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PubMed2002

Three-month neoadjuvant hormonal therapy before radical prostatectomy: a 7-year follow-up of a randomized controlled trial.

OBJECTIVE: To describe the outcome, assessed as the level of prostate specific antigen (PSA), of a mature (more than half the events recorded) prospective randomized study with a median follow-up of 82 months of neoadjuvant hormonal therapy before radical prostatectomy, as this has been suggested to decrease the rate of positive surgical margins (i.e. provide greater potential to completely excise the tumour). PATIENTS AND METHODS: From December 1991 to March 1994, 126 patients with clinically localized prostate cancer were randomized between direct radical prostatectomy or a 3-month course of a gonadotrophin-releasing hormone analogue before surgery. The patients were followed by PSA determinations and a value of > 0.5 ng/mL used to define progression. RESULTS: The incidence of positive surgical margins decreased from 45.5% to 23.6% (P = 0.016) with hormone treatment. Despite this there was no difference in PSA progression-free survival at the last follow-up; it was 51.5% for those undergoing radical prostatectomy only and 49.8% for those who received hormonal pretreatment (P = 0.588). CONCLUSIONS: Three months of neoadjuvant hormonal therapy before radical prostatectomy offers no benefit to the patient and cannot be recommended for routine clinical use.

Aged↗
PubMed2003

Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study.

OBJECTIVE: To evaluate urinary symptoms, sexual dysfunction and quality of life in patients with benign prostatic hypertrophy (BPH) before and after open prostatectomy, using the International Prostate Symptom Score (IPSS), the International Continence Society (ICS)-"BPH" (ICS-male, ICS-sex and ICS-QoL) and International Index of Erectile Function (IIEF) questionnaires. PATIENTS AND METHODS: Sixty men with BPH (mean age 68 years) underwent a digital rectal examination, transurethral ultrasonography, measurement of total prostatic specific antigen serum level and uroflowmetry. Their urinary symptoms, sexual function and quality of life were fully evaluated using the IPSS, ICS-"BPH" and IIEF before and 6 months after suprapubic prostatectomy. The body mass index (BMI) was also calculated for each patient. Univariate analysis was used to examine the relationship between symptom scores and age, tobacco use, alcohol intake and BMI. RESULTS: In a univariate analysis, age was the most important prognostic factor for both urinary and sexual symptoms. Prostatectomy resulted in a significant improvement in obstructive (mean 9.68 to 3.38) and irritative symptom (6.70 to 3.06), and quality-of-life scores (3.41 to 1.34). ICS-male scores were both significantly decreased, the mean voiding score from 13.72 to 10.28 and the incontinence score from 10.43 to 7.81. There was also a significant decrease in the ICS-QoL symptom score (from 9.20 to 7.27). Comparative results between IIEF and ICS-sex showed no improvement in sexual scores after open surgery, but there was a significant increase in sexual desire and overall satisfaction (both P = 0.035). CONCLUSIONS: The combined use of the IPSS, ICS-"BPH" and IIEF allows an evaluation of the relationship between age, prostatic symptoms and sexual dysfunction. Age may be considered both a direct and indirect (BPH-related) prognostic factor for sexual activity. Suprapubic prostatectomy resolves obstructive symptoms, and maintains sexual desire, overall sexual satisfaction and an improvement in quality of life. However, irritative symptoms, erection, orgasm and sexual intercourse satisfaction are not significantly altered.

Aged↗
PubMed2003

Technique of laparoscopic (endoscopic) radical prostatectomy.

During the last decade laparoscopy has become a standard technique available to the urologist, through constant technological advances and refinements. The progress of laparoscopic/endoscopic techniques allows the indications for this surgery to include complex oncological procedures like radical prostatectomy. Since the first description of laparoscopic radical prostatectomy (LRP) in the early 1990s the technique has undergone significant technical modifications. Transperitoneal LRP is now a standard procedure and can be used successfully and reproducibly, giving results comparable with those from the open retropubic procedure. Despite many advantages, transperitoneal laparoscopy is associated with potential intraperitoneal complications. Because of the limitations inherent in the transperitoneal route, a totally extraperitoneal endoscopic radical prostatectomy (EERPE) has been developed. The totally extraperitoneal endoscopic access provides a safe and minimally invasive approach to various urological procedures, including prostatectomy. This technical improvement completely obviates intra-abdominal complications. EERPE combines the advantages of minimally invasive laparoscopy and the open retropubic approach. We review the surgical techniques of LRP and EERPE, and highlight the indications, contraindications and outcomes.

Contraindications↗
PubMed2003

A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution.

UNLABELLED: The authors from the Vattikuti Institute in the USA report a prospective comparison of radical prostatectomy and robot-assisted prostatectomy. They found that the robot-assisted procedure was safer, and yielded favourable oncological and functional results. They also present work in association with the Department of Urology in Mansoura into robot-assisted radical cystoprostatectomy and urinary diversion, and point out the advantages and disadvantages associated with performing the most complex types of urinary diversion. There is also an interesting paper relating to the association between sexual factors and prostate cancer, from authors in institutions in Australia, New Zealand and Italy. They found that in a case-control study of men aged <70 years, ejaculatory frequency was negatively associated with the risk of prostate cancer. Technology has made many contributions to the management of urological patients. The classic example is that of urinary stone management. Authors from the USA evaluated cyroablation of renal carcinoma in patients with solitary kidneys. They are encouraged by their results and suggest that there is merit in this treatment, but indicate the need for a longer follow-up. OBJECTIVE: To prospectively compare standard radical retropubic prostatectomy (RRP) and the robotically assisted Vattikuti Institute prostatectomy (VIP) in the management of localized prostate cancer. PATIENTS AND METHODS: The study was a single-institution, prospective, unrandomized comparison of histopathological, and functional outcomes, at baseline and during and after surgery, in 100 patients undergoing RRP and 200 undergoing VIP. RESULTS: While the variables before surgery, the operative duration (163 vs 160 min) and pathological stages were comparable, there were significant differences in the measured outcomes. The blood loss was 910 and 150 mL for RRP and VIP, respectively, and transfusion was greater after RRP (67% vs none; both P < 0.001). There were four times as many complications after RRP (20% vs 5%, P < 0.05), the haemoglobin level at discharge was lower (100 vs 130 g/L, P < 0.005) and the hospital stay longer (3.5 vs 1.2 days; P < 0.05). Most (93%) of VIP and none of the RRP patients were discharged within 24 h (P < 0.001); the duration of catheterization was twice as long after RRP (15.8 vs 7 days; P < 0.05). Positive margin was more frequent after RRP (23% vs 9%, P < 0.05). After VIP, patients achieved continence and return of erections more quickly than after RRP (160 vs 44, and 180 vs 440 days, both P < 0.5). The median return to intercourse was 340 days after VIP but after RRP half the patients have as yet not resumed intercourse at 700 days (P < 0.05). CONCLUSIONS: The VIP procedure appears to be safer, less bloody and requires shorter hospitalization and catheterization. The oncological and functional results were favourable in patients undergoing VIP.

Adult↗
PubMed1995

Acute normovolemic hemodilution is a cost-effective alternative to preoperative autologous blood donation by patients undergoing radical retropubic prostatectomy.

BACKGROUND: Preoperative autologous blood donation is accepted as a standard of care for radical prostatectomy. Acute normovolemic hemodilution (ANH) is an alternative method for obtaining autologous blood. The cost and benefits of these two autologous blood-collection techniques are compared. STUDY DESIGN AND METHODS: Thirty consecutive patients scheduled for radical prostatectomy underwent ANH to a target hematocrit level of 28 percent. Blood was transfused in the perioperative period to maintain the hematocrit level > 25 percent. Hematocrit levels, transfusion outcomes and costs, and postoperative outcomes for these patients (hemodilution group) were compared with a matched patient cohort who preoperatively donated 3 units of blood for autologous use in prostatectomy surgery (nonhemodilution group, n = 30). RESULTS: Thirty patients underwent ANH to a hematocrit level of 28.7 +/- 1.7 percent, and 1740 +/- 346 mL (3.5 +/- 0.7 units) of blood were collected. Three (10%) of the patients in each cohort had allogeneic blood exposure. Transfusion costs were 73 percent higher for the nonhemodilution group patients than for the hemodilution group patients ($330 +/- $100 vs. $191 +/- $55, p < 0.001). No differences were found in postoperative outcomes. CONCLUSION: An integrated blood conservation program utilizing hemodilution and a defined transfusion trigger can decrease the requirement for preoperative donation of blood for autologous use in radical prostatectomy. Point-of-care autologous blood procurement is more cost-effective than preadmission donation of autologous blood units.

Aged↗
PubMed2000

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival.

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.

Adult↗
PubMed2005

[Long-term outcome of radical prostatectomy in an observation period of at least 10 years].

PURPOSE: To evaluate the long-term outcome of radical prostatectomy in unselected patients with prostate cancer of relatively poor prognosis. MATERIALS AND METHODS: Between 1977 and 1989, 293 patients underwent radical retropubic prostatectomy. We analyzed 224 patients with a minimum follow-up of 10 years (mean 14 years, range 10.5 to 24 years). RESULTS: The pathological stage distribution of these 224 patients was pT1 in 14.3 %, pT2 43.6 %, pT3 39.1 % and pT4 3 %. Of these patients, 50 (22.3 %) had positive lymph nodes and 45 (20.1 %) positive margins. At 10 years after surgery, the actuarial survival rate for all patients was 67.1 % and the cancer-specific survival rate 85 %. Once progression of the disease developed, the median actuarial time to death was 5.5 years. Since PSA measurements were not introduced in the follow-up after radical prostatectomy until 1986, PSA data were available in only 84 (37.5 %) patients. In a survival analysis, preoperative PSA (< 10 ng/ml vs. > or = 10 ng/ml) was a significant predictor of the probability of positive margins (22 % vs. 78 %) and cancer-specific survival (87 % vs. 69 %) after 10 years. CONCLUSIONS: Long-term survival can be expected even in patients with locally advanced prostate cancer treated with radical prostatectomy.

Biomarkers, Tumor↗
PubMed2002

Quality of life after radical prostatectomy or watchful waiting.

BACKGROUND: We evaluated symptoms and self-assessments of quality of life in men with localized prostate cancer who participated in a randomized comparison between radical prostatectomy and watchful waiting. METHODS: Between 1989 and 1999, a group of Swedish urologists randomly assigned men with localized prostate cancer to radical prostatectomy or watchful waiting. In this follow-up study, we obtained information from 326 of 376 eligible men (87 percent) concerning certain symptoms, symptom-induced distress, well-being, and the subjective assessment of quality of life by means of a mailed questionnaire. RESULTS: Erectile dysfunction (80 percent vs. 45 percent) and urinary leakage (49 percent vs. 21 percent) were more common after radical prostatectomy, whereas urinary obstruction (e.g., 28 percent vs. 44 percent for weak urinary stream) was less common. Bowel function, the prevalence of anxiety, the prevalence of depression, well-being, and the subjective quality of life were similar in the two groups. CONCLUSIONS: The assignment of patients to watchful waiting or radical prostatectomy entails different risks of erectile dysfunction, urinary leakage, and urinary obstruction, but on average, the choice has little if any influence on well-being or the subjective quality of life after a mean follow-up of four years.

Aged↗
PubMed2004

Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.

BACKGROUND: We evaluated whether men at risk for death from prostate cancer after radical prostatectomy can be identified using information available at diagnosis. METHODS: We studied 1095 men with localized prostate cancer to assess whether the rate of rise in the prostate-specific antigen (PSA) level--the PSA velocity--during the year before diagnosis, the PSA level at diagnosis, the Gleason score, and the clinical tumor stage could predict the time to death from prostate cancer and death from any cause after radical prostatectomy. RESULTS: As compared with an annual PSA velocity of 2.0 ng per milliliter or less, an annual PSA velocity of more than 2.0 ng per milliliter was associated with a significantly shorter time to death from prostate cancer (P<0.001) and death from any cause (P=0.01). An increasing PSA level at diagnosis (P=0.01), a Gleason score of 8, 9, or 10 (P=0.02), and a clinical tumor stage of T2 (P<0.001) also predicted the time to death from prostate cancer. For men with an annual PSA velocity of more than 2.0 ng per milliliter, estimates of the risk of death from prostate cancer and death from any cause seven years after radical prostatectomy were also influenced by the PSA level, tumor stage, and Gleason score at diagnosis. CONCLUSIONS: Men whose PSA level increases by more than 2.0 ng per milliliter during the year before the diagnosis of prostate cancer may have a relatively high risk of death from prostate cancer despite undergoing radical prostatectomy.

Aged↗
PubMed2004

Can prostate biopsies predict suitability for nerve-sparing radical prostatectomy?

OBJECTIVE: The process for selecting patients suitable for nerve-sparing radical prostatectomy (NSRP) has been the source of much debate. In this study we analysed the use of prostate biopsies as the principal selection tool. MATERIAL AND METHODS: Patients undergoing radical retropubic prostatectomy (n = 133) were retrospectively categorized as having "unilateral" (biopsy demonstrated malignancy confined to one side of the gland) or "bilateral" carcinoma. The accuracy and reliability of this categorization were determined by correlation with the final histopathology of the resected radical prostatectomy specimen. RESULTS: Prostate biopsy suggested "unilateral" carcinoma in 30/58 (52%) and 45/75 (60%) patients diagnosed using transrectal ultrasound-guided (TRUS) and transperineal digital-guided (TP) routes, respectively. Subsequent analysis of the resected specimen, however, revealed "bilateral" malignancy in 50 patients (86%) in the TRUS group and in 63 (84%) in the TP group. Furthermore, positive surgical margins were identified on the "benign" side (by preoperative biopsy) in 6 (20%) patients in the TRUS subgroup whose biopsy had suggested "unilateral" carcinoma, and in 12 (27%) of the comparative TP subgroup. CONCLUSIONS: Biopsy-suggested "unilateral" carcinoma was associated with both a high incidence of "bilateral" disease on final histology following radical prostatectomy and an alarming incidence (24%) of positive surgical margins on the "benign" side where NSRP might be advocated.

Adenocarcinoma↗
PubMed2003

Introducing a new, simple scoring system to evaluate oncological and functional outcome after radical prostatectomy.

OBJECTIVE: To create a scoring system which takes into account oncological outcome and functional results (continence and erectile function) of patients after radical prostatectomy. MATERIAL AND METHODS: A total of 146 consecutive men underwent radical prostatectomy for localized prostate cancer and were evaluated 1 year after surgery. Biochemical recurrence was defined as a single postoperative prostate-specific antigen (PSA) level of > 0.2 ng/ml. Continence, defined as not using a pad, and potency, defined as the ability to achieve and maintain an erection suitable for sexual intercourse, were evaluated by means of a prospective, self-administered questionnaire. Each patient received 4 points (if PSA was <0.2 ng/ml) or 0 points (if PSA was >0.2 ng/ml) for oncological outcome, 2 points (if continent) or 0 points (if incontinent) for urinary continence and 1 point (if potent) or 0 points (if impotent) for erectile function. The total score was calculated, with higher scores indicating a better outcome. The unique feature of this scoring system is that each individual score represents a particular clinical status regarding oncological and functional outcome. RESULTS: One year after surgery, 121 (82.8%) patients had PSA levels of <0.2 ng/ml, 103 (70.5%) were continent and 53 (36.3%) were potent. Patients with a total score of > or =4 points had good cancer control and could be further subdivided into those who were continent and potent (7 points; 22.6%), those who were continent but had erectile dysfunction (ED) (6 points; 34.2%), those who were incontinent and potent (5 points; 8.2%) and those who were incontinent and had ED (4 points; 17.8%). Similarly, patients with a score of <4 points had no cancer control and could be further subdivided into those who were continent and potent (3 points; 3.4%), those who were continent but had ED (2 points; 10.3%), those who were incontinent and potent (1 point; 2.1%) and those who were incontinent and had ED (0 points; 1.3%). CONCLUSIONS: This scoring system includes the three most important outcomes after radical prostatectomy, namely cancer control, continence and erectile function. It may allow us to better evaluate, communicate and compare the results of radical prostatectomy in a multinational, multicenter setting.

Aged↗
PubMed2003

Does initial surveillance in early prostate cancer reduce the chance of cure by radical prostatectomy?--A case control study.

OBJECTIVE: To evaluate whether initial surveillance followed by prostatectomy impairs pathological stage compared to immediate surgery in men with prostate cancer detected as a result of early screening. MATERIAL AND METHODS: A total of 26 patients with prostate cancer [T1c-T2, Gleason score <7, prostate-specific antigen (PSA) 3-13 ng/ml] who were managed by means of initial surveillance (mean 23.4 months, range 8-55 months) followed by radical retropubic prostatectomy (RRP) were evaluated. For each of these cases two matched control cases were selected from patients who were operated on without prior surveillance. The two groups were matched for PSA, age, T stage and Gleason score at biopsy. Evaluation of prostatectomy specimens included measurement of tumour volume, pT stage and Gleason score. RESULTS: Tumour volume did not differ significantly between cases and controls: 1.35 vs 1.05 cm (3), respectively. The frequency of extracapsular growth, Gleason score and time to progression after RRP within a mean follow-up period of 2 years were also similar between the two groups. CONCLUSION: In selected patients with very early prostate cancer it seems that close surveillance followed by prostatectomy when signs of progression appear is a low-risk option. However, before this strategy can be generally recommended longer follow-up periods should be used and a randomized study should be performed.

Aged↗
PubMed2006

Postoperative urinary continence after robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: Laparoscopic radical prostatectomy has shown excellent results concerning patient morbidity, with less blood loss compared to conventional surgery. Robot-assisted laparoscopy offers several additional important technical improvements and therefore it might be suggested that robotic radical prostatectomy would also offer surgical advantages. The objective of this study was to evaluate urinary continence for the first 72 cases of robot-assisted radical prostatectomy performed by a single surgical team. MATERIAL AND METHODS: We analysed the outcomes of the first 72 consecutive patients to undergo robot-assisted prostatectomy for localized prostate cancer at our hospital between January 2002 and May 2004. A self-administered questionnaire concerning urinary status was mailed to the patients 3 and 6 months after surgery. Pre- and peroperative characteristics were obtained from patient medical records. The mean age was 61.2 years (range 36-71 years) and the mean preoperative prostate-specific antigen level was 6.3 ng/ml (range 2.3-10.7 ng/ml). The preoperative clinical stage was T1c, 67%, T2, 28% and T3, 5% and the mean Gleason sum was 6 (range 5-9). RESULTS: Sixty-one of the 68 patients (90%) reported no use of pads and 6 (9%) used a maximum of 1 pad/day 3-6 months after surgery. One patient reported use of >1 pad/day 6 months after surgery. Three significant complications were noted: ureter injury, haemorrhage and femoral nerve injury. CONCLUSIONS: In this series, which represents the learning curve for one surgical team, only a tenth of the patients still required pads 3-6 months after surgery. Considering the short follow-up period, the results in this series will probably improve over time.

Adult↗
PubMed2005

T1 G1 urinary bladder carcinoma: fact or fiction?

OBJECTIVES: To record the occurrence of well-differentiated bladder carcinoma reported as T1 G1 to the Swedish Urinary Bladder Cancer Registry, to review the staging and grading of the carcinomas and to scrutinize the validity of the data on T1 G1 tumours reported to the registry during the period 1997-2000. MATERIAL AND METHODS: The primary histopathological diagnoses of 98 cases of well-differentiated bladder carcinoma reported to the Registry were compared with the data delivered by the local urologists. Also, the histopathology slides were obtained from the local laboratories and re-examined. RESULTS: Fifty-five cases had been erroneously reported to the Registry as T1 tumours by the urologists, even though they were clearly described as non-infiltrating G1 tumours by the pathologists. The results of the re-examination of the pathology slides were concordant with the judgements of the local pathologists in only 50% of cases (20 stage T and 29 grade G tumours). Most importantly, the re-evaluation did not reveal a single invasive G1 tumour. Simply by providing the urologists with information about this problem, it was possible to reduce the number of errors in the reports from 27 in 1997 to only five in 2000. CONCLUSIONS: Well-differentiated urothelial carcinoma (G1) has no propensity to infiltrate the bladder mucosa. For investigating specific problems the data collected in the Swedish Urinary Bladder Cancer Registry have to be validated.

Cell Division↗
PubMed2003

Technical evolution of laparoscopic radical prostatectomy after 450 cases.

BACKGROUND AND PURPOSE: In 1998, laparoscopic radical prostatectomy with primary access to the seminal vesicles was introduced. In 1999, we developed a laparoscopic technique similar to the classic retropubic radical prostatectomy. We focus here on the continuous technical evolution of our technique. PATIENTS AND METHODS: From March 1999 to May 2002, we performed 450 laparoscopic radical prostatectomies. All important data of the patients; data concerning the performance of the procedure, including technical modifications, conversion, reintervention, and complication rate; as well as follow-up information were documented contemporaneously. The patients were divided into three groups of 150 individuals each in order to analyze the influence of the technical evolution of the procedure. Additionally, we studied the transferability of our technique, comparing the learning curves of the three surgeons involved in the program. RESULTS: The technical modifications included the routine use of a voice-controlled robot (AESOP) for the camera, exposure of the apex with 120 degrees retracting forceps, a free-hand suturing technique instead of the Endostitch device for the dorsal vein complex, 5-mm clipping instead of bipolar coagulation for the nerve-sparing technique, initial 6 o'clock suturing of the urethra before complete division, control of the prostatic pedicles by use of 12-mm Hemo-lok clips instead of the Ultracision or Endo-GIA, the bladder neck-sparing technique in cases of T(1c) and T(2a) tumors, and interrupted instead of continuous sutures for the vesicourethral anastomosis. All these modifications resulted in a significant decrease in operating time and the rates of transfusion, open conversion, and reintervention. The introduction of the nerve-sparing technique increased the number of tumor-positive margins. The mean operating time of the third surgeon was significantly less than that of the first surgeon, but the transfusion, conversion, and reintervention rates did not differ significantly among the surgeons. CONCLUSIONS: Laparoscopic radical prostatectomy has undergone continuous technical evolution resulting in a significant improvement of the operative results. Although we were able to demonstrate the transferability of this difficult procedure, we feel that it should be performed only at centers of expertise.

Adult↗
PubMed2004

Transurethral holmium laser enucleation of the prostate compared with transvesical open prostatectomy: 18-month follow-up of a randomized trial.

PURPOSE: This ongoing randomized study aims to find out whether transurethral holmium laser enucleation of the prostate (HoLEP) could be an alternative to open transvesical prostatectomy in patients with prostates >100 g. PATIENTS AND METHODS: A series of 120 urodynamically obstructed patients were randomized to HoLEP or open prostatectomy, 60 patients to each group. The HoLEP was performed with high-powered Ho:YAG lasers at 80 to 100 W (2.0 J, 40-50 Hz) and 550-nm bare laser fibers. The American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes were evaluated preoperatively and at 1, 3, 6, 12, and 18 months postoperatively. All complications were noted. RESULTS: By the Mann-Whitney test, there was no significant difference between the HoLEP and open surgery groups in patient age (69.0 years HoLEP v 71.0 years open surgery), prostate volume (115 cc [range 100-230 cc] v 113 cc [100-230 cc], or weight of resected tissue (94 g [range 57-220 g] v 96 g [range 61-220 g]). There were significant differences in the mean operative time (136 v 91 minutes; P< 0.0001), mean hemoglobin loss (1.9 v 2.8 g/dL; P< 0.0001), median catheter time (1 day v 6 days; P< 0.0001), and median hospital stay (2 days v 10 days; P< 0.0001). Both HoLEP and open prostatectomy resulted in pronounced and lasting postoperative improvements in Symptom Scores, peak urinary flow rates, and postvoiding residual volumes (P< 0.0001). The differences between HoLEP and open prostatectomy were not significant at any interval for any parameter. Blood transfusions were required in 0 HoLEP patients v 8 open surgery patients. Arterial bleeding occurred in three patients in each group. Secondary apical resection was required in two HoLEP patients and no open surgery patients. Bladder neck contracture occurred in none of the HoLEP patients and two of those having open surgery. Thus, the total number of patients having complications was 7 with HoLEP and 13 with open surgery. There were no deaths in either group. CONCLUSIONS: The HoLEP appears to be an endourologic alternative to open surgical enucleation of the prostate for large glands. It entails significantly less blood loss and a much shorter catheter time and hospital stay. The perioperative outcome strongly favors the holmium procedure. The rate of late complications is equally low with each procedure. The postoperative micturition improvement was significant and lasting and was equivalent in the two groups.

Aged↗
PubMed2004

Laparoscopic radical prostatectomy: Washington University initial experience and prospective evaluation of quality of life.

BACKGROUND AND PURPOSE: The laparoscopic approach to radical prostatectomy offers an alternative to the open surgical procedure with less morbidity. We prospectively collected data including a validated quality-of-life questionnaires on our first 38 laparoscopic radical prostatectomies (LRPs). The first 10 patients (group 1), second 10 patients (group II), and the most recent 18 patients (group III) were examined separately to study the learning curve for this procedure. In addition, we determined the pattern of recovery of urinary continence, potency, and quality of life. PATIENTS AND METHODS: Between July 1999 and July 2002, 38 consecutive transperitoneal laparoscopic radical prostatectomies were performed for clinically localized prostate carcinoma. Patients completed quality-of-life questionnaires (Rand 36 Health Survey) before surgery as well as at 1, 3, 6, and 12 months and every 6 months thereafter. The patients were also interviewed by an individual not directly involved in patient care. RESULTS: One patient (the second in our experience) was converted to the open approach because of failure to progress. The average operating time for the whole series was 423 +/- 137.6 minutes (range 215-825 minutes), the last 10 procedures taking 305 +/- 63 minutes (range 215-420 minutes). Complications consisted of one case each of intraoperative bladder injury, transient superficial peroneal nerve palsy, pulmonary embolism, and bladder neck obstruction. The bladder injury was closed laparoscopically without further complication. Bladder neck obstruction was secondary to a bladder wall fold that was treated with transurethral resection 14 months after surgery with good results. Four patients in group 1 had minor anastomotic leaks, while only one patient after that had a leak (group III). Four patients required transfusion, two intraoperatively and two postoperatively. In group III, the urethral catheter remained in place for an average of 8 days (range 6-10 days). With a mean follow-up of 22.8 months (range 9-43 months), 84.8% of the patients had perfect urinary control. Postoperatively, 9 patients (27%) were fully continent on removal of the Foley catheter. At 1, 3, 6, and 9 months postoperatively, diurnal urinary control was reported by 30.3%, 48%, 72.7%, and 84.8% of the patients, respectively. One patient needed an artificial urinary sphincter. Among the incontinent patients, 24.2% had urinary urgency, and one third of these patients reported urge incontinence. CONCLUSIONS: Laparoscopic prostatectomy is a reproducible technique with a steep learning curve. Operating times and the incidence of anastomotic leaks and urinary incontinence decrease significantly after the initial 10 patients.

Erectile Dysfunction↗
PubMed2005

Extraperitoneal laparoscopic prostatectomy (adenomectomy) for obstructing benign prostatic hyperplasia: transvesical and transcapsular (Millin) techniques.

PURPOSE: We describe extraperitoneal laparoscopic resection of large prostatic adenomas (<100 g) as an alternative to open simple prostatectomy by both the transcapsular or Millin and the transvesical approaches. PATIENTS AND METHODS: We have performed more than 20 laparoscopic prostatectomies (adenomectomies) for benign prostatic hyperplasia (BPH) for glands >100 g. The initial two cases, with follow-up longer than 1 year, are included in this report. Using an extraperitoneal approach, enucleation of the obstructing prostatic lobes was performed with the aid of a Harmonic Scalpel and laparoscopic claw forceps. Hemostatic sutures were placed at 5 and 7 o'clock. The urethrovesical junction (transvesical) or capsulotomy (Millin) were closed in an interrupted fashion using intracorporeal sutures. RESULTS: Both procedures were successful. The total operative time was 180 minutes for first the case and 120 minutes for the second. The adenoma removed was approximately 138 g in the first case and 102 g in the second case. The estimated blood loss was <50 mL and <200 mL, respectively. The postoperative courses were unremarkable. Analgesic requirements were minimal, and the patient was discharged on postoperative day 2 and 3, respectively. A follow-up examination at 1, 3, 6, and 12 months showed that the flow rate is >20 mL and the postvoiding residual volume 0, with normal continence and sexual potency in both men. CONCLUSIONS: Extraperitoneal laparoscopic simple prostatectomy is a simple straightforward technique. Minimal bleeding, a reduced transfusion rate, shorter hospitalization, and faster recovery are additional advantages. This minimally invasive technique is a reasonable alternative to open simple prostatectomy for large glands with reduced morbidity.

Adenoma↗