Technique Of Laparoscopic Radical Prostatectomy Research Articles

Description of the technique for laparoscopic radical prostatectomy in canine cadavers: 2D vs. 3D camera.

To describe the technique of laparoscopic radical prostatectomy in canine cadavers. Cadaveric study. 8 canine cadavers. Specimens were randomly divided into a 2D or 3D group. The vesicourethral anastomosis (VUA) was performed with 5 mm laparoscopic needle holders. A unidirectional barbed suture was used to complete the VUA with two simple continuous suture patterns. The number of stitches placed, the patency of the anastomosis, and the distance between the VUA and the ureters were recorded. Four dogs were entered into each group. The prostatectomy was completed in each dog following the same technique. VUA were completed with nine stitches (range: 8-10 stitches) for the 2D group and ten stitches (range: 9-11 stitches) for the 3D group (p<0.176). All the stitches were placed full thickness. The VUA was patent in each case. The left ureter was 1.05 cm (range: 0.5 to 1.1cm) from the VUA in the 2D group and 1.8 cm (range: 1.3-1.8 cm) for the 3D group (p< 0.025). The right ureter was 1.5 cm (range: 1 to 2 cm) from the VUA in the 2D group and 1.75 cm (range: 1.3-2 cm) for the 3D group (p< 0.55). Laparoscopic radical prostatectomy can be performed with a 2D or a 3D camera in canine cadavers. The 3D camera results in more accurate placement of the sutures since they were placed further away from the left ureter. Radical prostatectomy with laparoscopy should be considered for dogs.

Incontinence after laparoscopic radical prostatectomy: a reverse systematic review.

ABSTRACTPurpose:To report the prevalence of the definitions used to identify post-prostatectomy incontinence (PPI) after laparoscopic radical prostatectomy (LRP), and to compare the rates of PPI over time under different criteria.Materials and Methods:In the period from January 1, 2000, until December 31, 2017, we used a recently described methodology to perform evidence acquisition called reverse systematic review (RSR). The continence definition and rates were evaluated and compared at 1, 3, 6, 12, and >18 months post-operative. Moreover, the RSR showed the “natural history” of PPI after LRP.Results:We identified 353 review articles in the systematized search, 137 studies about PPI were selected for data collection, and finally were included 203 reports (nr) with 51.436 patients. The most used criterion of continence was No pad (nr=121; 59.6%), the second one was Safety pad (nr=57; 28.1%). A statistically significant difference between continence criteria was identified only at >18 months (p=0.044). From 2013 until the end of our analysis, the Safety pad and Others became the most reported.Conclusion:RSR revealed the “natural history” of PPI after the LRP technique, and showed that through time the Safety pad concept was mainly used. However, paradoxically, we demonstrated that the two most utilized criteria, Safety pad and No pad, had similar PPI outcomes. Further effort should be made to standardize the PPI denomination to evaluate, compare and discuss the urinary post-operatory function.

Adoption of the technique of laparoscopic radical prostatectomy on the example of the regional cancer center

Adoption of the technique of laparoscopic radical prostatectomy on the example of the regional cancer center

Beforehand transection and suturing (BTS) of the dorsal vascular complex: a novel technique in laparoscopic radical prostatectomy.

Beforehand transection and suturing (BTS) of the dorsal vascular complex (DVC), a novel technique in non-neurovascular bundle sparing (NVB-sparing) extraperitoneal laparoscopic radical prostatectomy (eLRP), had been proposed; this study aimed to evaluate this technique in clinical laparoscopic procedures. Using this new technique, the DVC was transected and sutured after dissection of the pelvic fascia and before dissection of the prostate, especially before ligation of the bilateral prostatic pedicles. This study retrospectively analyzed the data of 90 non NVB-sparing eLRP patients [traditional technique (n=60) and BTS technique (n=30)]. The surgical time in the BTS technique group was 121.73±24.53 min, which was significantly shorter (P=0.0015) than the traditional technique group (144.12±39.68 min). The calculated blood loss in the traditional technique group was 388.45±232.78 mL, and 264.16±130.70 mL in the BTS technique group (P=0.0016). The estimated blood loss in the traditional technique group was 350.34±311.80 mL, which was significantly greater than the BTS technique group (250.33±145.31 mL, P=0.0422). The transfusion rate in the traditional technique group was significantly greater than the BTS technique group (15.00% vs. 0.00%; P=0.0266). The biochemical recurrence rate in traditional technique group was 48.33%, which was higher than in the BTS group (30.00%) (P=0.0465). There was no significant difference between the 2 groups with respect to the pre-operative hemoglobin (Hb) concentration, pre-operative hematocrit (HCT), post-operative Hb concentration, post-operative HCT, ΔHCT, pre-operative blood volume, rectal perforation, open conversion, apical capsule residue, false suture, post-operative bleeding, urinary leakage, re-operation, surgical site infection, post-operative stay, and emission time of urinary incontinence. In managing the relationship between the DVC and prostate in patients undergoing non NVB-sparing eLRP, the BTS technique was shown to be more effective and safer than the traditional technique.

A novel \u201cthree-port\u201d trocar placement technique for laparoscopic radical prostatectomy

BackgroundTo introduce a novel “three-port” trocar placement technique for laparoscopic radical prostatectomy (LRP) in prostate cancer (PCa) patients.MethodsWe retrospectively reviewed 300 patients with PCa who received surgical treatment between November 2010 and June 2015 at our institution. They were divided into group A, three-port LRP; group B, conventional four-five-port LRP; group C, open RP (ORP); and group D, robotic-assisted RP (RARP). A learning curve was analyzed by dividing patients of group A into the early and late stages.ResultsAll groups were comparable with regard to the preoperative characteristics except for the relatively smaller prostate volume in group A. The three-port LRP operations were performed successfully with only 8 cases of conversion to the conventional LRP. None of any severe complications or conversion to ORP occurred. In group A, the mean operative time (OT) duration was 113.8 min, the mean estimated blood loss (EBL) was 94.2 ml, the mean drainage days was 4.0 days, the mean hospitalization was 5.1 days, and 27.8% of the prostate specimen margins (PSM) were positive. The differences of OT, EBL, drainage days, hospitalization, and transfusion in group A were statistically significant among the majority of the other groups (p < 0.05). After undergoing the early stages of a learning curve analysis in three-port LRP, the EBL was obviously decreased.ConclusionsThree-port LRP is a novel technique that exhibits superior intraoperative advantages to the conventional LRP. Due to its less OT, EBL, drainage days, hospitalization, and transfusion with a shorter learning curve, it should be recommended and popularized in the clinical practice.

Сравнение безузловой и традиционной методик при наложении уретровезикального анастомоза при радикальной простатэктомии на этапе освоения

Laparoscopic radical prostatectomy (LRP) is the most popular treatment method for localized prostate cancer worldwide. This is a technically-demanding procedure with a long learning curve. Therefore, an improvement of the surgical technique is very important in order to simplify training for LRP. Dorsal vein ligation and vesicourethral anastomosis (VUA) are two major problems for surgeons with insufficient experience in LRP. Previous studies have shown that between 50 and 250 procedures are required in order to get necessary skills. to compare and study the advantages of the "free-tie" technique and interrupted suture during the formation of VUA during learning curve of LRP. a single-center retrospective analysis was performed by evaluating operational reports, video recordings and histories of patients who were operated at Saint Petersburg Public Hospital of Saint Luca from 2016 to 2018. A total of 114 patients were included in the study, 56 of them were undergone to "free-tie" technique and 48 patients had interrupted suture. All procedures were performed by four surgeons with an experience of less than 100 LRP. The evaluation criteria included the time of formation of VUA, the duration of whole procedure, the duration of bladder catheterization, frequency of anastomotic leak and stress urinary incontinence. For surgeons who learned the technique of LRP, the use of a continuous suture with a self-anchoring V-loc thread allowed to reduce significantly the time of formation of VUA and ligation of dorsal venous plexus. Such a suture is more convenient for the surgeon than interrupted suture and makes LRP more proficient and efficient, allowing to reduce the time of procedure, the duration of catheterization, postoperative complications rate associated with anastomotic leak, and also to lower frequency of stress urinary incontinence and obstruction of VUA. This technique may reduce the period necessary for mastering LRP. "Free-tie" VUA is a safer and more effective technique compared to interrupted suture technique during learning curve of LRP. According to our work, this technique allows surgeons with insufficient suturing experience to easily overcome the steep training curve.

Comparison Study Between Laparoscopic Radical Prostatectomy versus Robotic Radical Prostatectomy in Patient with TUR-P History

Background: The number of men with benign prostate hyperplasia undergoing transurethral resection of prostate (TURP) with the subsequent development of prostate cancer has been increasing. This study aimed to compare the surgical, oncological, and functional outcomes of robotic and laparoscopic radical prostatectomy techniques in patients with the history of TURP.Methods: Literature search of electronic databases was performed through Pubmed, Science Direct, SCOPUS, and CENTRAL databases. Cochrane Risk of Bias Tool was then employed to assess the risk of bias in each study. Grey literature was also searched from sources such as Cancer Care Ontario and conference abstracts. Critical appraisals of included studies were conducted using the Newcastle-Ottawa Scale.Results: The searches located 1258 citations, but only 11 studies were included in the final selection. Most studies had a good methodological quality based on the Ottawa Scale. The mean age of samples was varied among each study from 61.8 to 70.8 years. The TURP history significantly affects biochemical recurrences (OR 2.29, 95% CI 1.14–4.59), intraoperative blood loss (MD 57 ml; 95% CI 6–108 m), prolonged operative duration (MD 20 minutes; 95% CI 3–37 minutes), and surgical complications (OR 2.54, 95% CI 1.79–3.60) following radical prostatectomy for prostate cancer. In the subgroup analysis, only prolonged operative duration and surgical complications were significant both in laparoscopic and robotic radical prostatectomy. There was no association between the TURP history and the positive surgical margin rate in total and subgroup analyses. Conclusions: The previous TURP history affects the outcomes of patients who underwent radical prostatectomy, either laparoscopic or robotic.

Comparison of surgical, oncological, and functional outcomes of robot-assisted and laparoscopic radical prostatectomy in patients with prostate cancer.

To compare the oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP). We compared patients who underwent the RARP (n=778) and LRP (n=48) techniques for prostate cancer between January 2008 and July 2017 in our clinic. Patient demographics, preoperative and postoperative data, pathologic evaluation, continence, and potency rates were collected and analyzed retrospectively. The preoperative and demographic data of the patients we included in our study were similar. The mean operation time estimated blood loss, length of hospitalization, and catheterization time were significantly shorter in the RARP group. The statistical analysis was in favor of robotic prostatectomy in the terms of the mean length of hospitalization, catheterization time, and early (<30 days) and intermediate (31-90 days) complications. Positive surgical margins and biochemical recurrence rates, and recovery of continence and erectile function, were similar in both groups. RARP and LRP in organ-confined prostate cancer are safe and effective methods. Robotic prostatectomy has a shorter operative time, length of hospitalization, catheterization time, and lower early and late complication rates.

Application and Efficacy of Pubovesical Complex Preserving Technique During Laparoscopic Radical Prostatectomy

Urinary incontinence and Erectile function are two hot issues after radical prostatectomy. This study aims to explore the application and curative effect of “pubovesical complex preserving technique for intrafascial laparoscopic radical prostatectomy (PPLRP)”. Methods: This was a retrospective study of 200 patients who underwent laparoscopic radical prostatectomy (LRP) from January 2011 to May 2018. Results: During the study period, we collected 68 patients with PPLRP in group A, 46 patients with conventional intrafascial LRP in group B and 86 patients with interfascial LRP in group C, respectively. Three groups had no difference in terms of Preoperative age, Clinical stage, Prostate-specific antigen (PSA) value, Gleason score at biopsy and Preoperative good potency (IIEF-5 score) (P>0.05). There was no difference between the three groups in terms of operative time, intraoperative blood loss, time of catheter retain, postoperative stay and histologic status. All groups had similar PSM (positive surgical margin, PSM) rate. Continence rates at immediately after catheter removal, 1,3 and 6 months: 68% (46/68),85% (58/68),93% (63/68) and 100% (68/68) in group A; and 63% (29/46),80% (37/46),89% (41/46) and 96% (44/46) in group B; and 22% (19/63),49% (42/63),72% (62/63) and 84% (72/63) in group C. Regarding sexual function: No differences were found in the three groups in potency (IIEF-5 score). Baseline IIEF-score reached 50%,35% and 21% respectively at postoperative 6 months. Biochemical recurrence-free survival at 3 years was 79.3%,76.3% and 76.4% in A, B and C group, respectively. Conclusions: The PVC preserving technique for LRP provides early recovery from incontinence, faster recovery of sexual function preoperative levels. There is no adverse effect on the oncological outcome in the selective prostate cancer. It is an ideal way of nerve-sparing LRP.

Application of pubovesical complex preserving technique during laparoscopic radical prostatectomy

Objective To describe a novel pubovesical complex preserving technique for laparoscopic radical prostatectomy and to evaluate its postoperative outcomes. Methods From January 2011 to May 2017, 168 patients who underwent laparoscopic radical prostatectomy were enrolled and analyzed retrospectively. Their mean age were 62.8 (46-74) years, preoperative PSA 11.3ng/ml, Gleason score 6.7, preoperative prostate volume 46.5 ml. They all got preoperative potency (IIEF-5 score ≥15 score). TNM clinical stage: cT1 123 cases, 45 cases cT2. There were 59 patients with pubovesical complex preserving technique for laparoscopic radical prostatectomy(group A): without pelvic fascia cut and deep vein complex suture. The preservation of the periprostatic anatomy was kept by preserving the pubovesical complex, including detrusor apron with pubovesical ligaments, DVC and NVB. There were 46 patients with conventional intrafascial laparoscopic radical prostatectomy(group B) and 63 patients with interfascial laparoscopic radical prostatectomy(group C). No differences were found between the three groups in terms of preoperative age, clinical staging, prostate-specific antigen (PSA) values, Gleason score at biopsy and preoperative good potency (IIEF-5 score)(P>0.05). Continence was defined as zero to one security pad per day. The three groups were compared for perioperative variables, PSM(positive surgical margin, PSM)rate, postoperative urinary continence functional and potency (IIEF-5 score). Biochemical recurrence-free survival was by Kaplan-Meier and log-rank. Results No differences were found in the three groups in terms of operative times, blood loss, catheterization time and postoperative stay and histologic status (PSM was similar to that of the groups (8.5% in group A, 13.0% in group B vs. 11.1% in group C). Urinary incontinence: group A, the continence rate was 71%, 82%, 92% and 100% at 1, 3 and 6 months after catheter removal, respectively; group B, the continence rate was 63%, 80%, 89% and 96% respectively; group C, it was 24%, 54%, 79% and 86% respectively. The group A showed a significantly earlier recovery from incontinence compared with that in the group C at immediately after catheter removal and 1 month after catheter remove(χ2=27.47, P 0.05). Regarding sexual function, at the postoperative 1, 3, 6 months, median IIEF-score was 10, 11, 16 in the group A, respectively, 8, 9, 13 in the group B respectively, and 7, 8, 12 in the group C respectively. No differences were found in the three groups in potency (IIEF-5 score). Baseline IIEF-score was reached by 53%, 35% and 21% at postoperative 6 months. There were significant differences between the A and the C groups.(χ2=13.45, P 0.05). Follow-up was 31.6(6-69) months. Biochemical recurrence-free survival at 3 years was 79.3%, 76.3% and 76.4% by A, B and C group, respectively. Conclusions The pubovesical complex preserving technique for laparoscopic radical prostatectomy provides early recovery from incontinence, faster recovery of sexual function preoperative levels. Key words: Laparoscopic surgery; Prostate cancer; Sexual function; Urinary incontinence

Laparoscopic radical prostatectomy in 2018: 20 years of worldwide experiences, experimentations, researches and refinements.

After the first feasibility report in 1997, a growing interest has risen in the urologic community for laparoscopic radical prostatectomy (LRP) and several authors have contributed to the evolution of the technique. We attempt a review of the available evidences and provide a broad framework of different technical refinements considering their impact on pentafecta. The PubMed/Medline database was searched. Duplicates and "Expert opinion" papers were removed. Studies were included according to the aim of the present paper to present a selected review on LRP and report our personal experience. In 1999 Guillonneau et al. codified their transperitoneal-posterior-antegrade technique for LRP. Since then, several modifications of the transperitoneal approach were published and the extraperitoneal route was also proposed. Sparing the bladder neck and reconstructing the posterior muscolofascial plate were proven to improve continence rate. Nerve-sparing LRP were performed in order to maximize postoperative recovery of the sexual function. Novel techniques to ligate the Santorini plexus and sew the urethrovesical anastomosis provided improvement in operative time, intraoperative blood loss and reduced the incidence of postoperative urinary-leakages. In the recent years, the single-site approach as pushed the limits of LRP and three-dimensional (3D) systems for endoscopic surgery were developed. Thanks to several technical improvements, LRP provides brilliant oncologic and functional outcomes and it is now considered the treatment of choice in many institutions worldwide. Although it is a technically demanding procedure, the recent introduction of 3D systems will reduce the steepness of its learning curve.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy.

ABSTRACTIntroduction:This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP.Patients and Methods:110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used.Results:The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad).Conclusions:The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

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.

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

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

Continuous suture of a single absorbable suture: a new simplified vesicourethral anastomosis technique in laparoscopic radical prostatectomy.

The purpose of this study was to describe a new simplified technique for facilitating vesicourethral anastomosis in laparoscopic radical prostatectomy. After prostate removal, an approximately 15-cm-long absorbable suture with one three-eighths arc needle is passed from the outside in on the full thickness of the bladder neck at the 9 o'clock position and then from inside out on the full thickness of the urethra at the 9 o'clock position. It is knotted with the suture tail. Subsequently, a continuous suture is completed between the bladder neck and urethra. A 20-French silastic catheter is placed into the bladder before completing the anterior row of sutures. Three hundred twelve consecutive patients with localized prostate cancer who had undergone the new simplified vesicourethral anastomosis were included in this retrospective study. The average time of anastomosis was 10.5 minutes (range, 8-30 minutes), as recorded for an experienced laparoscopic surgeon. The incidence rate was 2.2% for urine leakage and 1.3% for bladder neck stenosis, and the continence rate was 86.9% at 1 month, 93.3% at 3 months, 98.1% at 6 months, and 98.7% at 1 year. We present a new simplified method for vesicourethral anastomosis. The method takes little operating time and is easy for novice laparoscopists to master. Moreover, this technique has low rates of urinary leakage and bladder neck stricture.

Impact of a Low-Volume Laparoscopic Radical Prostatectomy Learning Curve on Perioperative Outcomes: Is It Acceptable?

The reproducibility of high-volume published series of laparoscopic radical prostatectomy (LRP) is still debatable. Many questions about its implementation, safety, and number of procedures required to achieve competence and improvement of outcomes with the technique remain unclear, and a learning curve study is crucial to investigate the acceptable performance of this advanced, minimally invasive procedure. Between 2004 and 2011, 240 consecutive patients underwent an LRP performed by a single surgeon and were divided into the first, second, and third groups of 80 patients each. Perioperative and oncologic outcomes were compared across the groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). Mean (range) patient age was 61 (43-78) years. The mean (range) level of prostate-specific antigen was 6.47 (3-18) ng/mL. The mean (range) Gleason sum was 6 (5-9). There was a significant reduction in the mean operative time (P<.001), mean anastomosis time (P<.001), mean blood loss (P<.001), mean hospital stay (P<.001), and mean minor CDS complications (P<.01) among the three groups as the series progressed. The D'Amico tumor stage was an independent factor for positive surgical margin across the learning curve (P<.001). Our study demonstrated safety and low morbidity of the LRP technique since the beginning of a learning curve development, in which up to 80 cases were necessary to create a plateau to improve faster perioperative parameters, although, from the plateau created, it requires a very large number of surgeries for slightly better, additional overall benefits. In spite of its complexity and steep learning curve, new surgeons can be encouraged in the LRP technique with mentorship training without compromising overall outcomes, permitting the wide spread of an alternative minimally invasive procedure in low-volume centers.

IJU this issue

This issue covers a variety of practical and experimental topics, and contains one Review Article, eight Original Articles, two Short Communications, one Case Report and two Letters to the Editor. Regarding the trend of increasing interest in reduced port surgery, a timely Review Article on natural orifice transluminal endoscopic surgery (NOTES) in urological surgery by Izquierdo et al. (Barcelona, Spain) appears first. NOTES, which was first used in the early 2000s, utilizes one or more patent natural orifices of the body, and can be considered a natural evolution of laparoscopy towards the ideal of scarless surgery. The authors conclude with an assessment of the current situation, which is that pure NOTES is not yet feasible, mainly because of a lack of the surgical tools especially designed for this approach. They also state that the so-called hybrid approach is an available technique, in which a natural orifice approach is combined with the use of one or more abdominal trocars, using the natural orifice as the exit door for the specimen removal. In addition to this comprehensive review, four papers describe challenging practical topics associated with the operative management of urological cancers. An important current problem is how to select the most suitable surgery for patients with renal cell carcinoma, and a high risk of postoperative renal insufficiency is a problem we have to seriously deal with at present. Panumatrassamee et al. (Cleveland, USA) report the results of robot-assisted (n = 15) versus laparoscopic (n = 52) partial nephrectomy in solitary kidney cases. Early comparative outcomes show that the robot-assisted approach offers significant advantages over the laparoscopic approach in terms of operative time (171 vs 225 min, P = 0.02), warm ischemia time (15 vs 19 min, P = 0.04) and hospital stay (3 vs 4 days, P = 0.03). No significant differences were found in terms of estimated blood loss, complications, margin status or median percentage change of renal function. However, an evaluation of the two methods from a cost/benefit viewpoint would need to include factors specific to different countries. Malignant involvement of resected ureters in patients undergoing radical cystectomy for bladder cancer often presents surgical challenges. Thus, it would be beneficial if the risk of malignant ureteral involvement could be clearly estimated before surgery. Gondo et al. (Tokyo, Japan) investigated preoperative predictors of ureteral involvement in bladder malignancy. The predictors, they showed, are tumor location (involvement of vesical trigone), clinical T stage (≥cT3) and the number of tumors (≥3). These results seem worthy of further verification. Early achievement of continence after radical prostatectomy for prostate cancer has been one goal of this type of surgery. Hoshi et al. (Kanagawa, Japan) report that a new dorsal vein complex-preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome. The continence rates when using this new technique versus the conventional technique at 1, 3 and 12 months, were 57% versus 37%, 77% versus 63%, and 95% versus 90%, respectively. This new technique does not, however, offer a significant benefit regarding sexual function. Sunitinib malate, an orally active multi-target tyrosine kinase, is the standard of care for first-line treatment for metastatic renal cell carcinoma, often used in combination with radical or partial nephrectomy, despite associated high rates of various adverse effects. Neri et al. (Florence, Italy) investigate the efficacy and drug-related toxicity of a sunitinib regimen of 50 mg/day 2 weeks on/1 week off, compared with the standard regimen of 50 mg/day 4 weeks on/2 weeks off. They state that this shorter cycle regimen can provide a high response rate while reducing drug-related toxicities. None declared.

Dorsal vein complex preserving technique for intrafascial nerve‐sparing laparoscopic radical prostatectomy

ObjectivesTo describe a novel dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and to evaluate its postoperative outcomes.MethodsA total of 109 patients who underwent laparoscopic radical prostatectomy by a single surgeon were evaluated, including 44 patients with dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy, 20 patients with conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and 45 patients with non-nerve-sparing laparoscopic radical prostatectomy. Functional outcomes were evaluated using a self-administered questionnaire (Expanded Prostate Cancer Index Composite). Continence was defined as zero to one security pad per day. Oncological outcomes were evaluated based on positive surgical margin.ResultsIn the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group, the continence rate was 57%, 77% and 95% at 1, 3 and 12 months, respectively. The continence rate in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy group was 37%, 63% and 90%, and in the non-nerve-sparing laparoscopic radical prostatectomy group it was 23%, 57% and 82% at 1, 3, and 12 months, respectively. The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group showed a significantly earlier recovery from incontinence compared with that in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and non-nerve-sparing laparoscopic radical prostatectomy groups (log–rank test, P = 0.044 and P < 0.001). Similarly, the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group tended to show a more early recovery in relation to urinary function of the Expanded Prostate Cancer Index Composite. Regarding sexual function, there were no significant differences between the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and conventional intrafascial nerve-sparing laparoscopic radical prostatectomy groups. In pT2 patients, the positive surgical margin rate of the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group (11%) was similar to that of the other two groups (conventional intrafascial nerve-sparing laparoscopic radical prostatectomy 7%; non-nerve-sparing laparoscopic radical prostatectomy 11%).ConclusionsThe dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome.

Robot‐assisted or pure laparoscopic nerve‐sparing radical prostatectomy: What is the optimal procedure for the surgical margins? A single center experience

To compare positive surgical margin rates after robot-assisted and pure laparoscopic radical prostatectomy when neurovascular bundles are preserved, and to identify parameters affecting surgical margin status. From March 2004 to January 2009, 279 consecutive prostatectomies with preservation of neurovascular bundles were carried out by the same surgeon: 175 robot-assisted radical prostatectomies and 104 laparoscopic radical prostatectomies. An intraperitoneal Montsouris's technique was used for all cases. Patient's age, body mass index, prostate weight, prostate-specific antigen level, clinical stage, preoperative and postoperative Gleason score, percentage of positive biopsies, pathological stage, and positive surgical margin status were prospectively recorded in an institutional database. The two groups were retrospectively analyzed and compared. Positive surgical margin rates were 17% and 13% for the robot-assisted radical prostatectomy and laparoscopic radical prostatectomy group (P = 0.4), respectively. At multivariable analysis, only prostate-specific antigen level and prostate weight significantly affected the surgical margin status, where the type of procedure (robotic vs laparoscopic) did not have any effect. In our single-surgeon experience, prostate-specific antigen levels and prostate weight are predictive of positive surgical margin in patients undergoing nerve-sparing radical prostatectomy, whereas there seems to be no difference between the robot-assisted radical prostatectomy and the laparoscopic radical prostatectomy techniques.

UP-02.047 Experience with Single One-Centimeter Port Laparoscopic Radical Prostatectomy

Laparoscopic and robotic prostatectomy is traditionally performed using 2-3 larger 1cm ports and few 5mm ports. We have developed a technique for laparoscopic radical prostatectomy using a single 1cm port and few 5mm ports.