451Early oncological results of transperitoneal versus extraperitoneal laparoscopic radical prostatectomy

451Early oncological results of transperitoneal versus extraperitoneal laparoscopic radical prostatectomy

449 450 ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY (EERPE) - O N C O L O G I C A L AND F U N C T I O N A L RESULTS A F T E R 5 0 0 PROCEDURES ...

170KB Sizes 0 Downloads 39 Views

449

450

ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY (EERPE) - O N C O L O G I C A L AND F U N C T I O N A L RESULTS A F T E R 5 0 0 PROCEDURES

EXTRAPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY Cathelineau X., Rozet F., Galiano M., Barret E., Vallancien G.

Stolzenburg J.U. l, Rabenalt R. 1, Do M. t , Dorschner W.I, Jonas U.~, Tml3M.2 Institut Montsouris, 75014, Paris, France ~University of Leipzig, Department of Urology, Leipzig, Germany, 2Hannover Medical School, Department of Urology, Hannover, Germany INTRODUCTION & OBJECTIVES: Laparoscopic radical prostatectomy (LRPE) has become the operative procedure of choice for patients with clinically localized prostate cancer in specialized urological centres. Despite many advantages one major drawback of LRPE is the transperitoneal route of access to the extraperitoneal located prostate. EERPE overcomes the disadvantages of transperitoneai surgery by remaining in a strictly extraperitoneal environment. We review our experience with endoscopic (totally) extraperitoneal radical prostatectomy (EERPE) as first line therapy for localized prostate cancer. MATERIAL & M E T H O D S : A total of 500 patients with clinically localized prostate cancer underwent EERPE. There were no specific selection criteria or specific contraindication for the procedure. The mean age was 63.7. The mean preoperative PSA level was 12.1 ng/ml (1.4 - 67 ng/ml). After preparation of the preperitoneal space with the help of a ballon trocar, the technique of EERPE duplicates the steps of classic open descending retropubic radical prostatectomy. RESULTS: The mean operative time was 149 minutes (range: 50-285 minutes); 282 without and 218 with lymph node dissection. There was no corivei'sion;the transfusion rate was 0.8%. 35.6% bf oui'patienis had:a prior surgery in the' louverabdomen (including laparoscopic mesh placement for hernia repair) or prior prostate surgery. There were 3 early reinterventions •(2x ~bl6eding,. 1' haematoma)~ and'8 ]ate reinterventions (5 symptomatic lymphoceles, 1 colostomy caused by rectal fistula, 1 port hernia and 1 anastomotic stricture). There were no other m~ijorcot~aplicati0ns. The overall reintervention rate was 2.2%. Pathological stage was pT2a in 67 patients (13.4%), pT2b in 94 patients (18.8%), pT3a in 273 patients (54.6%), pT3b in 62 patients (12.4%) and pT4 in 4 patients (0.8%). Positive surgical margins were found in 10.5% (17/161) of patients with pT2-tumour, and 33.4% (112/335) of patients with pT3 tumour. In 12 patients lymph node metastases were diagnosed. The mean catheterization time was 6.8 days. Six month postoperatively, 84.8 % of the patients were completely continent. After 3 months 27.3% and after 6 months 45.2% of the patients with bilateral nerv-sparing prostatectomy had sufficient erection for intercourse. CONCLUSIONS: The relatively high percentage ofpT3 tumours (67%) reflects the fact that no specific contraindications for this procedure were present and all patients with clinically localized disease underwent EERPE. The results of this seriesare promising as perioperative morbidity are very low and functional outcome compares favourably to other treatment options. Our data demonstrate that EERPE is an easy technique which can be performed with equal efficacy and results compared to LRPE while providing the benefits of totally extraperitoneal approach consequently avoiding intraperitoneal complications.

I N T R O D U C T I O N & OBJECTIVES: To describe our experience with the extraperitoneal approach for laparoscopic radical prostatectomy. M A T E R I A L & M E T H O D S : 600 laparoscopic radical prostatectomies were performed by an extraperitoneal approach, and evaluated prospectively. RESULTS: 599 Extraperitoneal procedures were performed successfully, conversion to a transperitoneal approach was necessary in 5 patients with a previous mesh hernia repair. Mean operative time was 173 minutes. Mean operative blood loss was 380 cc. The transfusion rate was 1.2%. There were 2 major complications (pulmonary embolism, pulmonary oedema), 9 intermediate complications (4 rectal injuries, 1 peritonitis, 2 infected pelvic hematomas, 1 vesico cutaneous fistula, 1 anastomotic stenosis), and 59 minor complications. The transfusion rate was 1.2%. The reoperation rate was 1.7%. Mean hospital stay was 6.3 days. Mean vesical catheterization lasted 7.6 days. Pathological stages were pT2a, pT2b pT2c pT3a and pT3b in 12, 8, 52, 19, and 9% respectively. Mean Gleason score was 7. The margins were positive in 14.6% of the pT2 and in 25.6% of the pT3 tumours. The median follow-up was 12 months, 95% of the patients had a PSA level < 0.2 ng/ml. No patient has presented clinical port site metastasis. Patients were evaluated by self questionnaire sent by mail, before and after the surgery (ICS, IIEF5). With a median follow-up of 12 months, 84% of the patients were continent (no pad). 7% of the patients used 1 precaution pad, and 7% had the need for 1 pad routinely. With a median follow-up of 6 months, among the preoperative potent patients (IIEF5 > 20), the postoperative erection and intercourse rate was 64% and 43% in patients with bilateral nerve bundle preservation respectively. CONCLUSIONS: The extraperitoneal technique is a reliable approach for laparoscopic radical prostatectomy.

451

452

EARLY O N C O L O G I C A L RESULTS OF T R A N S P E R I T O N E A L VERSUS EXTRAPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY

C O S T C O M P A R I S O N B E T W E E N L A P A R O S C O P I C AND R A D I C A L R E T R O P U B I C P R O S T A T E C T O M Y 1N A SINGLE INSTITUTION

Hoznek A , Sal0mon L , De La Taille A., Yion R., Vordos D., Abbou C.C.

Bozzola A., Simonato A., Gregori A., Lissiani A., Galli S., Acquati P., Radice R., Gaboardi F.

H6pital Henri Mondor, Service d'Urologie, Creteil, France I N T R O D U C T I O N & OBJECTIVES: To compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach. M A T E R I A L & METHODS: Between 1998 and 2004, 583 consecutive men underwent laparoscopic radical prostatectomy for localized prostate cancer. The first 235 procedures were performed by a transperitoneal approach, while the last 348 were performed with an extraperitoneal approach. Clinical stage, serum PSA, biopsy Gleason score, operative time, surgical and medical complications, estimated blood loss, length of hospital stay and catheterization time were recorded. Specimen weight, pathological stage (1997 TNM classification) and margin status were also noted. The Fisher test as welt as the Chi square test was used for statistical analysis. Differences were considered significant when p<0.05. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics except for biopsy Gleason score which was higher in the extraperitoneal group (p<0.0001). The operating time was longer with the transperitoneal approach (260 min vs. 202 min, p<0.0001). There was no significant difference in transfusion rate among the transperitoneal and extraperitoneal approach, respectively (2.2% vs. 4.4%, p=0.6). In addition, there were no differences in hospital stay, medical complications, or surgical complications. The differences in margin positivity among patients in the transperitoneal and extraperitoneal treatment groups were nonsignificant among pT2 (16.6% vs. 15.8%, p= 0.40) and pT3 (43.3% vs. 8.7%, p= 0.89) tumours respectively. CONCLUSIONS: Based on these results, the extraperitoneaI approach to laparoscopic radical prostatectomy offers the same early oncological results as the transperitoneal approach and can be performed with a shorter operative time.

"1. Sacco" Hospital, Urology, Milan, Italy I N T R O D U C T I O N & OBJECTIVES: Laparoscopic radical prostatectomy (LRP) is emerging for the surgical treatment of prostate neoplasms but the retropubic approach to radical prostatectomy (RRP) is still the most widely used in patients with clinically localized prostate cancer. Cost is one of the drawbacks of laparoscopy when compared with open surgery. The aim of our study is to compare the costs of LRP and of RRP at our Institution. MATERIAL & METHODS: We considered the last 50 patients with prostate cancer who underwent laparoscopic or retropubic radical prostatectomy at our Institution. Surgery was performed by 2 surgeons with large experience in both techniques. Intra-institutional costs were provided b y our institutional billing office and operating room (OR) administration. Capital equipment costs were excluded since none of these items are used solely for prostatectomy. We evaluated the costs of: hospital stay, surgical consumables and OR occupation. Professional fees are included in the cost of hospital stay and OR occupation. At our Institution one day of hospital stay costs • 625 while one hour of OR costs £ 520. RESULTS: Mean time for the setting up and occupation of the OR was nearly 60 minutes and was the same for both procedures. Mean OR occupation time for LRP and RRP was respectively 180 and 120 minutes. Mean hospital stay for LRP and RRP was respectively 4 and 6 days. Surgical consumables costs for LRP and RRP were respectively E 637 and E 270. The total costs of considered issues are t~ 5217 for LRP and E 5580 for RRP. CONCLUSIONS: LRP and RRP are very similar in terms of cost at our Institution. In fact, LRP has proved to be almost as competitive as RRP. However, LRP has a cost advantage of C 363 over RRP. The benefit of laparoscopy or of open surgery for radical prostatectomy should not be evaluated in terms of economic costs.

European Urology Supplements 4 (2005) No. 3, pp. 115