Richard Gaston

Complete Periprostatic Anatomy Preservation During Robot-Assisted Laparoscopic Radical Prostatectomy (RALP): The New Pubovesical Complex-Sparing Technique

BACKGROUND Puboprostatic ligament preservation has been proposed as a method to accelerate continence recovery after radical prostatectomy (RP). However, these ligaments present anatomic continuity with the bladder, and there must be interruption at some point to expose the prostatourethral junction. OBJECTIVES To describe the surgical steps of pubovesical complex (PVC)-sparing robot-assisted laparoscopic RP (RALP) and present the preliminary results of our technique. DESIGN, SETTING, AND PARTICIPANTS Thirty PVC-sparing RALP procedures were performed in patients <60 yr with clinically localised prostate cancer between 2007 and 2009 by the same surgeon. SURGICAL PROCEDURE The principles of bladder neck preservation, tension and energy-free dissection of the bundles as well as seminal vesicle sparing are applied. Ventrally, a plane of dissection is developed between the detrusor apron and the prostate. The soft connective tissue between Santorinis plexus and the prostate is blandly dissected, leaving the plexus intact and in place. MEASUREMENTS The rates and location of positive surgical margins (PSM) as well as functional outcomes are presented. RESULTS AND LIMITATIONS Three of 30 patients (10%) had a PSM (two apical margins and one on the left posterolateral side). At catheter removal, 24 of 30 patients (80%) were dry (0 pads), and 6 of 30 patients (20%) needed one security pad. After 3 mo, 22 of 30 patients (73%) presented an International Index of Erectile Function score >17 (with or without phosphodiesterase type 5 inhibitors). Thirteen of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4. Small sample size, low mean age of enrolled patients (52 yr), and the absence of diseases that could impair the continence and potency recovery are some of the limitations of the study. Moreover, it is difficult to quantify the effect of each applied continence-sparing technique. CONCLUSIONS The holistic preservation of the PVC during RALP is technically feasible. It leads towards an absolute preservation of the periprostatic anatomy that may enhance early functional outcomes. Further studies are needed to confirm our results.

The Surgical Treatment of a Large Prostatic Adenoma: The Laparoscopic Approach-A Systematic Review

PURPOSE To present a critical overview of the current literature on the role of laparoscopy for the surgical treatment of patients with large prostatic adenomas. MATERIALS AND METHODS A MedLine search for peer-reviewed studies on laparoscopic simple prostatectomy (LSP) was performed. The clinical studies that reported most of the following information were included: number of patients, prostate volume, operative time, blood loss, hospital stay, and the duration of catheterization, as well as functional outcomes and complications. Articles reporting a mean total prostate volume of <80 mL or a mean prostatic adenoma of <60 mL were excluded. The review was performed according to the PRISMA statement. RESULTS Fourteen articles on LSP were included in this systematic review with a total of 626 patients treated. Both transperitoneal and extraperitoneal approaches, as well as transvesical and transcapsular routes, have been described. Eleven articles were case-series and three were comparative retrospective nonrandomized studies. When compared with open simple prostatectomy (OP), LSP is associated with a less blood loss and a reduced irrigation requirement, a shorter postoperative catheterization period, and a shorter hospital stay, at the expense of an extended operative time. The limited number of patients treated, the selection biases due to the retrospective nature of several published articles on LSP, and the short follow-up periods are evident limits of the literature. I-square test demonstrated a high heterogeneity (93%) and consequently a high variability in the intervention effects in terms of maximum urinary flow rate (Qmax). CONCLUSIONS Even if LSP seems feasible and safe, there is still limited evidence regarding its long-term outcomes compared with OP.

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: Critical appraisal of the anatomic landmarks for a complete intrafascial approach.

To provide an overview of the anatomical landmarks needed to guide a retropubic (Retzius)‐sparing robot‐assisted laparoscopic prostatectomy (RALP), and a step‐by‐step description of the surgical technique that maximizes preservation of the periprostatic neural network. The anatomy of the pelvic fossae is presented, including the recto‐vesical pouch (pouch of Douglas) created by the reflections of the peritoneum. The actual technique of the trans‐Douglas, intrafascial nerve‐sparing robotic radical prostatectomy is described. The technique allows the prostate gland to be shelled out from under the overlying detrusor apron and dorsal vascular complex (DVC‐Santorini plexus), entirely avoiding the pubovesical ligaments. There is no need to control the DVC, since the line of dissection passes beneath the plexus. Three key points to ensure enhanced nerve preservation should be respected: (1) the tips of the seminal vesicles, enclosed in a “cage” of neuronal tissue; a seminal vesicle‐sparing technique is therefore advised when oncologically safe; (2) the external prostate‐vesicular angle; (3) the lateral surface of the prostate gland and the apex. The principles of tension and energy‐free dissection should guide all the maneuvers in order to minimize neuropathy. Using robotic technology, a complete intrafascial dissection of the prostate gland can be achieved through the Douglas space, reducing surgical trauma and providing excellent functional and oncological outcomes. Clin. Anat. 28:896–902, 2015.

TEACHING LAPAROSCOPY: THE NEW CHALLENGE

In recent years laparoscopy in urology has become increasingly popular because it is less invasive and requires a shorter convalescence. It is now necessary for Residents and new urologists to learn the basic principles and advanced steps of urological laparoscopy. Appropriate training is mandatory to acquire the necessary laparoscopic skills. Indeed, there is an entirely different set of skills involved and a different way of viewing the anatomy; this minimally invasive surgery requires that beginners gain considerable training and experience [1].

Nerve Sparing, Robot-Assisted Radical Cystectomy with Intracorporeal Bladder Substitution in the Male

PURPOSE We provide a step-by-step description of our technique of nerve and seminal vesicle sparing robot-assisted radical cystectomy with an orthotopic neobladder. We also present preliminary oncologic and functional outcomes. MATERIALS AND METHODS Nerve and seminal vesicle sparing robot-assisted radical cystectomy with a modified Y-shaped orthotopic neobladder was performed by the same surgeon in 40 men with clinically localized bladder cancer from January 2011 to September 2014. Operative, perioperative and pathological data as well as continence and erectile function outcomes are presented. RESULTS Median followup was 26.5 months (range 8 to 52). A soft tissue positive surgical margin was found in a patient with pT3a disease. A global rate of 30% early and 32.5% late complications was observed. However, the grade III or higher complication rate was low in both settings at 2.5% and 5%, respectively. There was 1 cancer related death 23 months after surgery. Of the 40 patients 30 (75%) gained daytime continence (0 pad) within 1 month postoperatively. The 12-month nocturnal continence rate was 72.5% (29 of 40 patients). Mean preoperative IIEF-6 (International Index of Erectile Function-6) score was 24.4. Erectile function returned to normal, defined as an IIEF-6 score greater than 17, in 31 of 40 patients (77.5%) within 3 months while 29 of 40 patients (72.5%) returned to the preoperative IIEF-6 score within 12 months. CONCLUSIONS In the hands of an experienced surgeon nerve and seminal vesicle sparing robot-assisted radical cystectomy with intracorporeal reconstruction of the neobladder seems feasible and safe. It provides short-term oncologic efficacy and promising functional outcomes. Yet comparative, long-term followup studies with standard open cystectomy are required.

Robot-assisted laparoscopic radical prostatectomy with intrafascial dissection of the neurovascular bundles and preservation of the pubovesical complex: a step-by-step description of the technique.

The preservation of sexual potency after radical prostatectomy has always been the topic of much anxiety and debate. While cancer control and urinary continence are of supreme importance, the preservation of sexual function completes the trifecta that both patient and surgeon strive to achieve. The introduction of robotic assistance to modern laparoscopic surgery has provided many advantages, the two greatest being improved three-dimensional magnified vision and wristed instrumentation. These technical enhancements provide the surgeon with improved surgical tools that have the potential to facilitate a more precise surgical approach. One of the potential advantages during robot-assisted laparoscopic prostatectomy (RALP) is improving visualization, control, and dissection of the neurovascular bundle (NVB). With this article, we provide the description of our current technique of intrafascial, tension and energy-free dissection of the NVB during RALP, aiming to maximize the preservation of the periprostatic neuronal network and improve erectile function outcomes. A step-by-step description of the preservation of the pubovesical complex is also provided.

Bladder neck preservation during minimally invasive radical prostatectomy: a standardised technique using a lateral approach.

Anastasios D. Asimakopoulos * †‡ , Camille Mugnier *, Jean-Luc Hoepffner *, Thierry Piechaud * and Richard Gaston * * Department of Urology , Clinique Saint Augustin , Bordeaux , France ; † Division of Urology, Department of Surgery , Policlinico Tor Vergata, University of Tor Vergata , Rome , / Division of Urology , Policlinico Casilino , Rome ; and ‡ Department of Surgical Sciences , University of Tor Vergata, Policlinico Tor Vergata , Rome , Italy

Laparoscopic treatment of benign prostatic hyperplasia (BPH): overview of the current techniques.

TURP has been the ‘gold-standard’ surgical treatment for BPH over the past 30 years. However, its role in treating large prostates is limited mainly due to intraoperative and postoperative morbidities such as bleeding (with need for transfusion), TUR syndrome, urethral strictures as well as frequent need for re-operation [3]. The operative morbidity of TURP increases when it is performed for prostatic adenomas > 45 g, in procedures lasting > 90 min, or in patients aged > 80 years or with a history of acute urinary retention [4,5].

Adjuvant radiotherapy after radical cystectomy for muscle-invasive bladder cancer: A retrospective multicenter study

Objectives Radical cystectomy (RC) and pelvic lymph-node dissection (LND) is standard treatment for non-metastatic muscle-invasive urothelial bladder cancer (MIBC). However, loco-regional recurrence (LRR) is a common early event associated with poor prognosis. We evaluate 3-year LRR-free (LRRFS), metastasis-free (MFS) and overall survivals (OS) after adjuvant radiotherapy (RT) for pathological high-risk MIBC. Material and methods We retrospectively reviewed data from patients in 3 institutions. Inclusion criteria were MIBC, histologically-proven urothelial carcinoma treated by RC and adjuvant RT. Patients with conservative surgery were excluded. Outcomes were evaluated by Kaplan-Meier method. Acute toxicities were recorded according to CTCAE V4.0 scale. Results Between 2000 and 2013, 57 patients [median age 66.3 years (45–84)] were included. Post-operative pathological staging was ≤pT2, pT3 and pT4 in 16%, 44%, and 39%, respectively. PLND revealed 28% pN0, 26% pN1 and 42% pN2. Median number of lymph-nodes retrieved was 10 (2–33). Forty-eight patients (84%) received platin-based chemotherapy. For RT, clinical target volume 1 (CTV 1) encompassed pelvic lymph nodes for all patients. CTV 1 also included cystectomy bed for 37 patients (65%). CTV 1 median dose was 45 Gy (4–50). A boost of 16 Gy (5–22), corresponding to CTV 2, was administered for 30 patients, depending on pathological features. One third of patients received intensity-modulated RT. With median follow-up of 40.4 months, 8 patients (14%) had LRR. Three-year LRRFS, MFS and OS were 45% (95%CI 30–60), 37% (95%CI 24–51) and 49% (95%CI 33–63), respectively. Five (9%) patients had acute grade ≥3 toxicities (gastro-intestinal, genito-urinary and biological parameters). One patient died with intestinal fistula in a septic context. Conclusions Because of poor prognosis, an effective post-operative standard of care is needed for pathological high-risk MIBC. Adjuvant RT is feasible and may have oncological benefits. Prospective trials evaluating this approach with current RT techniques should be undertaken.

Laparoscopic extravesical ureteric re-implantation.

Laparoscopic ureteric surgery has been proven effective for various procedures including ureterolysis, ureterolithotomy, pyeloplasty [ 1 ] , as well as repair of obstructing retrocaval ureter [ 2 ] . For ureteric strictures various treatment options are available, based on the localisation, length and cause of the strictures. Whereas the treatment of long obstructed ureteric segments may require complex techniques (vesicopsoas hitch, Boari-fl ap, ileal ureteric substitution, autotransplantation), the treatment of short distal ureteric defects can be managed by end-to-end anastomosis or ureteroneocystostomy-ureteric re-implantation [ 1 ] .