923 THE INCIDENCE OF INGUINAL HERNIA AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY

921

Systematic classification of complications during endoscopic extraperitoneal radical prostatectomy (EERPE) Liatsikos E.1, Do M.2, Rabenalt R.2, Truss M.C.3, Stolzenburg J.U.2 1 3

University of Patras, Department of Urology, Patras, Greece, 2University of Leipzig, Department of Urology, Leipzig, Germany, Clinic of Dortmund, Department of Urology, Dortmund, Germany

Introduction & Objectives: The comparison of the different kinds of operative treatment in prostate cancer demands a thorough analysis of postoperative complications. A comparison among series is subjective and often impossible due to the lack of consistent complication categorisation. The Clavien-Classification (1982) provides a good standard for the categorization of perioperative complications. We applied the recently revised Clavien classification system to grade EERPE complications. Material & Methods: Between 2001 and 2005 we performed 900 endoscopic extraperitoneal radical prostatectomies (EERPE). According to the Clavien-Classification (Grades I-V) for intra- und postoperative complications we divided the complications into 5 grades. Results: Clavien Grade intraoperative complications I IIIa

n(%) Rectal injury 6 (0,7%) Injury of the interureteric crest 1 (0,1%)

Early complications (up to on month postoperatively) I Urinary retention I “d“ Anastomotic leak II Preperitoneal haematoma II Deep venous thrombosis II Infection of the urinary tract II “d“ temp. lesion of the oburator nerve II “d“ Osteitis pubis IIIa perineal haematoma IIIa IIIa Anuria

Double layer suture DJ-cath.-placement and suture

19 (2,1%) 16 (1,8%) 1 (0,1%) 6 (0,7%) 8 (0,9%) 2 (0,2%)

1-4 days longer catheterization longer cath.-time (>14 days) conservative conservative conservative conservative

1 (0,1%) 2 (0,2%) 2 (0,2%)

1 (0,1%)

antibiosis Percutanous punction DJ-Placement Percutanous nephrostomy 5x percutanous drainage 9x lap. fenestration 5x Mono-J-catheter 1x reanastomosation (2.p.o day) colostomy 4x endoscopic revision 5x open revision conservative (intensive care)

2 (0,2%) 2 (0,2%) 1 (0,1%) 1 (0,1%)

Incision of the bladder neck Open hernia repair Cardiac surgery conservative

IIIa IIIb

sympt. lymphocele

14 (3,6%)

IIIa, IIIb

Anastomoseninsuffizienz

6 (0,7%)

IIIb IIIb, IIIb

rectourethral fistula Bleeding/haematoma

1 (0,1%) 9 (1%)

IVa urosepsis late complications (longer than 1 months postoperatively) IIIa Anastomotic striktur IIIb Port side hernia IVa Myocardial infarction IVa stroke

therapy



922

Intraoperative frozen section analysis of posterolateral margins in laparoscopic radical prostatectomy has a good predictive value to allow nerve sparing without compromising cancer control

Marcy M.1, Coulibaly B.1, Chetaille B.1, Simonin O.2, Karsenty G.2, Gravis G.3, Salem N.4, Xerri L.1, Bladou F.2 Institut Paoli Calmettes, Biopathology, Marseille, France, 2Hôpital Salvator, Urology, Marseille, France, 3Institut Paoli Calmettes, Medical Oncology, Marseille, France, 4Institut Paoli Calmettes, Radiotherapy Oncology, Marseille, France

1

Introduction & Objectives: Nerve sparing laparoscopic radical prostatectomy (NSLRP) has two objectives: cancer control and preservation of potency. Intraoperative frozen section (IFS) examination is used to detect positive surgical margins (PSM) during nerve sparing procedure. We report our experience with the use of IFS in the detection of PSM in the neurovascular bundles region during NSLRP. Material & Methods: A series of 102 patients underwent IFS examination on either unilateral or bilateral posterolateral prostate margins, in the region of neurovascular preservation. This procedure led us to analyse 190 IFS. In case of positive IFS, additional resection was performed. The results of IFS were compared with final permanent sections. Results: Eleven out of 190 IFS showed PSM. Among these 11 samples, 9 demonstrated PSM on the final permanent sections. Out of the 179 cases with negative margins in IFS, 4 had PSM on permanent sections. The sensitivity, specificity, positive and negative predictive value were 69.2 %, 98.9 %, 81.8 % and 97.8 %, respectively. In 6 out of 11 samples, corresponding to 11 different patients with PSM on IFS, additional resection led to negative surgical margins on final histological analysis. Five of these 11 patients had PSM in another site of the prostate resection. Finally, among the 102 patients, IFS had decreased the overall PSM status to 5.9 % on final histological analysis (p=0.23).

Conclusions: Our experience with 900 cases has proved that EERPE is a well established and safe technique for the management of prostate cancer in centers of excellence. The herein presented report aims to emphasize on the need for unanimously accepted complication nomenclature and rating and enables the comparison of the results by different working groups and techniques.

Conclusions: In our experience, IFS examination does not significantly decrease the total rate of positive surgical margins. However, considering its good predictive value, IFS analysis on posterolateral prostate margins appears as an efficient and usefull method to successfully achieve nerve sparing.





923

The incidence of inguinal hernia after laparoscopic radical prostatectomy Hicks J., Eden C. North Hampshire Hospital, Urology, Basingstoke, United Kingdom

Introduction & Objectives: There is an increased risk of inguinal hernia (IH) after radical retropubic prostatectomy (RRP) of 14.8% and within this group of men with post operative hernias almost half of them (43.7%) are bilateral. This increased hernia rate is not observed in patients after radical perineal prostatectomy. The aim of this study was to compare these hernia rates with inguinal hernia rates after radical laparoscopic prostatectomy (RLP). The incidence of IH in the general population is 0.14-5%. Material & Methods: 614 consecutive men who underwent RLP between February 2000 and January 2006 were sent a postal questionnaire asking whether they had developed an IH since surgery. They were also asked if they had developed an anastomotic stricture post operatively. Results: Of the 614 questionnaires sent 432 (68.9%) replies were received and 2 patients had died and were therefore excluded. 50 (11.6%) hernias were recorded. 15 patients failed to answer the anastomotic stricture question leaving 17 (2.8%) recording a stricture overall. Of those patients with a hernia 4 (8%) reported a stricture with 2 of these patients reporting the stricture occurring before the hernia. Conclusions: IH rates after RLP are greater than that observed in the general population but is significantly less than that seen after RRP. This is likely to be related to the reduced retraction forces on the supporting structures of the posterior wall of the inguinal canal. The presence of an anastomotic stricture was not proven as an aetiological factor in the development of a post operative IH.

924

Surgical outcomes in men undergoing laparoscopic radical prostatectomy after a transurethral resection of the prostate Jaffe J., Cathelineau X., Barret E., Vallancien G., Prapotnich D., Rozet F. Institut Montsouris, Urology, Paris, France

Introduction & Objectives: To review the surgical outcomes in men with a prior history of transurethral resection of the prostate (TURP) who subsequently undergo a laparoscopic radical prostatectomy for prostate cancer. Material & Methods: Three thousand and three men between January 26th, 1998 and October 10, 2006 had a laparoscopic radical prostatectomy preformed at our institution. The laparoscopic radical prostatectomy was performed via either a transperitoneal or extraperitoneal approach. A retrospective review of these 3003 men, found 119 with a prior history of TURP. These men were then compared to randomized cancer matched controls (PSA, clinical stage, Gleason score) from our database with regard to operative and postoperative outcomes. Results: The mean age for the TURP and non-TURP groups was 66.2 ± 5.6 and 60.7 ± 7.0 respectively (p<0.01). The mean preoperative PSA and Gleason score for the TURP group compared to the non-TURP group was not statistically significantly different. For obvious reasons there was a statistically significant difference in the number of patients with either a T1a or T1b clinical stage in the TURP group. There were more T1c patients in the non-TURP group (n=81) compared to the TURP group (n=63) (p<0.01) since T1a and T1b from the TURP group were matched with T1c patients in the non-TURP group. The remainder of the clinical stages were statistically similar between the two groups. The mean estimated blood loss, transfusion rate, pathologic prostate volume, and reoperation rate were all statistically similar between the two groups. The length of stay for the TURP group and non-TURP group was 6.5 ± 3.0 and 5.29 ± 2.3 respectively (p<0.01). The operative time for the TURP group and non-TURP group was 179 ± 44 and 171 ± 38 respectively (p=0.02). The margins were positive in 21.8% of the patients in the TURP group compared to 12.6% of those in the nonTURP group (p=0.02). A total of 64 complications were seen in those patients with a prior history of TURP compared to 34 complications without a history of TURP (p<0.01). Conclusions: We have demonstrated in this retrospective study that patients with a prior history of TURP who are later diagnosed with prostate cancer and subsequently undergo a laparoscopic radical prostatectomy have worse surgical and postoperative outcomes with respect to estimated blood loss, length of stay, positive margin rate, and overall complication rate. We feel that this subset of patients should be made aware of these risks prior to undergoing a laparoscopic radical prostatectomy.

Eur Urol Suppl 2007;6(2):253