Laparoscopic ventral hernia repair is safe and cost effective

BACKGROUND: Ventral hernia repair is increasingly performed by laparoscopic means since the introduction of dual-layer meshes. This study aimed to compare the early complications and cost effectiveness of open hernia repair with those associated with laparoscopic repair. METHODS: Open ventral hernia repair was performed for 92 consecutive patients using a Vypro mesh, followed by laparoscopic repair for 49 consecutive patients using a Parietene composite mesh. RESULTS: The rate of surgical-site infections was significantly higher with open ventral hernia repair (13 vs 1; p = 0.03). The median length of hospital stay was significantly shorter with laparoscopic surgery (7 vs 6 days; p = 0.02). For laparoscopic repair, the direct operative costs were higher (2,314 vs 2,853 euros; p = 0.03), and the overall hospital costs were lower (9,787 vs 7,654 euros; p = 0.02). CONCLUSIONS: Laparoscopic ventral hernia repair leads to fewer surgical-site infections and a shorter hospital stay than open repair. Despite increased operative costs, overall hospital costs are lowered by laparoscopic ventral hernia repair.     

A direct comparison of robotic assisted versus pure laparoscopic radical prostatectomy: a single institution experience

PURPOSE: We compared a single institution experience with radical prostatectomy using a pure laparoscopic technique vs a robotically assisted technique with regard to preoperative, intraoperative or postoperative parameters. MATERIALS AND METHODS: From May 2003 to May 2005 we reviewed 133 consecutive patients who underwent extraperitoneal robot assisted radical prostatectomy and compared them to 133 match-paired patients treated with a pure extraperitoneal laparoscopic approach. The patients were matched for age, body mass index, previous abdominopelvic surgery, American Society of Anesthesiologists score, prostate specific antigen, pathological stage and Gleason score. Preoperative, perioperative and postoperative data, including complications and oncological results, were analyzed between the 2 groups. RESULTS: The 2 groups were statistically similar with respect to age, body mass index, prostate specific antigen, Gleason score and clinical stage. No statistical differences were observed regarding operative time, estimated blood loss, hospital stay or bladder catheterization between the 2 groups. The transfusion rate was 3% and 9.8% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.03). Conversion from robotic assisted laparoscopic prostatectomy to laparoscopic radical prostatectomy was necessary in 4 cases. None of the laparoscopic radical prostatectomy cases required conversion to an open technique. The percentage of major complications was 6.0% vs 6.8%, respectively (p = 0.80). The overall positive margin rate was 15.8% vs 19.5% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.43). CONCLUSIONS: We demonstrated that the laparoscopic extraperitoneal radical prostatectomy is equivalent to the robotic assisted laparoscopic prostatectomy in the hands of skilled laparoscopic urological surgeons at our institution with respect to operative time, operative blood loss, hospital stay, length of bladder catheterization and positive margin rate.     

Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy

PURPOSE: Options for treatment of large (greater than 100 gm.) prostatic adenomas have until now been limited to open surgery or transurethral resection by skilled resectionists. Considerable blood loss, morbidity, extended hospital stay and prolonged recovery occur with open surgery for large prostatic adenomas. Endoscopic surgery for benign prostatic hyperplasia has evolved during the last decade to offer the patient and surgeon significant advantages of transurethral removal of prostatic adenomas. Holmium laser enucleation of the prostate with transurethral tissue morcellation provides significant reductions in morbidity, bleeding and hospital stay for patients with large prostate adenomas. MATERIALS AND METHODS: A retrospective review of data on 10 cases of holmium laser enucleation and 10 open prostatectomies for greater than 100 gm. prostatic adenomas was performed from 1998 to 1999 at our institution. Patient demographics, indication for surgery, preoperative and postoperative American Urological Association (AUA) symptom scores, operating time, serum hemoglobin, resected prostatic weight, pathological diagnosis, length of stay and complications were compared. RESULTS: Patient age, indications for surgery (retention, failed medical therapy, high post-void residual, bladder calculi, bladder diverticula and azotemia) and preoperative AUA symptom scores were similar in both groups. Postoperative AUA symptom scores were significantly decreased (p <0.004) in both groups. Operating times were not significantly different. Serum sodium was unchanged by holmium laser enucleation (not significant), and postoperative hemoglobin was not significantly reduced in the holmium laser enucleation group but decreased significantly in the open prostatectomy group (mean decrease 2.9 +/- 0.7 gm., p = 0.0003). Resected weight was greater in the holmium laser enucleation group (151 versus 106 gm., p = 0.07). Length of stay was significantly shorter in the holmium laser enucleation group (2.1 versus 6.1 days, p <0.001). Complications in the holmium laser enucleation group included stress urinary incontinence in 4 cases, prostatic perforation in 1 and urinary retention in 1. No patient treated with holmium laser enucleation was discharged home with an indwelling catheter. Complications in the open prostatectomy group included bladder neck contractures in 2 cases, stress incontinence in 1 and urge incontinence in 1. All patients treated with open prostatectomy were discharged home with an indwelling catheter. CONCLUSIONS: Holmium laser enucleation is an effective, safe procedure for large prostatic adenomas with significantly lower morbidity, catheterization duration and length of stay. Performing holmium laser enucleation for large adenomas requires experience. Stress incontinence was seen frequently with laser but was short-term and self-limited. Holmium laser enucleation is a new procedure, and as experience and expertise increase, it may become an attractive alternative to open prostatectomy for patients with large prostate adenomas.     

经尿道钬激光前列腺剜除术治疗大体积良性前列腺增生

目的:评价经尿道钬激光前列腺剜除术(HoLEP)治疗大体积良性前列腺增生(BPH)的价值。方法:BPH患者60例,前列腺重量均>100g,分为HoLEP组(n=32)和耻骨上经膀胱前列腺切除术组(n=28),比较两组手术时间、术中出血量和术后膀胱冲洗时间、导尿管留置时间、住院时间;术后3个月随访,比较两组患者IPSS、生活质量评分(QOL)、最大尿流率(Qmax)、剩余尿量(PVR)等指标的变化。结果:HoLEP组与耻骨上经膀胱前列腺切除术组比较手术时间有所延长(P<0.01),但术中出血量减少(P<0.01),膀胱冲洗时间、导尿管留置时间、术后住院时间明显缩短(P<0.01)。术后3个月,两组IPSS、QOL、Qmax、PVR较自身术前显著改善(P<0.01),组间比较差异无显著性(P>0.05)。结论:HoLEP治疗大体积BPH具有与开放性前列腺切除术相似的疗效,同时手术安全性高、患者痛苦小、术后恢复快,是一种更适合于大体积BPH治疗的手术方式。     

新辅助治疗的优势:机器人辅助腹腔镜下前列腺癌根治术治疗局部进展期前列腺癌

目的探讨术前新辅助内分泌治疗(NHT)是否能使接受机器人辅助腹腔镜前列腺癌根治术(RLRP)治疗的局部进展期前列腺癌患者临床获益。方法回顾性研究中国医科大学附属第一医院泌尿外科自2018年5月至2019年8月根治术前通过穿刺活检及MRI诊断为局部进展期前列腺癌患者31例。其中术前行新辅助内分泌治疗12例,年龄(65.67±5.123)岁,未经内分泌治疗19例,年龄(66.58±8.520)岁。比较两组患者手术时间、术中出血量、术后住院时间、术后切缘阳性率、淋巴结阳性率、术后吻合口漏尿等情况。结果 31例手术均无中转开放及二次手术。新辅助治疗组手术时间[(176.84±54.875)min vs.(66.58±8.520)min,P=0.032]和术后住院时间[(9.50±2.505)min vs.(13.87±5.987)min,P=0.048]缩短,术中失血量[(165.68±79.746)mL vs.(13.87±5.987)mL,P=0.013]减少。治疗组肿瘤切缘阳性率(8.33%vs.26.32%,P=0.001)和清扫淋巴结阳性率(17.14%vs.38.18%,P=0.037)也明显低于对照组。术前辅助内分泌治疗并不能降低术后Gleason评分和临床分期(P>0.05)。结论术前新辅助内分泌治疗在RLRP治疗局部进展期前列腺癌患者中可能在一定程度上降低手术难度并且减少术中出血,使患者受益。     

Holmium laser enucleation of the prostate (HoLEP): the endourologic alternative to open prostatectomy

OBJECTIVE: To evaluate HoLEP for patients with enlarged prostate (traditionally treated by open prostatectomy) with long-term follow-up. METHODS: A retrospective analysis of 225 consecutive patients presenting with lower urinary symptoms secondary to benign prostatic hyperplasia with large prostate (>80 cc) who underwent HoLEP. Enucleation time, morcellation time, enucleated tissue weight, catheterization time, hospital stay, voiding outcome parameters, and complications were recorded. RESULTS: Mean preoperative prostate volume was 126+/-45.1 cc (range 80-351, median 111.2 cc), and resected tissue weight was 86.5 g. Mean follow-up was 31+/-12 months (median 24 months). Mean catheter time and hospital stay were 1.3 and 1.2 days, respectively. Patient symptom scores and peak flow rates were significantly improved immediately after surgery and continued to improve during subsequent follow up. Two patients required intraoperative blood transfusion, and a third patient needed blood transfusion in the early postoperative period for persistent hematuria. Bladder neck contracture and urethral stricture developed in 0.4% and 1.3%, respectively. CONCLUSIONS: HoLEP represents a safe and effective treatment for patients with symptomatic large prostates. It offers patients who traditionally required open prostatectomy the alternative of being treated endoscopically with minimal blood loss, short catheterization time and hospital stay.     

Randomized prospective study of totally extraperitoneal inguinal hernia repair: fixation versus no fixation of mesh.

BACKGROUND: Fixation of the mesh during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is thought to be necessary to prevent recurrence. However, mesh fixation may increase postoperative pain and lead to an increased risk of complications. We questioned whether elimination of fixation of the mesh during TEP inguinal hernia repair leads to decreased postoperative pain or complications, or both, without an increased rate of recurrence. METHODS: A randomized prospective single-blinded study was carried out in 40 patients who underwent laparoscopic TEP inguinal hernia repair with (Group A=20) or without (Group B=20) fixation of the mesh. RESULTS: Patients in whom the mesh was not fixed had shorter hospital length of stay (8.3 vs 16.0 hours, P=0.01), were less likely to be admitted to the hospital (P=0.001), used less postoperative narcotic analgesia in the PACU (P=0.01), and were less likely to develop urinary retention (P=0.04). No significant differences occurred in the level of pain, time to return to normal activity, or the difficulty of the operation between the 2 groups. No hernia recurrences were observed in either group (follow-up range, 6 to 30 months, median=19). CONCLUSIONS: Elimination of tack fixation of mesh during laparoscopic TEP inguinal hernia repair significantly reduces the use of postoperative narcotic analgesia, hospital length of stay, and the development of postoperative urinary retention but does not lead to a significant reduction in postoperative pain. Eliminating tacks does not lead to an increased rate of recurrence.     

Inguinal hernia is a common complication in lower midline incision surgery

Inguinal hernia is a known complication after radical retropubic prostatectomy (RRP). We have investigated whether other types of lower midline incision surgery in males increase the risk of inguinal hernia. Male patients operated with open prostatectomy for benign prostate hyperplasia (n = 95), pelvic lymph node dissection for staging of prostate cancer (n = 88), or cystectomy for bladder cancer (n = 76) were identified and were sent questionnaires in which they were asked about postoperative inguinal hernia morbidity. Two-hundred and seventy-one men operated with RRP had previously received a similar questionnaire. The answers were compared with those from a control group of 953 men who had not undergone surgery. Annual attributional hernia morbidity and Kaplan–Meier hernia-free survival were calculated. The cumulative incidence of post-operative inguinal hernia and annual attributional hernia morbidity after the respective surgical procedures were clearly higher during the early years post-operation than for nonoperated patients. Inguinal hernia is a common postoperative complication in males after all the lower midline incision surgery investigated.     

Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review

Background Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair. Methods A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair. Results In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair. Conclusions The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.     

Simultaneous extraperitoneal laparoscopic radical prostatectomy and intraperitoneal inguinal hernia repair with mesh.

OBJECTIVE: This report depicts the feasibility of the concomitant repair of a large direct inguinal hernia with mesh by using the intraperitoneal onlay approach after extraperitoneal laparoscopic radical prostatectomy. METHODS: A 66-year-old man with localized adenocarcinoma of the prostate was referred for laparoscopic radical prostatectomy. The patient also had a 4-cm right, direct inguinal hernia, found on physical examination. To minimize the risk of infection of the mesh, an extraperitoneal laparoscopic prostatectomy was performed in the standard fashion after which transperitoneal access was obtained for the hernia repair. The hernia repair was completed by reduction of the hernia sac, followed by prosthetic mesh onlay. In this fashion, the peritoneum separated the prostatectomy space from the mesh. A single preoperative and postoperative dose of cefazolin was administered. RESULTS: The procedure was completed with no difficulty. Total operative time was 4.5 hours with an estimated blood loss of 450 mL. The final pathology revealed pT2cN0M0 prostate cancer with negative margins. No infectious or bowel complications occurred. At 10-month follow-up, no evidence existed of recurrence of prostate cancer or the hernia. CONCLUSION: Concomitant intraperitoneal laparoscopic mesh hernia repair and extraperitoneal laparoscopic prostatectomy are feasible. This can decrease the risk of potential infectious complications by separating the mesh from the space of Retzius where the prostatectomy is performed and the lower urinary tract is opened.     

Inguinal hernia after radical retropubic prostatectomy for prostate cancer: a study of incidence and risk factors in comparison to no operation and lymphadenectomy

PURPOSE: The incidence, mechanisms and risk factors of inguinal hernia after radical retropubic prostatectomy are sparsely elucidated in the literature. We determined the rate of inguinal hernia after radical retropubic prostatectomy and compared it to the incidence in patients with prostate cancer who did not undergo operation or underwent only pelvic lymph node dissection. MATERIALS AND METHODS: We followed 375, 184 and 65 men who underwent radical retropubic prostatectomy plus pelvic lymph node dissection, pelvic lymph node dissection only and no surgery with respect to inguinal hernia for a mean of 39, 47 and 45 months, respectively. The prostatectomy group was also evaluated in regard to the potential risk factors of previous hernia surgery and post-prostatectomy anastomotic stricture. RESULTS: The incidence of hernia was 13.6%, 7.6% and 3.1% in the prostatectomy, lymph node dissection and unoperated group, respectively. The difference was statistically significant in the prostatectomy and unoperated groups according to the Mantel-Cox log rank test and Cox proportional hazards rate. Previous hernial surgery and post-prostatectomy anastomotic stricture were more common in patients with an inguinal hernia after prostatectomy. CONCLUSIONS: The incidence of inguinal hernia is clearly increased in men who have undergone radical retropubic prostatectomy plus pelvic lymph node dissection compared with those who undergo no surgery for prostate cancer. Inguinal hernia appears to develop more often in men with prostate cancer who undergo radical retropubic prostatectomy and pelvic lymph node dissection than in those who undergo pelvic lymph node dissection only. While surgical factors trigger hernial development, previous hernial surgery and post-prostatectomy anastomotic stricture may be important risk factors. In fact, the latter may largely explain the difference in the incidence of inguinal hernia in our lymph node dissection and prostatectomy groups. Prophylactic surgical procedures must be evaluated to address this problem.     

Inseparable interaction of the prostate and inguinal hernia

With an increase in their prevalence, it has become apparent that both benign prostatic hyperplasia and radical prostatectomy for cancer can induce inguinal hernia development. An inguinal hernia is a common late complication following radical prostatectomy, with an occurrence rate of 12–25%. Following radical prostatectomy, the space of Retzius can develop adhesions to surrounding tissue, often causing difficulty during inguinal hernia repair. Conversely, inguinal hernia repair before radical prostatectomy also induces severe adhesions around the space of Retzius and causes difficulty during radical prostatectomy. The association between radical prostatectomy and inguinal hernia development is complex and unclear. Both urologists and surgeons are challenged by this interaction. The surgical approaches for prostate cancer have undergone a major transition from open surgery to robotic surgery, and the treatment of inguinal hernia is also changing. Based on historical trends, several preventive and treatment measures have been proposed, although there is no direct evidence for risk factors that lead to inguinal hernia development. This article focuses on the complex interaction between the prostate and inguinal hernia, and considers preventive measures against inguinal hernia development.     

Oncologic outcome and continence recovery after laparoscopic radical prostatectomy: 3 years' follow-up in a "second generation center"

OBJECTIVES: Laparoscopic radical prostatectomy in major centers guarantees oncologic and functional results equal to open procedures. In our institution this operation was introduced in 2001 after an adequate training in laparoscopic surgery. We report the oncologic and functional results after 3 years of experience. METHODS: We considered our first 150 patients that had undergone transperitoneal laparoscopic radical prostatectomy. The following parameters were prospectively collected and analyzed: pathological findings, surgical margins, surgical time, blood loss, hospital stay, catheterization, complications, oncologic follow-up and continence. RESULTS: Single positive surgical margins were observed in 26 patients (17.3%) and multiple positive margins in 15 patients (10%). The rates of positive margins in organ confined tumors (pT2a/b) were 11.3%. Preoperative PSA>10 ng/ml (Chi-square p<0.01), pathological stage>pT2 (Chi-square p<0.001) and Gleason score>6 (Chi-square p<0.01) were significantly correlated with positive margins. Major complications occurred in 16 patients (10.7%). The total recurrence rate is 11.7%. The continence rate at 12 months is 91.7%.with 44.3% of patients completely continent at the moment of catheter removal. CONCLUSIONS: Laparoscopic radical prostatectomy in now a well codified operation that, after an adequate training, could be learned and reproduced safely. Actually this is our first choice surgical approach in patients with localized prostate cancer.     

The effect of previous transperitoneal laparoscopic inguinal herniorrhaphy on transperitoneal laparoscopic radical prostatectomy

PURPOSE: Previous laparoscopic herniorrhaphy has been considered a contraindication to laparoscopic radical prostatectomy (LRP). In this study we analyzed the impact of previous laparoscopic or open inguinal hernia repair on the outcome of transperitoneal laparoscopic radical prostatectomy using the Heilbronn technique. MATERIALS AND METHODS: In our database of 1,089 patients with LRP we identified 20 who underwent transperitoneal LRP and had a history of transperitoneal laparoscopic inguinal herniorrhaphy using prosthetic mesh (group 1). The outcome in that group was compared to that of 20 matched pair patients of a total of 95 in whom LRP was performed following open inguinal herniorrhaphy (group 2) and 20 matched pair patients of a total of 771 without previous surgery (group 3). Perioperative parameters (operative time, blood donation and complications) and postoperative results (duration and amount of analgesic treatment, catheterization and the continence rate) were analyzed. RESULTS: According to the matched pair algorithm the 3 groups did not differ with respect to age (63.8, 66.2 and 63.0 years, p = 0.226), prostate volume (47.2, 43.3 and 47.7 gm, p = 0.501) or body mass index (26.1, 25.8 and 26.2 kg/m, respectively, p = 0.641). Ten pelvic lymphadenectomies and 8 nerve sparing (4 unilateral and 4 bilateral) procedures were performed per group. Ten and 12 patients in groups 1 and 2 had a history of bilateral herniorrhaphy, while previous unilateral herniorrhaphy was noted in the remaining 10 and 8, respectively. Mean operative time +/- SD (203.3 +/- 3.54, 196.7 +/- 43.7 and 214.7 +/- 37.7 minutes, p = 0.346) and mean catheterization time (8.1 +/- 2.8, 7.7 +/- 2.5 and 7.4 +/- 2.1 days, respectively, p = 0.684) did not differ significantly among the 3 groups. However, the mean amount of narcotic analgesic was significantly higher in group 1 compared with groups 2 and 3 (32.1 +/- 11.9, 21.8 +/- 11.9 and 19.5 +/- 10.1 mg, respectively, p = 0.002). Continence rates were similar in the groups at 88%, 87% and 92%, respectively, 1 year after surgery. CONCLUSIONS: Previous laparoscopic inguinal herniorrhaphy using prosthetic mesh does not adversively affect the operative outcomes or functional results of LRP, while the total amount of narcotic analgesics was significantly higher, reflecting increased postoperative morbidity.     

Positive margins after laparoscopic radical prostatectomy: a prospective study of 100 cases performed by 4 different surgeons

OBJECTIVE: Laparoscopic radical prostatectomy (LRP) has been refined by experienced surgeons into a competitive treatment alternative for localized prostate cancer. Less is known, however, about the outcomes of "learning curve" cases from newly trained surgeons. We prospectively studied 100 cases of LRP performed by 2 senior and 2 junior surgeons and addressed the rates of positive margins-an important early endpoint of oncologic efficacy. METHODS: 100 consecutive cases of LRP were performed by two senior (n=62) and two junior surgeons (n=38) by a 5-port transperitoneal route. Whole-mount step-section prostate specimens were examined by Stanford protocol. RESULTS: Positive margins occured in 25% of cases: 18% for pT2a (2/11), 18% for pT2b (11/61), 45% for pT3a (10/22), and 50% for pT3b (2/4) (p=0.002 pT2 vs. pT3). By surgeon experience, the rates were 19% (12/62) for senior and 34% (13/38) for junior (p=0.04). However, in a multiple logistic regression analysis, only pathologic stage (p=0.083) and Gleason sum (p=0.0133) reached statistical significance, while surgeon experience did not (p=0.0992). CONCLUSION: Positive margin rates after laparoscopic radical prostatectomy are significantly influenced by pathologic stage and Gleason score, and are within the range reported from open series. The higher positive margin rate from junior surgeons, although not statistically significant, suggests the need for further study and continued mentoring during surgery and/or video review of cases to improve oncologic results.     

Radical prostatectomy after previous transurethral resection of the prostate: robot-assisted laparoscopic versus open radical prostatectomy in a matched-pair analysis

Abstract Purpose: To determine whether previous transurethral resection of the prostate (TURP) compromises the surgical outcome and pathologic findings in patient who underwent either radical robot-assisted laparoscopic prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, because TURP is reported to complicate radical prostatectomy and there are conflicting data. Patients and Methods: From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 (5.3%) patients had undergone previous TURP. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen, the biopsy Gleason score, the American Society of Anesthesiologists classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons. Results: Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217±51.9 minutes for RALP and 174±57.7 minutes for RRP (P<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT(2) tumors: 10.5% for RALP and 5.3% for RRP; P=1.0). Mean estimated blood loss was 333±144?mL in RALP patients and 1103±636?mL in RRP patients (P<0.001). The difference between preoperative and postoperative hemoglobin levels was 3.22±0.98?g/dL for RALP and 5.85±1.95?g/dL for RRP (P=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58±1.17 vs 11.74±5.22 days; P=0.0037), duration of catheterization (7.95±5.69 vs 11.78±6.97 days; P=0.0016), postoperative complications according to the Clavien classification system (6 vs 15 patients; P=0.0027), and transfusion rate (0% vs 10.5%; P<0.001). Conclusion: RALP offers advantages over open radical prostatectomy after previous surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.     

Critical comparison of laparoscopic, robotic, and open radical prostatectomy: techniques, outcomes, and cost

Radical prostatectomy has maintained paramount importance in prostate cancer management. Emerging alternative treatments are laparoscopic and robotic prostatectomy. Technical modifications have improved radical prostatectomy outcomes, yet surgery remains difficult to perform regardless of approach. Contemporary series have shown comparable outcomes with operative time, transfusion rates, analgesia, and length of catheterization. Open radical prostatectomy provides excellent long-term oncologic control, but sparse short-term data are available for laparoscopic and robotic prostatectomy. Favorable outcomes also have been reported for urinary control and sexual function, regardless of approach. Additional prospective data collection is needed to evaluate if minimally invasive approaches provide distinct advantages over open surgery.     

Comparison of transperitoneal and extraperitoneal laparoscopic radical prostatectomy using match-pair analysis

PURPOSE: Based on the experience of 1000 cases of laparoscopic radical prostatectomy, we compared the operative parameters of transperitoneal and extraperitoneal approaches in match-paired patient groups. PATIENTS AND METHODS: We reviewed the charts of 53 consecutive patients who underwent selectively extraperitoneal laparoscopic radical prostatectomy comparing it to 53 match-paired patients treated by transperitoneal laparoscopic radical prostatectomy. The patients were matched for age, PSA (ng/ml), prostate volume (g), pathologic stage, Gleason score, presence of pelvic lymph node dissection and type of nerve-sparing technique. Perioperative parameters (operating time, blood donation, complications) and postoperative results (duration and amount of analgesic treatment, catheterization time) as well as oncological (surgical margin status) and functional (continence rate) results were analyzed. RESULTS: Patients were 62.9 +/- 5.5 versus 62.9 +/- 5.4 years old, had 27.5 +/- 3.5 kg/m2 versus 26.7 +/- 2.8 kg/m2 body mass indices in the extraperitoneal and transperitoneal groups, respectively. Preoperative mean PSA and prostate volume were 7.4 +/- 4.6 ng/ml and 41.8 +/- 16.3 g in the extraperitoneal, 7.6 +/- 3.8 ng/ml and 42.0 +/- 14.8 g in the transperitoneal group. Pathologic stages were T2a in 12 vs. 13, T2b in 21 vs. 20, T2c in 7 vs. 8, T3a in 11 vs. 10 and T3b in 2 vs. 2 patients for both groups. Overall 211.8 vs. 197.1 minutes mean operative time (p = 0.328) and 21.9 +/- 15.4 mg vs. 26.3 +/- 15.8 mg narcotic analgesic requirements (p = 0.111) did not differ significantly in both groups. However, mean operating time was significantly longer in the extraperitoneal group when performing pelvic lymphadenectomy (244.5 vs. 209.6 minutes, p = 0.017). There was no statistical difference of complication rate (4% vs. 2%) and median catheter time (7 vs. 7 days), positive surgical margins (22.6% vs. 20.7%) and 12 months continence (86.7% vs. 84.9%). CONCLUSIONS: There was no significant difference between the extraperitoneal and transperitoneal approaches using the Heilbronn technique regarding all important parameters. In addition to the preference and experience of the individual surgeon, previous abdominal surgery, gross obesity and requirement of simultaneous inguinal hernia repair may be considered as selective indications for extraperitoneal laparoscopic radical prostatectomy.