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Background Continence after laparoscopic radical prostatectomy is critical to patients and to surgeons. In this setting, the management of deep venous complex (DVC) without involvement of the sphincter fibres could be an important step of the procedure. Objective To evaluate the effects of a personal selective suture of the plexus (selective ligature of the deep venous complex [SLDVC]) on continence, blood loss, and surgical margin status during laparoscopic radical prostatectomy (LRP). Design, setting, and participants We planned a prospective randomised study. Sixty consecutive patients with clinically localised prostate cancer were involved in the study and were divided into two groups: group A (30 patients) underwent LRP with extraperitoneoscopic approach with standard management of DVC; group B (30 patients) underwent LRP with SLDVC. Intervention In group A, a standard ligature of DVC was performed (ligature and subsequent section); in group B, a selective ligature of DVC after its section was performed. Measurements Continence was evaluated during follow-up visits at catheter removal, and after 1, 3, 6, and 12 mo, perioperative variables and pathologic features of specimens were recorded. Results and limitations The two groups were comparable in terms of age, body mass index (BMI), prostate-specific antigen (PSA) values, and Gleason score at biopsy. No differences were found between the two groups in terms of operative times, blood loss, catheterisation time, and postoperative stay or histologic status. As far as continence rate is concerned, a significant difference was recorded between the groups (53% in group A vs 80% in group B) after 3 mo. Conclusions This selective ligature of the DVC after its section can contribute to early recovery of continence. Our data suggest that SLDVC compromises neither the safety of the procedure nor its oncologic effectiveness.

Background Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages. Objective To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis. Design, setting, and participants From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]). Intervention All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed. Measurements Patients' mean age plus or minus standard deviation (± SD) was 53.1 yr±14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size±SD was 23.8mm±7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral. Results and limitations Mean operative time±SD was 70min±28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean±SD: 5.1 d±2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems. Conclusions ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.

Objectives To analyze, in a consecutive study, the perioperative, postoperative, and functional results of the transperitoneal and extraperitoneal approaches for laparoscopic radical prostatectomy. Methods A total of 160 patients underwent radical prostatectomy and were subdivided into two groups. Group 1 underwent the transperitoneal approach and group 2, the extraperitoneal approach. The preoperative parameters, age, prostate-specific antigen level, biopsy Gleason score, American Society of Anesthesiologists class, body mass index, and clinical stage, were considered. The perioperative parameters evaluated were the operative time, blood loss, blood transfusion, hospital stay, catheterization time, complications, histopathologic findings, TNM stage, Gleason score, prostate and tumor volumes, and functional results. Results The patients in both groups had comparable preoperative data. No differences were observed between the two groups in the intraoperative data, except for the mean operative time (179 ± 54.6 for group 1 versus 133.7 ± 27 minutes for group 2). Also, no differences were observed between the two groups in terms of the postoperative data. The proportion of complications was 21.25% in group 1 and 22.5% in group 2. We recorded symptomatic lymphocele requiring treatment with a drain or reoperation in 8 patients (10%) in group 2 and 0% in group 1 (P

Objective To demonstrate the safety of the Millin extraperitoneal laparoscopic adenomectomy by comparing the laparoscopic and open approaches. Methods From January 2003 to April 2005, patients, with indication of prostatic adenomectomy, were offered the chance to choose between 2 types of procedure: Millin adenomectomy with open or extraperitoneal laparoscopic approach. Forty patients were included in this prospective non-randomised study. The patients were divided into 2 Groups. Group A (20 patients) underwent extraperitoneal laparoscopic adenomectomy, while Group B (20 patients) was treated by open surgery. Pre-operative, peri-operative and post-operative parameters were evaluated. Group A was subdivided in two sub-groups (first ten and last ten) and peri-operative parameters were considered in order to determine the learning curve. Results In terms of pre-operative parameters considered, the 2 study groups are comparable ( p >0.3). As far as peri and post-operative parameters are concerned: mean blood loss for Group A was 411.6±419ml, for Group B 687.5±298.6ml ( p =0.004). For all the other parameters no significant statistical differences were recorded ( p >0.4). Mean operative time was 107.2±34.9min in Group A, and 95.5±22.5min in Group B. Mean adenoma weight in Group A was: 69,5±21.5g, in Group B: 88.1±43.8g. Mean haemoglobin levels in Group A was: 11.2±1.8g/dl, Group B: 11.6±1.2 (10–13.4) g/dl. Mean Analgesic consuming (Tramadol) during the post-operative stay was 385±36mg in Group A, versus 430±108mg in Group B. Mean catheterization time was 6.3±3.7 days in Group A, 5.6±1.1 days in Group B. The mean hospital stay was 7.8±4.1 days in Group A, and 7±1.6 days in Group B. One patient (5%) from Group A was re-operated for bleeding and clot retention, whilst in Group B patients did not present complications which required any further intervention. As far as peri-operative and post-operative parameters of the two sub-Groups A (first ten patients and last ten patients) are concerned, the statistical evaluation shows a significant difference only on operative time ( p =0.01). The p-value for the other parameters was not significant ( p >0.1). Conclusions The extraperitoneal laparoscopic adenomectomy is a safe technique presenting results comparable to open surgery with the advantage of significantly lower peri-operative blood loss.

We describe our technique of laparoscopic diverticulectomy under ultrasound (US) guidance after a transurethral resection of prostate (TURP) in the treatment of patients with benign prostatic hyperplasia and bladder diverticulum. A standard TURP is performed with an Iglesias resectoscope. A 12-Fr Foley catheter is positioned in the diverticulum and the catheter balloon is then inflated with 30 mL of water; then a Tiemann catheter is placed through the urethra into the bladder. A US probe is inserted through the 12 mm port placed in the right side by the surgeon, then laparoscopic transperitoneal bladder diverticulectomy is performed under US guidance. In our experience, the use of endolaparoscopic US makes identification and dissection of the diverticulum easy, safe and effective, even when the procedure has to be performed in disadvantageous anatomic conditions such as lateral-posterior diverticulum or post-TURP imbibition of pelvic tissue.

INTRODUCTION AND OBJECTIVES: In case of low risk prostate cancer (PCa), the question arises whether to treat or follow a program of active surveillance (AS). These programs can sometimes mistakenly select patients. Multiparametric MRI (mp-MRI) has shown promise in localizing and characterize PCa. Aim of this study was to evaluate the role of mp-MRI in improving the selection of patients eligible for AS programs. METHODS: We reviewed our prospectively maintained PCa database and extracted the data about consecutive patients treated with radical prostatectomy (RP) previously undergone mp-MRI. We compared data of patients who fulfilled the AS criteria with data of mp-MRI and the pathological analysis. Clinical AS criteria were those of PRIAS (Prostate Cancer Research International: Active Surveillance) protocol: PSA 10 ng/ml and density 0.2 ng/ml; 2 positive cores at prostate biopsy and GS 6; clinical stage T1c-T2. Radiological criteria of inclusion of AS on mp-MRI were major tumor diameter 10 mm, organ-confined PCa, ADC 0.8/1. Pathological criteria using Epstein definition of insignificant disease were: organ-confined PCa, non-evidence of Gleason 4 or 5; tumor volume 0.5 cc. The same surgeon, the same uro-pathologist and the same uro-radiologist performed all the procedures. Sensitivity, specificity, positive and negative predictive value (PPV and NPV) of PRIAS criteria, mp-MRI and PRIAS mp-MRI were calculated based on 2x2 tables, using pathological results as gold standard. RESULTS: On pathological examination, 19/180 (10.6%) patients would have been properly selected for AS. Results are summarized in Table 1. Using PRIAS criteria to select patients for AS, sensitivity, specificity, PPV and NPV were 15.8%, 75.8%, 7.1% and 88.4%, respectively. Using mp-MRI criteria only to select patients for AS, sensitivity, specificity, PPV and NPV were 100%, 87.9%, 50% and 100%, respectively. Using PRIAS mp-MRI criteria, sensitivity, specificity, PPV and NPV were 15.8%, 98.8%, 60% and 90.9%, respectively. Only 2 patients selected for AS with PRIAS and MRI criteria had a non-low risk PCa (GS 7). CONCLUSIONS: Our results suggested that actual inclusion criteria are inadequate to candidate patients with PCa for AS. In our cohort, mp-MRI seems to improve selection of patients for AS when used in combination with clinical criteria.

Background The advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials. Objective To compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery. Design, setting, and participants From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group. Intervention All RARP and LRP interventions were performed with the same technique by the same single surgeon. Outcome measurements and statistical analysis The demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ 2 test, Pearson χ 2 test, and multiple regression analysis were used for statistics. Results and limitations The two groups (RARP: n =60; LRP: n =60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group ( p =0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively ( p =0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively ( p =0.020). The limitations included the small number of patients. Conclusions RARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.

To analyse the surgical margins status of prostatic glands, resected by laparoscopic radical prostatectomy (LRP) for prostate cancer, and to correlate it with biochemical free survival rate (BFSR).Data were collected prospectively from 405 patients undergoing LRP from 2000 to 2009 at a single institution. Patients undergoing neoadjuvant and/or adjuvant therapy were excluded from the study. Three hundred patients matched all the criteria: 232 of these had negative surgical margins (NSM) and 68 positive surgical margins (PSM). The median follow-up was 62 months. PSM were classified based on the following: (a) the number of margins, monofocal and multifocal, (b) the location, apical or non-apical and (c) the extension, ≤2.8 mm or2.8 mm. These data were then entered into a multivariate analysis.Overall BFSR rate was 67.6% in PSM group and 88.8% in NSM group (P0.001). We registered a HR of 3.78 in multivariate analysis (P0.001). In terms of the extension, BFSR in univariate survival analysis was 77.8% in ≤2.8 mm PSM and 38.9% in2.8 mm PSM (P = 0.003), with a HR of 5.68 (P = 0.011) in multivariate analysis. BFSR was 59% for apical margins and 77% for non-apical margins (P = 0.038). In monofocal margins, BFSR was 73%, while 53% in multifocal (P = 0.014).We recommend careful evaluation of patients with PSM following LRP, especially if they are more than 2.8 mm, and in these cases, adjuvant therapy should be considered after radical surgery.

We present our results in terms of feasibility, safety and efficacy of flexible pneumocystoscopy during double J stenting in patients undergoing laparoscopic pyeloplasty (LP). The patient is placed on the flank at a 45 degrees angle. Laparoscopic pyeloplasty according to the Anderson-Hynes technique is carried out by transperitoneal access. After completing the running suture of the posterior wall of the uretero-pyelic anastomosis, the double J stent is placed in a retrograde manner with a pneumocystoscopy using flexible cystoscope. Thirty-six patients were prospectively evaluated; 28 of these were treated with standard LP and 8 with robot-assisted LP. Mean operative time was 124 min, whereas double J stenting time was 4.2 min (2-6). We observed one case of cranial migration of the stent, forcing us to repeat the procedure, which was completed without complications. No ancillary procedures or X-ray control were necessary. Retrograde double J stenting using flexible pneumocystoscopy during laparoscopic and robot assisted pyeloplasty is feasible, easy, safe and effective. The procedure can be completed without changing the patient's position and without the use of X-ray.

OBJECTIVES: To present a pilot study of laparoscopic unilateral sural nerve grafting during radical prostatectomy, with the aim of preserving sexual potency. PATIENTS AND METHODS: Because they had localized prostate cancer, 29 men had a laparoscopic radical prostatectomy with deliberate wide unilateral neurovascular bundle resection and preservation of the contralateral bundle. Fifteen men (group A) had an interposition sural nerve graft on the sectioned bundle, and 14 (group B) had laparoscopic radical prostatectomy with preservation of the unilateral bundle only. The men were also involved in a rehabilitation programme, and erectile function was evaluated after surgery, and at 3, 8, 12 and 18 months, using the five-item version of the International Index of Erectile Function (IIEF-5) questionnaire. RESULTS: The two groups had similar clinical characteristics (age, prostate-specific antigen level, body mass index, prostate volume, clinical stage, Gleason score before and after surgery, postoperative stage). The follow-up was complete for 12 men in group A and 10 in group B. Group A had significantly higher erectile function scores on the IIEF-5 at 12 and 18 months than immediately after surgery (P < 0.01), whereas in group B the improvement was not statistically significant. Overall, by 18 months after surgery five of 12 men in group A had achieved spontaneous unassisted erection or erection assisted with sildenafil, while three of 10 in group B achieved an erection assisted with sildenafil (not significant). CONCLUSIONS: These data suggests that laparoscopic sural nerve grafting during radical prostatectomy is feasible and safe; nevertheless we cannot conclude that sural nerve grafting is more effective than preserving the neurovascular bundle alone in retaining sexual potency. More research is required to validate the effectiveness of this technique.

We compared two techniques of early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy: a standard technique and a direct approach to the artery.Of 100 patients undergoing transperitoneal laparoscopic radical nephrectomy at our institution, in the last 70, we used early renal-artery ligature. Of these, the standard technique after exposure of the vascular pedicle was used in 45 patients (group A), and ligature with a direct access to the renal artery was attempted in 25 patients (group B).No statistical differences were noted between the two groups in terms of age, lesion size, operative time, estimated blood loss, or intraoperative and postoperative complications. There were no recurrences of disease by CT evaluation in either group during follow-up (range 1-46 months).Transperitoneal laparoscopic radical nephrectomy with direct access to renal artery for early ligature is technically difficult but feasible and safe.

Purpose: To describe and demonstrate the feasibility of early ligature of the renal artery using a direct access to the renal pedicle at the level of the Treitz ligament during left transperitoneal radical laparoscopic nephrectomy. Materials and methods: A total of 42 patient underwent left transperitoneal radical laparoscopic nephrectomies from February 2001 to July 2004. In the first consecutive 27 patients (Group A) we performed early ligature with the standard technique; in the last consecutive 15 patients (Group B) we attempted the early ligature with direct access to the renal artery at the level of the Treitz ligament. Comparative analysis was carried out between the two groups examining operative times, blood loss, intra and post operative complications, postoperative stay. Results: No difference was noted in gender, age and size of the lesions (6.2 versus 6.25cm respectively, p =0.9) in the two groups. In 12/15 (80%) of Group B cases we successfully identified and ligated the renal artery at the level of the Treitz ligament. In the other 3 cases (20%) we were constrained to revert to the more common laparoscopic approach. Mean Operative times were 131′ in group A versus 137′ in group B ( p =0.15). The time required to find the renal artery at the level of Treitz ligament in group B was 16′ (15′–30′). No differences were noted between the two groups in terms of blood loss (222cc versus 268ml, p =0.4), intraoperative and postoperative complications ( p =0.6), postoperative stay (5 days in the two groups, p =0.9). Mean follow-up was average 24 months (15–48) in Group A and average 7 months (3–12) in Group B. No complications and no recurrence of disease at CT evaluation were recorded neither in Group A nor in Group B. Conclusions: Radical laparoscopic left side nephrectomy with direct access to the renal artery at the level the Treitz ligament is technically feasible and safe and reproduces the classic principles of radical nephrectomy allowing to perform the procedure without any manipulation of the tumor.

Androgen deprivation therapy (ADT) is administered in patients with locally advanced metastatic disease, those with high-risk localized disease, and those with biochemical failure. The goal is to induce a profound drop in plasma testosterone levels. This study confirms that serum testosterone levels have a prognostic role in patients with prostate cancer receiving ADT. Serum testosterone levels lower than the currently adopted cutoff seem to be associated with prognosis. Background: Controversy exists about whether testosterone serum levels at a cutoff point of 50 ng/dL during luteinizing hormone–releasing hormone analogue (LHRHA) treatment are related to the outcome of patients with prostate cancer. We assessed the relationship between serum testosterone levels after 6 months of LHRHA therapy and disease outcome in a consecutive series of patients with prostate cancer. Patients and Methods: Serum testosterone levels were measured prospectively in a cohort of patients given LHRHA for 6 months. End points were time to progression (TTP) and overall survival (OS). Results: The study population was 153 patients: 54 with metastatic disease and 99 with biochemical failure. In multivariate analysis, adjustment for age, baseline serum prostatic specific antigen (PSA) levels, Gleason score, and disease stage, testosterone levels 50 ng/dL failed to be associated with TTP and OS. A cutoff of 20 ng/dL was associated with a nonsignificant lower risk of progression (adjusted hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.30-1.15; P .12) and a significant lower risk of death (adjusted HR, 0.19; 95% CI, 0.04-0.76; P .02). Only 25 patients attained serum testosterone levels 20 ng/dL. Using a receiver operating characteristic curve (ROC), we found that a testosterone value of 30 ng/dL offered the best overall sensitivity and specificity for prediction of death. Serum testosterone levels 30 ng/mL were associated with a significantly lower risk of death (adjusted HR, 0.45; 95% CI, 0.22-0.94; P .034. Conclusions: Serum testosterone levels lower than the currently adopted cutoff of 50 ng/dL have a prognostic role in patients with prostate cancer receiving LHRHA and are a promising surrogate parameter of LHRHA efficacy.