Philippe Koenig

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.

Is There a Role for α-Blockers in Ureteral Stent Related Symptoms? A Systematic Review and Meta-Analysis

PURPOSE We evaluated the efficacy of α-blockers to improve ureteral stent related morbidity and quality of life. MATERIALS AND METHODS We performed a search of MEDLINE®, Embase™ and The Cochrane Library plus a hand search of conference proceedings from January 2000 to October 2010 to identify randomized, controlled trials comparing treatment for ureteral stent symptoms with α-blockers. Two reviewers independently screened studies and extracted data. Trial methodological quality was assessed by The Cochrane Collaboration quality assessment tool. Placebo randomized, controlled trials with the ureteral stent symptom questionnaire as the outcome were eligible for meta-analysis. Meta-analysis was done using the mean difference to determine the aggregate effect size. RESULTS A total of 12 randomized, controlled trials including 2 α-blockers in a total of 946 patients were eligible, including 4 (33%) presented only as an abstract at a urological meeting and 4 (33%) eligible for meta-analysis. Meta-analysis using a random effects model showed that α-blockers were associated with a significant decrease in urinary symptoms (MD -6.76, 95% CI -11.52 to -2.00, p=0.005), a significant decrease in pain (MD -3.55, 95% CI -5.51 to -1.60, p=0.0004) and significant improvement in general health (MD -1.90, 95% CI -3.05 to -0.75, p=0.001). However, they were not associated with a benefit in work (MD 2.41, 95% CI -1.62 to 6.44, p=0.24) or sexual matters (MD 0.20, 95% CI -1.06 to 1.45, p=0.33). Eight studies were not included in the meta-analysis, of which 7 showed a significant clinical decrease in urinary symptoms and pain. CONCLUSIONS Existing evidence from randomized, controlled trials shows that α-blockers are associated with improvement in ureteral stent symptoms and supports their use in routine clinical practice.

Laparoscopic Partial Nephrectomy versus Laparoscopic Cryoablation for Multiple Ipsilateral Renal Tumors

BACKGROUND Management of multiple ipsilateral renal tumors is a dilemma in clinical practice. The effects of minimally invasive nephron-sparing procedures in this group of patients have not been assessed. OBJECTIVE To evaluate the technical feasibility and outcomes of laparoscopic partial nephrectomy (LPN) and laparoscopic cryoablation (LCA) for multiple ipsilateral renal tumors. DESIGN, SETTING, AND PARTICIPANTS Between September 1999 and December 2006, 27 patients were treated with minimally invasive nephron sparing surgery (LPN or LCA) for synchronous multiple ipsilateral renal tumors in a single operating session at our institution. Fourteen patients with 28 tumors underwent LPN, and 13 patients with 31 tumors underwent LCA as the sole treatment modality. INTERVENTION Medical records were retrospectively reviewed and data were collected. MEASUREMENTS Demographic, intraoperative, postoperative, and intermediate-term follow-up data were compared between the two groups. RESULTS AND LIMITATIONS Patients in the LPN group had fewer tumors (2 vs. 2.4, p=0.04) and larger dominant tumor size (3.6 vs. 2.5 cm, p=0.005) in the affected kidney and lower preoperative serum creatinine levels (1 vs. 1.4 mg/dl, p=0.02). Compared to the LCA group, patients in the LPN group had greater estimated blood loss (200 vs. 125 ml, p=0.02) and longer hospital stays (90 vs. 52.3h, p=0.02). There were no open conversions, and no kidneys were lost. Complication rate, renal functional outcomes, and intermediate-term cancer-specific survival rates were similar between the two groups. CONCLUSIONS Both LPN and LCA are viable options for patients with multiple ipsilateral renal tumors in select patients. Renal functional outcomes, complication rates, and intermediate-term survival rates are comparable between the two groups in this small series.

KIDNEY CANCER AND THE RISK FOR CHRONIC KIDNEY DISEASE: MATCHED-PAIRED COMPARISON WITH LIVING DONORS

laparoscopic transducer (Aloka Inc, Japan) was used to image renal tumors for the purpose of nephron sparing surgery. Transperitoneal robotic partial nephrectomies were performed in a non-survival pig model using the da Vinci S Surgical System (Intuitive Surgical, Sunnyvale). TilePro was used in all cases to overlay real-time ultrasound images on to the console (Figure 2). The robotic partial nephrectomy specimens

Learning curve of positive margin rate in laparoscopic radical prostatectomy

estimate -2.99, 95%CI -3.45,-2.53) but more anastomotic strictures (OR 1.40, 95%CI 1.04,1.87) and higher rates of salvage therapy (OR 3.67, 95%CI 2.81,4.81). Patients of high-volume MIRP experienced fewer anastomotic strictures (OR 0.93, 95%CI 0.87,0.99) and less salvage therapy (OR 0.92, 95%CI 0.88,0.98). CONCLUSIONS: Men undergoing MIRP vs. open radical prostatectomy have lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases with increasing MIRP surgical volume.

INNOVATIVE COMBINATION OF NEW TECHNOLOGIES IN RECONSTRUCTIVE LAPAROSCOPIC SURGERY: AN EVALUATION IN ANIMAL MODEL

V1056 VIDEO DEMONSTRATION OF ROBOTIC TESTICULAR SPERM EXTRACTION: CRITICAL EVALUATION COMPARED TO OPEN TESE AND PERCUTANEOUS NEEDLE LAVAGE TECHNIQUES IN CANINE MODEL AND THE FIRST HUMAN CASES Scott A Polackwich*, Patrick Villicana, Carl Bischoff, Bayo Tojuola, Benjamin K Canales, Marc S Cohen, Philipp Dahm, Johannes Vieweg, Sijo J Parekattil. Gainesville, FL. INTRODUCTION AND OBJECTIVE: Testicular sperm

Surrenalectomia laparoscopica robot-assistita

La laparoscopia e la tecnica di riferimento nella presa in carico chirurgica delle malattie surrenaliche benigne. Negli ultimi 5 anni vi sono stati parallelamente miglioramenti nel campo della chirurgia robotica. La quasi totalita degli interventi urologici, inizialmente eseguiti in laparoscopia, sono stati oggetto di miglioramento grazie all’impiego del robot. Dopo un cenno degli elementi di anatomia, questo articolo tratta delle indicazioni all’intervento di surrenalectomia laparoscopica robot-assistito; riassume poi gli inizi della sperimentazione robotica in questo campo e descrive infine dettagliatamente la tecnica della surrenalectomia laparoscopica robot-assistita. La surrenalectomia laparoscopica robotizzata e ad oggi poco diffusa. I suoi vantaggi rispetto a quella laparoscopica convenzionale non sono ancora stabiliti. Sono attesi miglioramenti nel campo della robotica, segnatamente l’aggiunta di capacita sensoriali tattili (da ritorno della spinta), miniaturizzazione dei diversi componenti, riduzione dei costi e nuove acquisizioni nel campo della telemanipolazione. Essi permetteranno di definire meglio il ruolo della robotica nella presa in carico delle patologie surrenaliche