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IMPACT OF A MULTIDISCIPLINARY CONTINUOUS QUALITY IMPROVEMENT PROGRAM ON THE POSITIVE SURGICAL MARGIN RATE AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY
277
278
MODIFIED TRANSPERITONEAL APPROACH FOR LAPAROSCOPIC RADICAL PROSTATECTOMY
IMPACT OF A MULTIDISCIPLINARY CONTINUOUS QUALITY IMPROVEMENT PROGRAM ON THE POSITIVE SURGICAL MARGIN RATE AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY
Häcker A.1, Al-Bodour A.2, Albquami N.2, Jeschke S.2, Prammer P.2, Leeb K.2, Janetschek G.2 1
University Hospital Mannheim, Urology, Mannheim, Germany, 2Elisabethinenkranken haus, Urology, Linz, Austria INTRODUCTION & OBJECTIVES: Recently the extraperitoneal approach has been widely favoured for laparoscopic radical prostatectomy. A disadvantage of this approach is that it allows only lymph node dissection (LND) in the obturator fossa. Extended lymph node dissection is not feasible. Furthermore, the risk of lymphocele formation is greater. We developed our modified transperitoneal approach with the aim to combine the advantages of the transperitoneal and extraperitoneal approach for laparoscopic pelvic LND and prostatectomy. MATERIAL & METHODS: The modified approach has been introduced in January 2004 and 94 pts. have been operated until now. We use the approach whenever LND (Sentinel or extended) is performed together with laparoscopic prostatectomy. The extraperitoneal approach is our standard approach when LND is not indicated. The peritoneum is incised lateral to the medial umbilical ligament on both sides. The layer between pelvic wall and bladder is opened down to the branches of the internal iliac artery. The ureter is always identified. This exposure allows good access to extended pelvic LND. Following LND the bladder is detached from the abdominal wall and the Retzius space is opened. The medial umbilical ligament and the urachus, however, are left intact. Since the bladder remains fixed to the umbilicus it has not to be retracted when dissecting the bladder neck region and the seminal vesicles.
Touijer K.1, Kuroiwa K.1, Vickers A.2, Reuter V.3, Hricak H.4, Scardino P.1, Guillonneau B.1 1
Memorial Sloan-Kettering Cancer Center, Urology, New York, United States, 2Memorial
Sloan-Kettering Cancer Center, Urology & Biostatistics, New York, United States, 3Memorial Sloan-Kettering Cancer Center, Pathology, New York, United States, 4Memorial SloanKettering Cancer Center, Radiology, New York, United States INTRODUCTION & OBJECTIVES: Outcome after radical prostatectomy is highly sensitive to fine nuances in the surgical techniques. We sought to determine the impact of a process of continuous control and monitoring on the positive surgical margin rate in a contemporary series of laparoscopic radical prostatectomy. MATERIAL & METHODS: Between January 2003 and June 2005, 485 men underwent laparoscopic radical prostatectomy for clinically localised prostate cancer (cT1-cT3a). A weekly case review conference involving surgeons, radiologists and uropathologists was held to discuss the pre-intraoperative and pathological findings of significant cases. We analysed the trend of positive surgical margins and compared the clinical and detailed pathological characteristics of the cancer during the study period. RESULTS: We created logistic regression models with positive margin as the dependent variable and surgical experience as the predictor, adjusting for possible secular changes in disease severity (PSA, pathological stage and Gleason grade). There was a decrease in the overall rate of positive surgical margins: odds ratio 0.71 per 100 patients treated; 95% C.I. 0.57 - 0.89, p=0.003, in organ confined disease: odds ratio 0.60 per 100 patients treated; 95% C.I.
RESULTS: Modified LND (Sentinel or extended) was feasible in all patients. The approach to prostatectomy was almost identical to that genuined by the extraperitoneal approach. Clinical evident lymphocele formation occurred in 2 pts. (pt.1: percutaneous drainage; pt. 2: laparoscopic marsupialization).
0.41 - 0.9, p=0.01, and nonorgan confined disease: odds ratio 0.25 per 100 patients treated;
CONCLUSIONS: Our modified transperitoneal approach combines the advantages of the conventional transperitoneal and extraperitoneal laparoscopic approach. It provides excellent exposure of the pelvic lymph nodes including the area of the internal iliac artery and branches as well as perfect exposure of the bladder neck region.
the study, and the rate of nerve sparing remained stable throughout the study period.
95% C.I. 0.06 - 1.05, p=0.06. The predicted probability for a positive surgical margin falls from 17.3% for the first patient to 7.5% for the 485th. These values are close to the observed rates for the first and last fifty patients. There was no important change in surgical risk over the course of
CONCLUSIONS: In this contemporary series, which is unaffected by downward stage migration, the decreasing rate of positive surgical margins can be explained by subtle surgical technique modifications and a continuous multi-departmental effort of quality improvement.
279
280
THE EFFECT OF PRIOR BLADDER OUTLET SURGERY ON
URETHOVESICAL ANASTOMOSIS DURING ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY: A PROSPECTIVE COMPARISON BETWEEN THE SINGLE-KNOT RUNNING AND INTERRUPTED TECHNIQUE
LAPAROSCOPIC RADICAL PROSTATECTOMY Richards A., Ooi J., Laczko I., Moon D., Eden C. The North Hampshire Hospital, Department of Urology, Basingstoke, United Kingdom INTRODUCTION & OBJECTIVES: Laparoscopic radical prostatectomy (LRP) is now well-established as a minimally invasive surgical treatment option for localised prostate cancer. A significant proportion of patients have had a transurethral resection of the prostate (TURP) or bladder neck incision (BNI) prior to LRP. In order to know how best to counsel these patients regarding the expected outcome of their surgery we interrogated our laparoscopic database to determine the effect of prior bladder outlet surgery (BOS) on the outcomes of LRP. MATERIAL & METHODS: 414 LRPs were carried out in our department between March 2000 and December 2004. Twenty-nine of the 414 patients had had a TURP or BNI prior to LRP. Patients were divided into TURP, BNI and no surgery (NS) groups and parameters compared. RESULTS: Seven percent of the patients had had BOS prior to LRP. No difference was noted between the groups with respect to any parameter except specimen weight, which was greater in the NS group (P = 0.02). CONCLUSIONS: Prior TURP or BNI has no impact on the short-term outcomes of LRP. In patients with a history of prior BOS, LRP is an effective minimally invasive treatment option for localised prostate cancer. Eur Urol Suppl 2006;5(2):92
Poulakis V., De Vries R., Dillenburg W., Witzsch U., Becht E. Krankenhaus Nordwest, Urology and Pediatric Urology, Frankfurt am Main, Germany INTRODUCTION & OBJECTIVES: To compare the efficacy of the single-knot running and interrupted technique for urethovesical anastomosis during the endoscopic extraperitoneal radical prostatectomy (EERPE). MATERIAL & METHODS: The last 202 patients who underwent consecutively EERPE by a single surgeon (VP) at our department were prospectively selected in 98 patients who underwent vesicourethral anastomosis using the single-knot running technique (group 1) and in 104 who underwent an interrupted suture anastomosis (group 2). The laparoscopic surgeon had already performed at least 40 anastomoses of each technique before the beginning of the present study. The selection criteria were arbitrary based mainly on surgeon’s and patient’s preference. The groups were statistically analysed relative to operative time, the difficulty scores, the extravasation rate, the time until healing and catheter removal, the occurrence of anastomotic strictures, and the early and late continence rate. RESULTS: No significant differences were found between the two groups regarding the clinical and pathologic findings (p>0.05). Similarly, the extravasation rate, the time until healing and catheter removal, and the occurrence of anastomotic strictures were not significantly different (p>0.05). However, the extravasation rate was higher in the 1st group in comparison to interrupted anastomosis (4% versus 2.5%, p=0.23). Overall, the continence rate at 3 and 6 months were 28% and % in group 1, and 10% and % in group 2 (p>0.05). The strongest independent predictors for extravasations were the integrity of the dorsal wall of the anastomosis (p<0.0001) and the degree of bladder neck opening (p=0.002). The anastomosis technique has no impact on extravasation or continence status (p>0.05). The only significant differences in favor of single-knot technique are the mean operative time and difficulty score (12 versus 18 minutes, p=0.02, and 4 versus 6, p=0.04, respectively). CONCLUSIONS: Both anastomotic techniques provide similar high qualitative functional results. However, because of its simplicity and shorter operative time, the single-knot running technique appears to be preferable.
278
MODIFIED TRANSPERITONEAL APPROACH FOR LAPAROSCOPIC RADICAL PROSTATECTOMY
IMPACT OF A MULTIDISCIPLINARY CONTINUOUS QUALITY IMPROVEMENT PROGRAM ON THE POSITIVE SURGICAL MARGIN RATE AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY
Häcker A.1, Al-Bodour A.2, Albquami N.2, Jeschke S.2, Prammer P.2, Leeb K.2, Janetschek G.2 1
University Hospital Mannheim, Urology, Mannheim, Germany, 2Elisabethinenkranken haus, Urology, Linz, Austria INTRODUCTION & OBJECTIVES: Recently the extraperitoneal approach has been widely favoured for laparoscopic radical prostatectomy. A disadvantage of this approach is that it allows only lymph node dissection (LND) in the obturator fossa. Extended lymph node dissection is not feasible. Furthermore, the risk of lymphocele formation is greater. We developed our modified transperitoneal approach with the aim to combine the advantages of the transperitoneal and extraperitoneal approach for laparoscopic pelvic LND and prostatectomy. MATERIAL & METHODS: The modified approach has been introduced in January 2004 and 94 pts. have been operated until now. We use the approach whenever LND (Sentinel or extended) is performed together with laparoscopic prostatectomy. The extraperitoneal approach is our standard approach when LND is not indicated. The peritoneum is incised lateral to the medial umbilical ligament on both sides. The layer between pelvic wall and bladder is opened down to the branches of the internal iliac artery. The ureter is always identified. This exposure allows good access to extended pelvic LND. Following LND the bladder is detached from the abdominal wall and the Retzius space is opened. The medial umbilical ligament and the urachus, however, are left intact. Since the bladder remains fixed to the umbilicus it has not to be retracted when dissecting the bladder neck region and the seminal vesicles.
Touijer K.1, Kuroiwa K.1, Vickers A.2, Reuter V.3, Hricak H.4, Scardino P.1, Guillonneau B.1 1
Memorial Sloan-Kettering Cancer Center, Urology, New York, United States, 2Memorial
Sloan-Kettering Cancer Center, Urology & Biostatistics, New York, United States, 3Memorial Sloan-Kettering Cancer Center, Pathology, New York, United States, 4Memorial SloanKettering Cancer Center, Radiology, New York, United States INTRODUCTION & OBJECTIVES: Outcome after radical prostatectomy is highly sensitive to fine nuances in the surgical techniques. We sought to determine the impact of a process of continuous control and monitoring on the positive surgical margin rate in a contemporary series of laparoscopic radical prostatectomy. MATERIAL & METHODS: Between January 2003 and June 2005, 485 men underwent laparoscopic radical prostatectomy for clinically localised prostate cancer (cT1-cT3a). A weekly case review conference involving surgeons, radiologists and uropathologists was held to discuss the pre-intraoperative and pathological findings of significant cases. We analysed the trend of positive surgical margins and compared the clinical and detailed pathological characteristics of the cancer during the study period. RESULTS: We created logistic regression models with positive margin as the dependent variable and surgical experience as the predictor, adjusting for possible secular changes in disease severity (PSA, pathological stage and Gleason grade). There was a decrease in the overall rate of positive surgical margins: odds ratio 0.71 per 100 patients treated; 95% C.I. 0.57 - 0.89, p=0.003, in organ confined disease: odds ratio 0.60 per 100 patients treated; 95% C.I.
RESULTS: Modified LND (Sentinel or extended) was feasible in all patients. The approach to prostatectomy was almost identical to that genuined by the extraperitoneal approach. Clinical evident lymphocele formation occurred in 2 pts. (pt.1: percutaneous drainage; pt. 2: laparoscopic marsupialization).
0.41 - 0.9, p=0.01, and nonorgan confined disease: odds ratio 0.25 per 100 patients treated;
CONCLUSIONS: Our modified transperitoneal approach combines the advantages of the conventional transperitoneal and extraperitoneal laparoscopic approach. It provides excellent exposure of the pelvic lymph nodes including the area of the internal iliac artery and branches as well as perfect exposure of the bladder neck region.
the study, and the rate of nerve sparing remained stable throughout the study period.
95% C.I. 0.06 - 1.05, p=0.06. The predicted probability for a positive surgical margin falls from 17.3% for the first patient to 7.5% for the 485th. These values are close to the observed rates for the first and last fifty patients. There was no important change in surgical risk over the course of
CONCLUSIONS: In this contemporary series, which is unaffected by downward stage migration, the decreasing rate of positive surgical margins can be explained by subtle surgical technique modifications and a continuous multi-departmental effort of quality improvement.
279
280
THE EFFECT OF PRIOR BLADDER OUTLET SURGERY ON
URETHOVESICAL ANASTOMOSIS DURING ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY: A PROSPECTIVE COMPARISON BETWEEN THE SINGLE-KNOT RUNNING AND INTERRUPTED TECHNIQUE
LAPAROSCOPIC RADICAL PROSTATECTOMY Richards A., Ooi J., Laczko I., Moon D., Eden C. The North Hampshire Hospital, Department of Urology, Basingstoke, United Kingdom INTRODUCTION & OBJECTIVES: Laparoscopic radical prostatectomy (LRP) is now well-established as a minimally invasive surgical treatment option for localised prostate cancer. A significant proportion of patients have had a transurethral resection of the prostate (TURP) or bladder neck incision (BNI) prior to LRP. In order to know how best to counsel these patients regarding the expected outcome of their surgery we interrogated our laparoscopic database to determine the effect of prior bladder outlet surgery (BOS) on the outcomes of LRP. MATERIAL & METHODS: 414 LRPs were carried out in our department between March 2000 and December 2004. Twenty-nine of the 414 patients had had a TURP or BNI prior to LRP. Patients were divided into TURP, BNI and no surgery (NS) groups and parameters compared. RESULTS: Seven percent of the patients had had BOS prior to LRP. No difference was noted between the groups with respect to any parameter except specimen weight, which was greater in the NS group (P = 0.02). CONCLUSIONS: Prior TURP or BNI has no impact on the short-term outcomes of LRP. In patients with a history of prior BOS, LRP is an effective minimally invasive treatment option for localised prostate cancer. Eur Urol Suppl 2006;5(2):92
Poulakis V., De Vries R., Dillenburg W., Witzsch U., Becht E. Krankenhaus Nordwest, Urology and Pediatric Urology, Frankfurt am Main, Germany INTRODUCTION & OBJECTIVES: To compare the efficacy of the single-knot running and interrupted technique for urethovesical anastomosis during the endoscopic extraperitoneal radical prostatectomy (EERPE). MATERIAL & METHODS: The last 202 patients who underwent consecutively EERPE by a single surgeon (VP) at our department were prospectively selected in 98 patients who underwent vesicourethral anastomosis using the single-knot running technique (group 1) and in 104 who underwent an interrupted suture anastomosis (group 2). The laparoscopic surgeon had already performed at least 40 anastomoses of each technique before the beginning of the present study. The selection criteria were arbitrary based mainly on surgeon’s and patient’s preference. The groups were statistically analysed relative to operative time, the difficulty scores, the extravasation rate, the time until healing and catheter removal, the occurrence of anastomotic strictures, and the early and late continence rate. RESULTS: No significant differences were found between the two groups regarding the clinical and pathologic findings (p>0.05). Similarly, the extravasation rate, the time until healing and catheter removal, and the occurrence of anastomotic strictures were not significantly different (p>0.05). However, the extravasation rate was higher in the 1st group in comparison to interrupted anastomosis (4% versus 2.5%, p=0.23). Overall, the continence rate at 3 and 6 months were 28% and % in group 1, and 10% and % in group 2 (p>0.05). The strongest independent predictors for extravasations were the integrity of the dorsal wall of the anastomosis (p<0.0001) and the degree of bladder neck opening (p=0.002). The anastomosis technique has no impact on extravasation or continence status (p>0.05). The only significant differences in favor of single-knot technique are the mean operative time and difficulty score (12 versus 18 minutes, p=0.02, and 4 versus 6, p=0.04, respectively). CONCLUSIONS: Both anastomotic techniques provide similar high qualitative functional results. However, because of its simplicity and shorter operative time, the single-knot running technique appears to be preferable.