Renaud Bollens

Extraperitoneal laparoscopic radical prostatectomy. Results after 50 cases.

INTRODUCTION After an initial experience using transperitoneal laparoscopic radical prostatectomy as described by Vallancien and Guillonneau, we developed a pure extraperitoneal approach. This approach seems more comparable to the open technique and avoid potential risks of specific complications due to the transperitoneal approach. We evaluated the perioperative parameters (blood loss, operating time, transfusion rate) and postoperative results (oncological results, continence and potency) after our first 50 cases. MATERIAL AND METHOD Between September 1999 and September 2000, we performed 50 laparoscopic radical prostatectomy. On average, patients were 63.3 years old (range 47-71), had preoperative mean PSA values of 9.14 ng/ml (1.1-23). Median Gleason score was 6 (4-10) with 2.5 (1-6) positive biopsies for a mean prostate volume of 40 cm(3) (17.5-95.0). Clinical stage was T1, T2a, T2b and T3 in 46.3, 41.5, 9.8 and 2.4% of the cases, respectively. We used a pure extraperitoneal approach and we performed a descending technique starting with the dissection at the bladder neck. The seminal vesicles dissection is comparable to the open approach. RESULTS 42 extraperitoneal and 8 transperitoneal procedures were performed (2 in the initial experience, 3 because of previous abdominal surgery and 3 because of incidental peritoneal opening). Mean operative time was 317 min, mean blood loss 680 cm(3), transfusion rate of 13%. 1 patient/50 was converted to an open procedure. Pathological stage was pT1a, pT2a, pT2b, pT2c, pT3a and pT3b in 2.2, 8.5, 42.5, 2.2, 34 and 10.6% of cases, respectively. Positive surgical margins were observed in 22% of cases. The potency rate after neurovascular bilateral bundle preservation was 43% at 3 months (n = 7) and 67% at 6 months and (n = 6) without any further treatment. The continence rate (no pad) was 39% at 3 months and 85% at 6 months. Detectable postoperative PSA at 3 month was observed in 2 patients only. Two major complications occurred: one acute transient renal failure one uretrorectal fistula at day 20. CONCLUSIONS The extraperitoneal laparoscopic radical prostatectomy results seem comparable to transperitoneal laparoscopic radical prostatectomy or open surgery. This approach is reproducible and seems to avoid the potential risks of intraperitoneal injury. Long-term follow up and comparative series are however necessary to further evaluate these new techniques.

Extraperitoneal Laparoscopic Radical Prostatectomy

Introduction: After an initial experience using transperitoneal laparoscopic radical prostatectomy as described by Vallancien and Guillonneau, we developed a pure extraperitoneal approach. This approach seems more comparable to the open technique and avoid potential risks of specific complications due to the transperitoneal approach. We evaluated the perioperative parameters (blood loss, operating time, transfusion rate) and postoperative results (oncological results, continence and potency) after our first 50 cases. Material and Method: Between September 1999 and September 2000, we performed 50 laparoscopic radical prostatectomy. On average, patients were 63.3 years old (range 47–71), had preoperative mean PSA values of 9.14 ng/ml (1.1–23). Median Gleason score was 6 (4–10) with 2.5 (1–6) positive biopsies for a mean prostate volume of 40 cm3 (17.5–95.0). Clinical stage was T1, T2a, T2b and T3 in 46.3, 41.5, 9.8 and 2.4% of the cases, respectively. We used a pure extraperitoneal approach and we performed a descending technique starting with the dissection at the bladder neck. The seminal vesicles dissection is comparable to the open approach. Results: 42 extraperitoneal and 8 transperitoneal procedures were performed (2 in the initial experience, 3 because of previous abdominal surgery and 3 because of incidental peritoneal opening). Mean operative time was 317 min, mean blood loss 680 cm3, transfusion rate of 13%. 1 patient/50 was converted to an open procedure. Pathological stage was pT1a, pT2a, pT2b, pT2c, pT3a and pT3b in 2.2, 8.5, 42.5, 2.2, 34 and 10.6% of cases, respectively. Positive surgical margins were observed in 22% of cases. The potency rate after neurovascular bilateral bundle preservation was 43% at 3 months (n = 7) and 67% at 6 months and (n = 6) without any further treatment. The continence rate (no pad) was 39% at 3 months and 85% at 6 months. Detectable postoperative PSA at 3 month was observed in 2 patients only. Two major complications occurred: one acute transient renal failure one uretrorectal fistula at day 20. Conclusions: The extraperitoneal laparoscopic radical prostatectomy results seem comparable to transperitoneal laparoscopic radical prostatectomy or open surgery. This approach is reproducible and seems to avoid the potential risks of intraperitoneal injury. Long–term follow up and comparative series are however necessary to further evaluate these new techniques.

Laparoscopic radical prostatectomy: The learning curve

Purpose of review Laparoscopic radical prostatectomy is now an accepted treatment option for the management of localized prostate cancer. Numerous studies have demonstrated the feasibility and the reproducibility of this procedure. Expert teams in high-volume centres routinely carry out laparoscopic radical prostatectomy but for the novice the obstacle to success is how to learn and gain proficiency in this procedure. In this review, we will present our views on how this can be done. Recent findings A learning curve includes the necessity for continuous self-evaluation in terms of cancer control, continence and potency. Many different methods can be used to acquire the technique: dry lab, animal live lab, cadaveric laparoscopic dissection or mentoring with an expert. All of these steps may not be essential as laparoscopic radical prostatectomy is not too dissimilar to open prostatectomy. However, one must understand that the physiological consequences of anaesthesia during laparoscopy and basic laparoscopic suturing technique should be perfected prior to taking on laparoscopic radical prostatectomy. The training then must continue under the supervision of a mentor. The opportunity for discussion with an expert allows the novice to learn the pitfalls and the tips and tricks of laparoscopic radical prostatectomy, thus reducing the length of the learning curve and negating the need to reinvent the wheel. Summary Laparoscopic radical prostatectomy is similar to any other new surgical procedure and as with open surgery we learn and gain experience with each procedure; the learning curve is never completely finished.

Localising prostate cancer: comparison of endorectal magnetic resonance (MR) imaging and 3D-MR spectroscopic imaging with transrectal ultrasound-guided biopsy.

Background: Magnetic resonance imaging (MRI) and MR spectroscopic imaging (MRSI) have been gaining acceptance as tools in the evaluation of prostate cancer. We compared the accuracy of transrectal ultrasound (TRUS)-guided biopsy and dynamic contrast-enhanced MRI combined with three-dimensional (3D) MRSI in locating prostate tumours and determined the influence of prostate weight on MRI accuracy. Patients and Methods: Between March 1999 and October 2006, 507 patients with localised prostate cancer underwent radical prostatectomy (RP) at the Jules Bordet Institute. Of these, 220 had undergone endorectal MRI (1.5 T Siemens Quantum Symphony) and 3D-MRSI prior to RP. We retrospectively reviewed data on tumour location and compared the results obtained by MRI and by TRUS-guided biopsy with those obtained on histopathology of the RP specimen. Results: Patient data were as follows: median age 62.4 years (45–74); median PSA 6.36 ng/ml (0.5–22.6); 73.6% of patients had non-palpable disease (T1c); median biopsy Gleason score 6 (3–9); median RP specimen weight 50 g (12–172); median pathological Gleason score 7 (4–10); 68.64% of patients had organ-confined (pT2) disease. Tumour localisation was correlated with RP data in a significantly higher percentage of patients when using MRI rather than TRUS-guided biopsy (47.4 vs. 36.6%, p < 0.0001). MRI was marginally superior to TRUS-guided biopsy in detecting malignancy at the prostate apex (48.3 vs. 41.9%, p = 0.0687) and somewhat better at the prostate base (46 vs. 39.1%, p = 0.0413). It was highly significantly better at mid-gland (52 vs. 41.1%, p = 0.0015) and in the transition zone (40.1 vs. 24.3%, p < 0.0001). MRI had higher sensitivity in larger (≧50 g) than smaller (<50 g) prostates (50.3 vs. 42.2%, p = 0.0017). Conclusions: MRI was superior to TRUS-guided biopsy in locating prostate tumours except at the gland apex. MRI was more accurate in larger (≧50 g) than smaller prostates.

Laparoscopic-Assisted Recipient Nephrectomy and Recipient Kidney Procurement during Orthotopic Living-Related Kidney Transplantation

Advanced atherosclerosis or thrombosis of iliac vessels can constitute an absolute contraindication for heterotopic kidney transplantation. We report the case of a 42-year-old women with end-stage renal disease due to lupus nephritis and a history of bilateral thrombosis of iliac arteries caused by antiphospholipid antibodies. Occlusion had been treated by the bilateral placement of wall stents which precluded vascular anastomosis. The patient was transplanted with a right kidney procured by laparoscopic nephrectomy from her HLA semi-identical sister. The recipient had left nephrectomy after laparoscopical transperitoneal dissection. The donor kidney was orthotopically transplanted with end-to-end anastomosis of graft vessels to native renal vessels and of the graft and native ureter. Although, the patient received full anticoagulation because of a cardiac valve and antiphospholipid antibodies, she had no postoperative complication in spite of a short period of delayed graft function. Serum creatinine levels three months after transplantation were at 1.0 mg/dl. Our case documents that orthotopical transplantation of laparoscopically procured living donor kidneys at the site of recipient nephrectomy is a feasible procedure in patients with surgical contraindication of standard heterotopic kidney transplantation.

Manual of laparoscopic urology: Foreword by Claude Schulman

In this book every urologic procedure is described in a step-by-step sequence of events and the text is supplemented with innumerous tips, colored illustrations and high definition photographs depicting the main steps of the procedures. The structure of every chapter is extremely clear, and emphasis is given to the laparoscopic surgical technique. The aim of this manual is to provide the Urologic Surgeon with the state-of-the-art of Laparoscopic Surgery. It guides guide the reader through every stage of the laparoscopic procedure, from the equipments settings to the correct position of the needle on the needle holder. The first chapter introduces the reader to the basic aspects of Laparoscopy, the physiologic effects of pneumoperitoneum and its potential clinical outcome in the body systems, anesthesia problems in laparoscopy, technical considerations and check list on equipment and instruments. It demonstrates the correct handling of laparoscopic instruments, going through basic and advanced suturing techniques. The following chapters describe the surgical technique of urological procedures, including an introduction to the subject and ending with a reading list.

Modified specimen retrieval facilitates urethro-vesical anastomosis in laparoscopic radical prostatectomy.

Laparoscopic radical prostatectomy (LRP) has now been formally accepted as a treatment option for localized prostate cancer [1]. In this procedure, the interval after complete excision of the prostate to its removal through a port-site depends on the time taken to complete the urethrovesical anastomosis. Surprisingly, a survey of published reports on both the transperitoneal and extraperitoneal techniques gave little information on precisely how to deal with the prostate before its extraction [2–12]. As appropriate handling of the prostate can facilitate the final and crucial part of the procedure, we describe a technique developed in our department over the last 5 years.