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Objectives: Identification of variables predicting positive surgical margins (PSMs) in patients undergoing laparoscopic radical prostatectomy (LRP) for clinically localized prostate cancer is lacking. Our objective was to determine preoperative risk factors and the association of ipsilateral degree of neurovascular bundle dissection (intraoperative factor) with side-specific PSMs in these patients., Material and Methods: Between October 2002 and April 2005, one surgeon performed LRP on 407 previously untreated patients. Of 814 evaluable prostate sides, 728 harboured prostate cancer in the specimen and composed the study population. For each prostate side, we obtained clinical stage, biopsy Gleason, maximum percentage of tumour in the biopsy, suspected extracapsular extension (ECE) on endorectal coil magnetic resonance imaging (MRI), degree of neurovascular bundle (NVB) dissection, and PSMs. PSM was defined as cancer cells at the inked margins. Logistic regression analyses with random effects were generated., Results: Of the 728 prostate sides with cancer, 51 (7%) had at least one PSM. In multivariable analysis, higher PSA (p=0.01), Gleason score of 7 compared with < or =6 in the biopsy (p=0.04), lower prostate volume on MRI (p=0.01), and interfascial NVB dissection compared with intrafascial dissection (p=0.01) were associated with an increased risk of side-specific PSMs. Suspected ECE on MRI (p=0.9) and clinical stage (p=0.3) were not significantly associated with side-specific PSMs. A subset analysis of 321 patients with bilateral tumours did not show statistically significant differences in PSMs according to tumour side (p=0.3)., Conclusions: High serum prostate-specific antigen, biopsy Gleason score of 7, low prostate volume, and interfascial NVB dissection were independently associated with side-specific PSMs after LRP, and should be considered during planning of the LRP surgical strategy.

Purpose: Incision of the anterior layer of Denonvilliers' fascia is commonly cited as a key step in successful dissection of the vasa deferentia and seminal vesicles from the posterior bladder neck during laparoscopic radical prostatectomy. However, anatomical descriptions do not support the presence of Denonvilliers' fascia anterior to the seminal vesicles. To address this inconsistency we performed a detailed anatomical study of tissue planes encountered during laparoscopic dissection of the posterior bladder neck., Materials and Methods: To grossly characterize the tissue planes encountered during laparoscopic posterior bladder neck dissection, ex vivo dissections were performed on 4 separate cystoprostatectomy specimens. Biopsies of the representative areas were obtained from 20 consecutive laparoscopic radical prostatectomy specimens by 2 dedicated uropathologists., Results: Following incision into the posterior bladder neck mucosa, longitudinally oriented fibers were readily visualized, extending from bladder neck to prostate base. Histologically this anatomical landmark represents the fusion of 2 separate tissue layers, that is an inner lamella composed of longitudinally disposed smooth muscle fibers in continuation with the longitudinal fascia of the bladder detrusor (medial fascicle of the detrusor running in between the ureters) and an outer lamella composed of fibroadipose tissue in continuation with the bladder adventitia., Conclusions: Our anatomical and histological analysis refutes the prevailing belief in the laparoscopic literature that the longitudinal muscle fibers identified during dissection of the posterior bladder neck represent the anterior layer of Denonvilliers' fascia. They correspond to the posterior longitudinal fascia of the detrusor muscle that is externally upholstered by the bladder adventitia.

Purpose: To determine whether preservation of accessory pudendal arteries (APAs) adversely influences the rate of positive surgical margins (PSMs) during laparoscopic radical prostatectomy (LRP)., Material and Methods: Between January 2003 and January 2005, 377 men with clinically localized prostate cancer underwent a LRP; 325 met inclusion criteria for this study. The variety (apical or lateral), laterality (left or right), size, and preservation status of all identified APAs were prospectively recorded. A genitourinary pathologist mapped the specimens and established tumor locations and PSM sites., Results: Ninety-six of 325 men (30%) were found to have 125 separate APAs. The apical variety predominated; 56% of APAs were apical and 44% were lateral. Successful preservation was possible for 104/125 (83%) individual arteries. The overall rate of PSM was 11.7%. The rates for those with and without identified APAs were 9% and 13%, respectively (p=0.4). The incidence of PSMs in the ipsilateral region of APA localization was not affected by preservation status; ipsilateral PSM rates were 3% and 6% for those preserved and not preserved, respectively (p=0.5)., Conclusions: Identification and preservation of APAs during laparoscopic radical prostatectomy did not adversely affect the rates of PSMs. APA preservation can be undertaken without compromise to the oncological integrity of the laparoscopic radical prostatectomy.

Purpose: The incidence of accessory pudendal arteries (APAs) varies from 4% to 70% depending on the means used to identify them. We provide a detailed laparoscopic anatomical description of their appearance, location and identification rate based on our series of radical prostatectomies., Materials and Methods: The distribution of APAs was prospectively recorded in 285 consecutive patients between October 2002 and November 2004. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum, other than cavernous arteries, corona mortis and satellite arteries to the superficial and deep vascular complex., Results: We identified 92 APAs in 72 of 285 patients (25%). Two distinct varieties of APAs were identified. In 10% of patients an APA coursed along the lateral aspect of the prostate, termed lateral APA, and in 13% an APA emerged through the levator ani fibers near the apical region of the prostate, termed apical APA. Five patients (1.7%) were found to have apical and lateral APAs., Conclusions: APAs are more frequent than previously reported in the surgical literature. To our knowledge apical APAs have never been reported previously. The visualization and accessibility advantages of laparoscopy may account for a higher intraoperative APA identification rate. Their roles in continence and potency remain to be determined.

Abstract: Objective: Describe the rationale for and surgical modifications to the original Montsouris technique for laparoscopic radical prostatectomy (LRP). Methods: This is a retrospective review of laparoscopic prostatectomy and experience involving 1071 cases performed between January 1998 and March 2006 at two centres: the Departments of Urology of the Institut Mutualiste Montsouris, Paris, France (first 502 cases) and Memorial Sloan-Kettering Cancer Center, New York, NY (next 569 cases). Results: Since the first systematic description of the LRP technique, several modifications have been implemented. Most of the modifications have not yet been subjected to rigorous prospective evaluation, but, in our experience, they reduce complications or shorten operative time, and presumably lead to better oncologic results with improved preservation of quality of life. We describe those modifications to the LRP technique 8 yr after the program started, including urachal-sparing transperitoneal approach, extended lymph node dissection, systematic identification of the posterior longitudinal fascia of the detrusor muscle during dissection of the posterior bladder neck, intra/inter/extrafascial dissection of the neurovascular bundles, anatomic dissection of the apex with ligature of the dorsal vascular complex after its sectioning, anchoring of the anterior urethrovesical anastomotic stitches to the endopelvic fascia and pubovesical ligaments, extraction and evaluation of the specimen before completing the anastomosis, and use of postoperative care pathways. Conclusions: LRP technique has been refined, which allowed us to decrease the positive surgical margins rate and improve functional outcomes. It is hoped younger laparoscopic surgeons can take advantage of our experience to build on their expertise. [Copyright &y& Elsevier]

Abstract: Objectives: A paucity of literature discusses biochemical recurrence (BCR) after laparoscopic radical prostatectomy (LRP). We report the intermediate-term cancer control and variables associated with BCR based on the 8-yr experience of a single surgeon. Methods: Between January 1998 and March 2006, one surgeon performed LRP on 1071 patients at two institutions. Excluded from analysis are 20 patients who received neoadjuvant therapy, 27 lost to follow-up, and 23 without prostate-specific antigen (PSA) controls due to recent date of surgery. Kaplan-Meier curves were generated to estimate time to BCR, defined as a PSA of 0.2ng/ml and rising or start of secondary therapy. The log-rank test was used to compare pathologic variables. Positive surgical margin (PSM) was defined as cancer cells at the inked margins. Cox regression analysis estimated variables associated with time to BCR. Results: Of the study population, 1%, 75%, 23%, and 1% had pT0, pT2, pT3, and pT4 disease, respectively; 41%, 1%, and 58% had no nodal involvement, lymph node metastases, and no lymph node dissection, respectively. The cumulative 5-yr BCR-free rate was 75% for the 1001 evaluable patients, with 95 patients fulfilling criteria for BCR. The mean follow-up was 22.3 mo (95%CI, 20,24.6). In multivariable Cox regression analysis, higher serum PSA (p <0.001), palpable nodule (p =0.009), presence of extracapsular extension (ECE; p =0.038), seminal vesicle invasion (SVI; p <0.001), pathologic Gleason 4+3 (p <0.001), and pathologic Gleason 8–10 (p <0.001) when compared to pathologic Gleason<6 were significantly associated with shorter time to BCR. The concordance index for the model was 0.86. The overall PSM rate was 13%, 9% for capsule-confined disease (pT2) and 24% for extracapsular extension (pT3). Conclusion: LRP seems to offer comparable oncologic outcomes to open surgery; however, more extended follow-up of patients is needed to better assess the oncologic safety of the LRP. [Copyright &y& Elsevier]