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World Journal of Urology Dec 2008Robotic radical prostatectomy claims optimal oncologic results, minimal morbidity and best outcomes of urinary continence and erection function. Potential benefits... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Robotic radical prostatectomy claims optimal oncologic results, minimal morbidity and best outcomes of urinary continence and erection function. Potential benefits concerning side effects and complications compared to open radical prostatectomy are analysed.
METHODS
Out of 450 robotic radical prostatectomies performed, the last 210 patients aged 64 (41-78), PSA of 7.2 ng/ml (0.6-75) and body mass index of 27 (20-37) were assessed in detail using the Clavien's classification of surgical complications. In addition, a retrospective Medline based meta-analysis of 4,928 patients from eight centres involved was performed and compared to published data of open retropubic radical prostatectomy.
RESULTS
In total 55/210 (26%) of the patients had complications, whereof 48/55 (87%) were minor (Clavien's grade I-IIIa). Complications (IIIb and IVa) with open reoperations occurred in 7/210 (3%) of the patients including three bleedings, two incarcerated small bowels, one perforation of a sigmoid diverticle and one trocar hernia. No IVb or V complication occurred. Overall robotic complication rate is very low and appears to be even less than in open series. Minor and major complications seem to decrease after 200 individual console surgeries.
CONCLUSIONS
Robotic radical prostatectomy has proven to be a safe and reproducible surgical treatment with low morbidity. We encourage further trials using the same classification of complications to evaluate the morbidity of robotic prostatectomy conclusively in the near future.
Topics: Adult; Aged; Equipment Failure; Humans; Intraoperative Complications; Male; Middle Aged; Morbidity; Postoperative Complications; Prostatectomy; Retrospective Studies; Robotics; Surgery, Computer-Assisted; Urologic Diseases
PubMed: 18584180
DOI: 10.1007/s00345-008-0287-7 -
The Journal of Urology Jun 2012We describe current trends in robotic and open radical prostatectomy in the United States after examining case logs for American Board of Urology certification.
PURPOSE
We describe current trends in robotic and open radical prostatectomy in the United States after examining case logs for American Board of Urology certification.
MATERIALS AND METHODS
American urologists submit case logs for initial board certification and recertification. We analyzed logs from 2004 to 2010 for trends and used logistic regression to assess the impact of urologist age on robotic radical prostatectomy use.
RESULTS
A total of 4,709 urologists submitted case logs for certification between 2004 and 2010. Of these logs 3,374 included 1 or more radical prostatectomy cases. Of the urologists 2,413 (72%) reported performing open radical prostatectomy only while 961 (28%) reported 1 or more robotic radical prostatectomies and 308 (9%) reported robotic radical prostatectomy only. During this 7-year period we observed a large increase in the number of urologists who performed robotic radical prostatectomy and a smaller corresponding decrease in those who performed open radical prostatectomy. Only 8% of patients were treated with robotic radical prostatectomy by urologists who were certified in 2004 while 67% underwent that procedure in 2010. Median age of urologists who exclusively performed open radical prostatectomy was 43 years (IQR 38-51) vs 41 (IQR 35-46) for those who performed only robotic radical prostatectomy.
CONCLUSIONS
While the rate was not as high as the greater than 85% industry estimate, 67% of radical prostatectomies were done robotically among urologists who underwent board certification or recertification in 2010. Total radical prostatectomy volume almost doubled during the study period. These data provide nonindustry based estimates of current radical prostatectomy practice patterns and further our understanding of the evolving surgical treatment of prostate cancer.
Topics: Age Factors; Certification; Humans; Laparoscopy; Logistic Models; Male; Professional Practice; Prostatectomy; Prostatic Neoplasms; Robotics; United States; Urology
PubMed: 22498227
DOI: 10.1016/j.juro.2012.01.061 -
Urology Apr 1974
Topics: Germany; History, 19th Century; History, 20th Century; Prostatectomy; Urology
PubMed: 4595714
DOI: 10.1016/s0090-4295(74)80159-7 -
Journal of Endourology Aug 2004
Topics: Humans; Laparoscopy; Male; Prostatectomy
PubMed: 15333226
DOI: 10.1089/end.2004.18.576 -
European Urology Jul 2009Since we last published our technique of robotic prostatectomy, we have introduced three technical refinements: superveil nerve sparing, bladder drainage with a...
BACKGROUND
Since we last published our technique of robotic prostatectomy, we have introduced three technical refinements: superveil nerve sparing, bladder drainage with a percutaneous suprapubic tube (PST), and limited node dissection of the obturator and internal iliac nodes in preference to the external iliac nodes in selected patients.
OBJECTIVE
To describe selection criteria, to explain the three techniques, and to evaluate functional and oncologic results.
DESIGN, SETTING, AND PARTICIPANTS
Single-institution study of 1151 radical prostatectomies performed from 2006 to 2008 by one surgeon.
SURGICAL PROCEDURE
The superveil nerve-sparing technique spares nerves from the 11-o'clock position to the 1-o'clock position. The bladder is drained with a PST rather than a urethral catheter. For low- or intermediate-risk disease, limited lymphadenectomy concentrates on the internal iliac and obturator nodes, excluding the external iliac lymph nodes.
MEASUREMENTS
Erectile function and patient comfort were evaluated using questionnaires administered by a third party. Lymph node yield was quantified by a qualified uropathologist.
RESULTS AND LIMITATIONS
At 6-18 months after surgery, 94% of men who attempted sexual intercourse were successful with a median Sexual Health Inventory For Men (SHIM) score of 18 out of 25. PST bladder drainage resulted in less patient discomfort; visual analog scores were 2 at 2 days after prostatectomy and 0 at 6 days after prostatectomy. The modified lymphadenectomy harvested few overall nodes, but it increased the yield of positive nodes >13-fold in patients with low-risk stratification (6.7% compared with 0.5%).
CONCLUSION
In this single-institution, single-surgeon study, these modifications improved erectile function outcomes, decreased catheter-associated discomfort, and enhanced the detection of positive nodes.
Topics: Adult; Aged; Aged, 80 and over; Drainage; Erectile Dysfunction; Humans; Ilium; Lymph Node Excision; Lymphatic Metastasis; Male; Middle Aged; Prostatectomy; Prostatic Neoplasms; Robotics
PubMed: 19403236
DOI: 10.1016/j.eururo.2009.04.032 -
International Urology and Nephrology Mar 2011To determine a learning curve for radical perineal prostatectomy after formal training in radical retropubic prostatectomy. (Comparative Study)
Comparative Study
OBJECTIVE
To determine a learning curve for radical perineal prostatectomy after formal training in radical retropubic prostatectomy.
METHODS
Using the William Beaumont Hospital Prostatectomy database, we analyzed peri-operative data from two surgeons performing radical perineal prostatectomies from their initial 96 cases to determine a learning curve.
RESULTS
Over time, data between the first and last quarters showed consistent, excellent results in terms of skin time (143 SD ± 22 and 136 SD ± 24 min), blood loss (310 SD ± 120 and 335 ± 216 cc), and length of stay (1.3 SD ± 0.6 and 1.2 SD ± 0.5 days), without significant change. However, only two positive margins were obtained in the 4th quartile representing a significant change and possibly representing a learning curve.
CONCLUSIONS
These data show that excellent, reproducible results can be obtained using basic surgical principles, without incorporating expensive technology and resources.
Topics: Clinical Competence; Education, Medical, Continuing; Follow-Up Studies; Humans; Learning Curve; Male; Middle Aged; Perineum; Prostatectomy; Prostatic Neoplasms; Reproducibility of Results; Retrospective Studies
PubMed: 20882343
DOI: 10.1007/s11255-010-9781-0 -
Actas Urologicas Espanolas Oct 1997Erectile dysfunction is one of the most common sequela from radical prostatectomy. The authors evaluate the incidence of erectile dysfunction after radical... (Review)
Review
Erectile dysfunction is one of the most common sequela from radical prostatectomy. The authors evaluate the incidence of erectile dysfunction after radical prostatectomy, study the likely causative vascular mechanisms and assess the efficacy of the treatments employed. Two hundred and four (204) radical prostatectomies were analyzed. 163 (80%) patients referred adequate erections prior to surgery. In 82 cases, surgery was performed with the intention of preserving one or both bands. For the remaining cases, radical surgery with exeresis of both bands was performed. Due to secondary erectile dysfunction, 75 patients were studied by preparing: clinical history, laboratory tests, penile neurophysiological studies and intracavernous prostaglandin E1 injection test. Dynamic drug-cavernosmetry was performed in 36 patients. After radical prostatectomy, only 9.2% previously potent patients retained adequate erections. Of the 82 cases where preservation of one or both bands was attempted, 9 (11%) patients retained their erections. Changes in neurophysiological parameters were found in 69.2% cases and general vascular injury detected in 23 (63.8%) patients by drug-cavernosmetry, the main injuries being cavernous arteries insufficiency in 58.3% and veno-occlusive failure in 33.3%. Of the 75 patients studied, 48 accepted the treatment: 40 (81.6%) used intracavernous auto-injection, 8 had penile prosthesis inserted, and one patient uses a vacuum device. Intracavernous Pg E1 auto-injection has provided adequate stiffness in 95% patients and, at 6 months from onset of treatment, a decrease of the minimal effective dose has been seen which is more noticeable in men under 60 and patients who start treatment within 6 months.
Topics: Aged; Erectile Dysfunction; Follow-Up Studies; Humans; Male; Middle Aged; Penile Erection; Penile Prosthesis; Prostaglandins E; Prostatectomy
PubMed: 9471875
DOI: No ID Found -
European Urology May 2000Retropubic and perineal radical prostatectomy are used for curative treatment of localized prostate cancer. More complex urological procedures are now being done with... (Clinical Trial)
Clinical Trial
BACKGROUND
Retropubic and perineal radical prostatectomy are used for curative treatment of localized prostate cancer. More complex urological procedures are now being done with laparoscopy. We present our initial results of transperitoneal laparoscopic radical prostatectomy.
MATERIALS AND METHODS
Twenty laparoscopic radical prostatectomies were performed between May 1998 and May 1999. The mean age at the time of surgery was 64.2 years. There were 14 stage T1c, 5 stage T2a and 1 stage T2b tumors. The preoperative PSA was 9. 3 ng/ml (normal <4 ng/ml). The Gleason score for positive specimens in 6 random echo-guided endorectal biopsies was 5.7. Four trocars were used. Insufflation pressure was 15 mmHg. The seminal vesicles were first dissected. The prostate was dissected free from the anterior face of the rectum to the prostate apex. Then the peritoneum was incised to find the apex of the prostate. The puboprostatic ligaments were isolated and cut, and the dorsal vein complex was ligated and cut to expose the urethra. The bladder neck was opened and dissected free from the prostate. The lateral pedicles were coagulated before sectioning the urethra. The radical prostatectomy specimen was left along the sigmoid colon, the bladder neck was reconstructed, and a urethrovesical anastomosis was performed with 6 interrupted sutures. The prostatectomy specimen was removed intact in a sack by enlarging the umbilical trocar port. All the prostatectomy specimens were processed according to the Standford protocol. Prostate weight, tumor weight, the Gleason score, and the tumor status of the capsule, seminal vesicles, lymph nodes and surgical margins were studied.
RESULTS
The operating time was 385 min. Two patients were transfused. The mean hospital stay was 7. 8 days. The Foley catheter was removed 10.7 days after the operation. Specimen weight was 61 (28-126) g, the Gleason score was 5.9, and tumor volume was 1.4 ml. There were 18 stage pT2, 1 stage pTa (capsular effraction) and 1 stage pT3b (seminal vesicle invasion) tumors. There were four positive surgical margins (2 at the apex and 2 at the bladder neck). All the patients had a postoperative PSA level <0.1 ng/ml at 1 month. The first patient had urethrovesical anastomotic leakage, and required Foley catheterization for 21 days. There was 1 colostomy for rectal injury and 1 urinoma because of urethrovesical anastomotic leakage that required an open surgical procedure. One month after surgery, 15 (75%) patients were fully continent. Six patients had erections, and 5 stated having sexual intercourse.
CONCLUSION
These preliminary results show that radical prostatectomy can be performed laparoscopically. Laparoscopy offered excellent vision of all the anatomical structures of the pelvis, permitting precise dissection. Long-term follow-up and further studies are required to confirm and improve these results.
Topics: Aged; Humans; Laparoscopy; Male; Middle Aged; Postoperative Complications; Prostatectomy; Prostatic Neoplasms
PubMed: 10765103
DOI: 10.1159/000020202 -
The Journal of Urology Jan 2011While perineal radical prostatectomy has been largely supplanted by retropubic and minimally invasive radical prostatectomy, it was the predominant surgical approach for... (Comparative Study)
Comparative Study
PURPOSE
While perineal radical prostatectomy has been largely supplanted by retropubic and minimally invasive radical prostatectomy, it was the predominant surgical approach for prostate cancer for many years. In our population based study we compared the use and outcomes of perineal radical prostatectomy vs retropubic and minimally invasive radical prostatectomy.
MATERIALS AND METHODS
We identified men diagnosed with prostate cancer from 2003 to 2005 who underwent perineal (452), minimally invasive (1,938) and retropubic (6,899) radical prostatectomy using Surveillance, Epidemiology and End Results-Medicare linked data through 2007. We compared postoperative 30-day and anastomotic stricture complications, incontinence and erectile dysfunction, and cancer therapy (hormonal therapy and/or radiotherapy).
RESULTS
Perineal radical prostatectomy comprised 4.9% of radical prostatectomies during our study period and use decreased with time. On propensity score adjusted analysis men who underwent perineal vs retropubic radical prostatectomy had shorter hospitalization (median 2 vs 3 days, p < 0.001), received fewer heterologous transfusions (7.2% vs 20.8%, p < 0.001) and required less additional cancer therapy (4.9% vs 6.9%, p = 0.020). When comparing perineal vs minimally invasive radical prostatectomy men who underwent the former required more heterologous transfusions (7.2% vs 2.7%, p = 0.018) but experienced fewer miscellaneous medical complications (5.3% vs 10.0%, p = 0.045) and erectile dysfunction procedures (1.4 vs 2.3/100 person-years, p = 0.008). The mean and median expenditure for perineal radical prostatectomy in the first 6 months postoperatively was $1,500 less than for retropubic or minimally invasive radical prostatectomy (p < 0.001).
CONCLUSIONS
Men who undergo perineal vs retropubic and minimally invasive radical prostatectomy experienced favorable outcomes associated with lower expenditure. Urologists may be abandoning an underused but cost-effective surgical approach that compares favorably with its successors.
Topics: Humans; Male; Minimally Invasive Surgical Procedures; Perineum; Prostatectomy; Prostatic Neoplasms; Treatment Outcome
PubMed: 21074198
DOI: 10.1016/j.juro.2010.08.090 -
The Journal of Urology Sep 2011We evaluated the feasibilty, safety and results of extraperitoneal laparoscopic Millin prostatectomy using finger enucleation through an additional 1 cm suprapubic... (Clinical Trial)
Clinical Trial
PURPOSE
We evaluated the feasibilty, safety and results of extraperitoneal laparoscopic Millin prostatectomy using finger enucleation through an additional 1 cm suprapubic incision.
MATERIALS AND METHODS
A total of 66 consecutive laparoscopic simple prostatectomies were performed with this technique in men with symptomatic bladder outflow obstruction and a prostate gland larger than 70 cc on transrectal ultrasound. Data such as operating time, intraoperative blood loss, transfusion rate, complications, catheterization period, hospitalization time and surgical specimen weight were prospectively collected and evaluated. Preoperative and 3-month postoperative International Prostate Symptom Score and urinary flow rates were used to assess the surgical outcome.
RESULTS
Average operating time was 55 minutes with a mean estimated blood loss of 200 ml. No blood transfusion was necessary, and no conversion, complications or mortality was present. The mean postoperative catheterization period was 7.3 days with a mean hospital stay of 5.2 days. Mean enucleated tissue weight was 85.5 gm. At 3 months postoperatively the International Prostate Symptom Score improved to a mean of 5.8 (from a mean preoperative score of 29.5) while maximum urine flow improved to a mean of 18.5 ml per second (from a mean preoperative rate of 5.8 ml per second).
CONCLUSIONS
This procedure is safe and fast with excellent functional outcomes. However, prolonged catheterization and hospitalization are still required.
Topics: Aged; Feasibility Studies; Hand-Assisted Laparoscopy; Humans; Male; Middle Aged; Peritoneum; Prospective Studies; Prostatectomy; Prostatic Hyperplasia
PubMed: 21788034
DOI: 10.1016/j.juro.2011.04.080