Biomedical subjects

Robert Rabenalt

Publications and source records attributed to Robert Rabenalt.

15 recordsLinked to original sources

PubMed2006

Complications of endoscopic extraperitoneal radical prostatectomy (EERPE): prevention and management.

Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of laparoscopic (transperitoneal) RPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. Endoscopic extraperitoneal radical prostatectomy has many advantages but is not without complications. The aim of this review article is to describe the most common complications of this procedure. Complications associated with endoscopic extraperitoneal radical prostatectomy are: vascular injury--bleeding--haematoma, bowel injury, lymphocele, injury to the bladder--ureter, port site hernia, anastomotic leakage--stricture, obturator nerve injury--paralysis, gas embolism, catheter blockage, and miscellaneous like perineal pain, pubic osteitis, infection- urosepsis. The present review paper focuses on the identification and management of these complications The incidence of most complications directly correlates with the surgeons' experience, and the various complications are related to technical errors rather than to the technique itself. The laparoscopist performing endoscopic/ laparoscopic radical prostatectomy should be aware of all these complications. He should be able to recognise promptly, treat efficiently, and ideally prevent these complications.

Endoscopy↗

PubMed2006

Categorisation of complications of endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy.

The aim of the present review is to focus on the various attempts of categorisation of complications after endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy. Several classifications of complications and adverse events have been proposed in the literature but none is widely accepted or applied so far. We thus present a review of the existing literature and the complications of our series of 900 patients treated with endoscopic extraperitoneal radical prostatectomy (EERPE). We applied the recently revised Clavien classification system to grade EERPE complications.

Age Distribution↗

PubMed2006

Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy.

OBJECTIVES: To present a modification of our previously published technique of nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE). METHODS: The technique enables puboprostatic ligament preservation, leaving intact the puboprostatic ligaments, endopelvic fascia, periprostatic fascia, and neurovascular bundles (intrafascial dissection). The modification of nsEERPE was performed in 50 consecutive patients. RESULTS: The total operative time was 131 minutes (range 75 to 165). The mean catheterization time was 5.4 days (range 5 to 14). CONCLUSIONS: The intrafascial nsEERPE is a modification of our previously published standard nsEERPE. The anterior approach to the periprostatic fascia enables less traumatic dissection from the prostate and thus, theoretically, a more viable neurovascular bundle.

Aged↗

PubMed2006

Nerve-sparing endoscopic extraperitoneal radical prostatectomy: University of Leipzig technique.

PURPOSE: To describe the various operative steps as well as the functional and oncologic results of nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERP). PATIENTS AND METHODS: One hundred twenty preoperatively potent patients have been treated with bilateral nsEERPE in our department. The average age of the patients was 60.3 years (range 41-74 years), and the mean prostate weight was 48.6 g (range 24-117 g). RESULTS: The mean operative time was 136 minutes (range 75-210 minutes). No conversions to open surgery were necessary. The mean catheterization time was 5.7 days (range 4-20 days). Lymphadenectomy was performed in 26 patients. The pathologic stages were pT2 in 78 and pT3 in 42 patients. Positive margins were detected in 7.7% (N = 6) and 19% (N = 8) of the patients with pT2 and pT3 disease, respectively. Erections sufficient for intercourse were reported in interviews with 58 patients (48.3%) during the 6-month follow-up period. Follow-up of at least 1 year is deemed necessary to draw more definite conclusions about erectile function. One week postoperatively, 32 patients (26.7%) required a maximum of 1 pad, 59 patients (49.2%) 2 or 3 pads, and 29 patients (24.2%) more than 3 pads per day because of incontinence, whereas 3 and 6 months after the procedure, 98 (82%) and 106 (88%) of the patients required a maximum of 1 pad, respectively. CONCLUSION: Our results demonstrate that nsEERPE can be performed with equal efficacy and preliminary results similar to those of standard open radical prostatectomy as well as transperitoneal laparoscopic prostatectomy while completely avoiding intraperitoneal complications.

Adult↗

PubMed2006

Anaesthetic considerations for endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy.

We focus on the anaesthesiology and requirements for minimally invasive procedures for treating localized prostate cancer. The management of anaesthesia for laparoscopic and endoscopic radical prostatectomy (RP) can be more complex than expected. Numerous groups, especially early in their experience, have had problems (e.g. hypercarbia) with the anaesthesiology of the procedure. Co-operation between the surgeon and the anaesthesiologist is of paramount importance for a safe and effective laparoscopic or endoscopic RP. Nevertheless, the relative anaesthetic equipment and trained personnel should be available before embarking on such technically proficient procedures.

Anesthesia↗

PubMed2005

Modular training for residents with no prior experience with open pelvic surgery in endoscopic extraperitoneal radical prostatectomy.

PURPOSE: To establish a teaching program for the performance of endoscopic extraperitoneal radical prostatectomy (EERPE) that would ascertain the safe and efficacious training of residents with no previous experience with open pelvic surgery. MATERIALS AND METHODS: The technique of EERPE was divided in 12 segments with 5 levels of difficulty. We thus designed a training program, where the resident learned the procedure in a mentor-defined schedule. During each educational EERPE, the trainee only performed the operative steps corresponding to his acquired skill level. The mentor performed the remaining parts of the EERPE, with the trainee assisting. The first 50 and consequent 100 cases performed by the residents were compared to the first 50 and last 100 cases (cases 521-621) performed by the mentor. RESULTS: Two residents with no prior experience with open pelvic surgery participated in the study, and required 43 and 38 procedures respectively, until they were considered to be competent. The initial 50 procedures performed completely independently by the residents had mean operative times of 176 and 173 minutes. There were 2 intraoperative rectal injuries (one patient developed recto-urethral fistula), and 1 hemorrhage, and 1 lymphocele, postoperatively. The positive margin rate for pT2 disease was 14.3 and 11.5%, and for pT3 tumors 38.8 and 29.1%, respectively. After an additional 100 procedures operated by the same residents, mean operative times were 142 and 146 minutes. There was one patient who needed a transfusion. Postoperative complications requiring re-intervention were 1 hemorrhage, 2 anastomotic leakages and 4 symptomatic lymphoceles. The positive margin rate for pT2 disease was 12.8% and 6.5%, and for pT3 tumors 33.3% and 26.3% respectively. No statistical significant differences were observed when comparing with the mentors cases. CONCLUSION: We have showed that residents with no prior experience in open surgery of the pelvis can adhere to the modular training scheme and successfully perform the EERPE procedure with similar risk of complications compared to the tutor.

Clinical Competence↗

PubMed2005

Nerve sparing endoscopic extraperitoneal radical prostatectomy--effect of puboprostatic ligament preservation on early continence and positive margins.

INTRODUCTION: A technical modification of nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with preservation of the puboprostatic ligaments is presented and compared to a previous technique. MATERIALS AND METHODS: nsEERPE was performed in 100 men with clinically localized adenocarcinoma of the prostate from March 2004 through February 2005. Patients were divided into two groups: Group A included patients in whom a standard nsEERPE was performed (n=50), and group B included patients in whom a puboprostatic ligament sparing nsEERPE was performed (n=50). The postoperative follow-up was 2 weeks and 3 months evaluating preliminary effects on early continence and positive margins. RESULTS: The early return to continence at 2 weeks postoperatively was achieved by 6 patients (12%) in group A, and 12 patients (24%) in group B. Three months after the procedure 24 (48%) and 38 (76%) patients were continent, in groups A and B respectively. Clinical outcome (early continence) was significantly better for Group B patients, at 2 weeks (chi-square test, p=0.0019) and at 3 months (chi-square test, p=0.0347) following surgery. No cases of complete or severe incontinence (more than 5 pads/day) were observed at 3 months after surgery, in either groups. Groups A and B did not exhibit significant differences regarding their histological status. In group A, positive margins were detected in 6.5% and 26.3% of patients with pT2 and pT3, respectively. In group B, positive margins were found in 3.2% and 15.8% of patients with pT2 and pT3, respectively CONCLUSION: We propose the use of puboprostatic ligament-sparing nsEERPE as an intriguing method to ascertain recuperation of early continence after nerve sparing procedures, without hindering the final oncological outcome.

Adenocarcinoma↗

PubMed2005

Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair.

INTRODUCTION: Since laparoscopic inguinal hernia repair has become a frequently performed surgical procedure, it is inevitable that patients who have been candidates for laparoscopic radical prostatectomy (LRP) may have had such prior intervention. The inguinal hernia repair might take the form of either total extraperitoneal hernioplasty (TEP) or transabdominal extraperitoneal hernioplasty (TAPP), with mesh placement. The objective was to show that performing endoscopic extraperitoneal radical prostatectomy (EERPE) in such patients was safe and feasible, and also to suggest modifications of the technique to facilitate the surgery. PATIENTS AND METHODS: There were no specific selection criteria and patients with prior mesh placements were encountered during the management of all consecutive patients undergoing EERPE. Modifications in the port placements were made to accommodate for previous mesh placements on the right and left side. The area of prior mesh placement was excluded from the dissection when creating the extraperitoneal space. The operation was performed, thereafter, using the standard EERPE method. RESULTS: Out of a total of 750 patients operated on with EERPE, 14 had prior TEP or TAPP with mesh placement. In both groups there were no differences found in the mean operative time. There were no major complications or reinterventions in patients with prior mesh placement. In each group (i.e. TEP and TAPP), a small bladder injury was diagnosed and managed intraoperatively with no further complication. One vascular injury to the inferior epigastric vessels was managed intraoperatively without significant blood loss. None of the 14 patients required blood transfusion. The mean catheterization time was 6.9 days. CONCLUSION: Although certain problems were presented by previous TEP/TAPP, it is nevertheless feasible to perform EERPE. By adapting port placements and surgical techniques the operation can be performed safely and with a good operative outcome.

Aged↗

PubMed2005

Impact of previous surgery on endoscopic extraperitoneal radical prostatectomy.

OBJECTIVES: To assess the impact of previous surgery on endoscopic extraperitoneal radical prostatectomy (EERPE). METHODS: A total of 500 patients who underwent EERPE for clinically localized prostate cancer between December 2001 and April 2004 were stratified into five groups: group 1, no previous abdominal, inguinal, or prostate surgery; group 2, previous upper abdominal surgery; group 3a, previous lower abdominal or pelvic surgery or open inguinal hernioplasty; group 3b, laparoscopic or endoscopic inguinal hernioplasty; group 4, previous prostate surgery; and group 5, a combination of groups 2, 3, and/or 4. Groups 1 and 2 were analyzed together, because the previous operative fields in group 2 were distant from the space of Retzius. The operative times, complications, and reinterventions were analyzed with the Mann-Whitney U test, chi-square test, and Fisher exact test. RESULTS: Of the 500 patients, 335 (67%) and 165 (33%) were in groups 1 and 2 and groups 3 to 5, respectively. The mean overall operative time was 149 +/- 30 minutes. Four patients (0.8%) required transfusions, with no conversion to open surgery and no mortality. A total of 90 complications (18%) and nine reinterventions (1.8%) occurred. EERPE was subjectively more demanding and challenging in patients with previous minimally invasive hernioplasty with mesh placement. No statistical significance was detected between the no=surgery (groups 1 and 2) and previous surgery (groups 3 to 5) patients in terms of overall operative time, positive surgical margin status, complications, or reinterventions. CONCLUSIONS: Endoscopic extraperitoneal radical prostatectomy is feasible in patients with various previous abdominal surgical procedures. Previous surgery did not seem to affect the overall operative time or complication or reintervention rate. Previous minimally invasive hernia repair with mesh placement made EERPE more demanding but was not a contraindication.

Abdomen↗

PubMed2005

Endoscopic extraperitoneal radical prostatectomy: oncological and functional results after 700 procedures.

PURPOSE: We review our experience with endoscopic (totally) extraperitoneal radical prostatectomy (EERPE) as first line therapy for localized prostate cancer. MATERIALS AND METHODS: A total of 700 consecutive patients underwent EERPE. Mean patient age was 63.4 years (range 42 to 77). Mean preoperative prostate specific antigen was 10.7 ng/ml (range 1.4 to 82). A total of 206 patients (29.4%) had a history of previous lower abdominal or pelvic surgery including inguinal hernioplasty with mesh placement and 43 patients (6.1%) had a history of prostatic intervention (transurethral resection of the prostate, high intensity focused ultrasound, Millin prostatectomy, radiotherapy). After preparation of the preperitoneal space the technique of EERPE duplicates the steps of classic open descending retropubic radical prostatectomy including a nerve sparing EERPE when indicated. RESULTS: Mean operative time was 151 minutes (range 50 to 320). There was no conversion and the transfusion rate was 0.9% in 6. Four patients (0.6%) had intraoperative rectal injuries which were treated endoscopically with a 2-layer suture. A total of 14 patients (2%) required early and 3 patients (0.4%) required late postoperative reintervention. Pathological stage was pT2a in 89 patients (12.7%), pT2b in 54 (7.7%), pT2c in 245 (35%), pT3a in 229 (32.7%), pT3b in 79 (11.2%) and pT4 in 4 patients (0.6%). Positive surgical margins were found in 10.8% (42 of 388) of patients with a pT2 tumor and in 31.2% (96 of 308) of patients with a pT3 tumor. Pelvic lymph node dissection was performed in 266 patients (38%), of whom 14 (5.3%) were found to have lymph node involvement. Mean catheterization time was 6.2 days. Six months after surgery 83.8% of the patients were completely continent, 10.4% needed 1 to 2 pads daily and 5.8% of patients needed more than 2 pads daily. Of all patients who underwent nerve sparing procedures, 100 patients had a postoperative followup of 6 months. Of the 66 patients with the unilateral nerve sparing approach 8 (12.1%) had erections sufficient for intercourse and 16 of 34 patients (47.1%) with the bilateral nerve sparing procedure had erections sufficient for intercourse with or without the help of phosphodiesterase type 5 inhibitors. CONCLUSIONS: The results of this series are promising. Perioperative morbidity is low, and short-term oncological and functional results are favorable. Although the followup is too short to draw definite conclusions, it is obvious that a nerve sparing approach in EERPE is feasible and reproducible. Our data demonstrate that EERPE can be performed with equal efficacy and results compared with laparoscopic transperitoneal radical prostatectomy, while providing the ease and safety of a totally extraperitoneal approach, completely avoiding intraperitoneal complications.

Adult↗

PubMed2005

Modular surgical training for endoscopic extraperitoneal radical prostatectomy.

OBJECTIVE: To develop a modular training scheme which enabled the use of individual steps of laparoscopic radical prostatectomy (RP) for teaching and training surgeons with varied experience, including residents with no experience in open RP, as in extending laparoscopic surgery to more complex operations like RP, the proper training of urologists is crucial. SUBJECTS AND METHODS: The technique of endoscopic extraperitoneal RP (EERP) was divided into 12 individual steps of differing complexity. The levels of difficulty were called "modules" and graded according to their requisite skills from module 1 (lowest level of difficulty) to module 5 (highest level). Based on this modular system we established a training programme whereby the trainee learns the procedure in a mentor-initiated schedule. During each training operation the trainee only performs the modules (steps) of the operation, which correspond with his or her actual skill level. The mentor performs all the other steps, with the trainee assisting. Four trainees with different surgical experience participated in the study. RESULTS: After a phase of assisting and camera holding during EERP, the trainees entered the modular training programme and required 32-43 procedures until they were considered to be competent. An analysis of the first 25-50 procedures done independently by the trainee showed mean operative times of 176-193 min and a transfusion rate of 1.3%. Complications during and after EERP requiring re-intervention were one each of recto-urethral fistula, haemorrhage, symptomatic lymphocele and anastomotic leak. The positive margin rate for pT2 disease was 12.2% and for pT3 tumours 37%. CONCLUSION: The modular concept for teaching EERP is an attractive concept, which overcomes many of the problems involved in complex laparoscopic procedures. Based on a highly standardized technique, this concept offers a short learning curve; it enables training on different sites in cooperation with a high-volume centre, and it makes it possible to start with this complex procedure as a beginner or with no experience in open RP.

Aged↗

PubMed2004

Does the extraperitoneal laparoscopic approach improve the outcome of radical prostatectomy?

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.

Humans↗

PubMed2003

Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE)--technical improvements and development of a nerve-sparing, potency-preserving approach.

During the last decade, laparoscopy has become a standard technique in the armoury of the urologist due to constant technological advances and refinements. Laparoscopic radical prostatectomy (LRPE), although technically demanding and associated with a considerable learning curve, has become the surgical procedure of choice in selected and specialized urological centers around the globe for patients with clinically localized prostate cancer. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal prostate. The principal disadvantages of LRPE are potential intraperitoneal complications, such as bowel injury, ileus, intraperitoneal bleeding, intraperitoneal urinary leakage, intraperitoneal adhesion formation and concomitant small bowel obstruction. Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of LRPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with those of an extraperitoneal procedure. Based on our growing experience with this procedure, we have introduced several technical modifications, improvements and refinements including a nerve-sparing, potency-preserving approach (nEERPE) in an effort to further improve this minimally invasive procedure.

Adult↗

PubMed2003

Hernia repair during endoscopic (laparoscopic) radical prostatectomy.

We retrospectively reviewed our experience in performing endoscopic extraperitoneal radical prostatectomy (EERPE) and totally extraperitoneal (TEP) hernia repair in one procedure to evaluate its feasibility and safety. Based on our experience of 70 laparoscopic radical prostatectomies, a total of 60 patients underwent EERPE. Eight of these had 10 hernias repaired with Prolene mesh. The median total operating time for EERPE was 165 minutes. Mesh placement required an additional 15 minutes for a unilateral hernia and 25 minutes for bilateral hernias. The conversion rate and the reoperation rate were 0%. The median duration of vesical catheterization was 8.3 days. One patient required a blood transfusion. The most common minor complications, occurring in eight patients, were edema and hematoma of the penis. No wound infection occurred. The only major complication was a deep venous thrombosis in one patient. No additional complications developed in the hernioplasty group. We conclude that the extraperitoneal approach for radical prostatectomy allows concomitant inguinal hernia repair with a low morbidity rate and within an acceptable operating time.

Aged↗

PubMed2003

Endoscopic extraperitoneal radical prostatectomy: initial experience after 70 procedures.

PURPOSE: After our initial experience with 70 transperitoneal laparoscopic radical prostatectomies we developed a totally extraperitoneal retropubic approach to radical prostatectomy using laparoscopic instruments. We report our initial experience with 70 endoscopic extraperitoneal radical prostatectomy procedures. MATERIALS AND METHODS: A total of 70 patients underwent endoscopic extraperitoneal radical prostatectomy. Mean patient age was 63.4 years (range 49 to 76). Mean preoperative prostate specific antigen was 12.48 ng./ml. (range 1.4 to 50.7). There were no specific selection criteria for the procedure. The steps of the procedure are preparation of the preperitoneal space with the help of a balloon trocar, trocar placement (a 3 x 5 and a 2 x 12 mm. port), pelvic lymph node dissection, exposure of the prostate and the bladder neck, incision of the endopelvic fascia, ligation of Santorini's plexus, bladder neck dissection, mobilization of the seminal vesicles, incision of Denonvilliers' fascia, sectioning of the prostatic pedicles with or without preservation of the neurovascular bundles, dissection of Santorini's plexus and apex, urethrovesical anastomosis with 7 to 9 interrupted sutures and removal of the specimen via an extraction bag. During the 70 endoscopic prostatectomies 11 hernia defects were treated in 9 patients concomitantly. RESULTS: There was no conversions and no re-interventions. Mean operative time was 155 minutes (range 90 to 260). One patient required transfusion with 2 units of blood cells. Pathological stage was pT2a in 19 patients, pT2b in 14, pT3a in 25, pT3b in 9 and pT4 in 3. Positive surgical margins were found in 2 of the 33 patients (6.1%) with pT2 tumors and in 13 of the 37 (35.1%) with pT3 and pT4 tumors. Postoperatively edema and hematoma of the penis in 10 cases was treated conservatively. Furthermore, 4 patients had asymptomatic lymphoceles, 1 required lymphocele drainage and 2 had partial obturator nerve paralysis, which resolved spontaneously. In 1 patient deep venous thrombosis developed. CONCLUSIONS: The preliminary results of this series are promising. Operative and perioperative morbidity was low. Functional results and oncological control were similar to the results of laparoscopic radical prostatectomy. The data demonstrate that endoscopic extraperitoneal radical prostatectomy can be performed with efficacy and results equal to those of laparoscopic radical prostatectomy, while providing the benefits of a totally extraperitoneal approach. Therefore, totally endoscopic extraperitoneal radical prostatectomy represents a technical improvement of laparoscopic technique because it completely obviates intra-abdominal complications and combines the advantages of minimally invasive laparoscopy and the retropubic open approach.

Aged↗