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Anterograde retropublic radical prostatectomy: technique and results in 632 patients
241 ANTEROGRADE TECHNIQUE AND
RETROPUBIC RADICAL RESULTS IN 632 PATIENTS
PROSTATECTOMY:
242 INTUSSUSCEPTION LEADS
TO
LESS
R.4TE
IJniversity of l.Iorencc. Urology. Florence. Italy
Wille S.. Van Knobloch
MATERIAL & METHODS: Betueen January 1989 and January 2002. 632 patients with clmically local&d prostate cancer. mean age 65.4 (range 48-72). lnean prcoperatlve pSA 14.8ngiml (range 2.3-7X.4), underwent anterograde retropubic radical prostatectolny at our institution. The technique consist5 in initial incision of the lateral pelvic fascia along the groove between the prostate and the rectum and. after transection of puboprostatic ligaments and control of the dorsal vein complex with transfixing stitches. in sectlon ofthe vesclcoprostaticjunction. saving or not the circular tibres of the bladder neck. Vasa dcfcrentu are sectwned and pulled up with seminal vewlea. to facilitate the identification of the Denonvillier’s fawa. which is incised. The plane between the anterior surface of the rectum and the prostate is developed up to the prostatic apex and the urethra, allowmg the 1 iwal and tactile evaluation ofneurocascular bundles. So It is possible to resect easily the bundles from their origin to the urethra. If d nerve sparing prostatectomy ib performed, ncurovascular bundles are released from the prostate beginning from the babe toward the apex. Now the prostate 15 only attached at the urethra and this allo\\\ the maximal mobillsatlon and a perfect ~wal and tactile evaluation of the apex. After the urethra is sectloned and the prostatic apex 1s dissected. vescico-urethral anastomosis is performed. Mean follow up was S6.3 months (range 7. 144). Progression free survival M~S evaluated with the Kaplan-Meyer method. RESULTS: At pathological analysis 3 I5/632 patients (4Y.7’!‘0)\\ere pT2, 167 were pT3a (26.4%). I 17 were pT3b (I X.5”/,). 33 were pT4 (5.2%) and X7 (I 3.7%) had neoplastic nodal metastasis. Overall actuarial progression free survival at I20 months was 71.4%. 87.8% for patients with organ-confined disease, 71.3% for those wth extracapsular extension only. 47.5% for those with semmal vesicle invasion and 35.9% for patients with positive limphnodes. rhe o~crall mcidence of powwe surgical margms was 14.1% (X9/632). In 246/636 (38.9%) wc performed the prostatectomy jawing both neurovascular bundles and at the follow-up I41 patuxts (57.3%) were potent. CONCLL’SIONS: Rnterogradc radul prostatectom) permit\ 011 ea\y, luld complete intraoperative control of neurovaccolar bundles and an acc~~rate apical dl\cectlon under 1 isible and tactile guide thank? to the wide moblllsation of the gland. This allows a lo\\ Incidence ofpo?~lve wrg~cal marglnr.
RADICAL
Philipps-University
THE
RECONSTRUCTED
EXTRAVASATION
carin{ M.. Ma\lrr~ L.. Lapmi A.. Mclonc F.. C‘ostanri A.. Farina II.. m
lNTRODUCTlON & OBJECTIVES: Radical prostatectomy currently represents the aold standard treatment of clinically local&d prostate cancer. Retrograde retropubic approach, described by Walsh. is the most frequently used by urologists. We propose an anterograde retropublc radical prostatectomy, based on Campbell’s techmque. modified according to further lmprovemcnt in the understanding of the periprostatic anatomy. It starts ujith the incision of the \escxw-prostatIc Junction and limshes with the apical dissectIOn
AFTER
OF
AND
BLADDER
BETTER
NECK
CONTINENCE
PROSTATECTOMY
R., Varga Z.. Heidcnrcich
A.. Hotinann
R
Marburg. Dept. of Urology. Marburg. Germany
& OBJECTIVES: The promising data published by \‘alsh of earlier continence by using buttressing sutures at the bladder neck prompted us to evaluate this technique with respect to extravasation, early catheter removal and urinary control.
INTRODUCTION
MATERIAL & METHODS: Thirty men (mean age 67 years. range 54 to 78) with clinical localized prostate cancer underwent radical retropubic prostatectomy. The bladder neck was then intussuscepted using two 3-O Vicryl sutures placed anterior and posterior to the reconstructed bladder neck. Cystogram was pcrformcd on day 4 and catheter was removed if no or mmor extravasation was seen. Outcome was then assessed using the 20 minutes padtest and a urine symptom inventory obtained on postoperative day 8 to 10. The data were compared to the most recent series of 75 case matched RRP’s without Intussusccptlon of the reconstructed bladder neck. On postoperative day 4. 89% of men who underwent intussusception of the bladder neck had no extravasation as compared to 61.3% of the control group (P=O.O06). Urinary retention occurred in two patients after catheter removal on day 4 with no need for further intervention after cathctcrisation. On postoperative day 8 to IO, 56% of men who underwent intussusception of the bladder neck were continent (less than I g. urine loss in 20 minutes) as compared to 33.3% in the control group (P=O.O23). RESULTS:
lntussusception of the bladder neck leads to a significant reduction of exlravasation on postoperative day 4 enabling early catheter removal. Earl> catheter removal on day 3 i< feasible and ulthout higher morbidity. Intussuscrption of the bladder neck leads to a hignilicant Improvcmcnt tn early urinary control immcdiatcly after catheter removal.
CONCLUSIONS:
243 A PROSPECTIVE COMPARISON OF STANDARD RADICAI, RETROPUBIC PROSTATECTOMY
AND
MINILAP
INTRODUCTION & OBJECTIVES: In 1993 Stcincr and Marshall proposed a surgical access, or minilap, for staging pelvic lymphadcncctomy as mmilaparotornic an alternative to the acandard and the laparoscopic approach. Subseqwntly. in 1998. the same authors published an extended series of consecutive patients submitted to radical prostatectomy with the minilap surgical access. The present study was
conceived to assess prospectively the reproducibility and benefits of the minilap retropubic prostatectomy, and to compare the results with the radical retropubic prostatectomy with the standard umbilico pubic incision. MATERIAL & METHODS: Thin prospective study was conducted on a total of 82 patients, candidates to radical retropubic prostatectomy. The surgical technique was essentially the anatomic approach as described by Walsh with minor alterations the only diffcrcncc being the length of the surgical wound, that is. the standard umbilicopubic for the standard group. whereas. a suprapubic opening of4 to 8 cm in length for the minilaparotomlc. or mmilap. group. The choice of the mclalon \\ab based on the surgeon’s preference with one surgeon performmg all the opcratlons. consecutively. “la the ctandard inclalona (PG). and another surgeon doing all the operations. conhecuticely.
via the minilap
(MM)
244 ROBOTIC RADICAL PROSTATECTOMY PATIENTS AND DIFFERENT EXTRA\PPROACHES
- EXPERIENCE WITH AND TRANSPERITONEAL
90
Hmdcr .I.. Wolfram M.. Bcntab W.. Bcecken W.D.. Jonas D.. Braeutigam
R
J.W.Cioethc Unl\crsltq Frankfurt tl-ankfurt am Main. Get-many
Urology.
am Mam. tirology
& I’aedtatrlc
IYTRODlICTIOU & OBJECTIVES: The daVinci’n Surgtcal System proxtdes a sophisticated computer mtcrface which bridges the surgeon’s hands wtth wrlsted laparoscopic instruments. Coupled with an excellent 3D vision, this system allows to perform even complex minimal-invasive procedures as anatomical radical prostatcctomy with high precision. We tested diffcrcnt operariLe approaches to optimise robot-assisted radical proslatectomy. MATERIAL & METHODS: Between May 2000 and Scptcmber 2002, 90 patients eligible for radical prostatectomy were treated with laparoscopic bilateral pelvic lymph node dissection and radical prostatovesiculectomy using the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). The operative technique II, 37 patient? was a combmed ascendmg and descending approach. while in 53 patients a descending technique was applied. In I6 patients. the access was cxtraperitoneal. in 74 patients transperltoneally.
The standard umlxhco pubic incision was pcrfonncd m 43 patients that form the standard group, whereas, the mmilap inclslon in 39, that form the minilap group. In one case the minilap incision was horizontal (a reduced Pfannenstiel type), whereas, a midline longitudinal in 38. The median length ofthe incision in the minilap group was 8 cm., range 4 to 8 cm. In no case was felt as necessary a conversion from a minilap incision to a standard one. Positive surgical margins were observed in I1 specimens of the standard group and in 7 of the minilap. Further parameters, such as the age, the height and weight of the patients, as well as the weight of the glands, the number of lymphnodes, the calculated blood losses, do not differ in both groups. The only difference was the need for analgetics that was reduced in the minilap group.
RESULTS: Median patient age was 62.5 years (range 45-75) and body mass index 25.3 kg/m? (I 9.0 32.7). Clinical tumour stage was Tl b, ‘1-lc, T2a or T2b, median PSA was 9.0 ngiml and median Gleason sum 6 (3-9). In X7 of 90 patients, the planned laparoscopic procedure was completed. The median operative time was 290 minutes and was decreased by > 50% between the first 30 operations (540 minutes) and the last 30 operations (250 minutes), regardless of technique. Likewise, the transfusion rate decreased from 33% to 10%. The histopathology of the specimen revealed a total of 4-24 pelvic lymph nodes (median 8 nodes). Prostate histology was as following: pT2aib in 5X patients with a positive margin rate of 12.1% and pT3a/b in 32 patients. The overall positive margin rate was 28.9”/0.
In the present study the mimlaparotomic (minilap) approach compared well with the standard retropubic approach for radical prostatectomy and pelvic lymphadcnectomy. The parameters observed, among others, the number of lymphnodes harvested, calculated blood losses, and pathologic stage, wcrc eqmvalent in both groups and uninfluenced by the choice of the surgical approach. The minilap radical retropubic prostatectomy can reproduce the results of the standard approach with a lower consumption of postoperative analgesu
CONCI~USIONS: Robotic radical prostatectomy is a new technique, which has been evolving since the introductton of the daVinci System into urology in May 2000. While early data by our group and others show encouraging data regarding postoperative complications. functional and oncological results, the optimal operative technique has yet to be determined. However, thts new technology has extraordinary potential to change the way we do surgery in urological oncology.
RESULTS:
CONCLUSIONS:
European
Urology
Supplements
2 (2003) No. 1, pp. 63
RETROPUBIC RADICAL RESULTS IN 632 PATIENTS
PROSTATECTOMY:
242 INTUSSUSCEPTION LEADS
TO
LESS
R.4TE
IJniversity of l.Iorencc. Urology. Florence. Italy
Wille S.. Van Knobloch
MATERIAL & METHODS: Betueen January 1989 and January 2002. 632 patients with clmically local&d prostate cancer. mean age 65.4 (range 48-72). lnean prcoperatlve pSA 14.8ngiml (range 2.3-7X.4), underwent anterograde retropubic radical prostatectolny at our institution. The technique consist5 in initial incision of the lateral pelvic fascia along the groove between the prostate and the rectum and. after transection of puboprostatic ligaments and control of the dorsal vein complex with transfixing stitches. in sectlon ofthe vesclcoprostaticjunction. saving or not the circular tibres of the bladder neck. Vasa dcfcrentu are sectwned and pulled up with seminal vewlea. to facilitate the identification of the Denonvillier’s fawa. which is incised. The plane between the anterior surface of the rectum and the prostate is developed up to the prostatic apex and the urethra, allowmg the 1 iwal and tactile evaluation ofneurocascular bundles. So It is possible to resect easily the bundles from their origin to the urethra. If d nerve sparing prostatectomy ib performed, ncurovascular bundles are released from the prostate beginning from the babe toward the apex. Now the prostate 15 only attached at the urethra and this allo\\\ the maximal mobillsatlon and a perfect ~wal and tactile evaluation of the apex. After the urethra is sectloned and the prostatic apex 1s dissected. vescico-urethral anastomosis is performed. Mean follow up was S6.3 months (range 7. 144). Progression free survival M~S evaluated with the Kaplan-Meyer method. RESULTS: At pathological analysis 3 I5/632 patients (4Y.7’!‘0)\\ere pT2, 167 were pT3a (26.4%). I 17 were pT3b (I X.5”/,). 33 were pT4 (5.2%) and X7 (I 3.7%) had neoplastic nodal metastasis. Overall actuarial progression free survival at I20 months was 71.4%. 87.8% for patients with organ-confined disease, 71.3% for those wth extracapsular extension only. 47.5% for those with semmal vesicle invasion and 35.9% for patients with positive limphnodes. rhe o~crall mcidence of powwe surgical margms was 14.1% (X9/632). In 246/636 (38.9%) wc performed the prostatectomy jawing both neurovascular bundles and at the follow-up I41 patuxts (57.3%) were potent. CONCLL’SIONS: Rnterogradc radul prostatectom) permit\ 011 ea\y, luld complete intraoperative control of neurovaccolar bundles and an acc~~rate apical dl\cectlon under 1 isible and tactile guide thank? to the wide moblllsation of the gland. This allows a lo\\ Incidence ofpo?~lve wrg~cal marglnr.
RADICAL
Philipps-University
THE
RECONSTRUCTED
EXTRAVASATION
carin{ M.. Ma\lrr~ L.. Lapmi A.. Mclonc F.. C‘ostanri A.. Farina II.. m
lNTRODUCTlON & OBJECTIVES: Radical prostatectomy currently represents the aold standard treatment of clinically local&d prostate cancer. Retrograde retropubic approach, described by Walsh. is the most frequently used by urologists. We propose an anterograde retropublc radical prostatectomy, based on Campbell’s techmque. modified according to further lmprovemcnt in the understanding of the periprostatic anatomy. It starts ujith the incision of the \escxw-prostatIc Junction and limshes with the apical dissectIOn
AFTER
OF
AND
BLADDER
BETTER
NECK
CONTINENCE
PROSTATECTOMY
R., Varga Z.. Heidcnrcich
A.. Hotinann
R
Marburg. Dept. of Urology. Marburg. Germany
& OBJECTIVES: The promising data published by \‘alsh of earlier continence by using buttressing sutures at the bladder neck prompted us to evaluate this technique with respect to extravasation, early catheter removal and urinary control.
INTRODUCTION
MATERIAL & METHODS: Thirty men (mean age 67 years. range 54 to 78) with clinical localized prostate cancer underwent radical retropubic prostatectomy. The bladder neck was then intussuscepted using two 3-O Vicryl sutures placed anterior and posterior to the reconstructed bladder neck. Cystogram was pcrformcd on day 4 and catheter was removed if no or mmor extravasation was seen. Outcome was then assessed using the 20 minutes padtest and a urine symptom inventory obtained on postoperative day 8 to 10. The data were compared to the most recent series of 75 case matched RRP’s without Intussusccptlon of the reconstructed bladder neck. On postoperative day 4. 89% of men who underwent intussusception of the bladder neck had no extravasation as compared to 61.3% of the control group (P=O.O06). Urinary retention occurred in two patients after catheter removal on day 4 with no need for further intervention after cathctcrisation. On postoperative day 8 to IO, 56% of men who underwent intussusception of the bladder neck were continent (less than I g. urine loss in 20 minutes) as compared to 33.3% in the control group (P=O.O23). RESULTS:
lntussusception of the bladder neck leads to a significant reduction of exlravasation on postoperative day 4 enabling early catheter removal. Earl> catheter removal on day 3 i< feasible and ulthout higher morbidity. Intussuscrption of the bladder neck leads to a hignilicant Improvcmcnt tn early urinary control immcdiatcly after catheter removal.
CONCLUSIONS:
243 A PROSPECTIVE COMPARISON OF STANDARD RADICAI, RETROPUBIC PROSTATECTOMY
AND
MINILAP
INTRODUCTION & OBJECTIVES: In 1993 Stcincr and Marshall proposed a surgical access, or minilap, for staging pelvic lymphadcncctomy as mmilaparotornic an alternative to the acandard and the laparoscopic approach. Subseqwntly. in 1998. the same authors published an extended series of consecutive patients submitted to radical prostatectomy with the minilap surgical access. The present study was
conceived to assess prospectively the reproducibility and benefits of the minilap retropubic prostatectomy, and to compare the results with the radical retropubic prostatectomy with the standard umbilico pubic incision. MATERIAL & METHODS: Thin prospective study was conducted on a total of 82 patients, candidates to radical retropubic prostatectomy. The surgical technique was essentially the anatomic approach as described by Walsh with minor alterations the only diffcrcncc being the length of the surgical wound, that is. the standard umbilicopubic for the standard group. whereas. a suprapubic opening of4 to 8 cm in length for the minilaparotomlc. or mmilap. group. The choice of the mclalon \\ab based on the surgeon’s preference with one surgeon performmg all the opcratlons. consecutively. “la the ctandard inclalona (PG). and another surgeon doing all the operations. conhecuticely.
via the minilap
(MM)
244 ROBOTIC RADICAL PROSTATECTOMY PATIENTS AND DIFFERENT EXTRA\PPROACHES
- EXPERIENCE WITH AND TRANSPERITONEAL
90
Hmdcr .I.. Wolfram M.. Bcntab W.. Bcecken W.D.. Jonas D.. Braeutigam
R
J.W.Cioethc Unl\crsltq Frankfurt tl-ankfurt am Main. Get-many
Urology.
am Mam. tirology
& I’aedtatrlc
IYTRODlICTIOU & OBJECTIVES: The daVinci’n Surgtcal System proxtdes a sophisticated computer mtcrface which bridges the surgeon’s hands wtth wrlsted laparoscopic instruments. Coupled with an excellent 3D vision, this system allows to perform even complex minimal-invasive procedures as anatomical radical prostatcctomy with high precision. We tested diffcrcnt operariLe approaches to optimise robot-assisted radical proslatectomy. MATERIAL & METHODS: Between May 2000 and Scptcmber 2002, 90 patients eligible for radical prostatectomy were treated with laparoscopic bilateral pelvic lymph node dissection and radical prostatovesiculectomy using the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). The operative technique II, 37 patient? was a combmed ascendmg and descending approach. while in 53 patients a descending technique was applied. In I6 patients. the access was cxtraperitoneal. in 74 patients transperltoneally.
The standard umlxhco pubic incision was pcrfonncd m 43 patients that form the standard group, whereas, the mmilap inclslon in 39, that form the minilap group. In one case the minilap incision was horizontal (a reduced Pfannenstiel type), whereas, a midline longitudinal in 38. The median length ofthe incision in the minilap group was 8 cm., range 4 to 8 cm. In no case was felt as necessary a conversion from a minilap incision to a standard one. Positive surgical margins were observed in I1 specimens of the standard group and in 7 of the minilap. Further parameters, such as the age, the height and weight of the patients, as well as the weight of the glands, the number of lymphnodes, the calculated blood losses, do not differ in both groups. The only difference was the need for analgetics that was reduced in the minilap group.
RESULTS: Median patient age was 62.5 years (range 45-75) and body mass index 25.3 kg/m? (I 9.0 32.7). Clinical tumour stage was Tl b, ‘1-lc, T2a or T2b, median PSA was 9.0 ngiml and median Gleason sum 6 (3-9). In X7 of 90 patients, the planned laparoscopic procedure was completed. The median operative time was 290 minutes and was decreased by > 50% between the first 30 operations (540 minutes) and the last 30 operations (250 minutes), regardless of technique. Likewise, the transfusion rate decreased from 33% to 10%. The histopathology of the specimen revealed a total of 4-24 pelvic lymph nodes (median 8 nodes). Prostate histology was as following: pT2aib in 5X patients with a positive margin rate of 12.1% and pT3a/b in 32 patients. The overall positive margin rate was 28.9”/0.
In the present study the mimlaparotomic (minilap) approach compared well with the standard retropubic approach for radical prostatectomy and pelvic lymphadcnectomy. The parameters observed, among others, the number of lymphnodes harvested, calculated blood losses, and pathologic stage, wcrc eqmvalent in both groups and uninfluenced by the choice of the surgical approach. The minilap radical retropubic prostatectomy can reproduce the results of the standard approach with a lower consumption of postoperative analgesu
CONCI~USIONS: Robotic radical prostatectomy is a new technique, which has been evolving since the introductton of the daVinci System into urology in May 2000. While early data by our group and others show encouraging data regarding postoperative complications. functional and oncological results, the optimal operative technique has yet to be determined. However, thts new technology has extraordinary potential to change the way we do surgery in urological oncology.
RESULTS:
CONCLUSIONS:
European
Urology
Supplements
2 (2003) No. 1, pp. 63