Standard Laparoscopic Radical Prostatectomy Research Articles

A Study of 57 Patients with Prostate Cancer to Compare Outcomes of Estimated Blood Loss and Postoperative Pain Between Robot-Assisted Laparoscopic Radical Prostatectomy and Standard Laparoscopic Radical Prostatectomy.

BACKGROUND Robot-assisted radical prostatectomy (RARP) is becoming an increasingly common method for treatment of prostate cancer. This study aimed to compare outcomes of estimated blood loss and postoperative pain, determined by patient-controlled analgesia (PCA), between RARP and standard laparoscopic radical -prostatectomy (LRP). MATERIAL AND METHODS We enrolled 57 patients who had localized prostate cancer (28 patients in RARP, 29 patients in LRP). Primary outcomes were estimated blood loss (EBL) measured by gravimetric method for gauze and visual estimation for suction bottle, and PCA bolus count that the bolus doses were injected at the 1st, the 6th, the 24th, and the 48th hour after the operation. We recorded anesthesia and operation time, pneumoperitoneum duration, vital signs, fluid volume, and remifentanil use. Using the numeric rating scale (NRS), adverse effects were checked at the 1st, the 6th, the 24th, and the 48th hour and patient satisfaction was assessed at the 48th hour after the operation. RESULTS Anesthesia time, operation time, and gas insufflation time were longer (P=0.001, P=0.003, P=0.021), and patient-controlled analgesia (PCA) bolus counts at the 1st hour after the operation and volumes of administered crystalloid and remifentanil were higher in the RARP group than in the LRP group (P=0.013, P=0.011, P=0.031). There were no significant differences in EBL. CONCLUSIONS The RARP group required longer anesthetic time and more analgesics during the acute postoperative period compared to the LRP group. Regarding anesthesia, LRP is as good a surgical procedure as RARP until the operation time and the number of ports are reduced.

Comparison of retropubic radical prostatectomy and standard laparoscopic radical prostatectomy: a meta–analysis

Objective To compare the outcomes of standard laparoscopic radical prostatectomy(SLRP) and retropubic radical prostatectomy (RRP) via meta–analysis. Methods A systematic literature search of articles from January 1992 to April 2015 was conducted via Pubmed, Web of Science, Cochrane Library, and EMBASE databases, and the references of the retrieved articles.Fixed– or random–effect models were used to summarize the estimates to evaluate operation time, blood loss, transfusion, catheterization time, hospital stay, surgical margin status, perioperative complications, postoperative erectile dysfunction, and postoperative urinary incontinence in these two approaches. Results A total of 17 articles were included in this study.Compared with RRP group, the operation time was longer in SLRP group (SMD=1.20, 95%CI 0.83, 1.58). On the contrary, the SLRP group held advantages in blood loss (SMD=–2.02, 95%CI –2.67, –1.37), transfusion (RR=0.22, 95%CI 0.16, 0.30), catheterization time (SMD=–1.44, 95%CI –2.34, –0.54), hospital stay (SMD=–0.97, 95%CI –1.29, –0.66)(P 0.05). Conclusions Compared with RRP, SLRP could be a more suitable approach to treat localized prostate cancer.Random clinical trials are needed in the future to better evaluate these two approaches. Key words: Standard laparoscopic radical prostatectomy; Retropubic radical prostatectomy; Meta–analysis; Clinical research

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.

A Simple Reconstruction of the Posterior Aspect of Rhabdosphincter and Sparing of Puboprostatic Collar Reduces the Time to Early Continence After Laparoscopic Radical Prostatectomy

Incontinence is a drawback after radical prostatectomy for prostate cancer. Several surgical methods to improve continence have been described however with contradictory results. To determine whether a modified surgical technique during laparoscopic radical prostatectomy (LRP) improves postoperative continence. This is a prospective nonrandomized study with two consecutive series of 100 patients in each group. The first group from 2005 to 2008 underwent a standard LRP. The second group from 2009 to 2011 was subjected to a modified LRP by sparing of puboprostatic ligaments, including the preservation of arcus tendineous, and using a simple posterior tension-releasing suture adapting the urethra stump to the bladder before the anastomosis. The patients had the same preoperative work-up and comparable preoperative baseline characteristics. The 2-year follow-up of the patients included a continence questionnaire and International Prostate Symptom Score (IPSS). Urinary peak flow (Qmax) and post-void residual (PVR) volume were assessed at 3 months. Continence was defined as 0-1 pad/day. Only 99 patients were evaluated in each group. The patients had comparable operative characteristics. The continence rates after the modified technique vs the standard were 33% vs 16%, p=0.007 at 1 month; 66% vs 44%, p=0.002 at 3 months; 81% vs 67%, p=0.034 at 6 months; 92% vs 80%, p=0.024 at 12 months; and 95% vs 86%, p=0.05 at 2 years. No significant differences were found regarding voiding functions, the Qmax, the PVR volume, or the IPSS. Three patients developed urethral stricture in the standard group compared with none in the modified group. The negative margin rates were unchanged. The anterior preservation and posterior suture technique studied is a simple, safe, and efficient method to shorten the time to continence after LRP without adverse effects on voiding or compromising the margin rates.

UROLOGICAL ONCOLOGY Blood loss during laparoscopic radical prostatectomy – is it significant or not?

IntroductionThe traditional assessment of blood loss during laparoscopic radical prostatectomy (LRP) is based on the blood volume collected intraoperatively in the suction device bottles. While this method is not perfect, analysis of changes in blood cell count (BCC) resulting from LRP is advisable.Material and methods71 men were submitted to LRP due to prostate cancer in our institution over an 18-month time period. From this group, we isolated 60 men with clinically minimal intraoperative blood loss (<200 ml) and included them into the study. Mean age of the cohort was 62.8 years. We performed standard BCC on the day before and 6 hours after the surgery. At the same time points, we measured creatinine serum concentration and calculated eGFR to avoid the data misinterpretation resulting from impaired renal function in the postoperative period.ResultsStatistically and clinically significant differences regarding all BCC parameters measured pre- and postoperatively were observed. The number of red blood cells, hemoglobin concentration, and hematocrit diminished by 17.5% (4.68T/l vs. 3.86T/l, p <0.02), 17.0% (8.93 mmol/l vs. 7.41 mmol/l, p < 0.02), and 17.9% (0.429 vs. 0.352, p <0.02), respectively. Simultaneously, renal function was stable with no significant change in eGFR (82.9 ml/min/1.73 m^2 vs. 79.09 ml/min/1.73 m^2, p = 0.28).ConclusionsStandard LRP brings on a significant blood loss. While clinically insignificant, this blood loss seems to be as high as approx. 600 ml based on laboratory findings. BCC seems to be a more accurate method of intraoperative blood loss estimation compared to measurement of blood volume collected intraoperatively in the suction device bottles.

Single-centre study comparing standard apical dissection with a modified technique to facilitate vesico-urethral anastomosis during laparoscopic radical prostatectomy

A modified apical dissection of the prostate to improve the efficiency of vesico-urethral anastomosis (VUA) in laparoscopic radical prostatectomy (LRP) was reported. A total of 42 patients were randomly selected and enrolled in this study. A standard LRP was performed in 21 patients (group 1), whereas a novel, modified apical dissection of the prostate in LRP was performed in another 21 patients (group 2). Surgical data, total operative time, VUA time, extravasation rate, catheterisation time, occurrence of anastomotic strictures, and the early and late continence rates were analysed statistically. No differences in clinical or pathological characteristics were determined between the two groups. The total operative time, VUA time, blood loss and catheterisation time were lower in group 2, which received the novel, modified technique compared with group 1, which received the standard technique to dissect the apex of the prostate (P < 0.01 for each variable). Regarding the extravasation rate and the occurrence of anastomotic strictures, no significant differences were found between the two groups (P > 0.05 for each). After catheter removal, a statistically significant difference in the continence rates was present at 3 and 30 days post operation in the two groups (P < 0.01, respectively). At 90 days post operation, the difference, although still present, was no longer statistically significant (P > 0.05). The novel, modified apical dissection of the prostate facilitates the VUA and significantly improves the efficacy of the procedure and early restoration of continence.

Comments on the Extraperitoneal Approach for Standard Laparoscopic Radical Prostatectomy: What Is Gained and What Is Lost

Laparoscopic extraperitoneal radical prostatectomy (LERP) is considered the standard care treatment option for the management of localized and locally advanced prostatic cancer (PCa) in many institutes worldwide. In this work, the main advantages and disadvantages of LERP approach are reviewed with regard to its outcomes, the complication management, the learning curve, and the extend of pelvic lymph node dissection (PLND). It is concluded that LERP demonstrates comparable cancer control, urinary continence, and potency outcomes with the open and the robot-assisted radical prostatectomy, while offering advantages in complication management in comparison to the transperitoneal approach. Learning curve of LERP is considered long and stiff and significantly affects perioperative outcomes and morbidity, cancer control, and functional results. Thus, close mentoring especially in the beginning of the learning curve is advised. Finally, LERP still has a role in the limited or modified PLND offered in intermediate risk PCa patients.

Primary left upper quadrant (Palmer's point) access for laparoscopic radical prostatectomy.

Although Palmer's point approach is described for upper urinary tract laparoscopy, we use this technique routinely for robotic and standard laparoscopic radical prostatectomy and we describe our experience with this approach. Since 2004, Palmer's point Veress entry has been used to create pneumoperitoneum in 126 robotic and 21 standard laparoscopic radical prostatectomies. On the left side, a 2-mm transverse skin incision was made 3 cm below the left costal margin on the midclavicular line. Through this incision, a Veress needle was inserted to create pneumoperitoneum. The mean patient's age and body mass index were 59.7 years (range, 37 to 73 years) and 27.92 kg/m2 (range, 22 to 39 kg/m2), respectively.Thirty-eight patients had prior abdominal operations. The mean number of punctures performed was 1.08 per case. In 93% of the subjects, Veress needle was inserted during the first attempt. The mean time to establish pneumoperitoneum was 5.63 minutes (range, 4 to 8 minutes). No major entrance injuries occurred. Palmer's point upper quadrant Veress needle access may be a safe and effective method of establishing pneumoperitoneum in patients subjected to robotic and standard laparoscopic radical prostatectomy.

Modified apical dissection of the prostate improves early continence in laparoscopic radical prostatectomy: technique and initial results

Incontinence after radical retropubic prostatectomy (RRP) is one of the greatest worries for all patients. One of the possible reasons for this urinary incontinence is a postoperative deficiency of the external striated urethral sphincter (EUS) complex and continence nerves. This study evaluated the application of a modified simple technique to dissection of the apical prostate in laparoscopic radical prostatectomy (LRP) and assessed the rate of urinary continence. A total of 104 patients were randomly selected using envelopes and enrolled in this study. A standard LRP was performed in 52 patients (standard LRP group) and a modified technique for simple dissection of the apical prostate in LRP was performed in another 52 patients (modified LRP group). The urethra was dissected and transected at the apex of the prostate, proximal to the nerve-distributing rhabdosphincter using sharp scissors to avoid damage to the EUS complex and continence nerves. In all patients, a pad test was performed on 3, 30 and 90 days postoperatively and correlated with urinary continence. Continence was defined as zero pads or a liner used for security reasons only. After catheter removal, the continence rates were regained in 66, 85 and 96% of patients in the modified LRP group compared with 28, 55 and 91% of the patients in the standard LRP group at 3, 30 and 90 days, respectively. A statistically significant difference was present at 3 and 30 days (p < 0.01, respectively). At 90 days, the difference, although still present, was not statistically significant (p > 0.05). In this preliminary study, the technique of simplified apical dissection of the prostate in LRP appears to be an easy and feasible technique in early recovery of urinary continence. Further long-term and larger sample studies are necessary to elucidate the modified technique in LRP on early restoration of urinary continence.

Critical Role of the Assistant in Laparoscopic and Robot-Assisted Radical Prostatectomy

The literature on standard laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP) is replete with technical descriptions of the primary surgeon's responsibility, but deficient with regard to the detailed role of the assistant surgeon. This video paper describes the critical role of the assistant surgeon and provides tips for the assistant to facilitate these operations.

Laparoscopic radical prostatectomy: Six months of fellowship training doesn't prevent the learning curve when incorporating into a lower volume practice

Introduction To assess whether 6 months of standard laparoscopic radical prostatectomy (LRP) training reduces the learning curve. Methods A single urologist (JAB) performed two 3-month fellowships at medical centers with high-volume LRP surgeons (Thomas Jefferson University, 2002 and Massachusetts General Hospital, 2003). He participated in 29 transperitoneal and 23 extraperitoneal LRPs, performing part or all (2) of 28 cases. He subsequently initiated a LRP program at our institution in July 2003, performing 32 procedures between July 2003 and June 2006 (excluding a 3-month 2004 robotic surgery sabbatical). Six residents served as assistant. Results Median patient age, BMI, and preoperative PSA were 58 (46–71) years, 30 (21–37), and 5.4 (3.2–13.6) ng/ml, respectively. Median estimated blood loss (EBL) and operative time were 400 (50–1700) ml and 411 (282–652) minutes. Median hospital stay, catheterization, and follow-up were 2 (1–12) days, 15 (8–52) days, and 10 (1–30) months, respectively. Ten (31%) and 6 (19%) underwent pelvic lymphadenectomy and open conversion. Five patients (16%) received transfusion. Twenty-three (72%) were pathologic stage pT2 and 9 (28%) pT3. Thirteen, 15, and 3 specimens were Gleason 6, 7, and ≥8, respectively. Fifteen (47%) had positive surgical margins (14 apical and 7 other sites). Nineteen (59%) had complications and 4 (12.5%) salvage radiation therapy. Of 20 patients followed 12 months, 12 (60%) are continent (pad free) and 4 (27%) potent patients remain so with or without PDE5 inhibitor. Conclusion Six months of training (52 cases, 28 as surgeon for part or all) did not alleviate the LRP learning curve.

Applications of robots in urology.

During the last two decades the field of urology has seen a tremendous growth in minimally invasive surgery. Potential advantages with this shift toward laparoscopic surgery include smaller incisions, reduced blood loss, less post-operative pain with reduced intake of narcotics, shorter hospital stays, and faster recovery. Nephrectomy, adrenalectomy, pyeloplasty, and prostatectomy have all established themselves as procedures benefitting from minimally invasive surgery. Complex laparoscopic procedures, for example prostatectomy, have proven to be quite a daunting task, because of the steep learning curve for many urologists [1]. Factors limiting the performance of standard laparoscopic radical prostatectomy are counter-intuitive motion, the lack of depth perception secondary to 2D vision, and rigid instrumentation with only four degrees of surgical freedom. These factors hinder visualization, dissection, and suturing in small spaces [1]. Introduction of robotic technology into modern day surgery has removed many of these technical barriers and has the potential to facilitate the broad-based adoption of complex laparoscopic procedures. There are more than 400 robotic systems in the USA and over 30,000 robotic procedures have been performed (communication with Intuitive Surgical). Although, initially, the equipment was conceived for use in cardiac surgery, adoption has been strongest in urology. It seems that robotic surgery has been uniquely adapted to urology, especially prostatectomy, because of the unique advantage of miniature instruments in the pelvis. Although prostatectomy is the main use of robotic surgery in urology its use in other urologic procedures is expanding rapidly as surgeons become more adept with its use. We review the current status of robotic technology, the constraints to its use and the surgical applications of robotic technology in urology.

58 Robotic laparoscopic radical prostatectomy for non‐laparoscopic surgeons ‐ what is the learning curve?

Introduction: Laparoscopic radical prostatectomy (LRP) has been shown to have many advantages over open surgery, but has proven difficult for many to become adept at. The use of the Da Vinci® robotic system greatly facilitates the performance of LRP. We set out to analyse how many cases it takes to become proficient at Robotic Assisted Laparoscopic radical Prostatectomy (RALRP).Methods and Methods: Two experienced open surgeons began performing RALRP using the Da Vinci® robotic system in December 2003. Duration of various steps were measured prospectively. Results were grouped sequentially in groups of 10 patients and analysed statistically to determine at what point these results reflected increased operative proficiency. Surgeons results were analysed separately to provide internal validation.Results: One hundred and ten consecutive patients were evaluated. Overall operative times for both surgeons decreased significantly (P &lt; 0.05) over the first 30 cases after which they plateaued at an average of 191 min (36.3% reduction). Actual operative time also decreased significantly (P &lt; 0.01) at or before the 30th case until plateauing at 146 min (39% reduction).Conclusion: RALRP is a procedure that can be mastered much more quickly than standard LRP by experienced open surgeons inexperienced in laparoscopic surgery, with surgical proficiency being attained at/before the 30th case.

Robot-assisted versus open radical prostatectomy: a comparison of one surgeon's outcomes

Objectives To compare internally one surgeon's standard open radical prostatectomy (RP) and robot-assisted laparoscopic RP (RLP) results. RLP, like standard laparoscopic RP, ultimately needs to produce similar or improved results compared with standard RP techniques. Little information comparing RLP with standard RP exists. Methods As an internal control, we selected the last 60 standard RPs performed by one surgeon (T.A.) before initiating RLPs. For the RLP group, we selected cases 46 to 105 (n = 60) after the learning curve had adequately matured. We compared the clinical characteristics, perioperative results, and early clinical outcomes. Results The study and control groups had similar clinical characteristics (age, body size, preoperative prostate-specific antigen level, clinical stage, and Gleason score). No statistically significant differences were found between groups for prostate size, pT stage, Gleason score, or margin status (16.7% versus 20%; P = nonsignificant). The RLP group had a statistically significant advantage for estimated blood loss (103 versus 418 mL), postoperative hemoglobin change (1.6 versus 3.3 mg/dL), and hospital stay (1.02 versus 2.2 days). Complete continence (0 pads) at 3 months of follow-up and the rate of postoperative complications were similar for the RLP and RP groups (76% versus 75% and 6.7% versus 10%, respectively). Conclusions We present the results of RLP and RP performed by one surgeon. With only a 100-case experience, RLP had oncologic and urinary outcomes that were at least equal to those after RP. RLP offers the benefits of minimally invasive surgery and does not compromise clinical or pathologic outcomes.

Complete solo laparoscopic radical prostatectomy: initial experience

Objectives To demonstrate the feasibility of “complete solo” (CS) laparoscopic radical prostatectomy (LRP) performed solely with robotic manipulation of the laparoscope and without any human assistant at all. A comparison was made between CS LRP and the standard technique to identify the advantages and drawbacks. Methods Sixteen consecutive patients undergoing CS LRP were compared with the last 16 patients undergoing standard LRP. The standard procedure was performed with five trocars and one human assistant. Therefore, the surgeon had three instruments immediately available and could switch quickly from one to another, while the assistant held the laparoscope and a retractor. The CS method used a voice-controlled robotic arm to manipulate the laparoscope and a mechanical arm for the assisting instrument. Results The mean operative time in the CS and standard groups was 324 and 347 minutes, respectively ( P >0.5). An additional human assistant was required, for 1 hour, in 3 patients of each group. No significant difference was noted between the two groups in terms of catheterization time, hospital stay, positive margin rate, complications, short-term cancer control, or functional results. The CS method has been demonstrated to be highly cost-effective compared with the standard technique. Conclusions The CS LRP is feasible and compares favorably with the standard technique. It offers unique advantages in terms of direct control of the operative view, standardization of the assistance, and higher stability of the laparoscope, thus greatly enhancing the surgeon’s comfort. The diminished need for human operative assistance provides significant economic and organizational benefits.