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Objective: To demonstrate the feasibility of robot-assisted vesicourethral reconstruction. Vesicourethral anastomotic stricture following radical prostatectomy is a real challenge for reconstructive surgery when facing several endoscopic management failures., Material and Methods: This is a case series of robot-assisted vesicourethral reconstruction for anastomotic stricture failing endoscopic management. The procedure was performed with an extraperitoneal approach. The fibrotic anastomotic region was resected and a new vesicourethral running suture was performed with well-vascularized tissue. Bladder catheter was removed after 7 days., Results: Six procedures were performed from April 2013 to May 2018 at our department. One patient had a robot-assisted radical prostatectomy at our department; the 5 others were referred from other institutions after receiving open prostatectomies. Three patients had salvage radiation therapy before reconstruction. Mean age was of 73.8 years (68-82). There was no peroperative complication. Mean operative time was of 108 minutes (60-180)], with a mean estimated blood loss of 130 mL (50-300). After surgery, 3 patients presented recurrences managed endoscopically without recurrence after 3, 5, and 11 months. Three patients presented incontinence treated with artificial sphincter implantation. One patient had no residual symptom after 5 years of follow-up., Conclusions: Robot-assisted vesicourethral reconstruction is a safe procedure. It is an option to consider when facing recurring anastomotic stricture following radical prostatectomy. It is an alternative to the perineal approach and an option before urinary diversion. Patients should be informed of the risks of incontinence and recurrence before surgery especially if they had radiation therapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy., Materials and Methods: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci ∗ robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen., Results: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins., Conclusions: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery., (Copyright © 2001 American Urological Association, Inc.®. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the prognostic value of extent, number, and location of positive surgical margins (PSM)., Methods: A total of 1,504 consecutive adjuvant treatment naive and node-negative radical prostatectomy men were included in a prospective database including extent, number, and location of PSM. Mean follow-up was 33 months. Endpoint was biochemical progression-free (bPFS) survival. The impact of margin status and characteristics was assessed in time-dependent analyses using Cox regression and Kaplan-Meier methods., Results: PSM was reported in 26.7 % of patients. The predominant PSM locations were apex and posterior locations. Median PSM length was 4.0 mm. The 2-year bPFS was 73.7 % in PSM patients as compared to 93.0 % in NSM patients (p < 0.001). The rate and extent of PSM increased significantly with pathologic stage (p < 0.001). The extent of PSM length was linearly correlated with bPFS (p = 0.017, coefficient: -0.122). In univariable analysis, extent and number of PSM were significantly linked to outcomes. None of PSM subclassifications significantly influenced the bPFS rates in the subgroup of pT2 disease patients. Conversely, stratification by PSM location (apex vs. other locations, p = 0.008), by PSM number (p = 0.006), and by PSM length (p < 0.001) showed significant differences in pT3-4 cancer patients. In that subgroup, PSM length also added to bPFS prediction using PSM status only in multivariable models (p = 0.005)., Conclusions: PSM subclassifications do not improve the biochemical recurrence prediction in organ-confined disease. In non-organ-confined disease, PSM length (≥3 mm), multifocality (≥3 sites), and apical location are significantly linked to poorer outcomes and could justify a more aggressive adjuvant treatment approach.

Objective: Positive surgical margins (PSMs) in men undergoing radical prostatectomy (RP) for prostate cancer are associated with an increased risk of biochemical recurrence. This study evaluated the long-term (>10 year) impact of PSMs on biochemical recurrence after RP in adjuvant treatment-naïve pT2-pT4 N0 men and determined predictors of prostate-specific antigen (PSA) failure., Material and Methods: The institutional registry of 1276 patients who underwent RP at Henri Mondor Hospital from 1988 to 2001 was reviewed, identifying 403 patients with regular follow-up at the time of analysis. The study included 108 patients with PSMs who did not receive neoadjuvant or adjuvant therapy before PSA relapse. Median follow-up was 12.2 years. PSA failure was defined by a PSA rising by more than 0.2 ng/ml and biochemical recurrence-free survival (RFS) was estimated using the Kaplan-Meier method. Cox proportional hazard regression models were used to analyse clinicopathological variables associated with biochemical recurrence., Results: Biochemical recurrence 10 years after RP was 33.5% for patients regardless of the margin status. The 10-year biochemical RFS was 73% in men with negative margins compared to 49% in the case of PSM (p < 0.001). In multivariate analysis, margin status was a significantly predictive for PSA failure (hazard ratio 1.46, p = 0.04). After stratification by pathological stage, margin status was significantly predictive for biochemical RFS in pT2 (p < 0.001) and pT3a (p < 0.001), whereas the impact of PSM did not reach significance in pT3b (p = 0.16)., Conclusions: After 10-year follow-up, PSMs remain an independent risk factor of biochemical RFS after RP with less relevant impact in pT3b disease. Randomized prospective trials are needed to determine the place of adjuvant versus delayed radiotherapy.

Background: In spite of the increasing use of robot-assisted radical prostatectomy (RALP) worldwide, no level 1 evidence-based benefit favouring RALP versus pure laparoscopic approaches has been demonstrated in extraperitoneal laparoscopic procedures., Objective: To compare the operative, functional, and oncologic outcomes between pure laparoscopic radical prostatectomy (LRP) and RALP., Design, Setting, and Participants: From 2001 to 2011, 2386 extraperitoneal LRPs were performed consecutively in cases of localised prostate cancers., Intervention: A total of 1377 LRPs and 1009 RALPs were performed using an extraperitoneal approach., Outcome Measurements and Statistical Analysis: Patient demographics, surgical parameters, pathologic features, and functional outcomes were collected into a prospective database and compared between LRP and RALP. Biochemical recurrence-free survival was tested using the Kaplan-Meier method. Mean follow-up was 39 and 15.4 mo in the LRP and RALP groups, respectively., Results and Limitations: Shorter durations of operative time and of hospital stay were reported in the RALP group compared with the LRP group (p<0.001) even beyond the 100 first cases. Mean blood loss was significantly lower in the RALP group (p<0.001). The overall rate and the severity of the complications did not differ between the two groups. In pT2 disease, lower rates of positive margins were reported in the RALP group (p=0.030; odds ratio [OR]: 0.396) in multivariable analyses. The surgical approach did not affect the continence recovery. Robot assistance was independently predictive for potency recovery (p=0.045; OR: 5.9). Survival analyses showed an equal oncologic control between the two groups. Limitations were the lack of randomisation and the short-term follow-up., Conclusions: Robotic assistance using an extraperitoneal approach offers better results than pure laparoscopy in terms of operative time, blood loss, and hospital stay. The robotic approach independently improves the potency recovery but not the continence recovery. When strict indications of nerve-sparing techniques are respected, RALP gives better results than LRP in terms of surgical margins in pathologically organ-confined disease. Longer follow-up is justified to reach conclusions on oncologic outcomes., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: To establish the rate of higher risk criteria in various definitions of an active surveillance population., Patients and Methods: Over a period of 10 years, 1161 patients were diagnosed with prostate cancer and underwent radical prostatectomy at our institution. Statistical analysis was performed comparing the rates of upgrading, extracapsular extension, seminal vesical involvment and unfavourable disease (Gleason score upgrading >6 and/or T3 disease) for six groups of patients eligible for the University of Toronto, Royal Marsden, John Hopkins, University of California San Francisco, Memorial Sloan Kettering Cancer Center and Prospective Randomized International Active Surveillance., Results: Active surveillance protocols including patients with biopsy Gleason score 3+4 (Royal Marsden) had significantly higher rates of extracapsular extension (P = 0.009), upgrading to pathological Gleason >3+4 (P = 0.004) and unfavourable disease (P = 0.001) compared to the most stringent John Hopkins criteria. Unfavourable disease was found in more than 40% of patients in all series with no significant difference between the Gleason 6 protocols. Biochemical recurrence-free survival at 5 and 10 years was 76.7% and 63.3% for the entire cohort. Positive margins (P < 0.001), pT3 tumours (P = 0.006) and unfavourable disease (P < 0.001) were significant predictors of biochemical recurrence., Conclusions: Active surveillance in patients with Gleason 3+4 presents a risk of missing unfavourable disease and should be limited to older patients with comorbidities. The differences in inclusion criteria between Gleason 6 protocols did not have a significant impact on the pathological results., (© 2013 BJU International.)

Objective: The apex is a particular region of the prostate in its surgical dissection and pathological analysis. We sought to evaluate the prognostic value of the apical localization of prostate tumors., Method: From 1988 to 2010, data pre- (age, clinical stage, preoperative PSA, biopsy Gleason score) and postoperative (prostate weight, pathologic stage TNM 2010, Gleason score, margin status) of 2765 total prostatectomies were collected prospectively. These data were compared according to existence or absence of tumor at the apex. The prognostic impact of tumor at the apex on biochemical recurrence-free survival (PSA>0.2 ng/mL) has been studied in univariate and multivariate models., Results: One thousand eight hundred seventeen tumors had a location at the apex (65.7%). In univariate analysis, there was a significant difference in the clinical stage, the biopsy and pathological Gleason score, the result of curage, the pathological stage and the margin status between apical tumors and others. With a mean decline of 34.6 months, 502 patients had a biochemical recurrence (18.1%). Disease-free survival at 10 years was 60.7% for tumor at the apex versus 65.9% in other cases. The location at the apex was significantly associated with biochemical recurrence on univariate analysis (P=0.01). After adjustment for clinical and pathological stage, PSA level, Gleason score and surgical margins, the apex was not anymore a pejorative independent predictor (P=0.0087)., Conclusion: The existence of tumor in the prostatic apex was associated with more aggressive tumoral criteria and was an independent and pejorative predictor of biochemical recurrence-free survival at 10 years in univariate analysis. The apical localization could be an additional argument in the decision of adjuvant therapy after prostatectomy., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objective: To identify the risk of failure of active surveillance (AS) in men who had the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria and had undergone radical prostatectomy (RP), by studying as primary endpoints the risk of unfavourable disease in RP specimens (stage >T2 and/or Gleason score >6) and of biochemical progression after RP., Patients and Methods: We assessed 626 patients who had the PRIAS criteria for AS defined as T1c/T2, PSA level of ≤10 ng/mL, PSA density (PSAD) of <0.2 ng/mL per mL, Gleason score of <7, and one or two positive biopsies. All patients underwent immediate RP at our department between January 1991 and December 2010. Multivariate logistic regression was used to test factors correlated with the risk of unfavourable prostate cancer. The risk of progression was tested using multivariate Cox regression models. Biochemical recurrence-free survival (BFS) was established using the Kaplan-Meier method., Results: Pathological study of RP specimens showed upstaging (>T2) in 129 patients (20.6%), upgrading (Gleason score >6) in 281 (44.9%) and unfavourable disease in 312 patients (50%). There was a statistically non-significant trend for BFS at P = 0.06. Predictors of favourable tumours were age <65 years (P = 0.005), one vs two positive biopsies (P = 0.01) and a biopsy core number >12 (P = 0.005). Preoperative factors predicting disease progression were a PSAD of >0.15 ng/mL(2) (P = 0.008) and biopsy core number of ≤12 (P = 0.017)., Conclusions: Even with stringent AS criteria, the rate of unfavourable disease remains high. Predictive factors of unfavourable disease and biochemical progression should be considered when including patients in AS protocols., (© 2012 BJU International.)

Objectives: Outcomes of continence, erectile function, and oncologic control are well-described in isolation especially for the retropubic open approach. However, only few series have yet reported combined results after radical prostatectomy. To determine the proportion of men who are continent, potent, and cancer-free (trifecta rate) 2 years after robot-assisted laparoscopic radical prostatectomy (RALRP)., Materials and Methods: We included patients who underwent a RALRP at our department and who were followed during at least 2 years. Men who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 500 men were included. All patients prospectively completed validated questionnaires (IIEF-5, ICS) before the medical visit and concerning their voiding and sexual disorders, preoperatively, 3, 6, 12, 18, and 24 months after RALRP. Biochemical recurrence was defined as any detectable serum PSA (≥ 0.2 ng/ml). The study end point was the trifecta rate (cancer control, continence, and potency) at 2 years of the surgery. Predictive factors of the trifecta outcome were assessed in univariate and multivariate analyses., Results: Median age and PSA level were 62.2 years and 9.7 ng/mL. A trifecta outcome was achieved in 44% and 53% of men at 12 and 24 months, respectively. The 2-year trifecta rate reached 62% in men undergoing bilateral nerve-sparing surgery and 71% in men < 60 years. Age < 60 years, PSA level < 10 ng/ml, organ-confined disease, and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome., Conclusion: Two years after RALRP, the trifecta outcome is achieved in 53% of preoperatively potent and continent men., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: Patients with localized prostate cancer (PCa) who are treated by radical prostatectomy (RP) have a good overall survival rate. Their quality of life, however, can deteriorate because of the incidence of bladder neck contracture (BNC). Our aim was to evaluate the incidence and the risk factors of BNC after minimally invasive radical prostatectomy (MIRP) with a single-knot running suture also known as the Van Velthoven technique (VVT)., Patients and Methods: From 2003 to 2010, 2115 patients underwent extraperitoneal, transperitoneal, or robot-assisted RP for localized PCa. A single-knot running suture according to the VVT was performed for the vesicourethral anastomosis. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. BNC was defined by a reduction of the lumen that does not allow the passage of an 18F fibroscope., Results: Mean follow-up of the patients was 43 (6-144) months. Of all, 1342, 241, and 532 had extraperitoneal, transperitoneal, and robot-assisted prostatectomy, respectively. BNC was diagnosed in 30 (1.4%) patients. Among them, 78% had the diagnosis within the first year of follow-up. Previous transurethral resection of the prostate (TURP) and external beam radiotherapy were independent risk factors of BNC., Conclusions: BNC incidence after MIRP using the single-knot running suture for the vesicourethral anastomosis is low. Previous TURP and external beam radiotherapy are identified as risk factors. This technique showed satisfying results regardless of the classic laparoscopic or robot-assisted approach.

Purpose: We aimed to evaluate the impact of the primary Gleason pattern on biochemical recurrence-free survival (RFS) after radical prostatectomy (RP) in a single-center cohort of patients with Gleason 7 tumors., Materials and Methods: From 1998 to 2008, 2,239 consecutive patients underwent RP for a localized prostate cancer. A total of 1,248 patients with Gleason score (GS) 7 cancers were included. Follow-up was standardized for all patients and recorded into a prospective database. Median postoperative follow-up was 23.4 months. Biochemical recurrence was defined by prostate-specific antigen level > 0.2 ng/ml., Results: In all, 721 patients (57.8%) had a final GS of 3 + 4 and 527 (42.2%) of 4 + 3. Patients with GS 4 + 3 had a significantly higher risk of biochemical progression than those with GS 3 + 4 (P < 0.001). The 3- and 5-year biochemical RFS for Gleason score 3 + 4 cancers was 84.6 and 76.4%, respectively, versus 69.9 and 61.1% in Gleason score 4 + 3 cancers. Multivariate analysis showed that the primary Gleason remained statistically predictive for PSA failure (P = 0.018). When analysis was stratified by both pathologic stage and margin status, predictive value of primary Gleason was significant in pT2R0, pT3-4R0, and pT3-4R1 cancers, whereas survival curves were not statistically different in pT2R1 cancers (P = 0.672)., Conclusion: Primary Gleason 4 pattern is an independent predictor for PSA failure. Analysis of Gleason patterns provides clinically relevant prognostic information, which may assist in the management of patients with Gleason score 7 cancers.

Study Type: Therapy (case series)., Level of Evidence: 4. What's known on the subject? and What does the study add? Despite excellent surgical cancer control, up to 40% of patients will have biochemical recurrence following radical prostatectomy (RP) for localized prostate cancer. Positive surgical margins (PSM) have been clearly demonstrated to be one of the main predictive factors for biochemical failure, disease progression and cancer mortality. However, decision of further management (adjuvant or salvage therapy) in patients with PSM remains controversial, and many debatable questions arise concerning the incidence of clinical progression and the impact of systematic adjuvant treatment on the cancer specific and overall survival. Analysis of the pathological and disease recurrence outcomes of our large cohort of patients treated by RP provides evidence that PSMs are associated with a poor prognosis in terms of PSA failure and need for salvage therapy. However, such a distinction between negative or positive margin cancers seems to appear clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score≥8 due to the predominant significance of these two poor prognosis factors for prediction of PSA failure., Objective: To study the impact of positive surgical margins (PSMs) as an independent predictor of prostate-specific antigen (PSA) failure after radical prostatectomy in adjuvant treatment-naïve patients., Patients and Methods: From 2000 to 2008, 1943 men who underwent a radical prostatectomy at Henri Mondor Hospital and who did not receive neoadjuvant or adjuvant therapy were included. Follow-up was recorded into a prospective database. Mean follow-up was 68.8 months. The biochemical recurrence-free survival (RFS), defined by a PSA>0.2 ng/mL, and the need for salvage therapy in univariate and multivariate models, were evaluated., Results: PSA failure was reported in 14.7% and PSMs were noted in 25.6%. In the overall cohort, PSM was significantly predictive for PSA failure (P<0.001; hazard ratio, HR, 2.6), need for salvage therapy (P<0.001; HR, 2.9) and specific deaths (P=0.006; HR, 3.7). The 5-year RFS was 84.4% in men with negative margins compared to 57.5% in the case of PSM. After stratification by pathological stage and Gleason score, margin status was significantly predictive for PSA failure in pT2 (P<0.001), pT3a (P=0.001) and/or Gleason score≤7 cancers (P<0.001), whereas the impact of PSM did not reach significance in pT3b (P=0.196), pT4 (P=0.061) and/or Gleason score≥8 cancers (P=0.115)., Conclusions: PSMs are associated with a poor prognosis in terms of RFS and the need for salvage therapy. Such a distinction between negative or positive margin cancers appears to be clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score (≥8)., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Objective: • To investigate the relationship between pretreatment testosterone levels and pathological specimen characteristics, by prospectively examining serum androgen concentrations in a well-studied cohort of patients who underwent radical prostatectomy (RP) for localized prostate cancer., Patients and Methods: • A total of 107 patients with clinically localized prostate cancer had an assay of total testosterone before laparoscopic RP at our institution. • The results were classified into two groups based on the total serum testosterone: group1, < 3 ng/mL; group 2, ≥ 3 ng/mL. • Student's t-test was used to compare continuous variables, and Fisher's exact test or the chi-squared test was used to compare categorical variables. • Survival curves were established using the Kaplan-Meier method and compared using the log-rank test. In all tests, P < 0.05 was considered to indicate statistical significance., Results: • All patients had localized prostate cancer based on digital rectal examination (DRE) and preoperative magnetic resonance imaging (MRI). Groups 1 and 2 were similar in terms of age, body mass index, preoperative co-morbidities (cardiovascular and diabetes mellitus), clinical stage of prostate cancer and preoperative PSA levels. • In pathological specimens, low total testosterone (< 3 ng/mL) was an independent risk factor for high Gleason score (> 7) and for locally advanced pathological stage (pT3 and pT4). • Higher preoperative testosterone correlated with disease confined to the gland. • There was no association between serum testosterone levels and surgical margin status, on the one hand, and biochemical recurrence on the other., Conclusion: • Low serum testosterone appears to be predictive of aggressive disease (Gleason score >7 and extraprostatic disease, pathological stage > pT2) in patients who underwent RP for localized prostate cancer., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Objective: To analyze pathological data of the radical prostatectomy specimen in patients operated for clinically-localized prostate cancer and who meet strict criteria for active surveillance necessary to be included in the French trial SURACAP., Patients and Methods: The data of patients who underwent a radical prostatectomy at our institution between 1998 and 2010 were reviewed. We only included the patients that met the usual criteria for active surveillance: clinical stage T1-2a tumor, PSA ≤ 10 ng/mL, biopsy Gleason sum inferior or equal to 6 with no pattern of grade 4 or 5, cancer involvement inferior or equal to two biopsy cores, inferior to 3 mm of malignant tissue in each positive biopsy core. From them, only those who were diagnosed from a second line biopsies cores were included for further analysis., Results: Overall, 48 patient who met the "SURACAP" criteria had a laparoscopic radical prostatectomy at out institution. Mean age was 65.4 years. The mean preoperative PSA was 6.1 ng/mL. Clinical stage of the tumor was T1c in 95% of patients and T2a in 5%. Biopsy Gleason score was 6 (3+3) in 100%. Pathological analysis of the surgical specimen showed that 19% of patients had a seminal vesicle invasion or an extracapsular extension. The Gleason score of the pathological specimen was 6 (3+3) in 57% of patients, 7 (3+4) in 38% and 8 (4+4) in 5% of patients. The Gleason score upgrading was 43% of patients., Conclusion: In our experience, 19% of patients who meet the criteria for active surveillance show an extracapsular extension or a seminal vesicle invasion on pathological analysis. Active surveillance is still under evaluation., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Objective: To determine the proportion of patients who are continent, potent and cancer-free (trifecta rate) 2 years after extraperitoneal laparoscopic radical prostatectomy (ELRP)., Patients and Methods: We included patients who underwent an ELRP at our department and who were followed for at least 2 years. Those who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 911 men were included. All patients prospectively completed objective, self-administered questionnaires before the medical visit, concerning their voiding and sexual disorders, before surgery and 12 and 24 months after ELRP. Biochemical recurrence was defined as any detectable serum PSA (≥ 0.2 ng/mL). Potency was defined as the ability to achieve an erection sufficient for penetration with or without the use of phosphodiesterase-5 enzyme inhibitor. Urinary continence was defined as absence, or occasional use, of a pad for anticipated vigorous activity. The primary study endpoint was the trifecta rate (cancer control, continence and potency) at 2 years after the surgery. Factors associated with the trifecta outcome were assessed in univariate analysis., Results: Median age and PSA level were 62.2 years and 9.9 ng/mL, respectively. A trifecta outcome was achieved in 29.7 and 54.4% of patients at 12 and 24 months, respectively. The 2-year trifecta rate reached 63.5% in patients undergoing bilateral nerve-sparing surgery and 73.5% in men aged < 60 years. Age < 60 years, PSA level < 10 ng/mL, organ-confined disease and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome. A total of 84.8% of patients were both cancer-free and continent at 24 months, regardless of erectile function., Conclusions: Two years after ELRP, the trifecta outcome is achieved in 54.4% of patients who remained potent and continent. This rate reaches 63.5% in patients undergoing a bilateral nerve-sparing procedure. Combined results of good cancer control and continence recovery are reported in 84.8% of patients, regardless of erectile function., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

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., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Study Type: Therapy (case series) Level of Evidence 4., Objective: To review the biochemical recurrence-free survival (RFS) rates of laparoscopic radical prostatectomy (LRP) in patients with a high risk of disease progression as defined by preoperative criteria of D'Amico et al., Patients and Methods: Between October 2000 and May 2008, 110 patients had extraperitoneal LRP and bilateral pelvic lymph node sampling for high-risk prostate cancer in our department. High-risk prostate cancer was defined as a prostate-specific antigen (PSA) level of >20 ng/mL, and/or a biopsy Gleason score >or=8, and/or a clinical stage of T2c-T4 stage. The median follow-up was 37.6 months. Risk factors for time to biochemical recurrence were tested using log-rank survivorship analysis and Cox proportional hazards regression., Results: Prostate cancer was organ-confined in 36% of patients; the Overall RFS was 79.4% and 69.8% at 1 and 3 years, respectively. The 3-year RFS rates for organ-confined cancer vs extracapsular extension were 100% and 54.3%, respectively (P < 0.001). The 3-year RFS rates for tumour-free seminal vesicle vs seminal vesicle invasion were 81.8% and 33.6%, respectively (P < 0.001). The 3-year RFS rates for negative surgical margins vs positive were 85.2% and 47.3%, respectively (P = 0.001). Compared with men with any single pathological risk factor or any two risk factors, men with all three risk factors had a significantly shorter time to PSA failure after LRP (log-rank test, P < 0.001)., Conclusion: Among patients at increased risk of disease progression as defined by preoperative criteria, a third of men with organ-confined disease have a favourable prognosis. Men at high risk for early PSA failure could be better identified by pathological assessment of RP specimens, and selected for phase III randomized trials investigating adjuvant systemic treatment.

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.

Objective: To describe our current procedure of robot-assisted laparoscopic radical prostatectomy (RALP), and to assess the effect of the learning curve on perioperative data, early oncological outcomes and functional results, as RALP has increasingly become a treatment option for men with localized prostate cancer., Patients and Methods: In all, 206 consecutive men had a RALP between July 2001 and November 2008 for localized prostate cancer. Among the overall cohort, the 175 men operated on by the same surgeon were distributed into five groups according to the chronological order of the procedures. The mean follow-up after RALP was 18.3 months. Patient demographics, surgical data and postoperative variables were collected into a prospective database. Data were compared by chronological groups into single-surgeon cohort., Results: The median operative time and blood loss were 140 min and 350 mL, respectively. The complication rate was 8.3%. Cancers were pT3-4 in 34.5%. The mean hospital stay and duration of bladder catheterization were 4.3 and 8.2 days, respectively. The rate of positive surgical margins (PSMs) was 17.2% in pT2 cancers. The recovery rate of continence was 98% at 12 months. Intraoperative time, blood loss and length of hospital stay were significantly improved after a short learning curve. The continence recovery, the rate and the length of PSM were also improved beyond the learning curve, but difference was not statistically significant., Conclusions: RALP is a safe and reproducible procedure and offers a short learning curve for experienced laparoscopic surgeons. Beyond the learning curve, continued experience might also provide further improvements in terms of operative, pathological and functional results., (© 2009 THE AUTHORS. JOURNAL COMPILATION © 2009 BJU INTERNATIONAL.)

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., (Copyright 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Prostate cancer incidence increases with age. Radical prostatectomy (RP) seems to be feasible for elderly well-selected patients. We report our experience with patients older than 75 years old who underwent laparoscopic RP., Methods: From 2000 to 2007, 22 patients older than 75 years old at time of surgery were included in the study. The patient clinical characteristics, the peri- and postoperative data, and the pathological data were collected retrospectively. The overall, specific and PSA-free survival were analysed with Kaplan-Meier method. The functional results such as continence and erectile function were assessed by self-questionnaires., Results: The mean patient age was 75 years (75-81), the median PSA level was 10.77 ng/ml (5-30). The mean American Society of Anesthesiologists score was 2.1 (2-3). Two (9%) perioperative complications occurred but no conversion was necessary. Five patients (23%) had a pT3 disease and the overall positive surgical margins rate was 14%. With a median follow-up of 42 months, no patient has died and five had a biochemical recurrence. At 12-month follow-up, 82% of patients were continent (no pad) and potency (erection sufficient for intercourse) rate was 36% with or without the use of phosphodiesterase-5 inhibitors., Conclusion: Laparoscopic RP is feasible for localized prostate cancer in elderly well-selected patients with satisfactory oncological and functional outcomes although the incontinence rate is increased comparing to younger patients., ((c) 2009. Published by Elsevier Masson SAS.)

Purpose: We compared the pathological findings and prostate specific antigen outcome after radical prostatectomy in men eligible for active surveillance according to 3 biopsy inclusion criteria., Materials and Methods: The study population included 177 men eligible for active surveillance who fulfilled clinicobiological criteria and biopsy criteria as group 1-less than 3 positive cores and less than 3 mm total tumor length, group 2-less than 3 positive cores with cancer involvement of less than 50% in any core and group 3-less than 33% of positive cores. Prostate specific antigen density cutoffs were also studied in these groups. Pathological findings on radical prostatectomy specimens and biochemical recurrence-free survival were studied. Median followup after radical prostatectomy was 34 months., Results: A majority of Gleason score 6 disease was observed in group 1 (51.7%) whereas a majority of Gleason score 7 or greater disease was reported in groups 2 (53.6%) and 3 (55.4%). Extracapsular extension was noted in 17.5% of radical prostatectomy specimens in group 3 vs 11.2% in group 1 (p = 0.175). The risk of overall unfavorable disease (defined as pT3-4 stage and/or Gleason score 8 or greater) was significantly higher in men with cancer involvement of 3 mm or greater on initial biopsy (27.3% vs 13.5%, respectively, p = 0.023). The 3-year biochemical recurrence-free survival rate was 94.0% and was not affected by the 3 active surveillance definitions., Conclusions: Even with the use of a 21-core biopsy protocol the rate of unfavorable disease in radical prostatectomy specimens remains increased in men eligible for active surveillance. Patients must be informed of this risk of misclassification which ranges from 20% to 28% in men who fulfill the less stringent biopsy criteria., (Copyright 2010 American Urological Association. Published by Elsevier Inc. All rights reserved.)

Background: Studies offer wide variations in inclusion criteria for active surveillance (AS) in prostate cancer (PCa), but the role of the biopsy core number has not been thoroughly assessed., Objective: To evaluate the impact of the biopsy core number on the risk of misclassification for AS eligibility., Design, Setting, and Participants: This prospective study included 411 men eligible for AS who fulfilled at least one of four of the criteria reported in the literature groupings among a screening cohort of 2917 patients., Intervention: All patients underwent a 21-core biopsy with cores mapped by location and acted as controls of themselves for the analysis of biopsy core number (6-, 12- and 21-core schemes). Radical prostatectomy (RP) was performed in 297 men (72%)., Measurements: The number of included patients, PCa extent on biopsy, rate of unfavorable disease in RP specimens, and biochemical recurrence-free survival were compared as a function of (1) the different criteria groupings for AS and (2) the biopsy core number (6, 12, or 21)., Results and Limitations: Of the 1104 patients with PCa, the proportion eligible for AS ranged from 22.5% to 35.4% based on AS criteria. In men who fulfilled AS criteria only in a 12-core strategy, tumor length and percentage of cancer involvement on biopsy were significantly greater than in those who fulfilled AS criteria in a 21-core scheme. The rate of unfavorable disease on RP specimens was also higher in the former group, from 28.6% to 35.9% relative to AS criteria (p=0.014, 0.044, and 0.113 in groups 2, 3, and 4, respectively)., Conclusions: Men eligible for AS based on a 21-core strategy have cancers with a lower extent of disease on biopsies and a lower risk of unfavorable disease on RP specimens regardless of how AS criteria are defined, compared with men eligible in a 12-core scheme.

Objective: To determine the value of a 21-sample biopsy protocol in predicting tumour localization in radical prostatectomy (RP) specimens, compared with sextant biopsies., Patients and Methods: In all, 300 consecutive patients underwent 21-sample prostate biopsies, followed by RP. The protocol consisted of sextant, three midline, six far lateral and six transitional zone biopsies. Tumour locations on biopsies and RP specimens were compared. The sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and accuracy were calculated., Results: There was no difference between sextant and 21-sample biopsies for sensitivity (38% vs 36%; P=0.50) and specificity (84% vs 87%; P=0.46), but the NPV was higher for 21-sample biopsies (57% vs 68% ; P<0.001). The PPV was higher in the sextant biopsies (74% vs 59%; P=0.007). Sextant, transitional zone and far lateral biopsies were re-grouped in six regions. Compared with 21-sample biopsies, sensitivity (54%) and PPV (79%) were higher (P<0.001), while specificity (74%) and NPV (46%) were lower (P=0.05 and P=0.001, respectively)., Conclusion: A negative biopsy does not confirm the absence of cancer in the corresponding site in the RP specimen in a sextant or 21-sample biopsy protocol and cannot be used as a prognostic element before RP. A positive biopsy does not always correspond with a tumour in the same zone of the RP specimen. When 21-sample biopsies are re-grouped in to six regions, the value of a positive biopsy increases. A positive biopsy corresponds thus to a tumour in the same region, rather than in precisely the same location. The results of this study could help in the biopsy protocol used for making surgical decisions, e.g. preserving the bladder neck or neurovascular bundles.

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.

Objective: To assess the prognostic significance of microscopic bladder neck invasion (BNI+) after radical prostatectomy (RP)., Patients and Method: From January 1988 to December 2006, 1480 patients with clinically localized prostate cancer were surgically treated at one tertiary university hospital. The risk of biochemical progression, defined as a prostate-specific antigen (PSA) level after RP of >0.2 ng/mL, was assessed with univariate and multivariate analyses for clinical and pathological variables. We compared the biochemical progression-free survival (bPFS) of patients with BNI+ vs stages pT2, pT3a, pT3b and positive lymph nodes (N+). In a second analysis, we evaluated the bPFS of patients in different stages associated with BNI+ and compared them with those in the same stages with no BNI., Results: BNI+ was found in 132 (9%) patients; the 5-year bPFS was 86%, 54%, 26% and 10% for stages pT2, pT3a, pT3b and N+, respectively, while it was 30% for BNI+ (P < 0.001). There was no difference in the 5-year bPFS between stage pT2 and pT2 + BNI (P = 0.32). Stages pT3a and pT3b had a better 5-year bPFS than stage pT3a + BNI (P = 0.003) and pT3b + BNI (P = 0.001), respectively. In the univariate analysis all variables were associated with BP. In the multivariate analysis, only BNI+ had no association with BP (odds ratio 1.14, 95% confidence interval 0.70-1.85; P = 0.59)., Conclusions: Microscopic BNI+ in prostate cancer is not an independent risk factor for biochemical progression and should be regarded as a factor that worsens the prognosis of the underlying tumour stage. A longer follow-up is necessary to confirm these findings.

Objectives: To compare the morbidity and functional results after laparoscopic radical prostatectomy with and without previous transurethral resection of the prostate (TURP)., Methods: From May 1998 to January 2005, 640 patients underwent laparoscopic radical prostatectomy, of whom 46 (7.2%) had previously undergone TURP. The perioperative and postoperative data were compared between group 1 (with previous TURP) and group 2 (without previous TURP). The functional results were assessed by self-administered questionnaires at 12 and 24 months after surgery., Results: In group 1, the operative time, hospital stay, and bladder catheterization duration was increased by 31 minutes, 1.9 days, and 2.9 days, respectively. The positive margin rate was not significantly different statistically between the two groups (P = .62). The 5-year actuarial freedom from biochemical recurrence rate was similar between the two groups (P = .86). Surgical complications occurred in 15.2% of group 1 and 5.7% of group 2 (P = .02). The risk of anastomotic stricture was 6.5% and 1.2% in groups 1 and 2, respectively (P = .02). Two years after surgery, the continence rate was 86.9% in group 1 and 95.8% in group 2 (P = .77), and the potency rate was 63.8% and 70.9%, respectively, after bilateral neurovascular bundle preservation (P = .61). However, neurovascular bundle preservation was performed after previous TURP in only 56.5% of group 1 vs 78.9% in group 2 (P = .02). The median follow-up was 50.8 months (range 30-107)., Conclusions: Laparoscopic radical prostatectomy can be performed after TURP without compromising the oncologic results. However, patients should be informed that the procedure is associated with worse intraoperative and postoperative outcomes. Although the urinary continence rate was not hampered by previous TURP, neurovascular bundle preservation is technically more difficult and compromises postoperative erectile function.

The aim of the study was to evaluate factors of progression after radical prostatectomy in patients with bladder neck invasion (BNI). From 1988 to 2006, 1395 patients underwent radical prostatectomy, 120 (8.6%) had microscopic BNI (pT4 N0, TNM 2002). Group 1 was defined as BNI alone, group 2 as BNI plus extracapsular extension and group 3 as BNI plus seminal vesicle invasion (SVI). Postoperative follow-up data were obtained through routine serum prostate-specific antigen (PSA) and digital rectal examination. Biochemical progression was defined as a single detectable PSA level postoperatively (>0.2 ng ml(-1)). Groups 1, 2 and 3 included 38 (31%), 35 (30%) and 47 (39%) patients, respectively. Preoperative PSA (11.1 vs 24.7 and 23.3 ng ml(-1), P=0.01), biopsy Gleason score (5 vs 6 and 6, P=0.003) and specimen Gleason score (6 vs 7 and 7, P=0.02) were statistically different between three groups. None of the patients had a specimen Gleason score >or=8 in group 1. After a mean follow-up of 27 months, 51 (42.5%) patients had biochemical progression. The 5-year progression-free survival was 87, 53 and 17% for groups 1, 2 and 3, respectively (P<0.001). Within pT4 prostate cancer, those tumors with isolated microscopic BNI appear to have better prognosis than those with associated extracapsular extension and/or seminal vesicle invasion, and should be distinguished in TNM classification.

A 21-samples saturation biopsy procedure (SBP) was developed in order to improve prostate cancer detection rate. Out of 650 patients who underwent this protocol, 150 had a clinically localized prostate cancer and underwent a radical prostatectomy. The number of cores positive for tumor was assessed in the SBP, and also in the sextant component of the SBP (SC) and in the non-sextant component of the SBP (NSC). Numbers of cores positive for tumor on SBP, SC, and NSC were significantly higher in pT3 group versus pT2 (P < 0.001 each) and in positive surgical margins (PSM) group versus no PSM (P < 0.001 each). When comparing area under the curve obtained from SBP with those obtained from NSC and SC, the SBP showed higher accuracy than the NSC and the SC for the prediction of pT3 and PSM. On multivariate analyses, SC and NSC were independent predictors of pT3 and PSM on radical prostatectomy.

The objective of the study was to evaluate the long-term results of retroperitoneal laparoscopic radical prostatectomy (LRP). From 2001 to 2005, 550 consecutive patients underwent a laparoscopic extraperitoneal prostatectomy in our department. Continence and erectile function were analysed prospectively by a self-administrated questionnaire. Mean operating time was 188 min, mean bladder catheterisation time 5.9 days, mean hospital stay 4.6 days Pathological stage was pT2 in 55.8%, pT3a in 29.6%, pT3b in 9.1% and pT4a in 5.4% tumours. Positive surgical margins were 17.9% for pT2, 44.8% for pT3 tumours and 71.4% for pT4a tumours. Five years survival without biochemical progression was 78.8%. After 24 months of follow-up, diurnal continence rate was 91%, and potency rate was 64% when both neurovascular bundles were preserved, 78.6% when the patients were younger than 60 years. LRP is now a standardised procedure. An extraperitoneal approach combines the advantages of a laparoscopic procedure with those of an extraperitoneal approach.

Objectives: Previous transurethral resection of the prostate (TURP) was reported to impose difficulties during open radical prostatectomy. We describe our experience in laparoscopic radical prostatectomy (LRP) following transurethral resection of the prostate., Patients and Methods: The series included 35 patients: 22 patients underwent transperitoneal LRP (tpLRP) and 13 underwent extraperitoneal LRP (epLRP). The minimal interval between TURP and laparoscopy was 3 months. Patients' charts were reviewed for their preoperative characteristics, intraoperative difficulties and complications, and outcome., Results: Patients' mean age was 67.5+/-4.4 years. 12 patients were cT1a,b and 23 patients were cT1c/T2. Twenty-two patients underwent tpLRP and 13 underwent epLRP. No statistical difference was found between the preoperative characteristics and the pathological results of cT1a,b vs. T1c/cT2 patients, or tpLRP vs. epLRP patients. Thirty-three procedures were completed laparoscopically and 2 were converted to open surgery. Perioperative complications included two leaking anastomoses, prolonged lymph drainage in 1 case, atelectasis (n=1) and duodenal ulcer (n=1). Twelve positive margins were noted, half of them in pT2 tumors. The mean follow-up was 28.5 months. Twenty-five of 35 patients had more than 12 months of follow-up. Among them 19 patients were completely continent (76%) and 6 (24%), reported mild stress incontinence., Conclusions: Although LRP following TURP is sometimes more technically difficult, simple modifications in the operative strategy help facilitate surgery. LRP following TURP favorably compares to open radical prostatectomy after TURP and laparoscopy in non-TURP patients., (Copyright (c) 2006 S. Karger AG, Basel.)

Purpose of Review: Laparoscopic and robotic-assisted prostatectomy have been proposed as alternatives to traditional open retropubic prostatectomy. In this review, we update the more recent data concerning the results, technical trends and controversies regarding these novel, minimally invasive procedures., Recent Findings: As a result of improved patient selection, a better understanding of surgical anatomy, and refinements in surgical techniques, traditional retropubic prostatectomy set the standards very high, leaving little room for improvement. In this review, the results of laparoscopic prostatectomy are compared with contemporary in addition to historical series. Besides the transperitoneal laparoscopic approach, which was almost exclusively used in the initial series, the introduction and development of the extraperitoneal laparoscopic approach meant a significant change in the surgical strategy of a number of teams worldwide. The relative merits of the transperitoneal and extraperitoneal approaches are discussed. Robotic radical prostatectomy is a promising technical innovation that allows us to overcome many of the inherent limitations of laparoscopic surgery. As a result of financial constraints, the experience has been limited to a few centres worldwide., Summary: Although long-term results are still lacking, novel minimally invasive techniques seem to fulfil the highest standards of radical prostatectomy in terms of early oncological cure, functional results and morbidity. A standardization of data collection and evaluation methodology will be indispensable for a better comparison of the different series.

Purpose: Compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach., Methods: 330 consecutive men underwent laparoscopic radical prostatectomy for localized prostate cancer, the first 165 by transperitoneal approach, and the last 165 by extraperitoneal approach. Clinical stage, serum PSA, Gleason score of biopsy were recorded, as well as operating time, surgical and medical complications, blood loss, length of hospital stay and catheterization time. The weight of the specimen, pathological stage (1997 TNM classification) and status of the surgical margins were noted. The Fisher test as well as the chi2-test were used for statistical analysis. Differences were considered significant when p < 0.05., Results: There were no significant differences between the two groups in terms of preoperative characteristics except for Gleason score of the biopsies which was higher in the extraperitoneal group (p < 0.0001). The operating time was longer with the transperitoneal approach (248.5 min vs. 220.0 min, p < 0.0001). There was no difference in transfusion rate (1.2% vs. 5.4%, transperitoneal vs. extraperitoneal, respectively, p = 0.6). There was no difference in hospital stay, medical and surgical complications. Respectively, in the transperitoneal and extraperitoneal groups, there were 108 and 88 pT2 tumors. There were no differences in terms of positive surgical margins between the two groups, 23% and 29.7% (p = 0.21) overall, 13.0% and 17.0% (p = 0.42) in pT2 tumors and 43.6% and 44.7% (p = 0.99) in pT3 tumors., Conclusions: Extraperitoneal approach offers the same early oncological results as transperitoneal approach with a shorter operative time., (Copyright 2004 Elsevier B.V.)

Laparoscopic radical prostatectomy (LRPE) became the operative procedure of choice for patients with clinically localized prostate cancer in selected urologic centers around the world. Principal advantages are the minimal invasive nature of the procedure, a superior visualization of the operative field because of the magnification of the optical system, an exact and watertight anastomosis, the possibility of early catheter removal, and a potentially reduced amount of blood loss. Recent data show that oncologic outcome is not compromised by the minimal invasive nature of the procedure. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal organ of the prostate. Therefore, principal disadvantages of LRPE are potential intraperitoneal complications. Endoscopic extraperitoneal radical prostatectomy is a further advancement of minimal invasive surgery because it overcomes the limitations of LRPE by the strictly extraperitoneal route of access, combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. This article reviews the literature on minimally invasive (laparoscopic and endoscopic-extraperitoneal) radical prostatectomy.

Purpose: We developed and assessed the feasibility of extraperitoneal laparoscopic radical prostatectomy performed using the da Vinci (Intuitive Surgical, Mountain View, California) robotic system., Materials and Methods: In June 2002, 4 consecutive patients with clinically localized prostate cancer underwent extraperitoneal, robotic assisted laparoscopic radical prostatectomy. After development of the extraperitoneal space the surgeon performed laparoscopic prostatectomy from the remote control unit. The assistant aligned and exchanged robotic instruments and used conventional laparoscopic instruments to facilitate prostatectomy. Perioperative data and pathological results were recorded., Results: No difficulties were noted when developing the extraperitoneal space. All additional steps were successfully performed with telerobotics. More distal placement of the robotic ports appeared to improve the feasibility of the extraperitoneal approach. The peritoneum acted as a natural bowel retractor and the distal port placement facilitated use of the assistant ports. Mean operative time was 274 minutes (range 124 to 360). Mean catheterization time and hospital stay were 2.7 and 5.3 days, respectively. A positive margin was observed in 1 patient and pathological stage was pT2 in 3 and pT3 in 1. No postoperative complications or open conversions were observed., Conclusions: The extraperitoneal approach was feasible with the da Vinci robotic system. Distal port placement for the robot appeared to create an ergonomic environment for the surgeon and assistant and more direct prostatic access. While additional clinical experience is required, the extraperitoneal approach may ultimately provide advantages for robotic and nonrobotic laparoscopic radical prostatectomy.

Objectives: To present our experience in the management of rectal injuries during laparoscopic radical prostatectomy., Methods: All patients underwent bowel preparation and received perioperative antibiotics. If rectal injury was suspected, digital rectal examination was performed, aided by bubbling air into the rectum if required. When the diagnosis was confirmed, the hole was closed in two layers of absorbable sutures. A fat flap was developed from the omentum (in the transperitoneal approach) or the perirectal fat (in the extraperitoneal approach) and placed on the suture line. Anal dilation was performed. After surgery, broad-spectrum antibiotics and a low-residue diet were prescribed., Results: Of 300 patients who underwent surgery between May 1998 and June 2002, 6 (2%) had a rectal injury. The first patient had received neoadjuvant hormonal therapy. Five cases were in the transperitoneal approach and were closed using omental fat and 1 was in the extraperitoneal approach with a perirectal fat flap. The first patient presented with a rectourethral fistula and was treated with catheterization for 1 month and a diverting colostomy. The others were detected intraoperatively and were treated laparoscopically. In the second patient, a diverting colostomy was performed at the end of surgery using a separate incision. Patients resumed oral intake within 2 to 7 days and were discharged from the hospital between 6 and 18 days postoperatively. No wound infection was noted., Conclusions: Rectal injuries during laparoscopic radical prostatectomy can be identified and managed intraoperatively without requiring conversion. Double-layered closure reinforced by a fat flap resulted in an uneventful recovery.

Objectives: To evaluate and compare prospectively the functional results (urinary continence and erectile function) after retropubic and laparoscopic radical prostatectomy., Methods: From 1998 to 2001, 300 patients underwent radical prostatectomy, 70 by the retropubic and 230 by the laparoscopic approach. All of them completed a confidential, self-administered questionnaire regarding urinary continence and erectile function before and 1, 3, 6, and 12 months after surgery. The results were analyzed separately for day and nighttime urinary continence and by neurovascular bundle status and age for erectile function., Results: No differences were found between the two groups except for the duration of bladder catheterization (7.8 days for the retropubic and 5.8 for the laparoscopic approach, P = 0.0006). Before surgery, 296 patients (98.7%) were continent and 290 (96.6%) were potent. One year after surgery, diurnal urinary continence increased progressively to 66.7% and 71.6% (P >0.05), nocturnal continence to 66.7% and 87.1% (P = 0.008), and potency rates to 30% and 41% (P >0.05) for the retropubic and the laparoscopic approaches, respectively. After preservation of one and two neurovascular bundles, the potency rate increased to 27% and 46% and 44% and 53% for the retropubic and laparoscopic approaches, respectively (P >0.05). For patients younger than 60 years old with bilateral neurovascular bundle preservation, the potency rates were 72% and 81% (P >0.05)., Conclusions: The two approaches showed similar outcomes regarding continence and erectile function 1 year after surgery. However, the recovery of nocturnal continence seemed to occur earlier after the laparoscopic approach. It is necessary to conduct additional studies to determine the potential benefits of the laparoscopic approach regarding nocturnal continence.

Purpose: We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy., Materials and Methods: Between May 1998 and September 2001, 235 men underwent laparoscopic radical prostatectomy at our institution. During this period modifications were made in the technique. We stopped preserving the puboprostatic ligaments during 1999 and stopped preserving the bladder neck during 2000. We compared the incidence of apical and bladder neck margins before and after these changes in surgical technique. Nerve sparing status was documented by the surgeon at the end of the operation and its effect on the incidence of lateral positive margins was evaluated. To concentrate on the surgically induced margins this study focused on pT2 cases., Results: There were 169 pT2 cases and 32 (18.9%) positive margin locations. A constant decrease was noted in the overall incidence of positive margins but, while apical margins were the most abundant in 1998, posterolateral margins were most abundant in 2001. Avoiding bladder neck preservation eliminated positive bladder neck margins in 2001. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%., Conclusions: The experience gained in this procedure led to a decrease in the incidence of positive margins. Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. Nerve preservation did not increase the incidence of positive margins. These technical modifications may improve the outcome of laparoscopic radical prostatectomy.

Objectives: To demonstrate the feasibility of "complete solo" (CS) laparoscopic radical prostatectomy (LRP) performed solely with robotic manipulation of the laparoscope and without any human assistant at all. A comparison was made between CS LRP and the standard technique to identify the advantages and drawbacks., Methods: Sixteen consecutive patients undergoing CS LRP were compared with the last 16 patients undergoing standard LRP. The standard procedure was performed with five trocars and one human assistant. Therefore, the surgeon had three instruments immediately available and could switch quickly from one to another, while the assistant held the laparoscope and a retractor. The CS method used a voice-controlled robotic arm to manipulate the laparoscope and a mechanical arm for the assisting instrument., Results: The mean operative time in the CS and standard groups was 324 and 347 minutes, respectively (P >0.5). An additional human assistant was required, for 1 hour, in 3 patients of each group. No significant difference was noted between the two groups in terms of catheterization time, hospital stay, positive margin rate, complications, short-term cancer control, or functional results. The CS method has been demonstrated to be highly cost-effective compared with the standard technique., Conclusions: The CS LRP is feasible and compares favorably with the standard technique. It offers unique advantages in terms of direct control of the operative view, standardization of the assistance, and higher stability of the laparoscope, thus greatly enhancing the surgeon's comfort. The diminished need for human operative assistance provides significant economic and organizational benefits.

Objectives: To compare the perioperative morbidity and surgical technique of the two main variants of laparoscopic radical prostatectomy: the more often used transperitoneal approach with primary dissection of the plane posterior to the seminal vesicles (TP-LRP) and a purely extraperitoneal approach (EP-LRP)., Methods: Our initial 20 consecutive patients who underwent EP-LRP and the last 20 consecutive patients who underwent TP-LRP were included in this retrospective study. The two groups were well matched for age, American Society of Anesthesiologists score, body mass index, prostate-specific antigen level, and Gleason score. The mean time for completion of the individual laparoscopic steps was assessed for both approaches., Results: With EP-LRP, the mean operative time was shorter (169.6 minutes versus 224.2 minutes, P <0.001) and patients resumed a full diet earlier (mean 1.6 days versus 2.6 days, P = 0.002). The mean total dose and duration of morphine administration were higher in the TP-LRP group, but the difference was not statistically significant (6.0 mg versus 12.8 mg and 0.5 day versus 0.9 day, respectively). The catheter time was nearly identical in the two groups (mean 5.3 days with TP-LRP and 4.2 days with EP-LRP). The incidence of positive margins was not affected by the surgical approach., Conclusions: These preliminary results suggest that the initial posterior dissection associated with TP-LRP is less efficacious than direct access of the prevesical space during EP-LRP. Measures of perioperative morbidity were at least equivalent, if not superior, for the EP-LRP technique. These findings, together with the significant decrease in operative time with EP-LRP, appear sufficiently important to abandon the transperitoneal technique.

Objectives: To evaluate and compare the location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer (pT2)., Methods: From 1988 to 2001, 538 patients underwent radical prostatectomy for clinically localized prostate cancer. Patient age at surgery, clinical stage, preoperative prostate-specific antigen, and Gleason score of positive biopsies were noted. Postoperatively, specimen weight, final Gleason score, and capsular, seminal vesicle, and lymph node status, as well as tumor volume, were studied. The incidence and location of positive margins and the pathologic stage were noted according to the surgical approach., Results: A total of 371 patients (69.5%) had organ-confined tumors. Of the 371 patients, 116 underwent the retropubic, 86 the perineal, and 169 the laparoscopic approach, and positive surgical margins were noted in 22 (18.9%), 12 (13.9%), and 32 (18.9%) patients, respectively. Positive surgical margins were reported in 72 specimen locations, 32 (44.4%) at the apex, 17 (23.6%) at the bladder neck, and 29 (31.9%) posterolaterally. The distribution for the retropubic, perineal, and laparoscopic approaches was apex in 50%, 33.3%, and 44.4%, bladder neck in 29.1%, 41.7%, and 13.9%, and posterolaterally in 20.8%, 25%, and 41.6%, respectively., Conclusions: In our series, each approach had a specific high-risk location of positive margins: the apex for the retropubic, the bladder neck for the perineal, and posterolaterally for the laparoscopic approach. Improvements in the surgical techniques should take these specific locations under consideration to decrease the incidence of positive surgical margins.

Objectives: To analyze the association between Gleason score, stage and status of surgical margins with tumor volume in prostate cancer progression after radical prostatectomy., Methods: 200 consecutive radical prostatectomy specimens were analyzed. Preoperative clinical stage, PSA, results of prostate biopsies as well as pathological results were noted. A biochemical recurrence was defined as a single, postoperative detectable PSA level (>0.2 ng/ml). Tumor volume was compared to postoperative staging, Gleason score, and surgical margin status to predict tumor progression. Univariate and multivariate analysis using stepwise logistic regression were used to identify parameters with additional prognostic value., Results: Pathological results of the prostatectomy specimens showed 149 (74.5%) pT2a-b, 29 (14.5%) pT3a and 22 (11%) pT3b tumors. Tumor volume was 0.57 cc for pT2a, 1.2cc for pT2b, 1.7cc for pT3a and 2.9cc for pT3b, respectively (p<0.05). Taken together, mean volume for pT2 and pT3 were 1.06 and 2.2 cc, respectively (p<0.0001). Five-year progression-free actuarial survival was 69.7%. Using univariate analysis, tumor progression correlated with final Gleason score (p<0.0007), positive surgical margins (p=0.02), tumor volume (p=0.009) and stage (p<0.0001). In a multivariate analysis, tumor progression correlated only with the final Gleason score (p=0.04) and stage (p=0.0002)., Conclusion: Gleason score and pathological stage are independent factors to predict prostate cancer progression after radical prostatectomy. When these parameters are known, tumor volume does not provide additional information.

Purpose: We evaluated the sexual function of patients who underwent laparoscopic radical prostatectomy. We assessed the effect of unilateral or bilateral preservation of the neurovascular bundle on the ability to achieve erections and have sexual intercourse postoperatively., Material and Methods: Between May 1998 and September 2001, 232 men underwent laparoscopic radical prostatectomy for localized prostate cancer at our institution. Sexual function questionnaires were given to the patients preoperatively. The study included 143 patients who were potent preoperatively. After the procedure the surgeon noted whether he performed unilateral, bilateral or no nerve sparing. Sexual function questionnaires were collected at 1, 3, 6 and 12 months after surgery., Results: Of the 143 patients, 100, 80, 48 and 26 responded to the questionnaire at 1, 3, 6 and 12 months respectively. Of the nonnerve sparing group 11.7%, 11.1%, 16.6% and 30%, of the unilateral nerve sparing group 20%, 35%, 41.6% and 50% and of the bilateral nerve sparing group 32.5%, 41.1%, 29.1% and 87.5% respectively reported spontaneous erections 1, 3, 6 and 12 months after surgery, respectively. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%., Conclusions: The overall rate of patients who had erections preoperatively and maintained erections after surgery (53.8%) is comparable to the results for open surgery. Patients with bilateral preservation did better than those with unilateral preservation. Our preliminary results show a promising rate of potency at 1 year after laparoscopic radical prostatectomy.

Objectives: To evaluate prospectively functional results (urinary continence and erectile function) after laparoscopic radical prostatectomy., Methods: From 1998 to 2001, 235 patients underwent laparoscopic radical prostatectomy for localized prostate cancer. All of them completed a confidential, self-administered questionnaire regarding urinary continence and erectile function before, and 1, 3, 6, and 12 months after surgery. Results were analyzed separately for day and night for urinary continence and status of neurovascular bundles as well as age for erectile function., Results: To date, 100 consecutive patients have completed all questionnaires. Diurnal and nocturnal urinary continence have increased to 90% and 97% one year after surgery. Overall, 49.3% of the 77 patients, who were potent preoperatively, and did not receive any form of adjuvant therapy, had erections sufficient for intercourse one year after surgery. Potency rates were 38.4%, 53.8% and 58.8% after no, unilateral, and bilateral nerve bundle preservation, respectively. For younger patients (<60 years) with unilateral and bilateral neurovascular bundle preservation, potency rates were 75% and 83.3%, respectively., Conclusion: One year after laparoscopic radical prostatectomy, urinary continence rate is 90% during the day and 97% during the night. Overall potency rates after bilateral preservation of neurovascular bundles are 58.8% and 83.8% for the subgroup of younger patients (<60 years)., (Copyright 2002 Elsevier Science B.V.)

Objective: To study the sites of positive surgical margins after radical prostatectomy according to the technique used: retropubic, perineal or laparoscopic., Material and Methods: 538 radical prostatectomies were performed between 1988 and 2001: 184 via a retropubic approach, 119 via a perineal approach and 235 by laparoscopy. Clinical examination, PSA assay (Hybritech, Normal < 4 ng/ml) and transrectal biopsies were performed in all patients. The radical prostatectomy specimen was examined by the same pathologist according to the Stanford protocol. The frequency and site of positive surgical margins were studied as a function of pathological stage., Results: The positive surgical margins rate was 32%, 18.5% and 26.4% for the retropubic, perineal and laparoscopic techniques, respectively. The most frequent site of positive surgical margins was the apex for retropubic (41.1%) and perineal (41.6%) prostatectomy and the posterolateral part of the prostate for laparoscopic prostatectomy (41.9%). The most frequent site of positive surgical margins in pT2 tumours was the apex for the retropubic approach (50%), the base of the prostate (bladder neck) for the perineal approach (41.6%) and the apex and posterolateral part of the prostate for the laparoscopic approach (44.4% and 41.6%)., Conclusion: Each radical prostatectomy technique corresponds to a preferential site of positive surgical margins: the apex for the retropubic approach, the bladder neck for the perineal approach and the posterolateral part of the prostate for the laparoscopic approach.

Objective: Seminal vesicle invasion (pT3b) is a known factor of poor prognosis after radical prostatectomy. The authors retrospectively studied the course of stage pT3b tumours, and the clinical, laboratory and histological factors that could influence this course., Methods: From 1988 to 2001, out of a total of 538 radical prostatectomies, 62 (11.5%) cases with isolated seminal vesicle invasion were analysed according to the Stanford technique. Half-yearly postoperative surveillance was based on physical examination and PSA assay. Progression was defined as PSA greater than 0.2 ng/ml or when complementary treatment was performed. Actuarial progression-free survival was studied according to the Kaplan-Meier method. Actuarial survivals were compared by the Log-rank method, and a difference was considered to be significant for p < 0.05. Multivariate analysis using the Cox model was performed., Results: The mean Gleason score of the radical prostatectomy specimen was 6.9, and the mean tumour volume was 2.7 cm3. Forty eight (77.4%) specimens showed capsular effraction and 33 (53.2%) had positive surgical margins. The 5-year laboratory progression-free survival was 16%. A low preoperative PSA, a radical prostatectomy specimen Gleason score less than 7 and capsular effraction were factors of good prognosis on multivariate analysis., Conclusion: Prostatic tumours with seminal vesicle invasion have a high risk of progression after radical prostatectomy. A preoperative PSA level less than 10 ng/ml, a Gleason score of the operative specimen less than 7 and effraction of the prostatic capsule can be used to identify a subpopulation of patients with a better prognosis.

Objectives: We retrospectively evaluated the oncological outcome of radical prostatectomy performed by the retropubic, perineal and laparoscopic approaches., Methods: From 1988 to 2000, 401 patients underwent radical prostatectomy for localized prostate cancer by the retropubic, perineal or laparoscopic approach. Age, clinical stage, preoperative PSA and Gleason score of positive biopsies were noted. Operating time, complication rate, transfusion rate, length of hospital stay, catheterization time and pathological results were reviewed. Kaplan-Meier analysis was used to evaluate the likelihood of biochemical recurrence (PSA > or =0.2 ng/ml)., Results: There were no significant differences between the three groups regarding preoperative characteristics, except for PSA (21.4 ng/ml, 13.2 ng/ml, and 11.6 ng/ml for the retropubic, perineal, and laparoscopic approach, p<0.05) and the frequency of stage T1c tumors (31.7%, 47.1% and 63.5%, respectively, p<0.05). The operating time was significantly longer in the laparoscopic approach (285 min) compared to the retropubic and perineal techniques (197 min and 178 min, respectively). The retropubic approach was associated with a higher transfusion rate (26.2% versus 15.9% and 2.9% with the perineal and laparoscopic approaches), longer bladder catheterization time (15.9 days versus 11.7 days and 6.8 days, respectively), and longer hospital stay (15.2 days versus 8.5 days and 7.4 days, respectively) (p<0.05 for each). With the retropubic, perineal and laparoscopic approaches, medical complication rates were 8.3%, 4.2% and 5.1%, and surgical complication rates were 16.5%, 12.7% and 13.1%, respectively. The rates of pathological stage pT2 tumors were 62.1%, 72.2% and 75.9%, in the retropubic, perineal and laparoscopic groups, respectively. Positive surgical margins in pT2 tumors were noted in 19%, 14% and 22%, respectively. The actuarial 3-year recurrence-free survival rates were not significantly different between the three techniques (75%, 85.2% and 84.1%, respectively; 91.7%, 95.8% and 90.4% among patients with organ-confined tumors)., Conclusion: Despite changes in patient selection criteria over time, and the relatively short follow-up, this study showed no significant difference in oncologic outcome between the retropubic, perineal and laparoscopic approaches to radical prostatectomy.

Laparoscopy has become an integral part of urologic surgery. Its indications have been progressively extended to the most advanced oncologic and reconstructive procedures. Within this frame, radical prostatectomy is of major interest, especially considering the incidence and clinical significance of prostate cancer. The procedure comprises several steps of challenging dissection in which the preservation of delicate nerve and muscular structures should be conciliated with safe tumor excision. The intervention ends with vesicourethral anastomosis, which is considered the most difficult reconstructive procedure in urologic laparoscopy. Laparoscopic radical prostatectomy has gradually become a wholly standardized procedure, and it is now routinely performed in several centers throughout the world.

Next to the retropubic and perineal approaches, laparoscopic radical prostatectomy has become the third most common technique in the surgical treatment of localized prostate cancer. Although long-term oncologic data are still lacking, based on several contemporary series, it seems likely that oncologic results will fulfill expectations. Over the past decade, quality-of-life issues have come into the spotlight in oncologic surgery in particular. In this regard, the aim of the laparoscopic technique is to become the best in terms of operative stress, postoperative morbidity, catheterization time, and return to normal activities. The unique intraoperative visibility and magnification of the operative field allow ultraprecise dissection and suturing of vital neural and sphincteric structures. Will the use of this new kind of surgery translate into better functional results? The goal of this review is to analyze the published results of laparoscopic radical prostatectomy in the context of its rapidly evolving open surgical counterpart.