Marcel Hruza

The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study

BACKGROUND We previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy. METHODS We did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patients operation and prostate-cancer recurrence, with adjustment for established predictors. FINDINGS After adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p<0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7). INTERPRETATION Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy. FUNDING National Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

The Learning Curve for Laparoscopic Radical Prostatectomy: An International Multicenter Study

PURPOSE It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. MATERIALS AND METHODS We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. RESULTS Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. CONCLUSIONS The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Complications in 2200 Consecutive Laparoscopic Radical Prostatectomies: Standardised Evaluation and Analysis of Learning Curves

BACKGROUND Laparoscopic radical prostatectomy (LRP) represents an established treatment modality for localised prostate cancer. OBJECTIVE To report standardised complication rates for LRP, evaluate the development of complication rates over time, and show changes within the learning curves of laparoscopic surgeons. DESIGN, SETTING, AND PARTICIPANTS We conducted a standardised analysis of 2200 consecutive patients who underwent LRP between 1999 and 2008 at a single institution. INTERVENTION LRP was performed using a transperitoneal (n=871) or extraperitoneal (n=1329) retrograde Heilbronn technique. Five surgeons operated on 96% of the patients. MEASUREMENTS Complications were classified according to the modified Clavien system. Total complication rates and changes over time were analysed. Three generations of surgeons were defined for evaluation of learning curves. RESULTS AND LIMITATIONS Minor complications occurred in 21.7% of patients (Clavien 1: 6.8%; Clavien 2: 14.9%); anaemia requiring transfusion (10.4%) dominated. Early reinterventions were necessary in 6.7% of patients (Clavien 3a: 3.6%; Clavien 3b: 1.5%; Clavien 4a: 1.5%; Clavien 4b: 0.1%). Late Clavien 3b complications occurred in 4.7% of patients-most of them anastomotic strictures. Mortality was 0.1% (Clavien 5). There was a significant decrease in overall complication rates over time, resulting predominantly from decreasing Clavien 1-2 events. Learning curves of third-generation surgeons plateaued earlier compared to the first generation (250 vs 700 cases). The limitation of this study is that data concerning comorbidity were not included. CONCLUSIONS LRP is a safe procedure characterised by an acceptable profile of complications. Specifically, few major complications are reported. According to the complication rates, the learning curve of third-generation surgeons is significantly shorter compared to first- and second-generation surgeons.

Laparoscopic Techniques for Removal of Renal and Ureteral Calculi

BACKGROUND AND PURPOSE Although most ureteral and renal stones are managed using endourologic techniques or shockwave lithotripsy in daily clinical practice, stone surgery has not completely disappeared. The increasing experience with laparoscopy in urology poses the question of whether urolithiasis may be an indication for laparoscopy. MATERIALS AND METHODS A review of the literature was conducted to point out the indications and techniques of laparoscopic stone surgery. RESULTS Indications for stone surgery are anatomic abnormalities, such as horseshoe kidneys, malrotated kidneys, or ectopic kidneys; symptomatic stones in diverticula of the renal pelvis; and extremely large stones, especially in children; or concomitant open or laparoscopic surgery. After failure of endourologic stone removal or shockwave lithotripsy, stone surgery may be a second option. In experienced hands, most procedures can be performed laparoscopically, either using a retroperitoneal or a transperitoneal approach. Accurate planning and imaging before surgery is mandatory. Intracorporeal ultrasonography or combined laparoscopic and endourologic techniques may be useful in difficult cases. Functional outcomes and complication rates of the laparoscopic approach are comparable to those of open surgery. The benefits of laparoscopy are lower postoperative morbidity, shorter hospitalization, shorter convalescence time, and better cosmetic results. CONCLUSIONS Laparoscopic removal of renal and ureteral calculi plays a role in special cases of urolithiasis. In experienced hands, it can be performed safely and efficiently and may therefore replace open stone surgery in most indications.

Long-term oncological outcomes after laparoscopic radical prostatectomy.

Laparoscopic radical prostatectomy (LRP) has shown good oncological short‐term and mid‐term outcomes, but long‐term outcomes are still lacking. We present long‐term oncological outcomes of LRP in a large cohort of patients operated on in one of the pioneering European centres. The data from the present study show high rates of biochemical and clinical recurrence‐free survival and low cancer‐specific mortality compared with open series.

Laparoscopic Radical Prostatectomy in Clinical T1a and T1b Prostate Cancer : Oncologic and Functional Outcomes-A Matched-Pair Analysis

OBJECTIVES To evaluate the effect of previous transurethral resection of the prostate (TURP) on surgical, functional, and oncologic outcomes after laparoscopic radical prostatectomy. METHODS From a series of 2100 patients undergoing laparoscopic radical prostatectomy, we compared the intraoperative complications and functional and oncologic outcomes for 55 patients who had been diagnosed with prostate carcinoma on previous TURP (group 1), with those of 55 matched patients who had not undergone previous prostate surgery (group 2). The patients were match-paired for age, operating surgeon, procedure type (eg, nerve-sparing, lymph node dissection), anastamotic technique, pathologic stage, and Gleason score. The minimal duration of follow-up was 24 months. RESULTS Both groups were similar with respect to patient age and pathologic stage. Of those with Stage cT1a and cT1b, 83.6% had a clinically significant tumor, with a mean tumor volume of 1.7 cm(3) for those with Stage cT1a and 2.4 cm(3) for those with Stage cT1b. The positive surgical margin rate was 14.5% and 16.3% for groups 1 and 2, respectively. Biochemical recurrence developed in 12.7% and 11% of patients in groups 1 and 2, respectively. Neither outcome was significantly different between the 2 groups. The long-term continence rates were similar; however, previous TURP was associated with a lower continence rate (49.1%) at 3 months compared with 61.8% for group 2 (P = .01). A nerve-sparing technique was used in 54% of group 1 patients. No significant difference was found in the potency rates between the 2 groups at 12 months. CONCLUSIONS Laparoscopic radical prostatectomy after TURP is a challenging, but oncologically safe, procedure. The interval to total continence was delayed, but the potency rates remain unchanged.

Prostate Biopsy in Selecting Candidates for Hemiablative Focal Therapy

Focal therapy (FT) for the management of clinically localized prostate cancer (PCa) is growing from a concept to reality because of increased interest of both patients and physicians. Selection protocols, however, are yet to be established. We discuss the role of prostate biopsy in candidate selection for FT and highlight the different strategies and technical aspects of the use of prostate biopsy in this setting. In our opinion, prostate biopsy plays a major role in the selection process and tailoring appropriate treatment strategy to the patient. FT necessitates dedicated biopsy schemes that would reliably predict the extent, nature, and location of PCa in selected patients. Currently, there is insufficient scientific evidence to propose a specific biopsy scheme that could fit every candidate, providing accurate characterization of the disease in the individual patient. Further research is necessary to establish solid selection protocols that would reliably identify appropriate candidates for FT of PCa.

Development, Validation and Operating Room-Transfer of a Six-Step Laparoscopic Training Program for the Vesicourethral Anastomosis

PURPOSE Development and full validation of a laparoscopic training program for stepwise learning of a reproducible application of a standardized laparoscopic anastomosis technique and integration into the clinical course. MATERIALS AND METHODS The training of vesicourethral anastomosis (VUA) was divided into six simple standardized steps. To fix the objective criteria, four experienced surgeons performed the stepwise training protocol. Thirty-eight participants with no previous laparoscopic experience were investigated in their training performance. The times needed to manage each training step and the total training time were recorded. The integration into the clinical course was investigated. The training results and the corresponding steps during laparoscopic radical prostatectomy (LRP) were analyzed. Data analysis of corresponding operating room (OR) sections of 793 LRP was performed. Based on the validity, criteria were determined. RESULTS In the laboratory section, a significant reduction of OR time for every step was seen in all participants. Coordination: 62%; longitudinal incision: 52%; inverted U-shape incision: 43%; plexus: 47%. Anastomosis catheter model: 38%. VUA: 38%. The laboratory section required a total time of 29 hours (minimum: 16 hours; maximum: 42 hours). All participants had shorter execution times in the laboratory than under real conditions. The best match was found within the VUA model. To perform an anastomosis under real conditions, 25% more time was needed. By using the training protocol, the performance of the VUA is comparable to that of an surgeon with experience of about 50 laparoscopic VUA. Data analysis proved content, construct, and prognostic validity. CONCLUSIONS The use of stepwise training approaches enables a surgeon to learn and reproduce complex reconstructive surgical tasks: eg, the VUA in a safe environment. The validity of the designed system is given at all levels and should be used as a standard in the clinical surgical training in laparoscopic reconstructive urology.

Transrectal ultrasound-guided biopsy of the prostate: development of the procedure, current clinical practice, and introduction of self-embedding as a new way of processing biopsy cores.

PURPOSE This study reviews the development of transrectal sonographically guided biopsy procedures of the prostate and optimization of the procedure in daily clinical practice. MATERIALS AND METHODS We conducted a literature review of the historic development and current practice of prostate biopsy procedures and present our systematic 12-core biopsy protocol. For processing the biopsy cores, we introduce the new technique of self-embedding. RESULTS The systematic biopsy protocols proposed in the literature can be summarized as sextant protocols, extended sextant protocols, 12-core protocols, extended 12-core protocols, and saturation biopsy protocols. The systematic 12-core prostate biopsy has become the new gold standard, replacing the classic sextant protocol. There is, however, little consensus about the biopsy procedure in the literature nor in daily practice. We propose a systematic biopsy protocol consisting of 12 cores in a fan-shaped arrangement that originates from the apex. Self-embedding of the biopsy cores is a simple new way of processing that provides additional information for the operating urologist (i.e., exact localization of the tumor and distance of the carcinoma from the capsule if a nerve-sparing procedure is planned). CONCLUSIONS A systematic 12-core prostate biopsy procedure should be used routinely. In large glands, it has proved to be useful to expand this protocol by taking additional cores. Self-embedding of the biopsy cores provides maximum information from the biopsy core distribution.

Impact of body mass index on outcomes of laparoscopic radical prostatectomy with long-term follow-up

Abstract Objective. The aim of this study was to investigate the impact of body mass index (BMI) on the functional and oncological results of patients who had undergone laparoscopic radical prostatectomy (LRP). Material and methods. In total, 1224 patients with follow-up data (>24 months) were enrolled. Patients were divided into three groups according to BMI (kg/m2) as: group 1 (normal, BMI <25, n = 425), group 2 (overweight, 25 ≤BMI <30, n = 594) and group 3 (obese, BMI ≥30, n = 205). Demographic, intraoperative and postoperative data with oncological outcomes were recorded. The impact of obesity on those parameters was evaluated and statistical analyses were performed. Results. Mean age was 63.8 ± 6.1 years and mean follow-up was 43.1 ± 25.1 months (mean ± SD). There were 425 (34.7%) patients in group 1, 594 (48.5%) in group 2 and 205 (16.8%) in group 3. Operation time, clinical stage and estimated blood loss were significantly higher in group 3 than in the other groups (p < 0.001, p = 0.001 and p = 0.001, respectively). Bilateral nerve-sparing rate and bladder neck-sparing rate were significantly decreased in group 3 compared with the other groups (p = 0.001 and p < 0.038, respectively). Statistically significantly higher pathological stage, tumour volume, positive surgical margin and Gleason scores were determined in group 3 compared with the other groups (p = 0.023, p = 0.018, p = 0.009 and p = 0.028, respectively). There were similar urinary continence rates among the groups. The rate of penetration with or without medication was significantly lower in group 3 than in the other groups (p = 0.593 and p = 0.007, respectively). Conclusions. LRP seemed safe and effective in obese patients, with similar mean overall survival, cancer-specific survival, complication rates and continence rates to normal weight patients in the long term.