675 A minimally invasive open surgical approach to prostate cancer: Minimal incision open radical prostatectomy

P37

LOCALIZED PROSTATECANCER Saturday, 27 March,13.30-15.00, Hall BI Red level 672 GENERAL VS. SPINAL ANAESTHESIA WITH DIFFERENT TYPES OF SEDATION IN PATIENTS UNDERGOING RADICAL RETROPUBIC PROSTATECTOMY: RESULTS OF A PROSPECTIVE RANDOMIZED TRIAL

POSTOPERATIVE CONTINUOUS

PAIN EPIDURAL

Mtiller

D., Frohneberg

Salonia A.‘, Suardi N.‘. Crescenti A.‘, Zanni G.‘, Bertml R.‘, Bocciardi Da Porro L.‘, Di Girolamo V.‘, Roscigno M.‘, Rlgatti P.‘, Montorsi F.’

Klinikum

A.M ‘, Colombo

R.‘,

‘Scientitic Institute II. San Raffaele, Department of Urology, Milan, Italy, ‘Scientific Institute H. San Raffaele, Department ofAnaesthesiology, Milan, Italy INTRODUCTION & OBJECTIVES: Aim of this randomized prospectwe study was to evaluate the impact of general (GA) versus spinal anaesthesia (SPA), performed with 3 types of sedation techniques, on intra- and post-operative outcome in pts undergoing radical retropubic prostatectomy (RRP) for clinical localized prostate cancer (pCa). MATERIAL & METHODS: One-hundred-twenty-one consecutive both age-matched (KmskalWallis analysis: p=O.O7; DF=3) and ASA physical status matched for(K-W p=O.69; DF=3) pts with pCa underwent a RRP and were randomly subdivided into Group I (GA: 34 pts; mean age+/-SE: 66+/-l .2 y’s), Group 2 (L2-L3 SpA with diazepam for the sedation: 28 pts; 65.3+/-1.32 yrs). Group 3 (L2-L3 SpA with propofol: 30 pts; 59.5+/-1.9 yrs) and Group 4 (L2-L3 SpA with midarolam: 29 pts; 64.1+1-1.5 yrs) and intra-op and post-op outcome parameters were subsequently evaluated. Data are presented as mean +/- standard error of the mean (SE). Statistical analysis was based on the Kmskal-Wallis test (K-W), the ANOVA one-way analysts of variance for multiple comparison and the Student-Newman-Keuls test (SNK). RESULTS: K-W analysis. Abdominal and pelvic muscle relaxation throughout the surgery (scale from I: bad muscle relaxation to 4: excellent muscle relaxation) was not significantly different (p=O.68; DF=2) among the 4 groups. Overall blood loss (p=O.22; DF=3) as well as homologous blood transfusion (p=O.O9; DF=3) and autologous blood transfusion (p=O.38; DF=3) were not significantly different among the 4 groups. Post-op SpO2(9/)0 was significantly better in Group 3 than in Group 4 > Group 2 > Group 1 (p=O.O2; DF=3; ANOVA: p=O.O07; F-ratlo=4.3). Post-op sedation score (SS: O-3) was significantly lower in Group 4 than in Group 2 > Group 3 > Group I (p Group 2 > Group 1 (p Group 1 > Group 2 (p=O.O004; DF=3; ANOVA: p=O.O04; F-ratlo=4.8). Pain on day-l after surgery was significantly lower in Group 3 than in Group 2 > Group I > Group 4 (p=O.O07; DF=3; ANOVA: p=O.O09; F-ratio=4l).Durmg day-l post-op flatus passage as well as overall mobilization and gait for at least 30 minutes was possible m a significantly higher amount ofpts in Group 4 than in Group 2 > Group 3 > Group 1 (p=O.OOOl; DF=3; ANOVA: p
673

E., Echtle Karlsruhe,

Department

MANAGEMENT: DRUG APPLICATION

PULSATILE

VERSUS

D of Urology,

Karlsruhe,

Germany

INTRODUCTION & OBJECTIVES: An epidural catheter is to be given preference over the systemic application of analgetics. The aim of our study was to compare the effectiveness of pulsatile versus continuous drug administration. The latter kind of application was supposed to offer a better pain control without complications of the central nervous system. MATERIAL & METHODS: Until May 2000 all patients (n=1,199) post radical prostatectomy were treated with buprenorphine (0.3 mg) and carbostesine (0.5 mg) given every 4 hours (pulsatile) for the first 4 days. Starting in June, 119 consecutive patients underwent continuous pain therapy using sufentanil (251.18) and ropivacaine (100 mg). Mean application time was 3.5 days. Efficacy was measured using the visual analogue scale (VAS). Adverse effects were classified by Bromage score (paralysis) and documented by neurological examination (paresthesia). RESULTS: In all patients postoperative pain therapy was effective (VAS = 30 [O901). Dose titration was necessary 6 times (2-10). Additional systemic application of analgetics was necessary in 8 l/l 19 (68%) patients, and in all cases opioids were administered at least once a day. 711119 (60%) patients showed paresthesias and 52/l 19 (44%) paralysis of the lower extremities. The Bromage score was rated 1.5 (l-3). Three of the latter group needed MRI to exclude the possibility of an epidural haematoma. The historical cohort was pain-free and showed adverse effects in 17%. The Bromage score of this group was 0.7 (l-2). 32% of the patients needed additional systemic analgetics. In both cohorts all neurogenic defects were completely reversible after the removal of the epidural catheter. Both therapies cost about 24 euros per day. CONCLUSIONS: Both epidural regimens are suitable to treat postoperative pain, However, continuous application seems to be less potent due to an increased rate of additional systemic analgetics. A significant difference was noted in adverse effects, mainly paresthesia. In total, the pulsatile application seems to be more advantageous.

674 PFANNENSTIEL RADICAL ANAESTHESIA: PROSPECTIVE

VS. MEDIAN RETROPUBIC PRELIMINARY TRIAL

INCISION IN PATIENTS UNDERGOING PROSTATECTOMY WITH SPINAL RESULTS OF A RANDOMIZED

675 A MINIMALLY INVASIVE OPEN MINIMAL PROSTATE CANCER: PROSTATECTOMY Guaglianone

Saionia A.‘, Suardi N.‘, Crescenti Montorsi F.’

A.‘, Zanni

‘Scientific Institute H. San Raffaele, Department H. San Raffaele, Department of Anaesthesiology,

G.‘, Scattoni

V.‘, Guaazom

G.‘, Rigatti

S., Leonardo

C., Mattace Raso D., Forastiere

APPROACH TO OPEN RADICAL

E.; Pompeo V., Gallucc~ M

P.‘, Regina Elena Cancer Institute, Department

of Urology, Milan, Italy; 2Scientific Milan, Italy

SURGICAL INCISION

Institute

INTRODUCTION & OBJECTIVES: The aim of the study was to evaluate both the intraoperative and the post-operative outcome parameters in patients (pts) undergoing radical retropubic prostatectomy (RRP) with a standard laparotomic median incision vs. a Pfannenstiel transverse supra-pubic m&ion. ,MATERIAL & METHODS: Forty-eight consecutive pts with clinically localized prostate cancer (pCa) underwent a RRP performed under LZ-L3 spinal anaesthesia by a single experienced surgeon and were enrolled in this still-ongoing randomized prospective study. Patients were subdivided into Group 1 (median incision): 24 pts (mean age+/-SE: 66.2+/-1.4 yrs) and Group 2 (Pfannenstiel incision): 24 pts (62.3+/-l .5 yrs; p=O.O6) comparable both in terms ofASA physical status (1.X2+/-0.10 vs. 1.60+/-0.10; ~~0.13) and BMI (25.7+/-0.5 vs. 24.X+/-0.6; p=O.24) and i&a-op as well post-op outcome parameters were subsequently evaluated. Statistical analysis was performed by means of Student’s T test for paired data. RESULTS: Group 1 vs. Group 2 parameters (mean+/-SE): length of the incision measured at the end of the procedure (cm): 11.5+/-0.6 vs. ll.O+/-0.3; p=0.6; surgical time (minutes): 112.6+1-5.7 vs. 107.1+/-4.8; p=O.5. Overall blood loss (mL) was not significantly different between the two groups (namely, 1277.1+/-159 vs. 1087.1+/-67; p=O.27). Intra-op homologous blood transfusion (mL): 260.9+/-54 vs. 237.1+/-42; p=O.7. Intra-op autologous blood transfusion (mL): 146.4+/-74.7 vs. 67.5+/-29.3; p=0.3.Post-op SpO2 (%): 97.9+/-0.6 vs. 98.2+/-0.4; p=O.72. Pain outcome: S-minute post-op pain (Visual Analogic Scale l-10): l.l+/-0,3 vs. 1.3+/-0,3: p=O.72. 3-hour post-op pain: 3.3+/-0.4 vs. 3.4+/-0.3; p=O.84. 24.hour post-op pain: 2.5+/-0.2 vs. 2.X+/-0.3; p=O.45. Post-op sedation score (SS: O-3): 1.13+/-0.1 vs. O.l+/-0.04; p=O.41. Post-op time in recovery room (minutes): 14.7+/-I.1 vs. 25.0+/-4.5; p=O.O6. No significant difference in day-l post-op first flatus passage (p=O.51) as well as in overall mobilization and gait for at least 30 minutes (p=O.49) was found between the two groups. Similarly, a non significant difference was also found regarding the overall number of surgical lymphonodes obtained during bilateral pelvic lymphadenectomy (p=O.93) as well as the number of patients with surgical positive margins (p=O.37) or the average number of days for the indwelling catheter removal (p=O.63). CONCLUSIONS: These preliminary results suggest that a Pfannenstiel transverse sovrapubic incision can represent a valid option in pts undergoing a RRP with L2-L3 SpA for clinically localized pCa when a standard laparotomic median incision cannot be performed.

of Urology,

Rome, Italy

INTRODUCTION & OBJECTIVES: In the last decade laparoscopic radical prostatectomy has been performed in an attempt to apply the minimally invasive techniques’ advantages to prostate cancer surgery. Still there is some concern about the real value of this approach as a gold-standard treatment. since its benefits are not clearly proved. In order to emphasise the predominant role of open surgery in the treatment of prostate cancer, we present a new open surgical approach that seems to encompass all the profits of laparoscopic radical prostate&my so far described in literature. -MATERIAL & METHODS: 404 patients affected by surgically treatable prostate cancer were treated with minimal incision open radical prostatectomy from February 2000 to May 2003. Technical procedure: high-dose and active mio-relaxants were administered to reach a maximum level of abdominal muscle relaxation. A 5-6 cm minimally extended midline incision was performed starting from the pubic symphisis almost to the middle point of puboumbelical line. The main surgical steps are already described by Walsh. Our changes were introduced to amplify the deep operative space since our minimal incision was incompatible with the application of traditional Walsh’s technique. The variants consisted of: 1. use of a 60 cm long mobile valve flexible tipped that allows gaining maximum space and depth while approaching pelvic fascia and preparing prostate apex. Infect, valve tip’s flexibility adapts a perfect contact with surrounding retracted tissues sticking the valve surface to visceral planes variable formed. 2. A mounted tampon is used to retract bladder-prostate complex while dissecting pelvic fascia and prostate apex, as described by Walsh, but we force extremely our push on the tampon to reach a considerable tissue stretching and dislocation widening the deep operative space and advantaging deep tissue bulging, such as urethra and its prostate junction. Combination of these two tricks can balance incision shortness and surgeons gain an outstanding visibility compmable to laparoscopic one. RESULTS: There were 3 perioperative deaths: 1 for pulmonary embolism and 2 for acute myocardial infarction. Mean operative time was 60 (range 45-88); mean blood loss was 450 cc (range 200-800); mean hospital stay was 4 days (range 2-6); mean indwelling catheter stay was 12 days (range 8.14); Impotence rate was about 70% and incontinence rate was about 2%. CONCLUSIONS: This new minimal incision open approach based on simple anaesthesiological, instmmental and spatial contributions seems to overcome laparoscopic approach in terms of benefits so far described in literature. So we believe to exclude laparoscopy as a routinely surgery in prostate cancer. especially since the costs don’t return the benefits compared to this new open approach.

European

Urology

Supplements

3 (2004)

No. 2, pp. 171