453 IMPLICATIONS OF LAPAROSCOPIC INGUINAL HERNIA REPAIR ON OPEN, LAPAROSCOPIC AND ROBOTIC RADICAL PROSTATECTOMY

21.8ml; 12m: 19.2ml vs. 20.2ml). However, the relative volume reduction was still significantly lower in the LV-Group at 6 weeks (32% vs. 39%, p<0.001), 6 months (37% vs. 49%, p<0.001) and 12 months (38% vs. 48%, p=0.02). An increase of volume reduction between catheter removal and 12 months measurement was detectable in both groups but significantly higher after LV (p= 0.02). Subjective and objective outcome parameters improved significantly in both groups and were comparable between the groups after 6 weeks, 6 and 12 months. Conclusions: 120W LBO-LV is an efficient procedure for prostatic de-obstruction evidenced by an absolute tissue ablation not significantly different to that after TURP. However, TURP seems to be superior due to a higher ablation in relation to the initial volume. The investigated outcome parameters show that this difference has no clinical impact after a follow-up period up to 12 months. The lower volume reduction measured after catheter removal compared to that measured after 12 months suggests that prostatic swelling occurs early after LV and then decreases subsequently.

Poster Session 38 OUTCOMES IN LAPAROSCOPIC AND ROBOTIC RADICAL PROSTATECTOMY Sunday, 20 March, 12.15-13.45, Hall E2

450

Patterns of biochemical recurrence after robot-assisted radical prostatectomy. Results of patients with a minimum follow-up of 5 years

Suardi N., Willemsen P., Pauwels E., De Wil P., De Naeyer G., Schatteman P., Carpentier P., Mottrie A.M. O.L.V. Clinic, Dept. of Urology, Aalst, Belgium Introduction & Objectives: Robot-assisted radical prostatectomy (RARP) represents a widely used treatment modality for organ-confined (OC) prostate cancer (PCa). Despite the fast diffusion of the technique, no long-term results are available yet for patients treated with RARP. We address the oncological outcomes after RARP in a series of patients with at least 5 years of follow-up. Materials & Methods: Between 2003 and 2005, 184 consecutive patients with OC PCa underwent RARP by two surgeons at a single institution. All patients reached the 5-year follow-up landmark in 2010. Kaplan-Meier and life tables analyses targeted the rates and patterns of overall mortality, cancer-specific mortality and biochemical recurrence (BCR) according to pathological parameters. Cox regression analyses addressed predictors of BCR. Results: Mean and median age were 61.9 and 63 years, respectively. Mean and median PSA were 8.7 and 7.5 ng/ml respectively. At final pathology 117 (62.5%), 56 (30%) and 14 (7.5%) patients had organ confined disease, extracapsular extension (ECE) and seminal vesicle invasion (SVI), respectively. Pathological Gleason score was 2-6, 7 and 8-10 in 111 (60.5%), 53 (29%) and 20 (10.5%), respectively. Positive surgical margin(s) were found in 3 (2.5%) and in 26 (37%) patients with OC and non-OC disease, respectively. Mean and median follow-up were 69.3 and 67.5 months, respectively. Seven patients (3.8%) were lost to follow-up. Five years after surgery, 1 and 10 patients died of either PCa or other causes, respectively. Mean time to BCR was 83.8 months (median not reached). The 3, 5 and 7 years BCRfree survival rates were 91, 84 and 81% respectively. The 5-year BCR-free survival rate was 87 and 68% for patients with negative and positive surgical margins respectively (p<0.001). The 5-year BCR-free survival rate was 90, 84 and 43% for patients with OC disease, ECE and SVI, respectively (p<0.001). The 5-year BCR-free survival rate was 88, 82 and 65% for patients with pathological Gleason score 2-6, 7 and 8-10, respectively (p<0.001). Univariable analyses showed that higher PSA, higher pathological Gleason score and presence of ECE and SVI were significantly associated with BCR. At multivariable analyses, SVI represented the strongest predictor of biochemical recurrence. Conclusions: We report on the longest available follow-up in patients treated with RARP. The oncological outcomes of patients with clinically localized PCa treated with RARP are highly satisfactory. The majority of recurrences are observed within the first 3 years after surgery. PSA level at surgery and pathologically unfavorable characteristics are associated with higher risk of BCR after RARP. Patients with SVI are at the highest risk of BCR.

451

Nomograms to predict biochemical recurrence after robotic-assisted laparoscopic radical prostatectomy

Sooriakumaran P., John M., Srivastava A., El-Douaihy Y., Grover S., Bhagat D., Rajan S., Leung R., Tewari A.K. Weill Cornell Medical College, Dept. of Urology, New York, United States of America Introduction & Objectives: Predictors of biochemical recurrence after roboticassisted laparoscopic radical prostatectomy (RALP) are not well reported in the literature. We wanted to investigate preoperative predictors as well as the influence of nerve sparing and positive surgical margin status on 3-year biochemical

Eur Urol Suppl 2011;10(2):154

recurrence such that potential patients could be adequately counselled about their risk of recurrence before undergoing RALP. Materials & Methods: 774 patients with at least 3 year follow up had undergone RALP by a single surgeon at our institution. Biochemical recurrence was defined as a postoperative PSA >0.2 ng/ml. Multivariable logistic regression models were used to develop the biochemical recurrence predictive nomograms: nomogram 1- age, BMI, PSA density, clinical stage, biopsy Gleason, percent positive cores, perineural invasion; nomogram 2- age, BMI, PSA density, clinical stage, biopsy Gleason, percent positive cores, perineural invasion, nerve sparing, positive surgical margins (none, unifocal, or multifocal). The predictive accuracy of the models was assessed in terms of discrimination and calibration. Predictors of biochemical recurrence after robotic-assisted laparoscopic radical prostatectomy (RALP) are not well reported in the literature. We wanted to investigate preoperative predictors as well as the influence of nerve sparing and positive surgical margin status on 3-year biochemical recurrence such that potential patients could be adequately counselled about their risk of recurrence before undergoing RALP. Results: Both nomograms discriminated well between patients that recurred and those that did not (bootstrap corrected c-indices of 0.766 and 0.806 for nomograms 1 and 2 respectively). Nomogram 1 was well calibrated, but nomogram 2 overpredicted the probability of biochemical recurrence in patients at >30% risk. Conclusions: Our nomogram based on age, BMI, PSA density, clinical stage, biopsy Gleason, percent positive cores, and perineural invasion on preoperative biopsy has a good predictive ability to differentiate between RALP-treated patients that biochemically recur by 3 years from those that do not. Adding nerve sparing and surgical margin status further improved discriminatory ability but at the expense of over-prediction for patients at high risk. These nomograms may be used to guide the use of nerve sparing and the management of positive margins in men undergoing RALP for clinically localized prostate cancer.

452

Rectal injury is a potential complication of robotic radical prostatectomy

Kheterpal E., Bhandari A., Trinh Q.D., Siddiqui S., Pokala N., Sukumar S., Peabody J.O., Menon M. Henry Ford Health System, Vattikuti Urology Institute, Detroit, United States of America Introduction & Objectives: Rectal injury is a potential complication of radical prostatectomy. We reviewed the incidence and management of rectal injury in 4,400 consecutive cases of robotic radical prostatectomy (RRP) at a single institution. Materials & Methods: Between September 2001 and September 2009, 4,400 patients underwent a RRP. We reviewed the intraoperative and postoperative management of patients with rectal injuries. Once recognized the rectal injuries were closed in 2 layers. Clear liquids were started the day after surgery. Healing of vesicourethral anastomosis was confirmed by cystogram between 5-14 days post-operatively. Results: Rectal injuries were identified in 10 patients (0.2%). Mean patient age was 58.6 years (range 44 to 68) and mean BMI was 25.8 kg/m2 (range 22 to 29). Mean PSA was 7.1 ng/ml (range 0.9 to 14.8) and mean prostate weight was 58.9 grams (range 22 to 102). Clinical stage was T1c, T2a, T2c in 7, 2, and 1 patient, respectively. Preoperative Gleason score was 6, 7 and 8 in 3, 3 and 4 patients, respectively. All rectal injuries were diagnosed and repaired intraoperatively. Seven patients underwent nerve sparing procedures. Of the 10 patients, 9 had an uneventful post-operative course. Average urethral catheterization time in these patients was 14 days (range 6 to 21 days) and mean hospital stay was 2.2 days (range 1 to 5 days). One patient had gross fecal spillage and developed a rectourethral fistula, which required a delayed diverting colostomy. There was no perioperative mortality. Conclusions: We report a low incidence of rectal injury during robotic radical prostatectomy. We also demonstrate that rectal injuries can be managed primarily with a meticulous closure with minimum morbidity.

453

Implications of laparoscopic inguinal hernia repair on open, laparoscopic and robotic radical prostatectomy

Spernat D.M.G.1, Woo H.H.2, Sofield D.3, Moon D.4, Louie Johnsun M.5 1 Sydney Adventist Hospital, Dept. of Urology, Sydney, Australia, 2Sydney Medical School, Sydney Adventist Hospital, University of Sydney, Dept. of Urology, Sydney, Australia, 3Bethesda Hospital, Dept. of Urology, Perth, Australia, 4Royal Melbourne Hospital, Dept. of Urology, Melbourne, Australia, 5Gosford Private Hospital, Dept. of Urology, Gosford, Australia Introduction & Objectives: Radical Prostatectomy (RP) can be a challenging operation. Further, tissue planes can be compromised by previous Laparoscopic Inguinal Hernia Repair (LIHR). Surgeons have anecdotally reported that RP has had to be abandoned due to the difficult access after LIHR. We prospectively collected data from four experienced prostate surgeons from separate institutions. Each surgeon has a different technique for RP, and thus we report on our experience with open, laparoscopic and robotic assisted RP. Our objective was to evaluate the success rate of performing RP with the three most common operative techniques,

Lymph Node dissection (LND), and the frequency of complications after LIHR. Materials & Methods: A prospective database was collected. The database recorded clinical and pathological T stage, PSA, Gleason grade, success or failure to perform RP, success or failure to perform LND, unilateral or bilateral mesh, type of RP and complications. Results: From our four institutions a total of 57 men underwent RP after LIHR. Of the 57 patients 28 had a previous bilateral LIHR, and 29 unilateral. An open approach was attempted in 19 patients, laparoscopic in 33, and robotic in 5. All 57 cases were able to be successfully completed. The decision to attempt LND was based on individual surgeon preference. A LND was attempted in 44 of the 57 patients (77.2%). The LND had to be abandoned in 16 (36.4%) of the patients. Additionally in 9 (20.5%) patients only a unilateral LND was possible due to mesh covering the nodes and external iliac vessels. Thus it was not possible to complete a LND in 25 of the 44 patients (56.8%). Complications were limited to nine patients. These complications included one laparoscopic RP converted to open due to failure to progress, one rectourethral fistula in a salvage procedure post failed HIFU, two blood transfusions, one prolonged lymph leak (5 days), one urinoma which was percutaneously drained, one episode of acute urinary retention, one wound infection, and one bladder neck contracture. Conclusions: LIHR is not a contra-indication to RP. Open, laparoscopic and robotic RP after LIHR is a safe and reasonable treatment option for patients with prostate cancer. However, it may not be possible to perform a LND in up to 56.8% of patients. LND offers important prognostic information. [1] Further, patients with limited lymph node metastases may derive a therapeutic benefit. [3-5] The current recommendation is that patients with higher than 7% risk of lymph node metastases undergo LND. [1] It is estimated that patients with D’Amico low risk prostate cancer have a risk of lymph node metastases of less than 7%. [2] However, the risk of lymph node metastases in patients with a Gleason score³ 7 is 25%. [6] Thus after LIHR up to 56.8% of patients with D’Amico intermediate and high risk prostate cancers may be under treated and under staged.

454

Simple method for preventing postoperative inguinal hernia after laparoscopic prostatectomy

technique should be applied after transperitoneal robotic-assisted laparoscopic prostatectomy.

455

Robotic prostatectomy oncologic outcomes according to risk group classification

Sanchez-Salas R.E.1, Secin F.2, Prapotnich D.1, Rozet F.1, Galiano M.1, Flamand V.1, Cathala N.1, Mombet A.1, Barret E.1, Cathelineau X.1 1 Institut Montsouris, Dept. of Urology, Paris, France, 2CEMIC, Dept. of Urology, Buenos Aires, Argentina Introduction & Objectives: To estimate BCR free survival curves according to risk group classification. Materials & Methods: We generated a retrospective analysis of a prospectively collected database. BCR free survival was defined as a postoperative PSA > 0.2 and rising or start of secondary therapy. Risk groups were defined as D´Amico´s 2001. We estimated BCR free survival with Kaplan Meier curves and identified predictors of BCR free survival with Cox Regression analysis. Results: From May 2000 through August 2010, 795 patients with localized prostate cancer were treated with robotic radical prostatectomy. The median age was 62 years (Interquartile range, IQR: 57,65), BMI was 25 (23, 27), and PSA was 6.7 (5.2, 9). Overall, 34% had palpable nodule (n=279), 2% had biopsy Gleason 8-10, 31% Gleason 7 and 67% Gleason 6 or less; and 18% (n=146) had positive surgical margins.(15% pT2 and 28% pT3a-b)The number of patients per risk Group was as follows (number of patients with BCR): Low Risk, 408 (32), Intermediate Risk,303 (53) and High risk, 33 (17). Figure shows KM curves according to risk groups. (Log Rank <0.001). In Cox regression analysis (Table), risk group, positive margins were significant predictors of BCR free survival after adjusting for age, BMI and contemporary surgery date. Conclusions: Our robotic radical prostatectomy oncologic outcomes seem to be comparable with laparoscopic and open surgery results. Year of surgery did not impact the results in present series.

Taguchi T.K., Yasui Y.T., Umemoto U.Y., Kojima K.Y., Kawai K.N., Yamada Y.Y., Tozawa T.K., Sasaki S.S., Hayashi H.Y., Kohri K.K. Nagoya City University Graduate School of Medical Sciences, Dept. of NephroUrology, Nagoya, Japan, Introduction & Objectives: Inguinal hernia (IH) is a late complication after radical retropubic prostatectomy (RRP). Some of our patients have developed IH during long-term observation after laparoscopic radical prostatectomy (LRP). Here, we compared the occurrence of IH with that of LRP. We also established a novel and simple method of preventing post-LRP IH.

Materials & Methods: We examined 272 and 340 patients after RRP and LRP (transperitoneal approach) between April 2004 and December 2009. As prophylaxis for IH after RRP, we released the bilateral spermatic cord from the peritoneum, which prevent the intestinal tract coated with the peritoneum from pushing through the internal inguinal tract. We applied prophylaxis for IH to 101 patients (RRP prophylaxis(+) group) compared them with 171 who did not receive prophylaxis for IH (RRP prophylaxis(-) group). We also applied the same prophylaxis for IH in LRP with the transperitoneal approach as that for RRP (LRP prophylaxis(+) group) (Fig.1). The patients in the RRP prophylaxis (-) and (+), and LRP prophylaxis (-) and (+) groups were respectively followed up for an average of 35.9, 23.6, 38.9 and 12.0 months, respectively. Results: IH developed in 20 (11.7%) and in 26 (7.6%) of the RRP and LRP prophylaxis (-) groups respectively. All postoperative IH were indirect. IH did not develop in any patients in the RRP and LRP prophylaxis (+) groups. The herniafree rate was significantly lower in both the RRP and LRP prophylaxis (+), than (-) groups. The median interval between surgery and hernia diagnosis was 10.6 ± 8.9 (range 2-24) and 13.2 ± 11.9 (range 1-48) months in the RRP prophylaxis (-) and LRP prophylaxis (-) groups, respectively. Among patients with and without IH in the LRP group, age, initial PSA, operative duration and blood loss, did not significantly differ. The BMI was lower in patients with, than without IH (22.0 ± 2.5 vs.23.2 ± 2.7; p < 0.05). The prophylactic procedure was accomplished within 5 minutes (234 ± 26 sec) without any side effects. Conclusions: Indirect IH similarly develop as a complication after LRP and RRP. A low BMI affects the incidence of IH after LRP. We developed a simple method of preventing IH after LRP, which can be completed within 5 minutes. This

Hazard Ratio

95% CI

p

Age, years

1.00

0.97, 1.03

0.9

BMI

1.02

0.96, 1.09

0.5

Damico´s Low Risk

(reference)

Intermediate Risk

0.07

0.04, 0.13

<0.0001

High Risk

0.19

0.11, 0.34

<0.0001

Positive margins

2.9

1.9, 4.3

<0.0001

Surgery after 2008

0.7

0.4, 1.2

0.2

456

<0.0001

Postoperative pain after pure and robotassisted laparoscopic radical prostatectomy. A prospective randomized study

Calza E., Fiori C., Porpiglia F., Prieri F., Meli A., Giannone A., Pais P., Tempia A. 'San Luigi Gonzaga' Hospital - University of Turin, Dept. of Anaesthesiology, Orbassano (turin), Italy, Introduction & Objectives: Compared to open prostatectomy, both pure laparoscopic radical prostatectomy (LRP) and robot assisted laparoscopic prostatectomy (RALP) remarkably reduce the post-operation pain. However, differences between LRP and RALP techniques in terms of postoperative pain have not been yet explored. Materials & Methods: 100 patients requiring prostatectomy were randomized in two groups. One group was treated with LRP (LRP group=50 pts), while the other group was treated with RALP (RALP group=50 pts). In both groups intraoperative anaesthesia and postoperative analgesia were managed according to the same protocols. The degrees of postoperative pain were evaluated on each patient by the Visual Analogue Scale diffused (VAS D), incident (the pain on light compression

Eur Urol Suppl 2011;10(2):155