Is laparoscopy dying for radical prostatectomy?

Training in laparoscopic urology, extensive experimental work, and dedicated surgical performance constitute the foundation of advanced laparoscopic urology, which is currently a reasonable surgical option in pediatrics, reconstructive surgery, and oncology. This article discusses topics related to laparoscopic approaches for radical prostatectomy, focusing on their introduction, development, accomplishments, and current standards and future goals for the minimally invasive treatment of urologic diseases. We highlight the dynamic status of the laparoscopic approach for radical prostatectomy (pure or roboticassisted) that constitutes one of the most rapidly evolving fields in urology.     

Calf compartment pressures in the Lloyd-Davies position: a cause for concern?

Lower limb compartment syndrome is a rare consequence of surgery where the lithotomy position is maintained for several hours. The aim of this study was to observe the effect of the lithotomy position on lower limb compartment pressure and blood flow to the lower limb in surgical patients having colorectal procedures. We prospectively studied 23 patients undergoing colorectal surgery requiring the lithotomy position and recorded lower limb compartment pressure, and the blood pressure in the upper and lower limbs. The lithotomy position led to a significant (p < 0.001) fall in blood pressure to the lower limb from 87 (SD 16) mmHg to 67.9 (SD 12) mmHg and a significant (p < 0.001) rise in lower limb compartment pressure from 13 (SD 7) mmHg to 31 (SD 12) mmHg. These two effects compromise blood flow to the lower limb in long surgical procedures where the lithotomy position is required. Intermittently lowering the legs and restoring blood flow may prevent compartment syndrome developing.     

Laparoscopic radical prostatectomy: a marketing or surgical strategy?

The aim of the present review is to compare the advantages and the disadvantages of radical perineal, retropubic and laparoscopic prostatectomy with a close look at the laparoscopic procedure, an operation which has gained much attention in the urological world over the last 3 years. Also reviewed are the motivations, in terms of real advantages for the patient and the needs of the urological 'market', that push the urologist towards using the laparoscopic technique instead of the radical retropubic or radical perineal prostatectomy.     

Salvage radical prostatectomy for radio-recurrent prostate cancer: is this a viable option?

The role of salvage prostatectomy for radio-recurrent prostate cancer remains unclear. Recurrent prostate cancer after radiation therapy is in many cases biologically aggressive. It is unclear whether the biologic aggressiveness of radio-recurrent prostate cancer is due to time-dependent cancer clonal evolution (potentially induced by radiation damage), or is due to an innately aggressive tumor secondary to overexpression or mutation of apoptotic inhibitors that render these tumors resistant to radiation. Recent studies examined the role of DNA ploidy, p53 and bcl-2 expression, proliferative indices and glutathione S-transferase-pi in predicting response to radiation therapy or salvage prostatectomy. Because of the potential for significant morbidity after salvage prostatectomy, preoperative parameters that aid in the identification of the patients who are most likely to benefit from surgery are needed.     

Is a cystogram necessary after radical prostatectomy?

Background: Improvements in the surgical technique of radical prostatectomy have allowed the length of postoperative catheterization to be reduced dramatically over the past 20 years. Today, many surgeons perform a cystogram to ensure the anastomosis is watertight before an ‘early’ (day 7 or less) trial of void (TOV). We aim to show that achieving an intraoperative watertight anastomosis may preclude the need for routine cystogram prior to TOV. Methods: Between 31 May 1999 and 29 February 2004, we performed a prospective study of 68 consecutive patients who underwent radical prostatectomy by a single surgeon. We tested the vesicourethral anastomosis for watertightness intraoperatively by instilling 250 mL of normal saline in to the bladder and compared this with evidence of extravasation on the cystogram on day 7. Results: Fifty‐four (79.4%) of the 68 patients had a watertight anastomosis intraoperatively. All men had a cystogram on day 7 (6?9 days). Sixty (88.2%) of these cystograms showed no evidence of extravasation. Three men (4.4%) who had evidence of a leak on their cystogram had achieved a watertight anastomosis intraoperatively. However, one of these men had suffered a postoperative septicaemia which may have jeopardized the anastomosis. Only two (2.9%) of the 68 patients had unsuspected extravasation at their day 7 cystogram. Therefore, 97.1% of patients (95% Confidence Interval: 95.1%?99.2%) could be suitably managed by our proposed protocol. Conclusion: Achieving an intraoperative watertight anastomosis is a very good predictor of a watertight cystogram on day 7. It seems feasible to avoid routine cystograms prior to TOV in the absence of other postoperative complications.     

Periurethral collagen injections for incontinence following radical prostatectomy: does the patient benefit?

Promising early results have been reported with periurethral collagen injections in the treatment of incontinence after radical prostatectomy. However, a significant proportion of patients does not benefit from this minimally invasive option. Recently, the results of longer follow-up studies have become available in some series. Investigators have also attempted to identify the prognostic factors of success. This review reports the latest advances on periurethral collagen injections in the treatment of incontinence after radical prostatectomy.     

Is the location of a positive surgical margin after radical prostatectomy important for prognosis?

This Practice Point commentary discusses the findings and limitations of the study by Eastham and co-workers, which concludes that the location of a positive surgical margin after radical prostatectomy is important for prognosis. The study found that posterolateral margins markedly increased the risk of biochemical failure while apical margins did not. Posterolateral margin status was found to be even more important for predicting biochemical failure than was lymph node positivity or seminal vesicle invasion. For several reasons, however, these results might not be generalizable to other groups of patients or to clinically relevant end points, such as cancer-specific survival. Consequently, these data should be regarded as preliminary and should not inform therapeutic decisions. Instead, knowledge of the most-common sites of margin positivity might direct surgeons to examine any shortcomings in their surgical technique. We contend that positive margins can be prevented at even the most difficult-to-access locations if appropriate steps are taken.     

Visual estimation of the tumor volume in prostate cancer: a useful means for predicting biochemical-free survival after radical prostatectomy?

Absolute and relative (ratio absolute tumor volume to gland volume) tumor volumes were visually estimated in 528 prostatectomy specimens. Surveying a mean post-surgical follow-up of 49 months, both parameters were analyzed regarding their aptitude for prognostication. We found relative tumor volumes exceeding 25% to independently predict biochemical recurrence reflected by post-surgical prostate-specific antigen progression, which was also determined to be increased to 28% when absolute tumor volumes exceeded 10 cm(3). However, this cutoff failed to be an independent prognosticator. Because the visual estimation of both parameters can easily be performed, they are felt to be formidable candidates for deriving prognostic information during routine procedures.     

Predictors for immediate recovery of continence following Retzius-sparing robot-assisted radical prostatectomy: a case–control study

International Urology and Nephrology - We evaluated urinary continence in a series of consecutive patients who underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) to identify...     

Urethral stricture disease after bipolar prostatectomy: Is it a concern?

Introduction

bipolar Transurethral Surgery of Prostate (BTUSP) is growing increasingly popular in the management of Benign prostatic hyperplasia related lower urinary tract symptoms (BPH-related LUTS). Compared to monopolar transurethral resection of the prostate (TURP), BTUSP has the potential advantages of less toxicity related to irrigation fluid absorption, and better hemostasis. However, there have been reports of BTUSP being associated with increased incidence of urethral stricture disease (USD). We aim at 2 years results of B-TUSP with special emphasis on USD and continence.

Venous thromboembolism in radical prostatectomy: is heparinoid prophylaxis warranted?

OBJECTIVE: To review the incidence of venous thromboembolism (VTE) after radical retropubic prostatectomy (RRP) and evaluate the need for heparinoid prophylaxis as opposed to mechanical compression devices after RRP. PATIENTS AND METHODS: RRP is classified as a category 1 (high risk) procedure for VTE by the American College of Chest Physicians and several international guidelines recommend subcutaneous heparinoids as the preferred prophylaxis. However, this regimen may be associated with a greater risk of bleeding. We have not used heparinoid prophylaxis but place a mechanical compression device for prophylaxis of VTE, and report our clinical experience over a 12-year period. Between 1992 and 2004, all RRPs carried out by one surgeon (M.S.S.) at our centre were retrospectively reviewed after obtaining institutional review board approval. The protocol for prophylaxis of VTE consisted of compression stockings and a sequential compression device from the time of entry into the operating room until complete ambulation (we encourage early ambulation). Patients were evaluated for VTE if they developed any clinical signs or symptoms. Patients were followed at 7 days, 6 weeks and 3 months after RRP in the first year and 6-monthly thereafter. All relevant clinical data and complications were entered in a database. RESULTS: In all there were 1364 RRPs; the mean (sd) age of the patients was 61 (7) years and the mean follow-up 44 (38) months. All patients had a mechanical compression device and ambulated on the first day after surgery. None received heparinoid prophylaxis. Three VTE events were identified (0.21%); two patients had a lower limb VTE and one an upper limb VTE. All were successfully treated with anticoagulation. No patient had a documented pulmonary embolus and none died from VTE. There was one death after RRP, from myocardial infarction. CONCLUSION: The incidence of VTE after RRP is low, possibly related to the use of a mechanical compression device and early aggressive mobilization. Despite the recommendations by some, we feel that routine heparinoid prophylaxis is questionable.     

Osteochondritis dissecans of the femoral head in Perthes disease: a cause for concern?

Osteochondritis dissecans (OCD) and loose body formation are rare following Perthes' disease. We have reviewed the literature about clinical presentation, treatment and outcome and added a further three cases of the condition. Cases mentioned in the literature were poorly documented. We feel that a thorough documentation should be carried out as soon as the diagnosis is made. Conservative treatment should be given when the disability is moderate. The loose body should only be removed surgically when it is mobile, when it bulges into the joint space or when there are signs of early arthritis.     

Is radical prostatectomy primarily a surgical debulking procedure?

Radical prostatectomy has been considered the gold standard for the curative treatment of clinically localized prostate cancer. After an extensive review of the literature, we concluded that surgery probably functions primarily as a tumor debulking procedure rather than a curative one. Morphometric studies suggest that the majority of patients undergoing surgery have tumors too large for cure. Histologic studies demonstrate that 55% of radical prostatectomy specimens show evidence of extraprostatic disease and approximately 15% have tumors so small that a clinical impact on longevity is unlikely. Thus, only 30% of patients have surgery that is clearly beneficial on a histopathologic basis. Given the rather long doubling time of prostate cancers, many patients with residual cancer following surgery die of other causes, giving the false impression of cure. However, long-term studies in men with positive surgical margins have demonstrated that the majority die from prostate cancer. Furthermore, using prostate specific antigen as a measure of progression, the biochemical disease-free survival rates are substantially lower than the cause-specific survival rates. Although radical prostatectomy may be the best tumor debulking procedure available, it is associated with substantial morbidity and cost. This information is important for both physician and patient when deciding on management of prostate cancer.