Impact of body mass index on outcomes of laparoscopic radical prostatectomy with long-term follow-up.

OBJECTIVE: The aim of this study was to investigate the impact of body mass index (BMI) on the functional and oncological results of patients who had undergone laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: In total, 1224 patients with follow-up data (>24 months) were enrolled. Patients were divided into three groups according to BMI (kg/m(2)) as: group 1 (normal, BMI <25, n = 425), group 2 (overweight, 25 ≤ BMI <30, n = 594) and group 3 (obese, BMI ≥ 30, n = 205). Demographic, intraoperative and postoperative data with oncological outcomes were recorded. The impact of obesity on those parameters was evaluated and statistical analyses were performed. RESULTS: Mean age was 63.8 ± 6.1 years and mean follow-up was 43.1 ± 25.1 months (mean ± SD). There were 425 (34.7%) patients in group 1, 594 (48.5%) in group 2 and 205 (16.8%) in group 3. Operation time, clinical stage and estimated blood loss were significantly higher in group 3 than in the other groups (p < 0.001, p = 0.001 and p = 0.001, respectively). Bilateral nerve-sparing rate and bladder neck-sparing rate were significantly decreased in group 3 compared with the other groups (p = 0.001 and p < 0.038, respectively). Statistically significantly higher pathological stage, tumour volume, positive surgical margin and Gleason scores were determined in group 3 compared with the other groups (p = 0.023, p = 0.018, p = 0.009 and p = 0.028, respectively). There were similar urinary continence rates among the groups. The rate of penetration with or without medication was significantly lower in group 3 than in the other groups (p = 0.593 and p = 0.007, respectively). CONCLUSIONS: LRP seemed safe and effective in obese patients, with similar mean overall survival, cancer-specific survival, complication rates and continence rates to normal weight patients in the long term.

Impact of laparoscopic radical prostatectomy on clinical T3 prostate cancer: experience of a single centre with long-term follow-up.

OBJECTIVE: To investigate the oncological safety and effectiveness of laparoscopic radical prostatectomy (LRP) for patients with clinical T3 (cT3) prostate cancer compared with patients with cT1 and cT2 prostate cancer. PATIENTS AND METHODS: In all, 2375 consecutive LRPs were evaluated between 1999 and 2013. Of the 1751 patients enrolled with complete follow-up data (>24 months), patients were divided into three groups according to clinical stage of prostate cancer using Tumour-Node-Metastasis (TNM) classification. Group 1 consisted of patients with cT1 stage prostate cancer, group 2 those with cT2, and group 3 those with cT3. Demographic, postoperative, and long-term data of patients were recorded and statistical analyses were performed. RESULTS: The mean (SD) age was 63.6 (6.2) years. The mean (SD) follow-up was 104 (28.4) months. There were 417 patients in group 1, 842 patients in group 2, and 492 patients in group 3. The mean prostate-specific antigen level, biopsy Gleason score, tumour volume, body mass index, and age, were all higher in group 3 (P < 0.001). Nerve-sparing techniques were used more in group 1 than in the other groups (P < 0.001). Extracapsular extension, seminal vesicle invasion, Gleason score, positive surgical margin (PSM), and rate of adjuvant hormone and radiotherapies were highest in group 3. However, urinary continence was similar in all groups. Group 1 contained the most patients with an erection sufficient for intercourse. Group 1 had the best cancer-specific survival rate, whereas overall survival (OS) rates and complications were similar in all groups. CONCLUSION: LRP seems effective and safe for patients with cT3 prostate cancer with similar OS rates as for those with cT1 and cT2; however, additional therapies may have contributed to these rates. LRP can be considered for the treatment of patients with cT3 prostate cancer.

Pain after hernia repair with simultaneous extraperitoneal laparoscopic radical prostatectomy.

PURPOSE: To compare postoperative pain levels and postoperative morbidity between patients who underwent extraperitoneal laparoscopic radical prostatectomy (EPLRP) concomitant hernia repair and patients who underwent only EPLRP, by matched-pair analyses. METHODS: From December 2003 to December 2012, 54 patients who underwent EPLRP with simultaneous hernia repair were categorized as group 1. Their postoperative pain levels were quantitatively compared with those of 54 patients who underwent only EPLRP (group 2), in matched-pair analyses, including age, body mass index, and American Society of Anesthesiologists scoring. Preoperative tumor characteristics, operative and postoperative data were recorded. Pain levels were evaluated by using the visual analog scale (VAS) scoring, every day, during the first postoperative week. Statistical analyses were performed. RESULTS: Mean follow-up was 21 months. Mean age was 65±0.5 years. Preoperative, perioperative, and postoperative data were similar in the two groups. Group 1 needed a mean of 9.17 mg and group 2 needed a mean of 8.06 mg morphine derivative analgesic (piritramide) postoperatively. Total mean VAS scores were 5.65 and 4.98, in group 1 and group 2, respectively (P=0.06). Moreover, there was no significant difference between groups for complications. CONCLUSION: Simultaneous hernia repair does not affect pain levels after EPLRP. The procedure also does not result in prolongation of operative time and does not increase complication rates.

Long-term oncological outcomes after laparoscopic radical prostatectomy.

OBJECTIVES: To investigate long-term oncological outcomes after laparoscopic radical prostatectomy (LRP). To identify parameters influencing recurrence-free survival in a single-institution series. PATIENTS AND METHODS: All patients underwent LRP using the transperitoneal retrograde Heilbronn technique. High-risk patients received adjuvant treatment according to an institutional algorithm based on prostate-specific antigen (PSA), Gleason score, tumour-node-metastasis stage, margin status and tumour volume. Data were collected prospectively on operative and postoperative parameters beginning in 1999. Complete follow-up data of 370 of the first 500 consecutive patients are available. Biochemical recurrence was defined as two consecutive PSA levels <0.2 ng/mL within the follow-up period. Kaplan-Meier estimates and Cox regression were applied to examine recurrence-free survival times. RESULTS: The estimated biochemical recurrence-free survival (BCRFS) rates 10 years after LRP were 80.2% in patients staged pT2, 47.4% in those staged pT3a and 49.8% in those staged pT3b/4, confirming a better prognosis in patients with organ-confined disease (P < 0.001). In the multivariate Cox regression analysis, only Gleason score and pT stage significantly influenced BCRFS. The 10-year clinical progression-free survival rates were 97.2% (pT2), 84.4% (pT3a) and 78.1% (pT3b/4), and prostate cancer-specific survival estimates were 100% (pT2), 97.3% (pT3a) and 90.6% (pT3b/4). CONCLUSIONS: The 10-year biochemical and clinical progression-free survival after LRP combined with a risk-adapted concept of adjuvant therapy is high, while prostate-cancer specific mortality is low. Our data shows no negative impact of laparoscopic techniques on oncologic outcomes compared to large series after retropubic radical prostatectomy. In a multivariate Cox regression, only Gleason score and pT stage had significant impact on BCRFS.

Development, validation and operating room-transfer of a six-step laparoscopic training program for the vesicourethral anastomosis.

PURPOSE: Development and full validation of a laparoscopic training program for stepwise learning of a reproducible application of a standardized laparoscopic anastomosis technique and integration into the clinical course. MATERIALS AND METHODS: The training of vesicourethral anastomosis (VUA) was divided into six simple standardized steps. To fix the objective criteria, four experienced surgeons performed the stepwise training protocol. Thirty-eight participants with no previous laparoscopic experience were investigated in their training performance. The times needed to manage each training step and the total training time were recorded. The integration into the clinical course was investigated. The training results and the corresponding steps during laparoscopic radical prostatectomy (LRP) were analyzed. Data analysis of corresponding operating room (OR) sections of 793 LRP was performed. Based on the validity, criteria were determined. RESULTS: In the laboratory section, a significant reduction of OR time for every step was seen in all participants. Coordination: 62%; longitudinal incision: 52%; inverted U-shape incision: 43%; plexus: 47%. Anastomosis catheter model: 38%. VUA: 38%. The laboratory section required a total time of 29 hours (minimum: 16 hours; maximum: 42 hours). All participants had shorter execution times in the laboratory than under real conditions. The best match was found within the VUA model. To perform an anastomosis under real conditions, 25% more time was needed. By using the training protocol, the performance of the VUA is comparable to that of an surgeon with experience of about 50 laparoscopic VUA. Data analysis proved content, construct, and prognostic validity. CONCLUSIONS: The use of stepwise training approaches enables a surgeon to learn and reproduce complex reconstructive surgical tasks: eg, the VUA in a safe environment. The validity of the designed system is given at all levels and should be used as a standard in the clinical surgical training in laparoscopic reconstructive urology.

Small-incision access retroperitoneoscopic technique (SMART) pyeloplasty in adult patients: comparison of cosmetic and post-operative pain outcomes in a matched-pair analysis with standard retroperitoneoscopy: preliminary report.

OBJECTIVES: To present small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp), a novel mini-laparoscopic approach for management of uretero-pelvic junction obstruction (UPJO) in adults including comparison with the standard retroperitoneoscopic technique (SRTp). METHODS: In a non-randomised study, we matched 12 adult patients treated from August to November 2010 by SMARTp with 12 patients treated with SRTp from January to November 2010. Mini-laparoscopic retroperitoneal space was created with a home-made 6-mm balloon trocar. One 6-mm (for 5-mm 30° telescope) and two 3.5-mm trocars (for 3-mm working instrument) were used. SRTp was performed with 11- and 6-mm trocar. Primary endpoints included evaluation of cosmetic appearance and post-operative pain evaluated respectively by the patient and observer scar assessment scale (POSAS) and analogue visual scale (VAS). Secondary endpoints were comparison between operative and functional parameters. RESULTS: Cosmetic cumulative results were statistically significant in favour of SMARTp (POSAS: 37.9 vs. 52.4; P = 0.002). A better trend has been shown by post-operative pain (first to fourth day VAS), although not statistically significant (4.2 vs. 4.9, P = 0.891). No differences were recorded in terms of operative time, pre- and post-operative Hb difference, DJ-stent removal and resistive index (RI) improvement. The SMARTp group showed a faster drain removal (2.4 vs. 3.4 day, P = 0.004) and discharge (4.5 vs. 5.4 day P = 0.017). CONCLUSIONS: Preliminary data support SMARTp as safe procedures in experienced hands, providing better cosmetic results compared to SRTp. Further studies and clinical randomised trial performed in a larger population sample are requested.

The learning curve for laparoscopic radical prostatectomy: an international multicenter study.

PURPOSE: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. MATERIALS AND METHODS: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. RESULTS: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. CONCLUSIONS: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Complications in 2200 consecutive laparoscopic radical prostatectomies: standardised evaluation and analysis of learning curves.

BACKGROUND: Laparoscopic radical prostatectomy (LRP) represents an established treatment modality for localised prostate cancer. OBJECTIVE: To report standardised complication rates for LRP, evaluate the development of complication rates over time, and show changes within the learning curves of laparoscopic surgeons. DESIGN, SETTING, AND PARTICIPANTS: We conducted a standardised analysis of 2200 consecutive patients who underwent LRP between 1999 and 2008 at a single institution. INTERVENTION: LRP was performed using a transperitoneal (n=871) or extraperitoneal (n=1329) retrograde Heilbronn technique. Five surgeons operated on 96% of the patients. MEASUREMENTS: Complications were classified according to the modified Clavien system. Total complication rates and changes over time were analysed. Three generations of surgeons were defined for evaluation of learning curves. RESULTS AND LIMITATIONS: Minor complications occurred in 21.7% of patients (Clavien 1: 6.8%; Clavien 2: 14.9%); anaemia requiring transfusion (10.4%) dominated. Early reinterventions were necessary in 6.7% of patients (Clavien 3a: 3.6%; Clavien 3b: 1.5%; Clavien 4a: 1.5%; Clavien 4b: 0.1%). Late Clavien 3b complications occurred in 4.7% of patients-most of them anastomotic strictures. Mortality was 0.1% (Clavien 5). There was a significant decrease in overall complication rates over time, resulting predominantly from decreasing Clavien 1-2 events. Learning curves of third-generation surgeons plateaued earlier compared to the first generation (250 vs 700 cases). The limitation of this study is that data concerning comorbidity were not included. CONCLUSIONS: LRP is a safe procedure characterised by an acceptable profile of complications. Specifically, few major complications are reported. According to the complication rates, the learning curve of third-generation surgeons is significantly shorter compared to first- and second-generation surgeons.

The Clavien classification system to optimize the documentation of PCNL morbidity.

High success rates exceeding 90% are reported with percutaneous nephrolithotomy (PNL) and modifications have further decreased the morbidity while maintaining efficacy. However, complications after or during PNL may occur with an overall complication rate of up to 83%. Although results from several large series on PNL from outstanding centers are reported in the literature, there is still no consensus on how to define complications and stratify them by severity. Hampering comparison of outcome data may generate difficulties in informing the patients about the severity of PNL complications. We therefore may conclude that standardization of complications of a certain procedure is necessary to allow comparison of outcomes between different centers, within a center over time, or between different instruments used and/or operating techniques. In 1992, Clavien et al proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading, allowing identifying most complications and preventing down rating. The Clavien Classification system differentiates in five degrees of severity upon the intention to treat. Several Urological teams have studied the use of classifications systems to document and grade outcomes and morbidity of interventions in urology. Also the modified Clavien system has been applied in urological surgery. Urologists have been using this classification to grade perioperative complications following laparoscopic radical prostatectomy, laparoscopic live donor nephrectomy, and retroperitoneoscopy. In the field of endourology, it has been recently applied to PCNL procedures as well, allowing comparison among different series between different hospitals and within the same center. Other benefits that the standardization of the complications by using the Clavien System allows is to give better information to the patient and, assisting them on making the correct therapeutical choice. There may also be a benefit for the health insurance bodies to obtain adequate information of the procedure, and the results achieved by a team. Besides all its benefits, the modified Clavien system was proposed as a grading system for perioperative complications in general surgery and there are some limitations in classifying PCNL complications. A graded classification scheme for reporting the complications of PCNL may be useful for monitoring and reporting outcomes. There are some limitations in classifying PCNL complications. Minor modifications, especially concerning auxiliary treatments, are needed. Further studies are awaited for the development of an accepted classification system applicable to all urologic procedures.

Laparoscopic and open stone surgery.

INTRODUCTION: Due to the increasing spread and technical enhancement of endourological methods, open surgery for renal and ureteral calculi almost disappeared. MATERIALS AND METHODS: Based on an actual review of literature, we describe indications, technique and clinical importance of the open and laparoscopic management of urolithiasis. RESULTS: In Europe and Northern America, the surgical therapy of urolithiasis only plays a role in cases of very large or hard stones, after failure of shock wave lithotripsy, percutaneous nephrolithotripsy or ureteroscopic stone removal and in cases of abnormal renal anatomy. However, in emerging markets with different structures and funding of the health care system and with a limited access to endourological procedures, these techniques still have a higher importance. Particularly in Europe laparoscopic surgery is emerging because calculi can be removed from almost all locations within kidney and ureter using a transperitoneal or retroperitoneal access. Functional outcomes and complication rates are comparable to open surgery. The benefits of laparoscopy are: less postoperative pain, shorter hospital stay, faster reconvalescence, and better cosmetic results. CONCLUSIONS: Although open and laparoscopic removal of renal and ureteral calculi is only performed in a limited number of cases in daily urological practice, they may be superior to the endourological techniques in some circumstances. Therefore, they should be considered as a part of the urological armamentarium.

Prostate biopsy in selecting candidates for hemiablative focal therapy.

Focal therapy (FT) for the management of clinically localized prostate cancer (PCa) is growing from a concept to reality because of increased interest of both patients and physicians. Selection protocols, however, are yet to be established. We discuss the role of prostate biopsy in candidate selection for FT and highlight the different strategies and technical aspects of the use of prostate biopsy in this setting. In our opinion, prostate biopsy plays a major role in the selection process and tailoring appropriate treatment strategy to the patient. FT necessitates dedicated biopsy schemes that would reliably predict the extent, nature, and location of PCa in selected patients. Currently, there is insufficient scientific evidence to propose a specific biopsy scheme that could fit every candidate, providing accurate characterization of the disease in the individual patient. Further research is necessary to establish solid selection protocols that would reliably identify appropriate candidates for FT of PCa.

Laparoscopic techniques for removal of renal and ureteral calculi.

BACKGROUND AND PURPOSE: Although most ureteral and renal stones are managed using endourologic techniques or shockwave lithotripsy in daily clinical practice, stone surgery has not completely disappeared. The increasing experience with laparoscopy in urology poses the question of whether urolithiasis may be an indication for laparoscopy. MATERIALS AND METHODS: A review of the literature was conducted to point out the indications and techniques of laparoscopic stone surgery. RESULTS: Indications for stone surgery are anatomic abnormalities, such as horseshoe kidneys, malrotated kidneys, or ectopic kidneys; symptomatic stones in diverticula of the renal pelvis; and extremely large stones, especially in children; or concomitant open or laparoscopic surgery. After failure of endourologic stone removal or shockwave lithotripsy, stone surgery may be a second option. In experienced hands, most procedures can be performed laparoscopically, either using a retroperitoneal or a transperitoneal approach. Accurate planning and imaging before surgery is mandatory. Intracorporeal ultrasonography or combined laparoscopic and endourologic techniques may be useful in difficult cases. Functional outcomes and complication rates of the laparoscopic approach are comparable to those of open surgery. The benefits of laparoscopy are lower postoperative morbidity, shorter hospitalization, shorter convalescence time, and better cosmetic results. CONCLUSIONS: Laparoscopic removal of renal and ureteral calculi plays a role in special cases of urolithiasis. In experienced hands, it can be performed safely and efficiently and may therefore replace open stone surgery in most indications.

The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study.

BACKGROUND: We previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy. METHODS: We did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and prostate-cancer recurrence, with adjustment for established predictors. FINDINGS: After adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p<0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7). INTERPRETATION: Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy. FUNDING: National Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

Laparoscopic radical prostatectomy in clinical T1a and T1b prostate cancer: oncologic and functional outcomes--a matched-pair analysis.

OBJECTIVES: To evaluate the effect of previous transurethral resection of the prostate (TURP) on surgical, functional, and oncologic outcomes after laparoscopic radical prostatectomy. METHODS: From a series of 2100 patients undergoing laparoscopic radical prostatectomy, we compared the intraoperative complications and functional and oncologic outcomes for 55 patients who had been diagnosed with prostate carcinoma on previous TURP (group 1), with those of 55 matched patients who had not undergone previous prostate surgery (group 2). The patients were match-paired for age, operating surgeon, procedure type (eg, nerve-sparing, lymph node dissection), anastamotic technique, pathologic stage, and Gleason score. The minimal duration of follow-up was 24 months. RESULTS: Both groups were similar with respect to patient age and pathologic stage. Of those with Stage cT1a and cT1b, 83.6% had a clinically significant tumor, with a mean tumor volume of 1.7 cm(3) for those with Stage cT1a and 2.4 cm(3) for those with Stage cT1b. The positive surgical margin rate was 14.5% and 16.3% for groups 1 and 2, respectively. Biochemical recurrence developed in 12.7% and 11% of patients in groups 1 and 2, respectively. Neither outcome was significantly different between the 2 groups. The long-term continence rates were similar; however, previous TURP was associated with a lower continence rate (49.1%) at 3 months compared with 61.8% for group 2 (P = .01). A nerve-sparing technique was used in 54% of group 1 patients. No significant difference was found in the potency rates between the 2 groups at 12 months. CONCLUSIONS: Laparoscopic radical prostatectomy after TURP is a challenging, but oncologically safe, procedure. The interval to total continence was delayed, but the potency rates remain unchanged.

Transrectal ultrasound-guided biopsy of the prostate: development of the procedure, current clinical practice, and introduction of self-embedding as a new way of processing biopsy cores.

PURPOSE: This study reviews the development of transrectal sonographically guided biopsy procedures of the prostate and optimization of the procedure in daily clinical practice. MATERIALS AND METHODS: We conducted a literature review of the historic development and current practice of prostate biopsy procedures and present our systematic 12-core biopsy protocol. For processing the biopsy cores, we introduce the new technique of self-embedding. RESULTS: The systematic biopsy protocols proposed in the literature can be summarized as sextant protocols, extended sextant protocols, 12-core protocols, extended 12-core protocols, and saturation biopsy protocols. The systematic 12-core prostate biopsy has become the new gold standard, replacing the classic sextant protocol. There is, however, little consensus about the biopsy procedure in the literature nor in daily practice. We propose a systematic biopsy protocol consisting of 12 cores in a fan-shaped arrangement that originates from the apex. Self-embedding of the biopsy cores is a simple new way of processing that provides additional information for the operating urologist (i.e., exact localization of the tumor and distance of the carcinoma from the capsule if a nerve-sparing procedure is planned). CONCLUSIONS: A systematic 12-core prostate biopsy procedure should be used routinely. In large glands, it has proved to be useful to expand this protocol by taking additional cores. Self-embedding of the biopsy cores provides maximum information from the biopsy core distribution.

A new postoperative predictor of time to urinary continence after laparoscopic radical prostatectomy: the urine loss ratio.

OBJECTIVES: To assess the correlation of a newly defined parameter, "urine loss ratio" (ULR), with the time to continence and probability for incontinence after laparoscopic radical prostatectomy (LRP). MATERIALS AND METHODS: A standardized "micturition protocol" that uses 24-h pad testing to objectively quantify urine loss after removal of the catheter was obtained from 939 patients who underwent LRP and were provided complete follow-up regarding continence. ULR was defined as the weight of urine loss in the pad divided by daily micturition volume, distinguishing between ULR on the first day after catheter removal and the last day of hospital stay. The time to continence was classified as early (0-3 mo), midterm (4-12 mo), and late continence (13-24 mo). RESULTS: Early continence was attained in 69.8% (n=655) of patients, midterm continence in 18.4% (n=173), and late continence in 3.5% (n=33). Of 939 patients in whom first-day ULR was quantified, 495 patients were not discharged immediately and their last-day ULR was quantified (2.3 d following catheter removal). There was a linear correlation between time to continence and ULR, which was more significant for last- than first-day ULR (p<0.001). A cutoff point of more than 15% of urine loss indicates a high risk of incontinence (ie, 8-fold for first-day ULR, 55-fold for last-day ULR). CONCLUSION: ULR predicts the time to continence and may be used to select patients for specific rehabilitation programs and early adjuvant medical therapy, particularly when urine loss exceeds 15%.

Assessing the predictive validity and efficacy of a multimodal training programme for laparoscopic radical prostatectomy (LRP).

OBJECTIVES: To assess the predictive validity (ability to correlate to real-life environment) and efficacy of a training programme for laparoscopic radical prostatectomy (LRP), based on a structured and progressive pelvitrainer component with hands-on clinical training in the operating room (OR). METHODS: Prospective data on 500 LRP cases were analysed with 80 excluded due to incomplete records. The operation was divided into multiple steps. Times for these steps were compared among 11 surgeons with different laparoscopic expertise (first-, second-, and third-generation surgeons in order of decreasing experience) and correlated to times for specific exercises on the pelvitrainer that simulated particular steps. Perioperative parameters were also evaluated among the three groups. RESULTS: Pelvitrainer times achieved by trainees (third-generation surgeons) did not differ significantly with times for corresponding steps of LRP. There was also no significant difference for total OR time between the second- and third-generation surgeons (205 and 207 min, respectively; p>0.05) although the time for the first-generation surgeons was faster than both (176 min). Short-term quality indicators for first, second, and third generations included transfusion rates (2.3%, 2.4%, and 2.6%, respectively), positive margin rates (20.3%, 21.5%, and 23.0%) and complications, which did not differ significantly among the generations although the first-generation surgeons had the lowest rates. CONCLUSIONS: A carefully designed training programme that incorporates both pelvitrainer and mentor-based operative training is essential for the effective and safe transfer of skills and knowledge required to learn LRP.

Laparoscopic and robotic assisted radical prostatectomy--critical analysis of the results.

OBJECTIVE: To evaluate the role of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RLRP) based on personal experience and a review of the literature. MATERIAL AND METHODS: Own experience at one European and one American LRP-center includes more than 2000 cases. We performed a MEDLINE search reviewing the literature on LRP and RLRP between 1992 and 2005 with special emphasis on historical aspects, technical considerations, comparison to open retropubic (RRP) and perineal radical prostatectomy (PRP), laparoscopic training, and the cost-efficiency of the techniques. RESULTS: Based on sophisticated training programs a continuous dissemination of the technique took place. In the United States, this process was accelerated by the use of the daVinci-robot. There is a trend towards the extraperitoneal access. Mid-term outcomes of LRP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower rate of complications, shorter convalescence, and better cosmesis. In contrast to RLRP, LRP may reach cost-equivalence with open surgery (i.e. by reduction of OR-time, use of multi-usable instruments). CONCLUSIONS: LRP reproduces the excellent results of open surgery providing the advantages of minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow. In contrast the United States, the use of robots is likely to remain limited in Europe.