RESTORATION OF POSTERIOR ASPECTS OF STRIATED SPHINCTER SHORTENS TIME TO CONTINENCE IN VIDEO LAPARORADICAL PROSTATECTOMY. A PROSPECTIVE RANDOMISED TRIAL

125

126

THE OUTCOME OF LAPAROSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY IN PATIENTS WITH HIGH BODY MASS INDEX, PRIOR PELVIC SURGERY AND LARGE PROSTATE SIZE

LAPAROSCOPIC RADICAL PROSTATECTOMY: THE IMPACT OF OBESITY

Rodriguez A., Buethe D., Pow-Sang J.

Ooi J., Gianduzzo T., Chang C., Moon D., Singh R., Patil N., Eden C.

Moffitt Cancer Center At The University of South Florida, Urology, Tampa, United States

The North Hampshire Hospital, Department of Urology, Basingstoke, United

INTRODUCTION & OBJECTIVES: Patients with a high body mass index (BMI), previous pelvic surgery, or large prostate size are not considered ideal candidates for surgical treatment of localised prostate cancer. We evaluated the impact of these characteristics in a series of patients treated with laparoscopic extraperitoneal radical prostatectomy (LERP) at our institution.

Kingdom

MATERIAL & METHODS: From Jan. of 2004 to Oct. 2005, 250 patients underwent LERP for the treatment of localised prostate cancer. We prospectively assessed the impact of BMI, prior pelvic surgery (PPS) and prostate weight (PW) on patient age, PSA, biopsy Gleason score, surgical time, blood loss, transfusion rate, transfusion volume, hospital stay, length of Foley catheter drainage, days of JP-drainage, post-operative Gleason score, pathological stage, % of tumour involvement, and margin status. All patients had a cystogram 2 weeks after surgery and the Foley catheter was discontinued if there was no leak. BMI was stratified into groups I (<29), II (30-35), III (36-40), and IV (>40). Prostate weight was stratified into groups I (<20g), II (21-40g), III (41-60g), IV (>60g). The groups were assessed for differences in outcomes.

INTRODUCTION & OBJECTIVES: The literature-based evidence as to whether or not obesity has any impact on the outcomes of radical prostatectomy is contradictory. This study investigates the effect of obesity on the peri-operative parameters of patients having laparoscopic radical prostatectomy (LRP). MATERIAL & METHODS: The database entries and case notes of 532 consecutive patients undergoing LRP from March 2000 to August 2005 were retrospectively examined. Complete data were available on 505 (95%) patients, 108 (21%) of whom were obese (BMI ≥30 kg/m2). All patients had clinical stage

RESULTS: Median age, PSA and biopsy Gleason score was 59 years, 5 ng./ml, and a 6 score, respectively. 29% had a BMI over 30 (15-50), 45% had prior lower abdominal or prostatic surgery, and 18% had a prostate weight greater than 60 grams (12-196). Median surgical time and blood loss was 245 minutes and 400 ml. 3.4% required more than 2 units of blood during hospital stay. The median hospital stay, days of JP-drainage and length of Foley catheter drainage was 2, 2, and 16 days, respectively. The median specimen Gleason score was 6 and % of tumour involvement was 10%. Positive margins were found in 9%, 32%, 40%, and 37% of patients with stages pT2a, pT2b, pT3a, and pT3b. BMI, PPS, and prostate weight did not have a significant impact on surgical time, transfusion rate, hospital stay, and length of JP drainage. BMI (p=0.4), and PPS (p=0.3) did not lengthen time of Foley drainage. However, larger prostates required longer Foley catheter drainage (p=0.0005) and although it correlated with higher blood loss (p=0.049), it did not affect the transfusion rate. PPS did not correlate with margin status. Larger prostates had a lower probability of a positive margin (p=0.03). BMI correlated with a higher % of tumour in the specimen (p=0.046).

T ≤ 3aN0M0 prostate cancer and had their procedure performed or supervised by

CONCLUSIONS: LERP can be performed in obese (BMI >30) men and those with PPS or very large prostates without increased peri-operative morbidity. Although blood loss was higher in patients with larger prostates, they did not have an increased transfusion rate. Larger prostates correlated with a lower positive surgical margin status.

but this was only by a mean of 15 minutes. All other parameters were comparable

the same surgeon. RESULTS: Patients’ PSA, Gleason score, clinical stage and prostate weight were similar. Non-obese & obese patients’ mean values for operating time = 182 & 197 min (P = 0.01), blood loss = 310 & 250 ml (P = 0.66), hospital stay = 3.0 & 3.3 nights (P = 1.00), complications = 3.5% & 4.6% (P = 0.77), positive margins = 15.4% & 20.6% (P = 0.26) and biochemical recurrence = 3.8 & 3.7% (P = 1.00) at a mean follow-up of 9.7 and 12.0 months, respectively. CONCLUSIONS: The operating time was significantly longer for obese patients in the two groups. Obese patients can expect a similar outcome to their non-obese counterparts following LRP when operated on by an experienced surgeon.

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RESTORATION OF POSTERIOR ASPECTS OF STRIATED SPHINCTER SHORTENS TIME TO CONTINENCE IN VIDEO LAPARORADICAL PROSTATECTOMY. A PROSPECTIVE RANDOMISED TRIAL

MODULAR TRAINING FOR RESIDENTS WITH NO PRIOR EXPERIENCE WITH OPEN PELVIC SURGERY IN ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY

Rocco B.1, Stener S.2, Bozzola A.2, Galli S.2, Gregori A.2, Scieri F.2, Scaburri A.3, Paoletti M.C.4, Gaboardi F.2 1

Istituto Europeo Di Oncologia, Urological Department, Milan, Italy, 2Ospedale Sacco, UO Di Urologia, Milan, Italy, Istituto Nazionale Per Lo Studio E La Cura Dei Tumouri, UO Registro Tumouri Ed Epidemiologia Ambientale, Milan, Italy, 4Università Di Florence, Divisione Di Urologia, Florence, Italy

Rabenalt R.1, Stoljenburg J.U.1, Do M.1, Horn L.C.2, Bhanot S.3, Anderson C.4, Liatsikos E.5

3

INTRODUCTION & OBJECTIVES: Urinary incontinence is one of the major drawbacks of radical retropubic prostatectomy. One of the possible reasons of the urinary incontinence, whether temporary or prolonged, is a post-op deficiency of the rhabdomyosphincter (RS). It has been recently demonstrated that anatomical reconstruction of the posterior aspects of RS allows a rapid recovery of continence after radical retropubic prostatectomy. (Rocco F et al. J Urol in press) The aim of this study was to evaluate the application of Rocco’s technique in video laparoscopic bladder neck sparing prostatectomy (VLRP), assessing early continence rate as main endpoint. MATERIAL & METHODS: In order to avoid caudal retraction of the RS, before the urethrovesical anastomosis, the posterior part of the RS is joined to the residuum of the Denonvilliers fascia and then fixed to the posterior bladder wall, 1-2 cm cranially and dorsally to the bladder neck, in order to replace the anatomical and functional length of the RS. A two arm prospective randomised trial was carried out. Starting in January 2005 31 patients were recruited for each arm. The A group underwent VLRP with Montsouris technique and the B group underwent VLRP with Montsouris technique and Rocco’s modification (VLRP-R). Early continence was defined as 0 pads or 1 diaper/day. Moderate incontinence as 2 pads. Severe incontinence more than two pads. Continence was assessed 3, 30, 90 and 180 days after the procedure. Due to the brevity of follow up, recovery of erectile function was not evaluated in this analysis. Statistical analysis was carried out comparing continent vs. moderate & severe incontinent patients. RESULTS: Patients’ characteristics and detailed results are summarised in table 1 and table 2. B group recover continence significantly earlier than A group. (3 days - p=0.0004, 30 days - p= 0.0001 30 days) At 90 days and 6 months, the difference between A group and B group was not significant. Table 1

group A

n° patients

group B

31

31

mean age

64,1

63,8

mean PSA

9,66

9,48

mean operative time

230

235

mean blood loss

360

300

organ confined

67.7

61.2

pT2 positive margins

14.2

5.3

catheter removal

9.9

8

Table 2 - % continence

group A

group B

Chi-square yates

3 days

25.8

74.2

12.65 - p=0.0004

30 days

32.3

83.8

14.90 - p=0.0001

90 days (26 ev. pts)

76.9

92.3

1.33 - p= 0.25

180 days (14 ev. pts)

78.6

92.9

0.29 - p= 0.59

CONCLUSIONS: Posterior reconstruction of the RS appears to be an easy and feasible technique even in a laparoscopic setting. Time to continence recovery was significantly shortened, even though in both groups the majority of the patients regained continence after 6 months of follow up.

Eur Urol Suppl 2006;5(2):54

1

University of Leipzig, Urology, Leipzig, Germany, 2University of Leipzig, Pathology, Leipzig, Germany, 3King George Hospital London, Urology, London, United Kingdom, 4St. Georges University Hospital, Urology, London, United Kingdom, 5University of Patras, Urology, Patras, Greece INTRODUCTION & OBJECTIVES: To establish a teaching program for the performance of endoscopic extraperitoneal radical prostatectomy (EERPE) that would ascertain the safe and efficacious training of residents with no previous experience with open pelvic surgery. MATERIAL & METHODS: The technique of EERPE was divided in 12 segments with 5 levels of difficulty. We thus designed a training program, where the resident learned the procedure in a mentor-defined schedule. During each educational EERPE, the trainee only performed the operative steps corresponding to his acquired skill level. The mentor performed the remaining parts of the EERPE, with the trainee assisting. The first 50 and consequent 100 cases performed by the residents were compared to the first 50 and last 100 cases (cases 521621) performed by the mentor. RESULTS: Two residents with no prior experience with open pelvic surgery participated in the study, and required 43 and 38 procedures respectively, until they were considered to be competent. The initial 50 procedures performed completely independently by the residents had mean operative times of 176 and 173 minutes. There were 2 intraoperative rectal injuries (one patient developed recto-urethral fistula), and 1 haemorrhage, and 1 lymphocele, postoperatively. The positive margin rate for pT2 disease was 14.3 and 11.5%, and for pT3 tumours 38.8 and 29.1%, respectively. After an additional 100 procedures operated by the same residents, mean operative times were 142 and 146 minutes. There was one patient who needed a transfusion. Postoperative complications requiring re-intervention were 1 haemorrhage, 2 anastomotic leakages and 4 symptomatic lymphoceles. The positive margin rate for pT2 disease was 12.8% and 6.5%, and for pT3 tumours 33.3% and 26.3% respectively. No statistical significant differences were observed when comparing with the mentors cases. CONCLUSIONS: We have showed that residents with no prior experience in open surgery of the pelvis can adhere to the modular training scheme and successfully perform the EERPE procedure with similar risk of complications compared to the tutor.