovesical anastomosis during ELRP improved early recovery of continence.

Comparison of robot assistant radical prostatectomy by transperitoneal versus extraperitoneal approach

Objective To compare the safety and oncological results of robot-assisted laparoscopic radical prostatectomy performed between transperitoneal and extraperitoneal approach. Methods 79 patients underwent transperitoneal robot-assisted laparoscopic radical prostatectomy(Tp-RLRP). The other 86 consecutive patients went through extraperitoneal robot-assisted laparoscopic radical prostatectomy(Ep-RLRP). Results All procedures were performed successfully without conversion. Total procedure time for Ep-RLRP was shorter than it for Tp-RLRP[(218.1±54.4) min vs.(180.2±47.1)min, P<0.001]. Docking time for Ep-RLRP was longer than Tp-RLRP[(21.5±7.1)min vs.(19.5±5.7)min, P<0.001]. Blood lost of Tp-RLRP was lesser than Ep-RLRP[(122.4±71.0)ml vs.(140.4±90.7)ml, P<0.05]. There were no significant differences between two groups in terms of bowel function recovery, drainage tube reserve, foley catheter duration, etc. There were 19 patients(24.1%)and 4 patients(4.7%)were suffered lymph leakage in two groups separately, P<0.001. One delayed vesiclurethra hemorrhagic patient and one mesenteric torsion patient were happened in Tp-RLRP group. There were no significant differences between two groups in terms of surgical margin, biochemical recurrence and urine continence. Conclusion Compared to Tp-RLRP, Ep-RLRP can provide similar short-term oncological control, recovery of postoperative urine continence, shorter operation time and lower complication rates. Key words: Robotics; Prostate cancer; Prostatectomy

Impact of Body Habitus on Operative Difficulties during Extraperitoneal Laparoscopic Radical Prostatectomy.

The aim of the present study was to investigate whether patients' body habitus affects the operative difficulties associated with extraperitoneal laparoscopic radical prostatectomy (LRP). Therefore, the associations between body habitus and perioperative outcomes of surgery, including bleeding, operative time, and resection margins, were evaluated. Between August 2010 and July 2012, 40 consecutive patients with preoperative magnetic resonance imaging and abdominal X-ray examinations underwent extraperitoneal LRP for localized prostate cancer at our institution. The associations between anthropometric measurements and demographics of patients, operation duration, estimated blood loss (EBL), and resection margins were analyzed retrospectively. Multivariate analyses were performed, and P < .05 was considered significant. On multiple regression analysis, the view of the prostatic apex (VPA) was significantly associated with EBL (P = .02), and body mass index (BMI) was significantly associated with operative time (P = .02). On multiple logistic regression analysis, protrusion of the prostate into the bladder was significantly associated with positive resection margins (P = .04). The findings of the present study suggest that poor VPA, protrusion of the prostate into the bladder, and high BMI were related to operative difficulties in extraperitoneal LRP. If operative difficulty is predicted preoperatively, it would be better to prepare blood for transfusion and/or special instruments (e.g. flexible scope), or switch to other therapeutic procedures.

Is It Possible to Draw a Risk Map for Obturator Nerve Injury During Pelvic Lymph Node Dissection? The Heilbronn Experience and a Review of the Literature.

Obturator nerve injury (ONI) is a rare complication during pelvic lymph node dissection (PLND), in extraperitoneal laparoscopic radical prostatectomy (e-LRP), and/or extraperitoneal robotic-assisted laparoscopic radical prostatectomy (e-RALP). It is important to recognize ONI during the initial operation, maximizing the feasibility of simultaneous repair. Here we report our experience with ONI during e-LRP/e-RALP procedures and draw an injury risk map. Between December 1999 and November 2014, 2531 e-LRPs and 1027 e-RALPs were performed. Five patients (3 during e-LRP, 2 during e-RALP) experienced ONI in the proximal part of the nerve. Obturator nerves were clipped during the 3 e-LRP cases. Clips were immediately removed, and patients received physiotherapy with medical treatments in the postoperative period. During e-RALP, two obturator nerves were transected and subsequently repaired using the robotic Da Vinci(®) Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). ONI types were investigated in detail in these patients, and current published studies were analyzed in order to draw a risk map. Mean follow-up was 18.8 ± 2.7 months. In total, 3558 cases (2531 e-LRPs, 1027 e-RALPs) were performed. ONI occurred in 3 e-LRP (0.1%) and 2 e-RALP (0.1%) patients. Simultaneous repair was performed successfully in all cases, as clips were removed in e-LRP cases and obturator nerves were repaired using 6/0 polypropylene (Prolene(®); Ethicon, Somerville, NJ) suture in e-RALP cases. There was no complication associated with obturator nerve functions such as adductor function and/or neurologic deficiency during long-term follow-up. In view of published studies in the literature, the proximal part of the obturator nerve is at highest risk for injury during PLND, representing 77.8% of reported cases of ONI. According to our ONI risk map, the proximal part of the obturator nerve is at higher risk for injury during PLND. Careful dissection and a good knowledge of pelvic anatomy are essential for preventing ONI. Successful ONI management can be performed simultaneously in experienced hands.

Learning curve and perioperative outcomes analysis in three–port extraperitoneal laparoscopic radical prostatectomy : initial experience in 95 cases in single center

Objective To evaluate the learning curve of three–port extraperitoneal laparoscopic radical prostatectomy(ELRP) and to minimize operative time and blood loss about this procedure. Methods From August 2013 to October 2014, the data from 95 consecutive patients, who had undergone three–port ELRP for prostate cancer, were retrospectively analyzed. The mean age was 65.9±7.7 years, mean total PSA level was 15.4±12.7 μg/L, and mean body mass index(BMI) was 24.8±3.2 kg/m2. According to the number of procedures performed by the surgeon, all patients were classified into three chronologic groups, including group A(No.1–32), group B(No.33–64) and group C(No.65–95). There were no significant differences including age, BMI, tPSA, estimated prostate volume, clinical stages, history of neoadjuvant endocrine therapy, history of transurethral resection of the prostate(TURP) among group A, B and C (P>0.05). The operative outcomes analyzed were operative time, estimated blood loss, hospital stay, drainage tube indwelling days, pathological Gleason scores, pathological stages, positive surgical margin rates, biochemical recurrence rates and urinary incontinence rates. Among these 95 patients, the results of the first 32 cases were compared with those of the remaining 63 cases, the first 64 with the remaining 31. Results The average operative time in 95 patients was 81.0±18.6 min. The sloping learning curve for this surgeon showed that the operative time for all 95 cases was strongly correlated with additional experience(|rs|=0.612, P 0.05). Group A had longer operative time than that of Group B plus C(96.4±11.3 min vs 73.2±16.7 min, P 0.05). There were no significant correlation between the accumulation of experience and positive surgical margin rates, biochemical recurrence rates and urinary incontinence rates. Conclusion Our experience of three–port ELRP cases appears to be favorable with decreasing tendency in operative time, estimated blood loss with experience accumulation. Exposure to 32 surgeries, operative time and estimated blood loss reduced significantly, and after 64 cases operative time and estimated blood loss further reduced. Key words: Prostate cancer; Radical prostatectomy; Extraperitoneal approach; Laparoscopy; Learning curving