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Non-narcotic robotic radical prostatectomy
S100
Uurological/Reproductive Surgery
cated to one of five deprivation categories using postcode at diagnosis. Regression trend analysis at one and five years was performed and p value derived from t-test statistic. RESULTS: In mid-80s, incidence rate ratio in affluent:deprived classes was 0.9 with age standardised rates (ASR) of 35.23 and 39.53/ 100,000. The ratio has increased to 1.5 by 2000 with ASR of 95.98 and 63.13 respectively (172% increase in affluent compared to 60% in deprived). The affluent groups had 7% and 13% survival advantages at 1 and 5 years which were statistically significant (p ⫽ 0.03 and 0.001). 130 deaths would have been avoided between 19891994 if deprived groups had rates similar to their affluent counterparts. CONCLUSIONS: The preferential changes in incidence and survival in the affluent social classes are likely due to heightened awareness resulting in increased PSA tests capturing early, relatively slow growing tumours with better overall prognosis. If these bipolar trends are allowed to persist, then the gap between the affluent and deprived will continue to widen.
Initial incision of the lateral pelvic fascia (LPF), development of a “perirectal pocket,” and ligation of the lateral pedicles in reducing positive margins (PM) during radical prostatectomy (RP) Sean McLaughlin MD, Marc Richman MD, Raj Pruthi MD, FACS The University of North carolina at Chapel Hill Chapel Hill, NC INTRODUCTION: Stephenson and Klein have reported reduced PM rates with modification of RP technique involving early incision of LPF and early release of the prostate off the rectum. We report our experience with this technique with additional modification of early ligation of lateral vascular pedicles during RP. METHODS: 100 patients underwent RP by single-surgeon for clinically-localized disease. Initial dissection involved early incision of LPF and development of the prostate-rectal plane prior to apical/ urethral dissection. This incision is medial to neurovascular bundles (NVB) in a nerve-sparing procedure. After this plane is developed, the prostatic vascular pedicles are divided. Once these maneuvers are also performed contralaterally, the prostate is lifted off the rectum, and gland held in place only by apex and bladder neck. The apical/ urethral dissection is then carried out, followed by dissection/ transection of seminal vesicles and bladder neck. RESULTS: Pt characteristics include mean age (61), PSA (8.9), and EBL (502cc). Pathologic stage included T2a (11%), T2b (69%), T3a (17%), T3b (3%), N⫹ (2%). 20 pts had capsular penetration (CP), at posteriolateral (15) and anterior (5) prostate. Overall PM rate was 13%. Location of PM included apex (10), base (2), and posteriolateral (1): No pt had a PM at site of CP. When stratified based on low (pT2, Gleason ⬍ 7), moderate (pT2, Gleason ⫽ 7), and high (pT3 or Gleason ⬎ 7) risk, PM rates were 2.5%, 13.9%, 29.2%, respectively. Reduction in PM and EBL was not associated with increased morbidity (continence, potency).
J Am Coll Surg
CONCLUSIONS: Early incision of LPF, development of a “perirectal pocket,” and ligation of pedicles, results in low PM rate. Early development of the pre-rectal fat plane may allow for more precise dissection below all layers of Denonvilliers fascia and wider tissue margin.
Non-narcotic robotic radical prostatectomy Vipul Patel MD Urology Centers of Alabama Vestavia Hills, AL INTRODUCTION: Open radical prostatectomy has traditionally been associated with significant bleeding requiring blood transfusion. The patients often have pain requiring nacotics. Recovery is usually over 4 weeks. Using the davinci robot and the on-q pain management system we are now able to perform prostatectomy without significant blood loss, transfusion or the use of narcotics. METHODS: 100 patients underwent robotic prostatectomy. The patients were not typed for blood, no cell saver was used. The prostate was removed laparoscopically. The on-q pain pump leads were placed subcutaneously over the trocar sites. The pump was filled with 300cc of 0.5 % marcaine (infusion 2cc/hr). No narcotics were ordered post-operatively, only toradol 30mg iv q 8hours. The patients were discharged home on day 1 with the on-q pump for 48 hrs along with a prescription for hydrocodone 5mg. RESULTS: Robotic prostatectomy was successful in all patients. Ebl was 37.5cc. No transfusions or narcotics were required during their hospital stay. 90% of the patients took no narcotics after dischage, the other 10% averaged 1.2 tabs for the entire post operative course. Hospital stay was one day and recovery a total of 1 week. CONCLUSIONS: Robotic radical prostatectomy provides a minimally invasive treatment for prostate cancer. There is minimal blood loss approximately 1/20th that of the open approach. The use of the on-q pump allows the majority of patients to completely avoid the use of narcotics.
A phase II trial of celecoxib in PSA recurrent prostate cancer after definitive radiation therapy (XRT) or radical prostatectomy (RP) Eric Derksen MD, Eric Wallen MD, FACS, Raj Pruthi MD, FACS The University of North carolina at Chapel Hill Chapel Hill, NC INTRODUCTION: COX-2 inhibitors may have anti-neoplastic effects in a variety of tumor types including prostate cancer. We evaluated the efficacy of celecoxib in PSA-recurrent prostate cancer after XRT or RP. METHODS: 24 patients with rising PSA after XRT (n ⫽ 4) or RP (n ⫽ 20) were treated with celecoxib 400 mg/day (n ⫽ 12) or 800 mg/day (n ⫽ 12) (bid dosing). PSA levels were obtained at 3, 6, and 12 months after initiation of treatment. Data was evaluated by calculating 1) PSA doubling times (PSADT) and 2) slope of logPSA vs. time before and after celecoxib treatment at each time point. Testosterone levels were also obtained.
Uurological/Reproductive Surgery
cated to one of five deprivation categories using postcode at diagnosis. Regression trend analysis at one and five years was performed and p value derived from t-test statistic. RESULTS: In mid-80s, incidence rate ratio in affluent:deprived classes was 0.9 with age standardised rates (ASR) of 35.23 and 39.53/ 100,000. The ratio has increased to 1.5 by 2000 with ASR of 95.98 and 63.13 respectively (172% increase in affluent compared to 60% in deprived). The affluent groups had 7% and 13% survival advantages at 1 and 5 years which were statistically significant (p ⫽ 0.03 and 0.001). 130 deaths would have been avoided between 19891994 if deprived groups had rates similar to their affluent counterparts. CONCLUSIONS: The preferential changes in incidence and survival in the affluent social classes are likely due to heightened awareness resulting in increased PSA tests capturing early, relatively slow growing tumours with better overall prognosis. If these bipolar trends are allowed to persist, then the gap between the affluent and deprived will continue to widen.
Initial incision of the lateral pelvic fascia (LPF), development of a “perirectal pocket,” and ligation of the lateral pedicles in reducing positive margins (PM) during radical prostatectomy (RP) Sean McLaughlin MD, Marc Richman MD, Raj Pruthi MD, FACS The University of North carolina at Chapel Hill Chapel Hill, NC INTRODUCTION: Stephenson and Klein have reported reduced PM rates with modification of RP technique involving early incision of LPF and early release of the prostate off the rectum. We report our experience with this technique with additional modification of early ligation of lateral vascular pedicles during RP. METHODS: 100 patients underwent RP by single-surgeon for clinically-localized disease. Initial dissection involved early incision of LPF and development of the prostate-rectal plane prior to apical/ urethral dissection. This incision is medial to neurovascular bundles (NVB) in a nerve-sparing procedure. After this plane is developed, the prostatic vascular pedicles are divided. Once these maneuvers are also performed contralaterally, the prostate is lifted off the rectum, and gland held in place only by apex and bladder neck. The apical/ urethral dissection is then carried out, followed by dissection/ transection of seminal vesicles and bladder neck. RESULTS: Pt characteristics include mean age (61), PSA (8.9), and EBL (502cc). Pathologic stage included T2a (11%), T2b (69%), T3a (17%), T3b (3%), N⫹ (2%). 20 pts had capsular penetration (CP), at posteriolateral (15) and anterior (5) prostate. Overall PM rate was 13%. Location of PM included apex (10), base (2), and posteriolateral (1): No pt had a PM at site of CP. When stratified based on low (pT2, Gleason ⬍ 7), moderate (pT2, Gleason ⫽ 7), and high (pT3 or Gleason ⬎ 7) risk, PM rates were 2.5%, 13.9%, 29.2%, respectively. Reduction in PM and EBL was not associated with increased morbidity (continence, potency).
J Am Coll Surg
CONCLUSIONS: Early incision of LPF, development of a “perirectal pocket,” and ligation of pedicles, results in low PM rate. Early development of the pre-rectal fat plane may allow for more precise dissection below all layers of Denonvilliers fascia and wider tissue margin.
Non-narcotic robotic radical prostatectomy Vipul Patel MD Urology Centers of Alabama Vestavia Hills, AL INTRODUCTION: Open radical prostatectomy has traditionally been associated with significant bleeding requiring blood transfusion. The patients often have pain requiring nacotics. Recovery is usually over 4 weeks. Using the davinci robot and the on-q pain management system we are now able to perform prostatectomy without significant blood loss, transfusion or the use of narcotics. METHODS: 100 patients underwent robotic prostatectomy. The patients were not typed for blood, no cell saver was used. The prostate was removed laparoscopically. The on-q pain pump leads were placed subcutaneously over the trocar sites. The pump was filled with 300cc of 0.5 % marcaine (infusion 2cc/hr). No narcotics were ordered post-operatively, only toradol 30mg iv q 8hours. The patients were discharged home on day 1 with the on-q pump for 48 hrs along with a prescription for hydrocodone 5mg. RESULTS: Robotic prostatectomy was successful in all patients. Ebl was 37.5cc. No transfusions or narcotics were required during their hospital stay. 90% of the patients took no narcotics after dischage, the other 10% averaged 1.2 tabs for the entire post operative course. Hospital stay was one day and recovery a total of 1 week. CONCLUSIONS: Robotic radical prostatectomy provides a minimally invasive treatment for prostate cancer. There is minimal blood loss approximately 1/20th that of the open approach. The use of the on-q pump allows the majority of patients to completely avoid the use of narcotics.
A phase II trial of celecoxib in PSA recurrent prostate cancer after definitive radiation therapy (XRT) or radical prostatectomy (RP) Eric Derksen MD, Eric Wallen MD, FACS, Raj Pruthi MD, FACS The University of North carolina at Chapel Hill Chapel Hill, NC INTRODUCTION: COX-2 inhibitors may have anti-neoplastic effects in a variety of tumor types including prostate cancer. We evaluated the efficacy of celecoxib in PSA-recurrent prostate cancer after XRT or RP. METHODS: 24 patients with rising PSA after XRT (n ⫽ 4) or RP (n ⫽ 20) were treated with celecoxib 400 mg/day (n ⫽ 12) or 800 mg/day (n ⫽ 12) (bid dosing). PSA levels were obtained at 3, 6, and 12 months after initiation of treatment. Data was evaluated by calculating 1) PSA doubling times (PSADT) and 2) slope of logPSA vs. time before and after celecoxib treatment at each time point. Testosterone levels were also obtained.