Pure laparoscopic and robotic-assisted laparoscopic radical prostatectomy in the management of prostate cancer.

BACKGROUND: Until recently, open radical prostatectomy was the only approach for the surgical management of prostate cancer. Laparoscopy is now increasingly used as an alternative approach. The procedure can be performed directly or with robot assistance. METHODS: We review the relevant literature regarding oncologic and functional outcomes with laparoscopic surgery in the management of localized prostate cancer. RESULTS: Oncologic and functional outcomes are similar between open and laparoscopic radical prostatectomy. Pure laparoscopic prostatectomy and robotic assisted laparoscopic prostatectomy result in less blood loss and shorter convalescence. Costs associated with the initial investment, disposables, and maintenance of the robot system are higher than for pure laparoscopic prostatectomy. CONCLUSIONS: Laparoscopic radical prostatectomy, either pure or robotic, is becoming the preferred approach for the surgical management of localized prostate cancer. Oncologic and functional outcomes are similar to the open approach.     

Open, laparoscopic and robotic radical prostatectomy: Optimizing the surgical approach

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery.     

Offene, laparoskopische und roboterassistierte radikale Prostatektomie im Vergleich

Based on the available literature, neither open nor laparoscopic nor robot-assisted radical prostatectomy demonstrates advantages in post-operative results relative to the other technique. However, the follow-up of the laparoscopic and the robot-assisted technique is still too short to allow conclusions to be drawn on cancer control. The functional results regarding post-operative continence and potency demonstrate comparable rates for each of the techniques. However, the comparison between the studies is complicated by the lack of standardized endpoints and methodology. The data suggest that the expertise and experience of the surgeons and the centres are the most important variables influencing post-operative results of radical prostatectomy, as most of the specialized centres report good results. This emphasizes the need for prostate cancer centres, in order to reduce costs and side effects related to the treatment and in order to improve post-operative quality of life of patients.     

Open radical retropubic prostatectomy 2007: the true minimally invasive surgery for localized prostate cancer?

The introduction of robotic laparoscopic assisted prostatectomy at our institution and nationwide has been a great advancement and has caused us to focus and fine-tune our goal for improvements in prostate cancer outcomes whether the patient elects for robotic laparoscopic assisted prostatectomy or open minimally invasive radical retropubic prostatectomy. While these authors favor the open technique performed by highly skilled urologic surgical oncologists, the lessons we have learned to date suggest that it is the skill of the surgeon that determines outcome, regardless of whether or not the operation is performed by an open or robotic laparoscopic technique. The concepts we have articulated here are related to resection and avoidance of positive margins, limited intraoperative blood loss and pain control, which allow equivalence in these outcome areas, regardless of technique.     

Open radical retropubic prostatectomy 2007: the true minimally invasive surgery for localized prostate cancer?

The introduction of robotic laparoscopic assisted prostatectomy at our institution and nationwide has been a great advancement and has caused us to focus and fine-tune our goal for improvements in prostate cancer outcomes whether the patient elects for robotic laparoscopic assisted prostatectomy or open minimally invasive radical retropubic prostatectomy. While these authors favor the open technique performed by highly skilled urologic surgical oncologists, the lessons we have learned to date suggest that it is the skill of the surgeon that determines outcome, regardless of whether or not the operation is performed by an open or robotic laparoscopic technique. The concepts we have articulated here are related to resection and avoidance of positive margins, limited intraoperative blood loss and pain control, which allow equivalence in these outcome areas, regardless of technique.     

Robotic-assisted laparoscopic prostatectomy: do minimally invasive approaches offer significant advantages?

Radical prostatectomy has maintained a cardinal role in the treatment of localized prostate cancer. Robotic-assisted laparoscopic prostatectomy (RALP) has been introduced as a less invasive surgical approach. Available data on RALP versus open approaches were reviewed for surgical and cancer related outcomes. RALP is consistently associated with decreased blood loss and limited postoperative pain and hospital stay. Surgical margins seem similar between most reported series of RALP or open radical prostatectomy. Most intrainstitutional comparisons demonstrate better postoperative continence and potency with RALP, but there is still debate about whether results are superior to radical retropubic prostatectomy in the hands of a highly experienced surgeon. RALP provides outcomes at least comparable, and, in some measures, superior to open surgery. Refinements of instrumentation may provide even better results in the future.     

Robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy(RARP)has emerged in the last decade. It has greatly improved clinical management of localized prostate cancer. Its use has been justified by its satisfactory oncological and functional outcomes and its fewer perioperative complications. RARP has the advantages of both conventional open radical retropubic prostatectomy and laparoscopic radical prostatectomy. However, its increased cost and the lack of tactile sensation it induces still remain problems.     

Nerve-sparing techniques in open and laparoscopic prostatectomy

Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.     

Nerve-sparing techniques in open and laparoscopic prostatectomy

Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.     

腹膜外入路腹腔镜前列腺癌根治术六例报告

探讨经腹膜外入路腹腔镜前列腺癌根治术的初步经验。采用经腹膜外入路对6例确诊为局限性前列腺癌的患者施行腹腔镜前列腺癌根治术,手术切除前列腺、精囊、输精管壶腹以及部分膀胱颈,然后行膀胱尿道吻合。结果6例手术均获得成功,手术时间270~420min,平均350min,术中出血量250~600mL,平均480mL,术后48h内胃肠功能恢复,术后2~3d下床活动,术后住院时间7~12d,平均8·5d。术后随访3~8个月,无尿失禁,3例术前有勃起功能的患者,2例术后可有满意的性生活。1例出现膀胱尿道吻合口狭窄,定期尿道扩张,排尿通畅。初步研究结果提示,经腹膜外入路腹腔镜前列腺癌根治术创伤小、对肠道无干扰和患者术后恢复快,可以成为治疗局限性前列腺癌的较好方法。     

机器人辅助在前列腺癌外科治疗的研究进展

前列腺癌发病率和死亡率逐年升高,开放性根治性前列腺切除术仍是局部晚期前列腺癌的治疗金标准。近年来,腹腔镜和机器人辅助前列腺切除术等微创技术已广泛应用,与传统开放性手术比较,其在肿瘤切缘控制、尿控能力和性功能等方面取得巨大进步。另外机器人辅助前列腺切除术在改善患者功能学方面更具优势。本综述就根治性前列腺切除术的发展、不同手术入路的选择、围手术期并发症、肿瘤学、功能学及学习曲线等方面阐述机器人运用在前列腺癌根治术中的进展。     

Counterpoint: robot-assisted laparoscopic prostatectomy: perhaps the surgical gold standard for prostate cancer care

Robot-assisted laparoscopic prostatectomy (RALP) has gained immense popularity. This article examines the most critical outcome measures in prostate cancer surgery and shows the reasons why this technique is gaining in popularity. Operative time, length of stay, blood loss, transfusions, postoperative pain, continence, potency, and cancer control all favor or tend toward improvement and benefit in RALP compared with traditional radical retropubic prostatectomy. In addition, as even greater experience and technological improvements are incorporated, further outcome improvements will be appreciated. RALP is now an accepted treatment option for prostate cancer and may soon be the most desirable treatment of prostate cancer patients.     

后腹腔镜肾癌根治术治疗43例肾癌的临床报告

背景与目的:随着腹腔镜技术的发展,越来越多的肾癌患者接受腹腔镜手术的方法替代传统的开放手术,本研究介绍对后腹腔镜肾癌根治术的手术方法改良及疗效评价.方法:2003年11月至2006年8月使用免水囊扩张建立操作通道及Hem-o-lok结扎锁处理肾动静脉的方法行后腹腔镜肾癌根治术43例(简称腔镜组).同时期行开放性肾癌根治术患者34例(简称开放组),比较两组疗效.结果:腔镜组与开放组手术时间比较差异无统计学意义(149 min vs.140 min,P=0.24),腔镜组术中出血量显著少于开放组(53 ml vs.199 ml,P＜0.01),腔镜组术后肠功能恢复时间、引流管留置时间、下床活动时间及住院时间显著短于开放组(P＜0.01),腔镜组术中、术后未发生明显并发症,开放组2例出现术后切口感染.随访1～32个月,腔镜组未出现复发或转移,开放组1例出现肺部转移.结论:后腹腔镜肾癌根治术具有创伤小、术后恢复快的优点,用免水囊扩张方法建立腹膜后操作通道安全可行,疗效可靠.用Hem-o-lok结扎锁处理肾动静脉安全可靠,经济实用.     

Radical retropubic prostatectomy accompanied with inguinal hernioplasty via preperitoneal approach

Radical prostatectomy is now widely practiced in the treatment of prostatic cancer (PC). If PC patients have inguinal hernia, hernioplasty can be made simultaneously with radical prostatectomy without one more surgical approach. The article presents pathogenetic rationale of hernioplasty from preperitoneal approach and an original technique of the simultaneous operation. Positive experience with 32 radical prostatectomies with hernioplasty is described.     

Laparoscopic and robotic radical prostatectomy

Radical retropubic prostatectomy is the current gold standard for surgical removal of the prostate gland. Recently, laparoscopic radical prostatectomy has been developed in an attempt to decrease surgical morbidity, and the technical difficulty of laparoscopy has been countered with the development of the da Vinci robotic interface. Studies that have compared the minimally invasive approaches with the traditional open approach have reported comparable perioperative outcomes. While long-term oncological data are available for open prostatectomy, there are only short-term studies available for laparoscopic prostatectomy. Functional outcomes, including urinary continence and sexual function, appear to be similar between the surgical approaches in the short term. However, currently, costs appear to favor open surgery, with the da Vinci-assisted prostatectomy having the highest expenses. Longer-term data are required to confidently determine the optimal balance between morbidity, oncological efficacy, functional outcomes and cost among the differing surgical approaches.     

Salvage laparoscopic surgery in advanced prostate cancer: is it possible or beneficial?

Purpose: The surgical management of recurrent urological cancer continues to evolve. This review focuses on the role laparoscopic surgical techniques have within recurrent prostate treatments. Methods: A literature search from 1990 to 2007 was conducted using the PubMed database to determine the role of laparoscopic salvage surgery for prostate cancers. In all articles studied, we evaluated: estimated blood loss; transfusion rates; hemoglobin level; serum and drain fluid creatinine levels; bowel injury; hospital stay and complication rates. Results: Laparoscopic surgery is used regularly for the treatment of urological cancers; however, its role in treating radiorecurrent or chemoradiorecurrent cancer is unknown. Adjuvant chemo-radiotherapy, other experimental localized therapies (cryotherapy) or hormonal therapy are known to affect the operative field, causing greater morbidity in open surgery. Relative survival rates were lowest among patients who received no treatment and highest among patients who underwent surgical procedures. Conclusions: Although associated with significant morbidity, salvage prostatectomy remains a viable form of therapy. Laparoscopic salvage radical prostatectomy for recurrent cancer is feasible with no more morbidity than an open procedure, with promising short-term oncologic and functional outcomes. Long-term data will ultimately confirm the viability of the laparoscopic approach most probably in a multicenter setting.     

Operative Therapie des lokal begrenzten Prostatakarzinoms

Prostate cancer is the most common cancer in men in Germany with increasing tendency, particularly of the potentially curable locally limited stages. The most commonly carried out operative procedures in Germany are the open radical retropubic prostatectomy (ORP) and robot-assisted laparoscopic radical prostatectomy (RARP), with and without lymphadenectomy. In comparative retrospective studies both procedures show no differences with respect to the oncological results. Differences in functional results have been reported but are controversial. The aims of operative therapy are retention of urine continence and penile tumescence in addition to complete removal of the prostate gland. An improvement of the functional results can be achieved by retention of the intrafascial nerve, intraoperative rapid frozen section technique or retention of the maximum length of the external sphincter of the urethra.     

Laparoscopic and robotic radical prostatectomy

Radical retropubic prostatectomy is the current gold standard for surgical removal of the prostate gland. Recently, laparoscopic radical prostatectomy has been developed in an attempt to decrease surgical morbidity, and the technical difficulty of laparoscopy has been countered with the development of the da Vinci^® robotic interface. Studies that have compared the minimally invasive approaches with the traditional open approach have reported comparable perioperative outcomes. While long-term oncological data are available for open prostatectomy, there are only short-term studies available for laparoscopic prostatectomy. Functional outcomes, including urinary continence and sexual function, appear to be similar between the surgical approaches in the short term. However, currently, costs appear to favor open surgery, with the da Vinci-assisted prostatectomy having the highest expenses. Longer-term data are required to confidently determine the optimal balance between morbidity, oncological efficacy, functional outcomes and cost among the differing surgical approaches.     

Laparoscopic surgery in urologic oncology.

BACKGROUND: Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy. METHODS: We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies. RESULTS: All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States. CONCLUSIONS: When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.