Developing a laparoscopic radical prostatectomy service: defining the learning curve.

BACKGROUND AND PURPOSE: Laparoscopic radical prostatectomy (LRP) is an established treatment for patients with prostate cancer in selected centers with appropriate expertise. We studied our single-center experience of developing a LRP service and subsequent training of two additional surgeons by the initial surgeon. We assessed the learning curve of the three surgeons with regard to perioperative outcomes and oncologic results. PATIENTS AND METHODS: Three hundred consecutive patients underwent a LRP between January 2005 and April 2011. Patients were divided into three equal groups (1-100 group 1], 101-200 [group 2], and 201-300 [group 3]). Age, American Society of Anesthesiologists score, preoperative comorbidities, and indications for LRP were comparable for all three patient groups. Perioperative and oncologic outcomes were compared across all three groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). RESULTS: The mean age was 61.9 years (range 46-74 y). There was a significant reduction in the mean operative time (P<0.05), mean blood loss (P<0.05), mean duration of hospital stay (P<0.05), and duration of catherization (P<0.05) between the three groups as the series progressed. The two most important factors predictive of positive surgical margins at LRP were the initial prostate-specific antigen level and tumor stage at diagnosis. The overall positive margin rate was 27.7%. For pT(2) tumors, the positive margin rate was 21%, while patients with pT(3) tumors had a positive margin of 44%. For pT(2) tumors, positive margin rates decreased with increasing experience (group 1, 27% vs group 2, 17% vs group 3, 19%). The incidence of major complications--ie, grade CDS score ≤ III--was 4.6% (14/300). CONCLUSION: LRP is a safe procedure with low morbidity. As surgeons progress through the learning curve, perioperative parameters and oncologic outcomes improve. Using a carefully mentored approach, LRP can be safely introduced as a new procedure without compromising patient outcomes.

Laparoscopic partial nephrectomy: Technical considerations and an update.

The widespread use of radiological imaging (ultrasound, computed tomography and magnetic resonance imaging) has resulted in a steady increase in the incidental diagnosis of small renal masses. While open partial nephrectomy (OPN) remains the reference standard for the management of small renal masses, laparoscopic partial nephrectomy (LPN) continues to evolve. LPN is currently advocated to be at par with OPN oncologically. The steep learning curve and technical demand of LPN make it challenging to establish this as a new procedure. We present a detailed up-to-date review on the previous, current and planned technical considerations for the use of LPN, highlighting important surgical techniques, including single-port and robotic surgery, techniques on improving intra-operative haemostasis and the management of complications specific to LPN.