Mid-term oncological control after laparoscopic radical cystectomy in men: a single-centre experience.

OBJECTIVE: • To assess the mid-term (3 years of follow-up) oncological control of laparoscopic radical cystectomy (LRC) for high-grade muscle-invasive bladder cancer in a well studied male population. PATIENTS AND METHODS: • We assessed 40 men with bladder cancer (mean [range] age 66.5 [50-75] years) who underwent LRC and extended pelvic lymphadenectomy at our institution between April 2004 and September 2008. • Of the 40 patients, 13 (32.5%) had a complete laparoscopic procedure (ileal conduit: seven patients; neobladder: five patients; bilateral ureterostomy: one patient) and 27 (67.5%) had an LRC procedure only (ileal conduit: 15 patients; neobladder: 12 patients). RESULTS: • No major complications were observed intraoperatively. • The mean operating time was 407 min and the mean blood loss was 720 mL. Four patients (10%) required conversion to open surgery. The mean (range) hospital stay was 10.2 (7-25) days. One patient died of myocardial infarction in the postoperative period. • Pathological analysis showed organ-confined tumours (stage pT0/pT1/pT2/pT3a) in 22 patients (55%) and extravesical disease (pT3/pT4) in 18 (45%). Of the 40 patients, six (15%) had lymph node involvement. The mean (range) number of nodes removed was 19.9 (5-40). • At a mean (range) follow-up period of 36 (0-72) months, 26 patients were alive with no evidence of disease (disease-free survival rate 67%). CONCLUSION: • Laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy (ORC). The 3-year oncological efficacy was comparable with that of ORC.

Evaluation of combined oncological and functional outcomes after radical prostatectomy: trifecta rate of achieving continence, potency and cancer control--a literature review.

The first objective of radical prostatectomy is cancer control. However, the success of RP should be also measured by the long-term morbidity outcomes and by the maintenance of quality of life. We performed a review of the literature for combined results of continence, erectile function, and cancer control after radical prostatectomy. Since 2003 and the first report of "trifecta," only 7 series have yet reported such combined results (trifecta rate range: 20%-76%). The preoperative risk (D'Amico) predicted for quality of life outcomes and biochemical recurrence is an aggregate endpoint, the trifecta.

Robot-assisted laparoscopic sacral colpopexy: initial experience in a high-volume laparoscopic reference center.

PURPOSE: To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center. PATIENT AND METHODS: 12 women with symptomatic urogenital prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence. RESULTS: Mean operative time was 144 minutes (range 120-180 min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60 mL (range 20-200 mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred. CONCLUSION: RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques.

Intrafascial nerve-sparing radical prostatectomy with a laparoscopic robot-assisted extraperitoneal approach: early oncological and functional results.

OBJECTIVE: We investigated whether an intrafascial approach to prostatectomy would provide significantly improved outcomes compared with retropubic and laparoscopic approaches. We performed 50 radical prostatectomies with an intrafascial, nerve-sparing, laparoscopic, robot-assisted extraperitoneal approach. METHODS: From December 2007 to June 2008, 50 consecutive patients underwent nerve sparing surgery using the intrafascial technique with robotic assistance. All surgeries were performed by the same senior urologist. Patient characteristics and perioperative data were collected prospectively. Oncological outcomes were assessed by pathological examination and postoperative prostate-specific antigen levels. Functional outcomes, including continence, potency, and quality of life, were assessed from patient questionnaires. RESULTS: The mean operative time was 127 minutes (range: 80-205), the mean hospital stay was 4.2 days (range: 2-9), and the mean catheterization time was 7.8 days (range: 4-11). No perioperative complications occurred. One patient required a transfusion at the postoperative stage. The overall positive surgical margin rate was 12%; adjusted by tumor, nodes, and metastasis stage, it was 9.5% in pT2 and 17% in pT3 disease. At the 1-month follow-up, 66% of the patients were continent (no pad), 12% presented a minimal stress urinary incontinence (1 pad), and 22% required >1 pad(s) per day. Further, 60% of patients exhibited potency (erection sufficient for intercourse: 30% without the use of phosphodiesterase 5 inhibitors, 30% required a phosphodiesterase 5 inhibitor) and the remaining 40% required prostaglandin injections. CONCLUSIONS: An intrafascial approach with robotic assistance provided satisfactory early functional results with respect to postoperative continence and potency. Long-term oncological results remain to be assessed.

Oncologic outcome after extraperitoneal laparoscopic radical prostatectomy: midterm follow-up of 1115 procedures.

BACKGROUND: Although the first laparoscopic radical prostatectomy was performed in 1997, few midterm oncologic data have been published for the extraperitoneal procedure. OBJECTIVE: To determine the oncologic outcome of extraperitoneal laparoscopic radical prostatectomy (ELRP). DESIGN, SETTING, AND PARTICIPANTS: From 2000 to 2007, 1115 consecutive patients underwent ELRP for a localized prostate cancer at our department. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. Median postoperative follow-up was 35.6 mo. INTERVENTION: All ELRP were performed by three surgeons at the Department of Urology, Hospital Henri Mondor, Créteil, France. MEASUREMENTS: Biochemical recurrence was defined by prostate-specific antigen level > or =0.2 ng/ml. RESULTS AND LIMITATIONS: In pN0/pNx cancers, postoperative stage was pT2 in 664 patients (59.5%), pT3 in 350 patients (31.4%), and pT4 in 77 patients (6.9%). Positive lymph nodes were reported in 24 patients (2.2%). Margins were positive in 16.1% and 34.6% of pT2 and pT3 cancers, respectively. Final Gleason score was <7 in 288 men (25.8%), =7 in 701 men (62.9%), and >7 in 126 men (11.3%). Overall prostate-specific antigen (PSA) recurrence-free survival was 83% at 5 yr. The 5-yr progression-free survival rates were 93.4% for pT2, 74.5% for pT3a, and 55.0% for pT3b tumors, respectively. Multivariate Cox model showed that PSA, Gleason score, pT category, nodal status, and surgical margins were significant independent predictors of biochemical recurrence-free survival. CONCLUSIONS: This assessment of oncologic results demonstrates that ELRP is a safe and effective procedure. On the basis of midterm follow-up data, the prognostic factors of PSA after ELRP failure are the same as those described previously in transperitoneal or open retropubic approaches. The oncologic results of ELRP also are in line with those reported with the use of the retropubic or the transperitoneal laparoscopic approaches.

Is robot assistance affecting operating room time compared with pure retroperitoneal laparoscopic radical prostatectomy?

PURPOSE: To compare operating room times between retroperitoneal robot-assisted laparoscopic radical prostatectomy (RALRP) and pure retroperitoneal laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS: From March 2007 to April 2008, 288 patients underwent an extraperitoneal LRP in our institution. Eighty-three LRPs were performed with robot assistance using the da Vinci Surgical System (RALRP) whereas 205 pure LRPs were performed. Operating room times were compared between the two groups. RESULTS: Both groups were statistically equal concerning age (P = 0.95), body mass index (P = 0.52), prostate-specific antigen level (P = 0.40), prostate volume (P = 0.49), clinical stage (P = 0.11), and Gleason score on biopsy (P = 0.57). Total operating room time was not significantly different between the two groups (223.6 vs 215.7 minutes in LRP and RALRP groups, respectively; P = 0.23). Mean patient installation was longer in the RALRP group (33.2 vs 24.0 minutes, P < 0.01). Mean operative time was significantly shorter by about 20 minutes in the RALRP group (145.6 vs 164.7 minutes, P < 0.01). Mean estimated blood loss was significantly lower in the RALRP group (469 mL vs 889 mL in the LRP group, P < 0.01). No statistical differences were observed regarding hospital stay, bladder catheterization, and complication rate between the two groups. CONCLUSION: Occupation times of the operating room are equivalent during pure retroperitoneal LRP and RALRP. For a trained team performing four procedures per week, the use of the robot for LRP with no lymph node dissection decreases actual operative time at the expense of an increase in installation time, compared with pure laparoscopy.

Physics contributions and clinical outcome with 3D-MRI-based pulsed-dose-rate intracavitary brachytherapy in cervical cancer patients.

PURPOSE: To assess the physics contributions and clinical outcome with three-dimensional magnetic resonance imaging-guided pulsed-dose-rate (PDR) intracavitary brachytherapy in cervical cancer patients. METHODS AND MATERIALS: The data from 45 patients with primary locally advanced cervical carcinoma were analyzed. The median tumor cervical volume was 64.0 cm(3) (range, 3-178). Of the 45 patients, 24 (53%) had histologic and/or radiologic pelvic involvement. After pelvic with or without para-aortic concomitant chemoradiotherapy, a PDR brachytherapy boost was delivered to a three-dimensional magnetic resonance imaging-based clinical target volume, taking into account the dose-volume constraints for critical organs and optimization of the target volume coverage. RESULTS: At a median follow-up of 26 months (range, 9-47), the 2-year overall survival and disease-free survival rate was 78% and 73%, respectively. At the last follow-up visit, the disease of all patients remained locally controlled. Adding external beam radiotherapy and PDR using the equivalent dose in 2-Gy fractions model, the median dose received by 100% and 90% of the target was 54.4 Gy(alpha/beta10) and 63.5 Gy(alpha/beta10) for the intermediate-risk clinical target volume and 61.6 Gy(alpha/beta10) and 74.9 Gy(alpha/beta10) for the high-risk clinical target volume, respectively. Of the 45 patients, 23 and 2 developed acute Grade 1-2 and Grade 3 complications, respectively; 21 patients presented with delayed Grade 1-2 complications. One other patient presented with Grade 3 vesicovaginal fistula. No Grade 4 or greater complications, whether acute or delayed, were observed. CONCLUSION: Magnetic resonance imaging-guided PDR brachytherapy with optimization integrating the limits of tolerance to critical organs allows for excellent local control rates. Moreover, the present results have confirmed that the ability to optimize dwell times can contribute to an improvement in local control rates with a low level of late side effects.

New trends in the evaluation and treatment of cervix cancer: the role of FDG-PET.

INTRODUCTION: Positron emission tomography (PET) with F18 Flurodeoxyglucose (FDG) has been evaluated and found to be a useful diagnostic tool in a certain number of malignancies, particularly in providing crucial assessment of metabolic activity of the tumour. We herein review and discuss the place and role of FDG-PET scan in cervix carcinoma patients' management. MATERIALS AND METHODS: Data for this review were identified by searches of Medline with and without MeSH database and Cancerlit. Studies were selected only if they were randomised clinical trials or historical reports. References were also identified from reference lists in relevant previously published articles. Recent guidelines and meta-analyses were included. Only published articles were taken into consideration. RESULTS: Although FDG-PET may be useful in the primary cervical tumours morphologic and metabolic evaluation, it seems to have limited place for disease staging in patients with early-stage disease (less than 4 cm). Hybrid PET/CT is an effective imaging technique in the lymph node staging of locally advanced cervix carcinoma with negative CT findings and may lead to substantial changes in treatment planning for several patients. FDG-PET provides meaningful information for the early evaluation of therapeutic response and long-term follow-up. CONCLUSION: Several reports have demonstrated the efficacy of FDG-PET in both pre-treatment staging and post-treatment evaluation of patients with cervical carcinoma. Further evaluation in prospective clinical trials will be required to assess the clinical benefit of this strategy.