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THE IMPORTANCE OF VIDEO-DOCUMENTED LAPAROSCOPIC RADICAL PROSTATECTOMY FOR IMPROVEMENT OF POSITIVE SURGICAL MARGIN RATE IN ORGAN-CONFINED PROSTATE CANCER
273
274
ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY EXPERIENCE WITH 900 PROCEDURES
THE IMPORTANCE OF VIDEO-DOCUMENTED LAPAROSCOPIC RADICAL PROSTATECTOMY FOR IMPROVEMENT OF POSITIVE SURGICAL MARGIN RATE IN ORGAN-CONFINED PROSTATE CANCER
Stoljenburg J.U.1, Rabenalt R.1, Do M.1, Burchardt M.2, Bhanot S.3, Horn L.C.4, Truss M.C.5, Liatsikos E.6 1 University of Leipzig, Urology, Leipzig, Germany, 2Medizinische Hochschule Hannover, Urology, Hanover, Germany, 3King George Hospital London, Urology, London, United Kingdom, 4University of Leipzig, Pathology, Leipzig, Germany, 5Klinikum Dortmund, Urology, Dortmund, Germany, 6University of Patras, Urology, Patras, Greece
INTRODUCTION & OBJECTIVES: We review our experience with endoscopic (totally) extraperitoneal radical prostatectomy (EERPE) as first line therapy for localised prostate cancer. MATERIAL & METHODS: A total of 900 consecutive patients underwent EERPE. The mean age was 63.5 (41-77) years. The mean preoperative PSA level was 10.6 (0.64–82) ng/ml. A total of 285 patients (31.6%) had a history of previous lower abdominal or pelvic surgery. After preparation of the preperitoneal space the technique of EERPE duplicates the steps of classic open descending retropubic radical prostatectomy including a nerve-sparing procedure (nsEERPE) where indicated. RESULTS: The mean operative time was 156 minutes (range: 50-320 minutes).There was no conversion and the transfusion rate was 1.2% (n=11). Six patients (0.7%) had intraoperative rectal injuries, which were treated endoscopically by a two-layer suture. 30 patients (3.3%) required early and 4 patients (0.4%) required late postoperative reinterventions. Pathological stage was pT2a in 100 patients (11.1%), pT2b in 64 patients (7.1%), pT2c in 363 patients (40.3%), pT3a in 269 patients (29.9%), pT3b in 100 patients (11.1%) and pT4 in 4 patients (0.6%). Positive surgical margins were found in 12.9% (68/527) of patients with a pT2tumour, and 37.4% (138/369) of patients with a pT3 tumour. The mean catheterization time was 6.4 days. Six month postoperatively, 82.9% of the patients were completely continent, 10.3% needed 1-2 pads per day and 5.8% of patients needed more than 2 pads per day. of all patients who had a nerve-sparing procedures, a total of 146 patients had a postoperative follow-up of six months: Out of the 74 patients with unilateral nerve-sparing approach 14 patients (18.9%) had erections sufficient for intercourse and 37/72 patients (51.4%) with a bilateral nerve sparing procedure had erections sufficient for intercourse with or without the help of PDE 5 inhibitors. CONCLUSIONS: The results of this series are promising. Although the follow-up is too short to draw definite conclusions it is obvious that a nerve-sparing approach in EERPE is feasible and reproducible, providing the ease and safety of a totally extraperitoneal approach completely avoiding intraperitoneal complications.
Erdogru T.1, Teber D.2, Marrero R.3, Hammady A.3, Frede T.3, Rassweiler J.3 Akdeniz University Faculty of Medicine, Urology, Antalya, Turkey, 2Heidelberg University, SLK Klinikum Heilbronn, Urology, Heilbronn, Germany, 3Heidelberg University SLK Klinikum Heilbronn, Urology, Heilbronn, Germany
1
INTRODUCTION & OBJECTIVES: Laparoscopic radical prostatectomy represents a continuously evolving technique with no more than 10000 patients treated in Europe. In an effort to understand the mechanism by which positive surgical margin (PSM) occur and improve our dissection during laparoscopic radical prostatectomy (LRP), we analysed pathological status and operative details before and after video-documentation. MATERIAL & METHODS: We prospectively documented the intraoperative video capturing of 45 patients with prostate cancer and re-evaluated the operative steps combined with pathology findings in patients with PSM. We compared the perioperative parameters, pathological status and postoperative outcomes between before (Group-1) and after (Group-2) video documentation including consecutive 112 patients of each, operated by a single surgeon (JR). RESULTS: Not only operation time and estimated blood loss but also specimen and tumour volumes were not statistically different. In addition, the percentage of pathologic stages were also identical between the two groups. The rate of PSM were significantly decreased after video documentation and re-evaluation of surgical steps according to pathological status (32.1% vs. 22.3%, p<0.001), while the significant reduction in positive surgical margin was obtained particularly in organ confined disease with 9.8% vs. 1.4% (p:0.05) and especially at the apical region with 5 to 1 patients. However, there was no difference in the rate of PSM in pT3 disease with this video assessment (48.7% vs. 48.7%, p:1.000). CONCLUSIONS: Intraoperative video documentation and re-evaluation of operation steps according to the pathological findings can help to decrease the positive surgical margin rate especially at the apical region and particularly in organ confined disease (pT2) despite of the prostatic apical anatomic variations.
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A SIMPLE AFFORDABLE HOMEMADE LAPAROSCOPIC MODEL FOR NARROWING THE LEARNING CURVE OF UROLOGICAL TRAINEESSKILL ACQUISITION USING TWO KEY LAPAROSCOPIC RADICAL PROSTATECTOMY STEPS
ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY IN THE ELDERLY: COMPARISON OF CLINICAL OUTCOMES AND SHORT-TERM ONCOLOGICAL RESULTS BETWEEN YOUNGER AND OLDER MEN
Kommu S.S.1, Mumtaz F.H.2
Poulakis V., De Vries R., Wolfgang D., Witzsch U., Becht E.
1
The Institute of Cancer Research and The Royal Marsden Hospitals NHS Foundation Trust, Urology, London, United Kingdom, 2Barnet and Chase Farm Hospitals NHS Trust, Urology, London, United Kingdom
Nordwest Krankenhaus, Urology and Paediatric Urology, Frankfurt am Main, Germany
INTRODUCTION & OBJECTIVES: Current laparoscopic training is expensive, restrictive and is rapidly becoming unsustainable in many centres. As the transition from open to laparoscopic skills evolves, training and rapid skill acquisition in a cost conscious health care system is critical. Training programs based on cadavers and animals are facing increasing ethical, medico legal, logistical and economical problems. It is hence necessary to develop new cost conscious tools for training. We developed a simple, cheap home made laparoscopic model for training using over the counter material available to all. The kit cost a fraction of the current commercial kits. We tested its applicability in acquiring laparoscopic skills using two key laparoscopic radical prostatectomy steps i.e. dorsal vein ligation and laparoscopic vesicourethral running anastomosis.
INTRODUCTION & OBJECTIVES: To analyze the safety and efficacy of endoscopic extraperitoneal radical prostatectomy (EERPE) in elderly versus younger men with localised prostate cancer.
MATERIAL & METHODS: The model was a do it yourself laparoscopic training kit (DIYLTK) and was made using a web cam (Logitech QuickCam SphereTM -with manual on console control with an infrared panning device-cost=£80), laptop and a box frame. No light source was used, as the box was a mesh frame utilising room light. Our kit cost a fraction of the current commercial kits. The DIY-LTK was evaluated against a modified version of a Pelvitrainer (PT). Four junior doctors with no prior laparoscopic experience were enrolled and asked to execute two tasks, tying of the dorsal vein complex and circular continuous vesicourethral anastomosis [in an ex-vivo reconstruction model fashioned using skin of a supermarket chicken and dye filled Dacronä grafts]. The time required to complete the two tasks was recorded and differences in performance were calculated. Analysis of variances (ANOVA) Kruskal-Wallis test was conducted for differences in performance times. RESULTS: The time for completion of the anastomosis on the model was mean of 92 minutes initially to 32 minutes after repetition of tasks n=28 anastomoses each. The time for placing the equivalent of a secure dorsal vein stitch was mean of 39 minutes initially to 25 minutes after repetition of tasks n=17 attempts each. Statistical analyses of the two tasks showed no significant difference for the PT and web cam trainers. ANOVA indicated no overall difference for the two tasks (P=0.67 and 0.86 respectively). CONCLUSIONS: DIY laparoscopic kit (DIY-LTK) is a useful, inexpensive and efficient mode of training at home for prospective trainee laparoscopist and can be set up at home with current over the counter technology. This simple model allows the trainee to acquire skills necessary to perform a laparoscopic vesicourethral anastomosis; one of the more complex steps in laparoscopic radical prostatectomy. In addition, standard web cam software allows easy recording of tasks, which can be reviewed instantly and can be subject to scoring and feedback by mentors. This is a useful and affordable alternative training tool, in the preliminary stages, for trainees interested in laparoscopic urological surgery.
MATERIAL & METHODS: Patients undergoing EERPE between January 2004 and July 2005 were retrospectively subdivided into group EERPE1 – 41 men aged 75 years and older and group EERPE2 – 128 men aged 59 and younger. Also, group EERPE1 was compared with a group of 48 contemporary, comparable patients undergoing open retropubic radical prostatectomy aged 75 years and older (group OPEN-RPE). RESULTS: Compared with group EERPE2, patients of group EERPE1 had higher pathologic stage (71 versus 45% stage pT3 or greater, p<0.001) and higher Gleason score lesions (49 versus 21%, p<0.001). PSA recurrence was significantly worse compared with age-matched controls for younger patients with high-stage or high-grade lesions (p<0.001). Importantly operative time, analgesic requirements, hospital stay, and convalescence and complication rates were comparable. Urinary continence rate was significantly better in group EERPE2 at 6 months (62% versus 93%, respectively, p<0.001). Group EERPE1 and group OPEN-RPE patients had similar median pathological stage and Gleason score (pT3a and 7, respectively, each p>0.5), similar operative time (p=0.12), but lesser blood loss (p<0.001), shorter hospital stay (p <0.001) and more rapid convalescence (p=0.02) occurred in EERPE1. CONCLUSIONS: EERPE is feasible and efficacious even in elderly patients with unfavourable, large-volume disease. EERPE offers the advantages of decreased blood loss, shorter hospital stay and more rapid recovery over open radical prostatectomy. However, the observed higher incontinence rate in the elderly should be discussed preoperatively with the patient. Eur Urol Suppl 2006;5(2):91
274
ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY EXPERIENCE WITH 900 PROCEDURES
THE IMPORTANCE OF VIDEO-DOCUMENTED LAPAROSCOPIC RADICAL PROSTATECTOMY FOR IMPROVEMENT OF POSITIVE SURGICAL MARGIN RATE IN ORGAN-CONFINED PROSTATE CANCER
Stoljenburg J.U.1, Rabenalt R.1, Do M.1, Burchardt M.2, Bhanot S.3, Horn L.C.4, Truss M.C.5, Liatsikos E.6 1 University of Leipzig, Urology, Leipzig, Germany, 2Medizinische Hochschule Hannover, Urology, Hanover, Germany, 3King George Hospital London, Urology, London, United Kingdom, 4University of Leipzig, Pathology, Leipzig, Germany, 5Klinikum Dortmund, Urology, Dortmund, Germany, 6University of Patras, Urology, Patras, Greece
INTRODUCTION & OBJECTIVES: We review our experience with endoscopic (totally) extraperitoneal radical prostatectomy (EERPE) as first line therapy for localised prostate cancer. MATERIAL & METHODS: A total of 900 consecutive patients underwent EERPE. The mean age was 63.5 (41-77) years. The mean preoperative PSA level was 10.6 (0.64–82) ng/ml. A total of 285 patients (31.6%) had a history of previous lower abdominal or pelvic surgery. After preparation of the preperitoneal space the technique of EERPE duplicates the steps of classic open descending retropubic radical prostatectomy including a nerve-sparing procedure (nsEERPE) where indicated. RESULTS: The mean operative time was 156 minutes (range: 50-320 minutes).There was no conversion and the transfusion rate was 1.2% (n=11). Six patients (0.7%) had intraoperative rectal injuries, which were treated endoscopically by a two-layer suture. 30 patients (3.3%) required early and 4 patients (0.4%) required late postoperative reinterventions. Pathological stage was pT2a in 100 patients (11.1%), pT2b in 64 patients (7.1%), pT2c in 363 patients (40.3%), pT3a in 269 patients (29.9%), pT3b in 100 patients (11.1%) and pT4 in 4 patients (0.6%). Positive surgical margins were found in 12.9% (68/527) of patients with a pT2tumour, and 37.4% (138/369) of patients with a pT3 tumour. The mean catheterization time was 6.4 days. Six month postoperatively, 82.9% of the patients were completely continent, 10.3% needed 1-2 pads per day and 5.8% of patients needed more than 2 pads per day. of all patients who had a nerve-sparing procedures, a total of 146 patients had a postoperative follow-up of six months: Out of the 74 patients with unilateral nerve-sparing approach 14 patients (18.9%) had erections sufficient for intercourse and 37/72 patients (51.4%) with a bilateral nerve sparing procedure had erections sufficient for intercourse with or without the help of PDE 5 inhibitors. CONCLUSIONS: The results of this series are promising. Although the follow-up is too short to draw definite conclusions it is obvious that a nerve-sparing approach in EERPE is feasible and reproducible, providing the ease and safety of a totally extraperitoneal approach completely avoiding intraperitoneal complications.
Erdogru T.1, Teber D.2, Marrero R.3, Hammady A.3, Frede T.3, Rassweiler J.3 Akdeniz University Faculty of Medicine, Urology, Antalya, Turkey, 2Heidelberg University, SLK Klinikum Heilbronn, Urology, Heilbronn, Germany, 3Heidelberg University SLK Klinikum Heilbronn, Urology, Heilbronn, Germany
1
INTRODUCTION & OBJECTIVES: Laparoscopic radical prostatectomy represents a continuously evolving technique with no more than 10000 patients treated in Europe. In an effort to understand the mechanism by which positive surgical margin (PSM) occur and improve our dissection during laparoscopic radical prostatectomy (LRP), we analysed pathological status and operative details before and after video-documentation. MATERIAL & METHODS: We prospectively documented the intraoperative video capturing of 45 patients with prostate cancer and re-evaluated the operative steps combined with pathology findings in patients with PSM. We compared the perioperative parameters, pathological status and postoperative outcomes between before (Group-1) and after (Group-2) video documentation including consecutive 112 patients of each, operated by a single surgeon (JR). RESULTS: Not only operation time and estimated blood loss but also specimen and tumour volumes were not statistically different. In addition, the percentage of pathologic stages were also identical between the two groups. The rate of PSM were significantly decreased after video documentation and re-evaluation of surgical steps according to pathological status (32.1% vs. 22.3%, p<0.001), while the significant reduction in positive surgical margin was obtained particularly in organ confined disease with 9.8% vs. 1.4% (p:0.05) and especially at the apical region with 5 to 1 patients. However, there was no difference in the rate of PSM in pT3 disease with this video assessment (48.7% vs. 48.7%, p:1.000). CONCLUSIONS: Intraoperative video documentation and re-evaluation of operation steps according to the pathological findings can help to decrease the positive surgical margin rate especially at the apical region and particularly in organ confined disease (pT2) despite of the prostatic apical anatomic variations.
275
276
A SIMPLE AFFORDABLE HOMEMADE LAPAROSCOPIC MODEL FOR NARROWING THE LEARNING CURVE OF UROLOGICAL TRAINEESSKILL ACQUISITION USING TWO KEY LAPAROSCOPIC RADICAL PROSTATECTOMY STEPS
ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY IN THE ELDERLY: COMPARISON OF CLINICAL OUTCOMES AND SHORT-TERM ONCOLOGICAL RESULTS BETWEEN YOUNGER AND OLDER MEN
Kommu S.S.1, Mumtaz F.H.2
Poulakis V., De Vries R., Wolfgang D., Witzsch U., Becht E.
1
The Institute of Cancer Research and The Royal Marsden Hospitals NHS Foundation Trust, Urology, London, United Kingdom, 2Barnet and Chase Farm Hospitals NHS Trust, Urology, London, United Kingdom
Nordwest Krankenhaus, Urology and Paediatric Urology, Frankfurt am Main, Germany
INTRODUCTION & OBJECTIVES: Current laparoscopic training is expensive, restrictive and is rapidly becoming unsustainable in many centres. As the transition from open to laparoscopic skills evolves, training and rapid skill acquisition in a cost conscious health care system is critical. Training programs based on cadavers and animals are facing increasing ethical, medico legal, logistical and economical problems. It is hence necessary to develop new cost conscious tools for training. We developed a simple, cheap home made laparoscopic model for training using over the counter material available to all. The kit cost a fraction of the current commercial kits. We tested its applicability in acquiring laparoscopic skills using two key laparoscopic radical prostatectomy steps i.e. dorsal vein ligation and laparoscopic vesicourethral running anastomosis.
INTRODUCTION & OBJECTIVES: To analyze the safety and efficacy of endoscopic extraperitoneal radical prostatectomy (EERPE) in elderly versus younger men with localised prostate cancer.
MATERIAL & METHODS: The model was a do it yourself laparoscopic training kit (DIYLTK) and was made using a web cam (Logitech QuickCam SphereTM -with manual on console control with an infrared panning device-cost=£80), laptop and a box frame. No light source was used, as the box was a mesh frame utilising room light. Our kit cost a fraction of the current commercial kits. The DIY-LTK was evaluated against a modified version of a Pelvitrainer (PT). Four junior doctors with no prior laparoscopic experience were enrolled and asked to execute two tasks, tying of the dorsal vein complex and circular continuous vesicourethral anastomosis [in an ex-vivo reconstruction model fashioned using skin of a supermarket chicken and dye filled Dacronä grafts]. The time required to complete the two tasks was recorded and differences in performance were calculated. Analysis of variances (ANOVA) Kruskal-Wallis test was conducted for differences in performance times. RESULTS: The time for completion of the anastomosis on the model was mean of 92 minutes initially to 32 minutes after repetition of tasks n=28 anastomoses each. The time for placing the equivalent of a secure dorsal vein stitch was mean of 39 minutes initially to 25 minutes after repetition of tasks n=17 attempts each. Statistical analyses of the two tasks showed no significant difference for the PT and web cam trainers. ANOVA indicated no overall difference for the two tasks (P=0.67 and 0.86 respectively). CONCLUSIONS: DIY laparoscopic kit (DIY-LTK) is a useful, inexpensive and efficient mode of training at home for prospective trainee laparoscopist and can be set up at home with current over the counter technology. This simple model allows the trainee to acquire skills necessary to perform a laparoscopic vesicourethral anastomosis; one of the more complex steps in laparoscopic radical prostatectomy. In addition, standard web cam software allows easy recording of tasks, which can be reviewed instantly and can be subject to scoring and feedback by mentors. This is a useful and affordable alternative training tool, in the preliminary stages, for trainees interested in laparoscopic urological surgery.
MATERIAL & METHODS: Patients undergoing EERPE between January 2004 and July 2005 were retrospectively subdivided into group EERPE1 – 41 men aged 75 years and older and group EERPE2 – 128 men aged 59 and younger. Also, group EERPE1 was compared with a group of 48 contemporary, comparable patients undergoing open retropubic radical prostatectomy aged 75 years and older (group OPEN-RPE). RESULTS: Compared with group EERPE2, patients of group EERPE1 had higher pathologic stage (71 versus 45% stage pT3 or greater, p<0.001) and higher Gleason score lesions (49 versus 21%, p<0.001). PSA recurrence was significantly worse compared with age-matched controls for younger patients with high-stage or high-grade lesions (p<0.001). Importantly operative time, analgesic requirements, hospital stay, and convalescence and complication rates were comparable. Urinary continence rate was significantly better in group EERPE2 at 6 months (62% versus 93%, respectively, p<0.001). Group EERPE1 and group OPEN-RPE patients had similar median pathological stage and Gleason score (pT3a and 7, respectively, each p>0.5), similar operative time (p=0.12), but lesser blood loss (p<0.001), shorter hospital stay (p <0.001) and more rapid convalescence (p=0.02) occurred in EERPE1. CONCLUSIONS: EERPE is feasible and efficacious even in elderly patients with unfavourable, large-volume disease. EERPE offers the advantages of decreased blood loss, shorter hospital stay and more rapid recovery over open radical prostatectomy. However, the observed higher incontinence rate in the elderly should be discussed preoperatively with the patient. Eur Urol Suppl 2006;5(2):91