Laparoscopic versus open radical prostatectomy: a comparative study at a single institution

PURPOSE: There is an ongoing debate about the benefits of laparoscopic radical prostatectomy compared to the open retropubic approach. We compared the last 219 patients treated with open retropubic prostatectomy with 438 patients treated with laparoscopic radical prostatectomy at our institution, focusing on operative data, complications and mid-term outcome. MATERIALS AND METHODS: From December 1994 to November 1999 a total of 219 patients were treated with open prostatectomy and pelvic lymph node dissection (group 1). From March 1999 to September 2002, 219 patients underwent early (group 2) and 219 underwent late (group 3) laparoscopic radical prostatectomy and pelvic lymph node dissection. The same surgeons performed both operations. All 3 groups were similar with respect to mean patient age, mean prostate specific antigen value, median Gleason score, previous transurethral resection of the prostate and neoadjuvant treatment, although there was a slight stage shift in favor of the 2 laparoscopic groups. RESULTS: Mean operating time was significantly shorter after open surgery (196 minutes) compared to the early laparoscopic group (288) but it did not differ significantly from the late laparoscopic group (218). Mean blood loss (1,550 versus 1,100 versus 800 cc) and transfusion rates (55.7% versus 30.1% versus 9.6%) in groups 1 to 3 favored the laparoscopic groups. The complication rate in groups 1 to 3 was lower for laparoscopy (19.2% versus 13.7% versus 6.4%), but the spectrum differed. The early laparoscopic group had a higher incidence of rectal injuries (1.8% versus 3.2% versus 1.4% in groups 1 to 3, respectively) and urinary leakage (0.5% versus 2.3% versus 0.9%), whereas more lymphoceles (6.9% versus 0% versus 0%), wound infection (2.3% versus 0.5% versus 0%), embolism/pneumonia (2.3% versus 0.5% versus 0.5%) and anastomotic strictures (15.9% versus 6.4% versus 4.1%) occurred after open surgery. The amount of postoperative analgesia was significantly greater after open surgery (50.8 versus 33.8 versus 30.1 mg. in groups 1 to 3, respectively). Median catheter time was longer after open retropubic prostatectomy (12 versus 7 versus 7 days in groups 1 to 3, respectively) but the continence rates were similar in all 3 groups at 12 months (89.9% versus 90.3% versus 91.7%). The rate of positive margins did not differ significantly in groups 1 to 3 (28.2% versus 21.0% versus 23.2%), prostate specific antigen recurrence was equivalent related to the different observation periods. CONCLUSIONS: Laparoscopic radical prostatectomy is technically demanding, with an initially longer operative time, higher incidence of rectal injuries and urinary leakage. The overall outcome after 219 cases favors the laparoscopic approach. Consequently, at our institution laparoscopic radical prostatectomy has become the method of choice.     

Experience of laparoscopic paraesophageal hernia repair at a single institution

BackgroundParaesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy.MethodsBetween January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients.ResultsThe average length of the surgery was 125 minutes (range, 51–304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1–14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%.ConclusionsLaparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.     

Chemotherapy for small-bowel Adenocarcinoma at a single institution

Purpose  Small-bowel adenocarcinoma (SBA) is rare. No standard chemotherapy for this type of cancer has yet been established. At Cancer Institute Hospital (CIH), the chemotherapy regimen used for colorectal cancer is initially used for patients with SBA, followed by that used for gastric cancer. Methods  Patients with advanced or recurrent SBA who had been treated with chemotherapy in CIH were retrospectively analyzed. The first-line treatments were fluoropyrimidines used alone or in combination with other drugs, such as 5-fluorouracil plus leucovorin (FL), UFT-E, or TS-1. The second-line treatment was irinotecan (CPT-11) monotherapy. Results  Fluoropyrimidine-based regimens, mainly FL, were used for 10 patients. Seven patients received the second-line CPT-11 regimen. Disease control was seen in five patients (50%) with the first-line chemotherapy and in three (43%) with the second-line. The median overall survival time was 12 months (range 3–39). The treatments were generally tolerated. Gastrointestinal symptoms were the most common adverse effects. Conclusions  Fluoropyrimidines as the first-line and CPT-11 as the second-line chemotherapy yielded low response, although the adverse effects were mild. The FOLFOX and FOLFIRI regimens such as those used for metastatic colorectal cancer are potential alternative strategies. Extensive trials are needed to develop standard chemotherapy with new drugs.     

One hundred pancreas transplants at a single institution.

Clinical pancreas transplantation at the University of Minnesota began in 1966. An initial series of 14 whole pancreas grafts was reported in part to the American Surgical Association in 1970. Only one patient survived for more than 1 year with a functioning graft. Twenty attempts at islet allotransplantation in the mid-1970s were unsuccessful. In 1978 we resumed performing pancreas transplants by the segmental technique, allowing the use of related donors. The current series (July 25, 1978 to December 20, 1983) includes 86 pancreas transplants (51 cadaver, 35 related) in 75 patients (41 with and 34 without previous kidney grafts). Variations in management of the pancreatic duct include three ligated, 15 duct-open, 39 duct-injected, and 29 pancreaticojejunostomies. The latter technique is currently preferred. Currently (April 1984) 61 patients are alive (81%), 24 have functioning grafts (32%), and 21 are insulin-independent (28%), three with open-duct grafts for 4.4 to 5.7 years, seven with silicone-injected grafts from 10 to 39 months, and 14 with pancreaticojejunostomies for 3 to 31 months; 15 of the grafts have functioned for greater than 1 year. Twenty-two of the grafts (25%) failed for technical reasons (thrombosis, infection, or ascites); 35 grafts functioned for 1 to 13 months before totally failing from either rejection, fibrosis, or recurrent disease; five patients died with functioning grafts. The graft survival rate has been higher for pancreases from related (15/35, 43% functioning) than from cadaver (9/51, 18% functioning) donors. The success rate has increased, e.g., 11/22 recipients of pancreas transplants in 1983 currently have functioning grafts (50%). Metabolic studies show most patients with functioning grafts to be euglycemic; however, three of 24 have chronic hyperglycemia unless supplemented with insulin, but they are no longer ketosis-prone. Glucose tolerance test results are normal or nearly normal in 12 and abnormal in 12 of the recipients with currently functioning grafts. Regression of diabetic nephropathy has been documented in two long-term recipients. Pancreas transplantation is currently applicable as treatment for selected diabetics who have demonstrated their propensity to develop serious secondary complications.     

Predictors of positive surgical margins at open and robot-assisted laparoscopic radical prostatectomy: a single surgeon series

Robot-assisted laparoscopic radical prostatectomy (RALRP), increasingly used to treat localized prostate cancer, has advantages over open radical prostatectomy (ORP) in terms of reduced bleeding and quicker convalescence. However, debate continues over whether RALRP provides superior or at least equivalent surgical outcomes. This study compares positive surgical margins (+SM), as a surrogate for long-term cancer control, at RALRP and ORP performed by a single experienced surgeon during the process of taking up RALRP. 400 consecutive patients undergoing surgery for prostate cancer under a single surgeon (DW) between November 1999 and July 2009 were studied. Prior to July 2005, all patients underwent ORP; after this date, most patients were treated by RALRP. Data were collected by retrospective chart review and analysed independently of the treating surgeon. +SM were defined as the presence of cancer at an inked surface. Overall, 23 (11.5%) of 200 patients undergoing RALRP had +SM, compared to 40 (20.0%) of 200 patients undergoing ORP (P?<?0.05). On univariate logistic regression analysis, in addition to surgical approach (odds ratio [OR]?=?1.92), patient age (OR?=?1.05), pathologic stage (OR?=?3.93) and specimen Gleason (GS) score (OR?=?1.86) were significant predictors of +SM. On multivariate analysis, surgical approach, p-stage and specimen GS remained significant predictors of +SM. RALRP is associated with lower rates of +SM compared to ORP, even after adjusting for other known risk factors. Of note, the RALRP in this study were part of the surgeon??s learning curve.     

单一术者机器人辅助单孔腹腔镜前列腺癌根治术学习曲线分析

目的 评估单一术者在不同时间段开展的机器人辅助单孔腹腔镜前列腺癌根治术（sp-RALP）之手术效果,探讨该手术方式的学习曲线。方法 回顾性分析南京中医药大学附属医院2020年1月至2020年12月由同一手术医师连续完成的100例sp-RALP的临床资料。按时间顺序将患者分为5组（A组即第一阶段组为第1～20例,B组即第二阶段组为第21～40例,C组即第三阶段组为第41～60例,D组即第四阶段组为第61～80例,E组即第五阶段组为第81～100例）,比较5组间的手术时间、术中出血、引流管留置时间、术后住院天数等方面的差异。结果 随术者经验例数的累积,手术时间、术中出血量均呈下降趋势,A、B两组与C、D、E三组间分别对比差异均有统计学意义（P均<0.05）,A组与B组间对比仅手术时间的差异存在统计学意义（P<0.05）,C、D、E三组间两两对比差异均无统计学意义（P均>0.05）;而引流管留置时间、术后住院天数各组间研究的差异均无统计学意义（P均>0.05）。结论 机器人辅助单孔腹腔镜前列腺癌根治术（sp-RALP）学习曲线相对陡峭,大约在40例手术经验积累之后基本...     

Karolinska prostatectomy: a robot-assisted laparoscopic radical prostatectomy technique

OBJECTIVE: The last decade has witnessed an increasing trend towards minimally invasive management of prostate cancer, including laparoscopic and, more recently, robot-assisted laparoscopic prostatectomy. Several different laparoscopic approaches have been continuously developed during the last 5 years and it is still unclear which technique yields the best outcome. We present our current technique of robot-assisted laparoscopic radical prostatectomy. MATERIAL AND METHODS: The technique described has evolved during the course of >400 robotic prostatectomies performed by the robotic team since the robot-assisted laparoscopic radical prostatectomy program was introduced at Karolinska University Hospital in January 2002. SURGICAL PROCEDURE: Our procedure comprises several modifications of previously reported ones, and we utilize fewer robotic instruments to reduce costs. An extended posterior dissection is performed to aid in the bladder neck-sparing dissection. In nerve-sparing procedures the vesicles are divided to avoid damage to the erectile nerves. In order to preserve the apical anatomy the dorsal venous complex is incised sharply and is first over-sewn after the apical dissection is completed. CONCLUSIONS: Our technique enables a more fluent dissection than previously described robotic techniques. Minimizing changes of instruments and the camera not only cuts costs but also reduces inefficient operating maneuvers, such as switching between 30 degrees and 0 degrees lenses during the procedure. We present a technique which in our hands has achieved excellent functional and oncological results.     

Radical prostatectomy for high-risk clinically localized prostate cancer: a prospective single institution series

Objective:

The objective of this paper is to report on the pathologic and biochemical progression-free outcomes of patients who underwent radical prostatectomy for high-risk localized prostate cancer.

Methods:

Data was collected prospectively from 299 patients who underwent radical prostatectomy for high-risk clinically localized prostate cancer by 2 surgeons at a single institution. High risk was defined as 1 or more of 3 adverse factors: prostate-specific antigen (PSA) >20, biopsy Gleason score 8 to 10 and clinical stage T3. PSA recurrence was defined as PSA >0.4 ng/mL or any salvage therapy.

Results:

Median age was 63.3 years (46.1–75.9). Median follow-up was 4.7 years (range 0.5–17.3 years). PSA at diagnosis was >20 ng/mL in 31.4%. Biopsy Gleason score was 8 to 10 in 66.9%. Clinical stage was T3 in 24.4%. 81.6% of patients had a single baseline risk factor, 15.7% had 2 risk factors and 2.7% had all 3 risk factors. Neoadjuvant therapy was administered to 184 patients (61.5%). Pathologic stage was organ-confined in 39.6%, specimen-confined in 26%, non-specimen-confined in 26.4%, and 8% had lymph node positive disease. Overall survival, cancer-specific survival and biochemical progression-free survival was 99%, 99.67% and 70.2%, respectively. Univariate analysis showed that PSA at diagnosis, percentage of cores positive and number of risk factors were predictors of PSA recurrence (p < 0.05). Multivariate analysis showed that PSA at diagnosis was an independent predictor of PSA recurrence (p < 0.05).

Conclusion:

Radical prostatectomy is associated with favourable biochemical progression-free, clinical and overall survival in selected men with high-risk localized prostate cancer, and should therefore be considered an option in these patients. Baseline PSA >20 ng/mL is a significant independent predictor of PSA recurrence.     

Experience with 247 living related donor nephrectomy cases at a single institution in Japan

There is currently much concern over the morbidity and mortality of donors undergoing nephrectomy for living related renal transplants. Between April, 1970 and July, 1986, 247 cases of living related renal transplants were performed at the Second Department of Surgery, Kyoto Prefectural University of Medicine. The average age of the donors was 50.3 +/- 9.7 years, 81 per cent of the donors being parents of the recipients. Minor abnormalities which did not affect the donors suitability were found in 71 cases. Nephrectomies were performed extraperitoneally in all cases. Peri-operative complications, including wound complications in 13 cases, urinary infection in 12 cases and pulmonary complications and arrhythmia in 4 cases, were considered to be minor in nature. A variety of renal function tests, carried out two weeks after nephrectomy revealed normal levels, although they had become slightly worse than those estimated pre-operatively. Long-term sequelae in the follow-up period from 18 months to 16 years and 2 months, was studied on 124 donors who answered questionnaires. Currently, there are 5 late deaths, none of which are directly related to the nephrectomy. Of the 124 donors, 85.5 per cent stated that there had been no change in their physical states following surgery. Pain or a feeling of discomfort at the wound site was reported by 10 donors (8.1 per cent) and hypertension was observed only in 3 (2.4 per cent). No major complication directly related to the donor nephrectomy was found, except for one case of incisional hernia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experience with 247 living related donor nephrectomy cases at a single institution in Japan

There is currently much concern over the morbidity and mortality of donors undergoing nephrectomy for living related renal transplants. Between April, 1970 and July, 1986, 247 cases of living related renal transplants were performed at the Second Department of Surgery, Kyoto Prefectural University of Medicine. The average age of the donors was 50.3±9.7 years, 81 per cent of the donors being parents of the recipients. Minor abnormalities which did not affect the donors suitability were found in 71 cases. Nephrectomies were performed extraperitoneally in all cases. Peri-operative complications, including wound complications in 13 cases, urinary infection in 12 cases and pulmonary complications and arrythmia in 4 cases, were considered to be minor in nature. A variety of renal function tests, carried out two weeks after nephrectomy revealed normal levels, although they had become slightly worse than those estimated pre-operatively. Long-term sequalae in the follow-up period from 18 months to 16 years and 2 months, was studied on 124 donors who answered questionnaires. Currently, there are 5 late deaths, none of which are directly related to the nephrectomy. Of the 124 donors, 85.5 per cent stated that there had been no change in their physical states following surgery. Pain or a feeling of discomfort at the wound site was reported by 10 donors (8.1 per cent) and hypertension was observed only in 3 (2.4 per cent). No major complication directly related to the donor nephrectomy was found, except for one case of incisional hernia. The donor nephrectomy operation thus appeared to be quite safe, and successful long-term sequelae can be obtained if the donor is selected carefully, according to the strict prospective evaluation of medical state and renal functions.