Extraperitoneal Laparoscopic Radical Prostatectomy Research Articles

A 10–year experience of extraperitoneal laparoscopic radical prostatectomy for localized prostate cancer from a single centre

Objective To report a 10–year single–centre experience in extraperitoneal laparoscopic radical prostatectomy (EPLRP) for localized prostate cancer and report perioperative, functional and oncologic outcome. Methods From 2005 to 2015, 418 men with localized prostate cancer underwent EPLRP at urology department of Shanghai Changzheng Hospital. The mean preoperative prostate–specific antigen (PSA) was 15.9±7.0 μg/L and mean age was 67.8±6.7 years. Stage distributions were cT1a–b in 8 cases, cT1c in 198 cases, cT2 in 123 cases and cT3 in 89 cases. Disease recurrence was defined as PSA≥0.2 μg/L in 2 consecutive measurements. Results Mean operation time, mean blood loss and drainage removal time were 144.4±58.4 min, 164.0±231.1 ml and 6.9±4.8 d. There were 4 conversions to open surgery. The urine leak rate was 4.5%, and rate of positive surgical margins was 14.6%. The continence rate was 87.8% (367/418) at 12 month after operation, and the overall PSA recurrence rate at 2 years was 17.9% (75/418). Conclusion EPLRP could be an effective minimally invasive approach for localized prostate cancer, and patients can expect satisfactory outcome in experienced hand. Key words: Prostate cancer; Laparoscopes; Radical prostatectomy; Complications

Robotic-assisted laparoscopic partial nephrectomy for small renal cell carcinoma: Chi Mei Medical Center experience

Robotic-assisted laparoscopic partial nephrectomy for small renal cell carcinoma: Chi Mei Medical Center experience

Efficacy of extra-peritoneal laparoscopic radical prostatectomy in the treatment of high-risk prostate cancer

Objective To investigate the efficacy and feasibility of extra-peritoneal larparoscopic radical prostatectomy (eLRP) in the treatment of patients with high-risk prostate cancer (HRPC). Methods From February 2009 to December 2013, 121 patients, who were diagnosed as HRPC according to the D′Amico definition, were received eLRP.The mean age was 70 years old (range 54~82 years old). The mean PSA level was 25.45 (range 2.40~111.31) μg/L and mean Gleason score was 8 (range 6~10). The classification of clinic stage in this study included 52 cases in cT1-cT2b, 58 cases in cT2c, 8 cases in cT3a, and 3 cases incT3b, respectively.The perioperative data were collected, including operative time, blood loss, intraoperative complications, urine leakage, lymph leakage, incontinent ability, erectile function and changing of PSA level. Results All the operations were successfully performed.The mean operative time was 165 minutes (range 105~341min), the average blood loss was 150 ml(range 50~1500ml). The intraoperative complications included hemorrhage in 4 cases and intra-operative obturator nerve injury in 3 cases.The mean duration of intestinal function recovery was 35h (range 24~72h) The mean interval of catheter indwelling was 9 days (range 7~14 days). The anastomotic leakage was found in 12 cases, including 1 day after surgery in 5 cases, 2 days after surgery in 3 cases, 3 days after surgery in 2 cases, 4 day after surgery in 1 case and 5 day after surgery in 1 case.The anastomotic stricture in 3 cases within 2 to 4 months after operation, which the symptom improved after urethral dilation in 2 cases and urethrotomy in 1 case. Deep vein thrombosis was noticed in 1 case 5 days after the procedure.And lymphatic fistula was recorded in 1 case after the operation.Positive surgical margin, seminal vesicle invasion, and positive iliac vessel lymph node were found in 18, 21, and 9 patients, respectively.The mean hospitalization duration was 10 days (range 5~22 d). Of the 107 patients followed-up, Ninety-six patients were continent in 1 year, except other 11 patients.Nerve sparing procedure was performed in 51 patients, and thirty-three of them were potent.The mean PSA level was 0.14 μg/L (range 0~8.75 μg/L) six weeks after the surgey.Fourty-eight patients had biochemical recurrence with 5~36 months followed-up, mean 18 months. Conclusions Extraperitoneal LRP is an efficacious approach for patients with high-risk prostate cancer. Key words: Extroperitoneal; Laparoscopic radical prostatectomy; High-risk prostate cancer

A matched-pair comparison of single plus one port versus standard extraperitoneal laparoscopic radical prostatectomy by a single urologist

We conducted this study to report on our initial experience and assess the safety, feasibility, and efficacy of extraperitoneal single plus one port laparoscopic radical prostatectomy (SPOPL-RP), and determine whether it shows any objective advantage over standard laparoscopic radical prostatectomy. From June 2009 to September 2011, 15 extraperitoneal SPOPL-RPs were performed through a 2–3-cm subumbilical longitudinal incision and another 5-mm trocar placed at the McBurney point. This cohort was compared with 37 contemporary patients who underwent standard extraperitoneal laparoscopic radical prostatectomy performed by the same urologist. Peri- and postoperative outcomes, including continence, potency, and scar length, were statistically analyzed. The two groups were comparable with respect to patient demographics, estimated blood loss, drainage time, duration of catheterization, catheterization rate >14 days, complication rate, postoperative hospitalization, and postoperative functional and oncologic outcomes (p > 0.05). The SPOPL-RP procedures had a longer mean operative time (170.1 minutes vs. 139.5 minutes, p = 0.005), but with fewer patients requiring analgesics (20% vs. 54.1%, p = 0.038) and earlier resumption of oral intake (20.7 hours vs. 26.8 hours, p = 0.037). The mean scar length in the SPOPL-RP group was much smaller (3.4 cm vs. 5.8 cm, p = 0.000) owing to the significant reduction of the skin incision. The peri- and postoperative outcomes of SPOPL-RP for low-risk prostate cancer are comparable to those with the standard laparoscopic approach. In addition, SPOPL-RP provides better postoperative pain control, faster recovery of bowel function, and smaller scar length than standard laparoscopy, albeit with a longer operative time.

Comparison the short-term effect of robot-assisted laparoscopic prostatectomy with extraperitoneal laparoscopic radical prostatectomy

Objective To compare the short-term effect between robot-assisted laparoscopic prostatectomy (RALP) and extraperitoneal laparoscopic radical prostatectomy (ELRP).Methods Between January,2012 and December,2012,the data of 160 cases with prostate cancer was reviewed.Among them,86 cases were underwent the RALP with da Vinci S system (Intuitive Surgical Inc.).The median age was 67 years old (ranged 46-75 years) and the median preoperative t-PSA level was 15.20 μg/L (ranged 4.28-126.26 μg/L).At the same time,74 cases of ELRP were performed,in whom the median age was 68 years (ranged 45-78 years) and the median preoperative t-PSA level was 17.32 μg/L (ranged 4.65-131.35 μg/L).Perioperative data,short-term oncological control,recovery of continence and potency were analyzed retrospectively.Results All the operations were successful without conversion.In the RALP group,the median operative time was 90 min (ranged 80-145 min) and the median estimated blood loss was 60 ml (20-280 ml).In the ELRP group,the median operative time was 85 min (60-130 min) and the median estimated blood loss was 70 ml (20-300 ml).The differences of operative time and estimated blood loss in both groups were all not statistically significant (P=0.325 and P=0.466).The differences of pathological Gleason scores,the pathological stages and positive surgical margin rates in both groups were all not significant (P=0.523,P=0.739 and P=0.735).During the 10-21 months follow-up,7 cases and 5 cases were lost in RALP and ELRP group,respectively.Six cases and 5 cases were diagnosed as the biochemical recurrence and accepted the endocrine therapy in RALP and ELRP group,respectively.Equally continent results in both groups were found (P＞0.05).The neurovascular bundle preserved procedure was conducted in RALP (n =55) and ELRP (n =53) group,respectively.Better postoperative potency rates at 6 months (30 vs 18) and 12 months (40 vs 27) were found in RALP group (P=0.048 and P=0.025,respectively).Conclusion Compared to ELRP,RALP can provide similar perioperative data,short-term oncological control,recovery of postoperative continence and better postoperative potency rates. Key words: Robot-assisted; Prostate cancer; Radical prostatectomy ; Extraperitoneal approach ; Laparoscopy

Novel technique to enhance bladder neck dissection with traction of Foley catheter during extraperitoneal laparoscopic radical prostatectomy

BackgroundLaparoscopic radical prostatectomy (LRP) is a challenging technique that is associated with a steep learning curve. We describe a novel technique to develop bladder neck traction using a Foley catheter during extraperitoneal LRP to enhance bladder neck dissection, thereby improving patient and procedural outcomes. Materials and methodsThe novel technique employed a four-trocar approach to prostatectomy, which involved the introduction of a 1-0 Vicryl suture into the extraperitoneal space using an Endo Close needle to pull up the Foley catheter tip and make the bladder neck prominent. From June 2006 to November 2012, clinicopathological data of 71 patients who underwent four-port extraperitoneal LRP (modified extraperitoneal LRP, Group 1) were assessed and compared with those from 22 patients who underwent transperitoneal LRP (Group 2) retrospectively. ResultsThe two groups were comparable in terms of pathological staging and Gleason score. The operative time was significantly shorter (p < 0.05) and the total blood loss was less in Group 1 patients (p < 0.05). No patient in either group underwent early reintervention for bleeding or blood transfusion. Bilateral or unilateral nerve sparing surgery was performed in 80.3% and 45.5% of Group 1 and Group 2 patients, respectively. The immediate, 1 month, 3 month, 6 month, and 1 year continence rates were, respectively, 19.7%, 38%, 69%, 91.5%, and 100% in Group 1 and 18.2%, 50.0%, 77.3%, 86.4%, and 95.5% in Group 2. In Group 1, 100% of patients were continent 12 months postprocedure. The potency rate was 71.4% in both groups. ConclusionImproved bladder neck enhancement provides a clearer vision during bladder neck dissection. Similar functional results and cancer control rates were also encountered during modified extraperitoneal radical prostatectomy. This novel technique is a feasible method for performing endoscopic radical prostatectomy using four ports instead of five.

Are early continence recovery and oncologic outcomes influenced by use of different devices in prostatic apex dissection during laparoscopic radical prostatectomy?

Treatment of patients with prostate cancer has evolved considerably in the last decade, especially in terms of minimization of the negative impacts on erectile function and continence to ensure good quality of life for treated patients. New surgical devices, such as dissectors and hemostatic scalpels, allow precise definition of the surgical field with finer dissection of the anatomic structures, with subsequent reductions in operative times and better oncologic and functional outcomes. Although monopolar scissors (MS) are still widely used, radiofrequency (RF) and ultrasound (US) scalpels have been introduced recently in laparoscopic radical prostatectomy (LRP). Despite the widespread use of these scalpels, however, few studies have compared these devices in terms of oncologic and functional outcomes after radical prostatectomy. The present study aimed to prospectively assess the impact of MS, RF, and US scalpels on margin status at apex, and recovery of urinary continence and erectile function in patients undergoing extraperitoneal LRP. A total of 150 men were prospectively enrolled between September 2009 and April 2013 and postoperatively evaluated for continence and clinical factors. There were no differences in terms of operative times (P=0.9433), blood loss (P=0.9681), apical margin positivity (P=0.3965) or postoperative hospital stay (P=0.9257) among the groups. Moreover, no differences in the functional outcome scores, as evaluated by the International Consultation on Incontinence self-administered Questionnaire, at 1, 3, and 6 months postsurgery were observed. Our study represents the first evaluation of continence recovery in LRP with respect to different devices used for prostatic apex dissection. We found that the oncologic, functional, and operative outcomes were similar between these different devices during LRP, with no scalpel demonstrating superiority in continence recovery.

A novel practical trocar placement technique for extraperitoneal laparoscopic and robotic-assisted laparoscopic radical prostatectomy in patients with lower midline abdominal incisions.

To describe a novel practical technique for trocar placement in extraperitoneal laparoscopic radical prostatectomy (eLRP) and robotic-assisted laparoscopic radical prostatectomy (eRALP) in patients who had lower midline abdominal incisions. Between March 1999 and November 2013, 3080 LRPs were performed in our department. In total, 1745 eLRPs and 416 eRALPs were enrolled in the study. Group 1 consisted of 57 cases (45 eLRPs and 12 eRALPs) with median lower incision scars after previous abdominal surgery. Group 2 consisted of the same numbers of patients without previous surgeries after matched-pair analyses was performed according to body mass index, age, and operation style. Demographic, perioperative, and postoperative data were recorded. Additionally, we described our novel practical trocar replacement technique for extraperitoneal approach. Statistical analyses were performed. Mean age was 65.6±6.2 years. Mean follow-up was 102.9±24.5 months. There were 12 eRALPs and 45 eLRPs in each group. Demographic, perioperative, and postoperative data were similar in the two groups except for trocar placement time. The trocar placement time was longer in Group 1 than in Group 2 (P<.001). In all patients with previous abdominal surgery with lower abdominal incision scars, we were able to establish trocar placement and correct access to the extraperitoneal space. Moreover, we had no conversions or complications in any patient. Our technique seems safe and practical for trocar placements for eLRP and eRALP in patients with lower abdominal incision scars.

A case report of the first laparoscopic radical nephrectomy done at the Clinic of urology, Clinical centre of Serbia

Laparoscopic interventions are at the very beginning of its evolution in the Clinic of Urology. The first steps have been made primarily to cope with problem of varicocele. We continued to gain laparoscopic experience by switching to solving some demanding intervention, primarily kidney cyst. The only logical next step lead to laparoscopic renal surgery. So, after a few successful primary simple nephrectomy, the next step was to perform a laparoscopic radical nephrectomy. Today, at the Clinic of Urology, Clinical Center of Serbia we successfully perform much more demanding interventions, such as extraperitoneal laparoscopic radical prostatectomy. In this paper we present our experience with the first laparoscopic radical nephrectomy, which was done at the Clinic of Urology, Clinical Center of Serbia.

S200 Comparison of operative, pathologic and continence results of transperitoneal and extraperitoneal robot-assisted laparoscopic radical prostatectomy: Single surgeon experience

S200 Comparison of operative, pathologic and continence results of transperitoneal and extraperitoneal robot-assisted laparoscopic radical prostatectomy: Single surgeon experience

A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1:2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤ 65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.

Prospective Randomized Study of Radiofrequency Versus Ultrasound Scalpels on Functional Outcomes of Laparoscopic Radical Prostatectomy

Surgical treatment of patients with prostate cancer currently involves laparoscopic radical prostatectomy (LRP) or robot-assisted LRP. Continence and nerve-sparing procedures in these techniques are supported by dissection and hemostatic surgical devices powered by different types of energy. The aim of this study was to assess recovery of continence and erectile function after laparoscopic extraperitoneal radical prostatectomy comparing two surgical devices for dissection and hemostasis-radiofrequency (RF) and ultrasound (US) scalpels. A total of 132 men with localized prostate cancer were prospectively enrolled and scheduled for extraperitoneal LRP. Patients were randomly assigned to the RF group (LigaSure; n=66) or the US group (UltraCision; n=66). Outcomes were measured by the self-administered questionnaires (International Consultation on Incontinence Questionnaire-Urinary Incontinence [ICIQ-UI] and International Index of Erectile Function 5 [IIEF 5]) 15 days before surgery, 90 and 180 days after prostatectomy to assess recovery of urinary continence and erectile function. No significant difference was found between the two groups regarding operative time, intra- and perioperative complications, or time of hospital stay. At 180 days after surgery, patients in the RF-treated group showed better recovery in terms of continence and erectile function compared with patients in the US group (ICIQ-UI: p=0.0016; IIEF 5: p=0.0352). The use of the RF scalpel provided better functional outcomes compared with the US scalpel in patients undergoing extraperitoneal LRP. This might be attributed to the low contiguous damage of those tissues, which are not directly involved in dissection and hemostasis, achieved using the RF device.

Long-term oncological and functional results of extraperitoneal laparoscopic radical prostatectomy: one surgical team’s experience on 1,600 consecutive cases

To determine the oncologic and functional outcomes of ELRP on a single surgical team's series. A total of 1,600 consecutive ELRP patients were recorded with a 2-year follow-up. In 778 patients, a 5-year follow-up was available. The mean operative time was 125,6 min (PLND not included) and 150,9 min (PLND included). Postoperative stage was pT2a in 282 patients (17.6 %), pT2b in 877 (54.8 %), pT2c in 18 (1.1 %), pT3a in 241 (15 %), and pT3b in 182 (11.3 %). Positive margins were detected in 7.4 and 13.4 % of pT2 and pT3 tumors, respectively. Overall complication rate was 4 %. PSA levels resulted in <0.2 ng/mL in 96.4, 94.9, 92, 90.9, and 81.5 % of the cases at 3, 12, 24, 36, and 60 months after surgery, respectively. BCRFS rates 5 years after ELRP were 88.7 % for patients staged as pT2, 73.9 % for pT3a, and 62.4 % for pT3b. Complete urinary continence rate resulted in 39 and 92 % after 1 and 12 months, respectively, with a further increase from 92 to 98.4 % at 24-month follow-up. A nerve-sparing procedure was performed in 45 % of patients. The overall potency rate at 12-month follow-up was 38.67 % for UNSS patients and 75 % for BNSS patients. Potency recovery was age-dependent, with patients aged <55 years who resulted potent in 46.8 % of UNSS and 95.8 % of BNSS after 24 months. ELRP is a standardized and safe procedure that implies advantages of both minimally invasive and extraperitoneal approaches with elevated standards for oncologic and functional outcomes obtained at long-term follow-up.

Commentary on “Impact of body mass index on perioperative morbidity, oncological, and functional outcomes after extraperitoneal laparoscopic radical prostatectomy.” Campeggi A, Xylinas E, Ploussard G, Ouzaid I, Fabre A, Allory Y, Vordos D, Abbou CC, Salomon L, de la Taille A, Institut National de la Sante et de la Recherche Medicale Unit 955 EQ7, Department of Urology, APHP, CHU Henri

ObjectiveTo evaluate the impact of obesity on the outcomes of laparoscopic radical prostatectomy. Methods and materialsIn a prospective urologic cancer database, 765 patients underwent extraperitoneal laparoscopic radical prostatectomy for localized prostate cancer. The patients were categorized into 3 groups of body mass index (kg/m2):<25.0 (n = 276, 30%, “normal weight”, 25.0 to 30.0 (n = 365, 48%, “overweight”) and>30.0 (n = 124, 16%, “obese”). We assessed the perioperative, oncological, and functional outcomes in this cohort of patients. Preoperative and postoperative evaluation of continence and erectile function were performed using validated questionnaires. ResultsMean operative time was significantly longer in obese patients (P< 0.001) and blood loss was also more important (P< 0.01). The obese patients had the highest likelihood of having aggressive tumors: nonorgan confined prostate cancer (49%, P = 0.002) and Gleason score≥7 (80%, P = 0.005). The obese group had the higher positive surgical margins rate (overall: 27%, P = 0.012; pT2: 20%, P = 0.02). With a mean follow-up of 38 months, obesity was not an independent predictive factor of biochemical recurrence. At the 12-month follow-up, 85%, 74%, and 72% of normal, overweight, and obese men, respectively, were continent (no pad) (P = 0.04). At the 12-month follow-up, 57%, 58%, and 40% of normal, overweight, and obese men, respectively, reported an erection sufficient for intercourse (P = 0.01). ConclusionLaparoscopic radical prostatectomy is a safe and effective procedure in obese men with midterm cancer control. However, obese patients are at higher risk of aggressive disease. Recovery of continence and potency in these patients are significantly lower compared to non-obese men.

Comparisons of the Perioperative, Functional, and Oncologic Outcomes After Robot-Assisted Versus Pure Extraperitoneal Laparoscopic Radical Prostatectomy

BackgroundIn spite of the increasing use of robot-assisted radical prostatectomy (RALP) worldwide, no level 1 evidence-based benefit favouring RALP versus pure laparoscopic approaches has been demonstrated in extraperitoneal laparoscopic procedures. ObjectiveTo compare the operative, functional, and oncologic outcomes between pure laparoscopic radical prostatectomy (LRP) and RALP. Design, setting, and participantsFrom 2001 to 2011, 2386 extraperitoneal LRPs were performed consecutively in cases of localised prostate cancers. InterventionA total of 1377 LRPs and 1009 RALPs were performed using an extraperitoneal approach. Outcome measurements and statistical analysisPatient demographics, surgical parameters, pathologic features, and functional outcomes were collected into a prospective database and compared between LRP and RALP. Biochemical recurrence–free survival was tested using the Kaplan-Meier method. Mean follow-up was 39 and 15.4 mo in the LRP and RALP groups, respectively. Results and limitationsShorter durations of operative time and of hospital stay were reported in the RALP group compared with the LRP group (p<0.001) even beyond the 100 first cases. Mean blood loss was significantly lower in the RALP group (p<0.001). The overall rate and the severity of the complications did not differ between the two groups. In pT2 disease, lower rates of positive margins were reported in the RALP group (p=0.030; odds ratio [OR]: 0.396) in multivariable analyses. The surgical approach did not affect the continence recovery. Robot assistance was independently predictive for potency recovery (p=0.045; OR: 5.9). Survival analyses showed an equal oncologic control between the two groups. Limitations were the lack of randomisation and the short-term follow-up. ConclusionsRobotic assistance using an extraperitoneal approach offers better results than pure laparoscopy in terms of operative time, blood loss, and hospital stay. The robotic approach independently improves the potency recovery but not the continence recovery. When strict indications of nerve-sparing techniques are respected, RALP gives better results than LRP in terms of surgical margins in pathologically organ-confined disease. Longer follow-up is justified to reach conclusions on oncologic outcomes.

Managing urine leakage following laparoscopic radical prostatectomy with active suction of the prevesical space.

IntroductionUrine leakage following laparoscopic radical prostatectomy (LRP) is a possible complication that may herald chronic urine incontinence. Intraoperative measures aiming to prevent this is not standardised.AimPresentation of experience with active suction of the prevesical space in managing postoperative urine leakage.Material and methodsAt the Department of Urology, where laparoscopy of the upper abdomen and open RP were performed, a protocol for extraperitoneal LRP was established in 8/2008. Until 5/2011, 154 LRPs have been performed. Urine leakage from a suction drain appeared in 9 cases (5.8%). Permanent active suction (with a machine for Büllae thoracic drainage) of the prevesical space with negative pressure of 7-12 cm of H2O was started immediately.ResultsUrine leakage started after a mean of 0.9 (0-2) days postoperatively and stopped after a mean of 8.1 (15-42) days. Leakage stopped with only suctioning in 7 cases. In one case, open re-anastomosis was performed on the 7th postoperative day (POD). In another case, ineffective active suction was replaced on the 10th POD by needle vented suction without effect and the leakage stopped following gradual shortening of the drain up to the 15th POD.ConclusionsActive suction of the prevesical space seems to be an effective intervention to stop postoperative urine leakage after laparoscopic radical prostatectomy.

Extraperitoneal laparoscopic radical prostatectomy: A prospective 2-year single-surgeon experience with 171 cases

ObjectiveTo assess the safety and the oncological and functional efficacy of a prospective series of extraperitoneal laparoscopic radical prostatectomy (ELRP). Patients and methodsThis prospective study included 171 consecutive patients (mean age 62.9years, SD 6.5) who underwent ELRP by one surgeon between January 2008 and December 2009. The variables analysed were operative duration, blood loss, conversion rate, complications, hospital stay, duration of catheterisation, and the oncological results. We also assessed the rates of continence and erectile function. ResultsThere were no conversions to open surgery. The mean (SD) operative duration was 112.7 (19.4) min, the blood loss was 372.1 (219.1)mL, the hospital stay was 6.8 (2.0) days, and the duration of catheterisation 6.7 (1.5) days. Collectively, 23.4% (40/171) of patients had positive surgical margins. Urinary continence at 1, 3, 6 and 12months was achieved in 63.3% (95/150), 88.6% (78/88), in 90.3% (121/134) and 92.1% (117/127) of patients, respectively. The respective percentages for physiological erections after nerve-sparing ELRP at the same times were 11.8% (13/110), 11.8% (13/110), 18.2% (20/110) and 25.5% (28/110). The overall potency recovery rates (including patients on pharmacotherapy) were, respectively, 26.4% (29/110), 35.5% (39/110), 52.7% (58/110) and 69.1% (76/110), for the nerve-sparing procedure. ConclusionELRP gave good oncological and functional results, especially in terms of urinary continence.

Knotless “three‐U‐stitches” technique for urethrovesical anastomosis during laparoscopic radical prostatectomy

We describe a new technique for urethrovesical anastomosis that consists of placing three "U" stitches of Monocryl 2-0 to connect the bladder neck and urethral stump together. The margins are united by a double passage of the suture, without tying any knots. The sutures are tied on the bladder's surface using Lapra-Ty clips fixed at a certain distance from where to two mucosal margins have been joined. We carried out this technique on 90 patients who underwent laparoscopic extraperitoneal radical prostatectomy. The good joining of the margins, the absence of knots and the minimum trauma to the urethral wall together enable to create an anastomosis that is both "sealed" and "tension free", allowing a quick "welding" of the margins and an early catheter removal. Regarding urinary continence, 56.6% (51) of patients were continent at catheter removal, 87.6% (78) were continent 3 months later and 98.9% (89) were continent after 6 months. In nine patients (10%), an episode of acute urinary retention occurred within 24 h after the removal of the catheter. We did not encounter any cases of vesicourethral anastomosis stenosis.

What is the predictor of prolonged operative time during laparoscopic radical prostatectomy?

To study the impact of high body mass index and large prostate weight on operative time of laparoscopic radical prostatectomy. A retrospective analysis of medical records from patients who had undergone extraperitoneal laparoscopic radical prostatectomy by a single surgeon at our institution between September 2008 and April 2011 was carried out. For each case, the following parameters were recorded: age, body mass index, prostate weight, cross-section area of the Retzius space, and history of previous lower abdominal surgery, repeated prostate biopsy and neoadjuvant hormone therapy. The laparoscopic radical prostatectomy procedure was divided into seven surgical steps: (i) port insertion and lymph node dissection; (ii) endopelvic fascia incision; (iii) dorsal vein complex ligation; (iv) prostate dissection from bladder neck; (v) dissection of seminal vesicles and vas deferens; (vi) prostate dissection from rectum; and (vii) vesicourethral anastomosis. The overall operative time and the duration of each surgical step were retrieved. Potential predictors of prolonged total operative time and prolonged duration of a step were assessed by multivariate logistic regression analysis. A total of 152 patients were analyzed. High body mass index (≥25.0 kg/m(2) ) and prostate weight were independent predictors of prolonged total operative time. High body mass index was an independent predictor of prolonged step 1, 3, 4, 5 and 6. Prostate weight was an independent predictor of prolonged step 2, 5 and 6. A history of previous lower abdominal surgery was a predictor of prolonged step 1. High body mass index and high prostate weight are independent predictors of prolonged total operative time in extraperitoneal laparoscopic radical prostatectomy. Although high body mass index seems to affect most of the surgical steps of the procedure, prostate weight mainly impacts the dissection close to the prostate, as enlarged prostate results in a narrower working space.

Impact of Body Mass Index on Perioperative Morbidity, Oncological, and Functional Outcomes After Extraperitoneal Laparoscopic Radical Prostatectomy

To evaluate the impact of obesity on the outcomes of laparoscopic radical prostatectomy. In a prospective urologic cancer database, 765 patients underwent extraperitoneal laparoscopic radical prostatectomy for localized prostate cancer. The patients were categorized into 3 groups of body mass index (kg/m(2)): <25.0 (n = 276, 30%, "normal weight"), 25.0 to 30.0 (n = 365, 48%, "overweight") and >30.0 (n = 124, 16%, "obese"). We assessed the perioperative, oncological, and functional outcomes in this cohort of patients. Preoperative and postoperative evaluation of continence and erectile function were performed using validated questionnaires. Mean operative time was significantly longer in obese patients (P < .001) and blood loss was also more important (P < .01). The obese patients had the highest likelihood of having aggressive tumors: nonorgan confined prostate cancer (49%, P = .002) and Gleason score ≥ 7 (80%, P = .005). The obese group had the higher positive surgical margins rate (overall: 27%, P = .012; pT2: 20%, P = .02). With a mean follow-up of 38 months, obesity was not an independent predictive factor of biochemical recurrence. At the 12-month follow-up, 85%, 74%, and 72% of normal, overweight, and obese men, respectively, were continent (no pad) (P = .04). At the 12-month follow-up, 57%, 58%, and 40% of normal, overweight, and obese men, respectively, reported an erection sufficient for intercourse (P = .01). Laparoscopic radical prostatectomy is a safe and effective procedure in obese men with midterm cancer control. However, obese patients are at higher risk of aggressive disease. Recovery of continence and potency in these patients are significantly lower compared to nonobese men.