Biomedical subjects

Thomas Frede

Publications and source records attributed to Thomas Frede.

At least 19 recordsLinked to original sources

PubMed2006

The radius surgical system - a new device for complex minimally invasive procedures in urology?

OBJECTIVE: Complex laparoscopic procedures in urology are technically demanding with an extended learning curve. Robotic systems add significant cost to laparoscopic procedures. We therefore evaluated the use of the Radius Surgical System (RSS), a mechanical manipulator, for complex laparoscopic cases in urology. MATERIAL AND METHODS: The RSS (Tuebingen Scientific) consists of two hand-guided surgical manipulators and provides a deflectable and rotatable tip allowing six degrees of freedom. We evaluated the system by using a series of standardized models in the pelvitrainer. We analyzed the effectiveness of the system and the learning curve. We then evaluated the system in the clinical setting during laparoscopic radical prostatectomy. RESULTS: Surgeons with experience on the RSS were compared to surgeons without previous experience on the system. We identified a learning curve in those participants without experience on the system only when performing complete anastomoses in the pelvitrainer. However, this learning curve included less than 10 anastomoses. The first clinical experiences during laparoscopic extraperitoneal radical prostatectomy (n=10) are promising. All anastomoses were patent on routine (X-ray) examination 8 days after surgery. CONCLUSIONS: The RSS system is easy to use and we identified a very short learning curve. We now optimize the system for use in urology. This device may facilitate complex laparoscopic procedures without the use of costly robotic systems and should be further evaluated in the experimental and clinical setting.

Equipment Design↗

PubMed2006

Assessing the predictive validity and efficacy of a multimodal training programme for laparoscopic radical prostatectomy (LRP).

OBJECTIVES: To assess the predictive validity (ability to correlate to real-life environment) and efficacy of a training programme for laparoscopic radical prostatectomy (LRP), based on a structured and progressive pelvitrainer component with hands-on clinical training in the operating room (OR). METHODS: Prospective data on 500 LRP cases were analysed with 80 excluded due to incomplete records. The operation was divided into multiple steps. Times for these steps were compared among 11 surgeons with different laparoscopic expertise (first-, second-, and third-generation surgeons in order of decreasing experience) and correlated to times for specific exercises on the pelvitrainer that simulated particular steps. Perioperative parameters were also evaluated among the three groups. RESULTS: Pelvitrainer times achieved by trainees (third-generation surgeons) did not differ significantly with times for corresponding steps of LRP. There was also no significant difference for total OR time between the second- and third-generation surgeons (205 and 207 min, respectively; p>0.05) although the time for the first-generation surgeons was faster than both (176 min). Short-term quality indicators for first, second, and third generations included transfusion rates (2.3%, 2.4%, and 2.6%, respectively), positive margin rates (20.3%, 21.5%, and 23.0%) and complications, which did not differ significantly among the generations although the first-generation surgeons had the lowest rates. CONCLUSIONS: A carefully designed training programme that incorporates both pelvitrainer and mentor-based operative training is essential for the effective and safe transfer of skills and knowledge required to learn LRP.

Adult↗

PubMed2006

Multislice computed tomography for detection of patients with aortic valve stenosis and quantification of severity.

OBJECTIVES: The purpose of this study was to evaluate whether multislice computed tomography (MSCT) provides a reliable, noninvasive imaging modality for identification of patients with degenerative aortic valve stenosis (AS) by quantifying the aortic valve area (AVA) in comparison to the accepted diagnostic standard transthoracic echocardiography (TTE). BACKGROUND: Management of patients with degenerative AS is based on the severity of disease. The severity of AS in clinical practice is assessed by TTE and classified as mild, moderate, or severe according to the AVA. METHODS: Forty-six patients were examined with contrast-enhanced, electrocardiogram-gated, 16-row MSCT for the evaluation of the diagnostic accuracy. In 30 patients, quantification of the AVA with MSCT was compared to TTE using the continuity equation with Doppler velocity-time integral for calculation of the AVA. RESULTS: Sensitivity of MSCT for the identification of patients with degenerative AS was 100%, and the specificity was 93.7%. Thirty of 46 patients had AS determined by TTE. Quantification of AVA by MSCT (mean AVA = 0.94 cm2) in patients with AS showed a good correlation to TTE (r = 0.89; p < 0.001). Bland-Altman plot illustrated good intermodality agreement between the two methods (limits of agreement, 0.20; 0.29). CONCLUSIONS: Multislice computed tomography may provide an accurate, noninvasive imaging technique for detection of patients with AS and quantification of AVA.

Aged↗

PubMed2006

Anatomic nerve-sparing laparoscopic radical prostatectomy: comparison of retrograde and antegrade techniques.

OBJECTIVES: To compare the anatomic retrograde and antegrade preservation of the neurovascular bundle (NVB) during laparoscopic radical prostatectomy. METHODS: Anatomic studies were reviewed, focusing on the fascial layers surrounding the prostate and NVB and the terminology used as described by Walsh and colleagues. Important operative steps have been illustrated using video clips. For the retrograde technique, after incision of levator fascia, the NVBs were released from the apex before division of the urethra. Along the plane between the laterally incised Denonvilliers and perirectal fascia, the prostate was mobilized from the rectum. Isolated clipping of the seminal vesicle arteries was performed in an antegrade manner, followed by control of the lateral pedicles, and identification of the course of the NVB. For the antegrade technique, after dissection of the seminal vesicles, the levator fascia was incised to develop a lateral NVB groove. After bladder neck division and lateral pedicle ligation, the lateral NVB groove was used as a guide for antegrade preservation of the NVB. During anastomosis, the NVBs located at the 5-o'clock and 7-o'clock positions were avoided in both techniques. RESULTS: A questionnaire-based potency rate of 67% and 76%, respectively, was reported after bilateral nerve sparing using retrograde and antegrade laparoscopic radical prostatectomy techniques. CONCLUSIONS: Both techniques allowed replication of open surgical principles. The video magnification enabled excellent demonstration of the periprostatic anatomy. The principles of interfascial dissection of the NVB, use of task-specific instrumentation, and avoiding energy sources around the NVB may be more important than the actual nerve-preservation technique used.

Humans↗

PubMed2006

The impact of neoadjuvant hormonal therapy on the outcome of laparoscopic radical prostatectomy: a matched pair analysis.

PURPOSE: We evaluated the effect of androgen ablation treatment on laparoscopic radical prostatectomy operative and postoperative parameters. MATERIALS AND METHODS: A total of 50 patients (group 1) on neoadjuvant androgen deprivation, followed by laparoscopic radical prostatectomy, were compared to 50 (group 2) without any treatment who were matched for prostate volume, laparoscopic pelvic lymphadenectomy, nerve sparing procedure, surgical access type and pathological stage. We analyzed operative time, blood loss, intraoperative and postoperative complications, catheter time, procedure difficulty as scored by the surgeon and surgical margin status. RESULTS: There was no significant difference between the neoadjuvant and nonneoadjuvant groups with respect to mean operative time +/- SD (228.6 +/- 62.9 vs 219.4 +/- 65.1 minutes), mean blood loss (667.6.1 +/- 217.1 vs 729.8 +/- 285.1 ml) and median catheter time (7 vs 7.5 days). We also found no difference related to the complication rate. Ten of 50 prostate dissections (20%) in group 1 were classified as difficult, whereas in group 2 only 4 of 50 (8%) were scored as difficult (p = 0.084). The positive surgical margin rates did not differ. CONCLUSIONS: There was no significant difference with respect to operative or postoperative parameters in patients undergoing neoadjuvant androgen ablation therapy compared to controls. At centers where there is experience laparoscopic radical prostatectomy can be safely performed in patients who have undergone neoadjuvant hormonal therapy.

Androgen Antagonists↗

PubMed2005

Prosthetic mesh hernioplasty during laparoscopic radical prostatectomy.

OBJECTIVES: To evaluate the role of simultaneous laparoscopic mesh prosthetic hernioplasty during laparoscopic radical prostatectomy (LRP), because 5% to 10% of candidates for radical prostatectomy present with a detectable inguinal hernia at their preoperative physical examination. Moreover, data have suggested a greater incidence of inguinal hernia after open radical prostatectomy. METHODS: During 1035 LRP procedures, 50 laparoscopic mesh prosthetic hernioplasty procedures were performed in 37 patients (3.6%) for 13 bilateral and 24 unilateral inguinal hernias. We compared the outcome of LRP with simultaneous laparoscopic inguinal hernioplasty (group 1) with that of 37 match-paired patients treated by LRP alone (group 2). Both groups were matched according to age, prostate-specific antigen level, prostate volume, pathologic stage, and Gleason score. Perioperative parameters (ie, operative time, analgesic requirements) and postoperative results were analyzed. RESULTS: The patient age was 64.1 +/- 6.4 years versus 62.8 +/- 4.9 years old and had a body mass of 26.5 +/- 3.0 versus 27.4 +/- 3.2 kg/m2 in groups 1 and 2 (with and without laparoscopic hernioplasty), respectively. The mean operating time (221.9 versus 191.2 minutes, P = 0.011) and the total amount of narcotic analgesic requirements (26.8 mg versus 17.5 mg, P = 0.026) was significantly increased in the patients who underwent simultaneous laparoscopic inguinal hernia mesh repair. No statistically significant difference was found in the complication rate (4% versus 2%), median catheter time (7 days), and positive surgical margins (21.8%). CONCLUSIONS: Simultaneous repair of inguinal hernia during LRP using prosthetic mesh is feasible without adverse effects on surgical and functional parameters. Neither the transperitoneal nor extraperitoneal approach is associated with an increase in complications or morbidity. However, an extraperitoneal access allows an easier repair without the refixation of the peritoneum.

Digestive System Surgical Procedures↗

PubMed2005

Laparoscopic radical prostatectomy--impact of training and supervision.

To define the influence of training and supervision on the quality of laparoscopic radical prostatectomy we compared our perioperative parameters, as well as the postoperative functional and oncological outcomes of four generations of surgeons with significantly different training modalities. The first two generations were trained in open retropubic radical prostatectomy, but the third and fourth generation were trained mostly laparoscopically. Overall the data of more than 1000 performed cases were compared: We could not find any significant difference concerning our complication rates. Also the data of oncological (positive margins) and functional results (data of continence with a follow-up of more than two years) were comparable within all groups. A learning curve was observed only for the operating time, but proved to be significantly shorter for the third and fourth generations. Therefore we can conclude that the quality of laparoscopic radical prostatectomy does not depend on the individual experience in open surgery but to a considerable extent on the quality of laparoscopic education (e.g. simulation trainer, supervision).

Journal Article↗

PubMed2005

Laparoscopic radical cystectomy with and without orthotopic bladder replacement.

The successful introduction of laparoscopic radical prostatectomy at the end of the last millennium represented a quantum leap in the technical development of minimally invasive surgery in urology. Therefore it seemed a logical step that, at the beginning of this millennium, first centers reported their initial experience with laparoscopic radical cystectomy. Based on more than 2000 laparoscopic radical prostatectomies, two centers have performed this procedure in 48 patients including a variety of urinary diversion (i.e. ileal conduit, ileal neobladder, sigmoid neobladder). In this article, all important surgical steps of laparoscopic radical cystectomy are presented, including the description of the most important techniques of urinary diversion. Based on our own experience, the results of 238 cases presented in the current literature are reviewed. The operating time mainly depended on the type and technique of urinary diversion and ranged between 352 and 430 minutes for ileal conduit, and between 478 and 649 minutes for orthotopic neobladder. The complication rate ranged between 16 and 18%, and the reintervention rate was 4-6%. Long-term follow-up is not available, disease-free survival after three years in a limited number of series ranges between 50 and 67%. No port site metastases have been reported so far. Even for the experienced surgeon laparoscopic radical cystectomy with urinary diversion represents a technically challenging procedure. Nevertheless, feasibility and safety have been proved by various authors. However, larger studies with long-term clinical outcome are necessary to determine the final value of the procedure.

Journal Article↗

PubMed2005

The Heilbronn laparoscopic training program for laparoscopic suturing: concept and validation.

BACKGROUND AND PURPOSE: More than a decade after the first description of laparoscopic nephrectomy, an increasing number of laparoscopic procedures are being performed worldwide. Nevertheless, there still exists a significant lack of standardized training programs to teach ablative and, most important, reconstructive laparoscopic operations (i.e., pyeloplasty, radical prostatectomy). We evaluated and validated a new standardized step-by-step program to improve laparoscopic skills and enable trainees not experienced in laparoscopy to perform a urethrovesical anastomosis. MATERIALS AND METHODS: In an inanimate model (pelvic trainer) with defined trocar positions, the 10 participants were exposed to six reconstructive exercises. The steps consist of improvement of hand-eye coordination (two-row metal-pin model; step I), linear and curved suturing with changing angles of the needle (chicken leg and catheter model; steps II-V), and performance of an anastomosis in a porcine bladder (step VI). Times of 3, 15, 15, 10, 20, and 30 minutes for steps I, II, III, IV,V, and VI, respectively, were defined as the goal before proceeding to the next stage. The time required to succeed in each step and the increase in the speed of suturing and knotting activities were analyzed with the Wilcoxon signed-rank test. RESULTS: After a mean of 40 hours of training, all participants were able to perform all steps within the specified times and complete an accurate urethrovesical anastomosis in 30 minutes. The time required to succeed before and after training showed a significant decrease (P < 0.05). Continual training in reconstructive procedures decreased the time needed for suturing activities by between 66.3% and 72.2%. The time needed for the knotting activities decreased by between 34.3% and 38.3%. CONCLUSIONS: Our program enabled participants not experienced in laparoscopy to increase reproducible performance in reconstructive laparoscopy. These results indicate that the challenging parts of reconstructive laparoscopy such as intracorporeal suturing can be taught using a standardized concept. This experience could be incorporated easily by every department developing a laparoscopic training program.

Anastomosis, Surgical↗

PubMed2005

The effect of previous transperitoneal laparoscopic inguinal herniorrhaphy on transperitoneal laparoscopic radical prostatectomy.

PURPOSE: Previous laparoscopic herniorrhaphy has been considered a contraindication to laparoscopic radical prostatectomy (LRP). In this study we analyzed the impact of previous laparoscopic or open inguinal hernia repair on the outcome of transperitoneal laparoscopic radical prostatectomy using the Heilbronn technique. MATERIALS AND METHODS: In our database of 1,089 patients with LRP we identified 20 who underwent transperitoneal LRP and had a history of transperitoneal laparoscopic inguinal herniorrhaphy using prosthetic mesh (group 1). The outcome in that group was compared to that of 20 matched pair patients of a total of 95 in whom LRP was performed following open inguinal herniorrhaphy (group 2) and 20 matched pair patients of a total of 771 without previous surgery (group 3). Perioperative parameters (operative time, blood donation and complications) and postoperative results (duration and amount of analgesic treatment, catheterization and the continence rate) were analyzed. RESULTS: According to the matched pair algorithm the 3 groups did not differ with respect to age (63.8, 66.2 and 63.0 years, p = 0.226), prostate volume (47.2, 43.3 and 47.7 gm, p = 0.501) or body mass index (26.1, 25.8 and 26.2 kg/m, respectively, p = 0.641). Ten pelvic lymphadenectomies and 8 nerve sparing (4 unilateral and 4 bilateral) procedures were performed per group. Ten and 12 patients in groups 1 and 2 had a history of bilateral herniorrhaphy, while previous unilateral herniorrhaphy was noted in the remaining 10 and 8, respectively. Mean operative time +/- SD (203.3 +/- 3.54, 196.7 +/- 43.7 and 214.7 +/- 37.7 minutes, p = 0.346) and mean catheterization time (8.1 +/- 2.8, 7.7 +/- 2.5 and 7.4 +/- 2.1 days, respectively, p = 0.684) did not differ significantly among the 3 groups. However, the mean amount of narcotic analgesic was significantly higher in group 1 compared with groups 2 and 3 (32.1 +/- 11.9, 21.8 +/- 11.9 and 19.5 +/- 10.1 mg, respectively, p = 0.002). Continence rates were similar in the groups at 88%, 87% and 92%, respectively, 1 year after surgery. CONCLUSIONS: Previous laparoscopic inguinal herniorrhaphy using prosthetic mesh does not adversively affect the operative outcomes or functional results of LRP, while the total amount of narcotic analgesics was significantly higher, reflecting increased postoperative morbidity.

Aged↗

PubMed2005

Laparoscopic radical prostatectomy with the Heilbronn technique: oncological results in the first 500 patients.

PURPOSE: Laparoscopic radical prostatectomy has become an accepted alternative to open surgery. However, there is still a lack of data concerning the oncological outcome. MATERIALS AND METHODS: From March 1999 to July 2004, 1,078 patients underwent laparoscopic radical prostatectomy at our institution. Oncological results in the first 500 patients with a minimal followup of 23 months were analyzed, focusing on positive margins, prostate specific antigen (PSA) failure, clinical progression and survival. RESULTS: Median followup was 40 months (range 23 to 65). Of the patients 417 underwent pelvic lymph node dissection, which revealed positive nodes in 6 (1.2%). Positive margins were documented in 22 of 296 pT2 tumors (7.4%), 27 of 107 pT3a tumors (25.2%) and 29 of 69 pT3b tumors (42.0%). PSA recurrence was diagnosed in 55 patients (11.0%) at a mean of 20.8 months (range 6 to 36) that is stages pT2a, pT2b, pT3a and pT3b/4 in 3.2%, 6.5%, 15.9% and 23.9%, respectively. PSA progression-free rates were 83.0% at 3 years and 73.1% at 5 years. Two patients died of disease and 6 died of other causes (99.2% overall survival). The clinical progression rate was to 4.1% at 3 years and 9.8% at 5 years. No port site metastasis was observed. CONCLUSIONS: At centers of expertise laparoscopic radical prostatectomy may provide an oncological outcome similar to that of the open procedure. However, it offers the advantages of minimally invasive surgery.

Adult↗

PubMed2005

Comparison of training modalities for performing laparoscopic radical prostatectomy: experience with 1,000 patients.

PURPOSE: We report a detailed analysis of different training modalities on the transferability of laparoscopic radical prostatectomy to generations of surgeons. MATERIAL AND METHODS: The first generation surgeon with experience with 600 cases and the second generation surgeon with 150 were trained in open retropubic radical prostatectomy and laparoscopy, whereas the third generation surgeon with 150 cases was trained only laparoscopically. The fourth generation of surgeons with a total of 50 cases was trained in our fellowship program. We analyzed groups of 50 operations. The groups were comparable with respect to patient age, prostate weight and pathological tumor stage. RESULTS: We observed a continual decrease in operative time between (322 to 247 minutes.) and within (332 to 196 minutes.) the analyzed groups. This result was also expressed in a decrease in the time required for anastomosis. A significant decrease was observed for the initial transfusion rate (4% to 10%). No difference was found in the complication rate (ie conversion in 8% to 0% of cases). Pathological outcomes (ie positive margins for pT2/pT3) were comparable in the first 3 surgeon groups (14.9%, 14.2% and 22%, respectively) and available functional results (followup greater than 2 years) did not reveal any influence of the learning curve. A learning curve was observed only for overall operative time and the time required for anastomosis but it was shown to be significantly shorter for the following generations. CONCLUSIONS: Based on a specific training program the personal level of education has a minor impact on the results and reproducibility of the laparoscopic radical prostatectomy technique.

Clinical Competence↗

PubMed2005

Human DNA topoisomerase II-alpha expression in laparoscopically treated renal cell carcinoma.

To investigate whether the expression of Topoisomerase II-alpha (TII-alpha) can serve as a prognostic factor in renal cell carcinoma (RCC), histological sections from 27 renal tumors were stained immunohistochemically for TII-alpha expression. The percentage of positive cells in the area of greatest staining was recorded as the TII-alpha index. TII-alpha nuclear staining was positive in all the samples except one. The mean TII-alpha index was 12.5 for grade 1, 44 for grade 2 and 113 for grade 3 tumors. The mean TII-alpha index was 22.3 in tumors which did not recur and 81 for tumors which recurred during the follow-up period. In this study, a higher TII-alpha index correlated with more aggressive tumor behaviour. However, a large cohort of patients should be assessed before drawing definitive conclusions.

Adult↗

PubMed2004

Comparison of transperitoneal and extraperitoneal laparoscopic radical prostatectomy using match-pair analysis.

PURPOSE: Based on the experience of 1000 cases of laparoscopic radical prostatectomy, we compared the operative parameters of transperitoneal and extraperitoneal approaches in match-paired patient groups. PATIENTS AND METHODS: We reviewed the charts of 53 consecutive patients who underwent selectively extraperitoneal laparoscopic radical prostatectomy comparing it to 53 match-paired patients treated by transperitoneal laparoscopic radical prostatectomy. The patients were matched for age, PSA (ng/ml), prostate volume (g), pathologic stage, Gleason score, presence of pelvic lymph node dissection and type of nerve-sparing technique. Perioperative parameters (operating time, blood donation, complications) and postoperative results (duration and amount of analgesic treatment, catheterization time) as well as oncological (surgical margin status) and functional (continence rate) results were analyzed. RESULTS: Patients were 62.9 +/- 5.5 versus 62.9 +/- 5.4 years old, had 27.5 +/- 3.5 kg/m2 versus 26.7 +/- 2.8 kg/m2 body mass indices in the extraperitoneal and transperitoneal groups, respectively. Preoperative mean PSA and prostate volume were 7.4 +/- 4.6 ng/ml and 41.8 +/- 16.3 g in the extraperitoneal, 7.6 +/- 3.8 ng/ml and 42.0 +/- 14.8 g in the transperitoneal group. Pathologic stages were T2a in 12 vs. 13, T2b in 21 vs. 20, T2c in 7 vs. 8, T3a in 11 vs. 10 and T3b in 2 vs. 2 patients for both groups. Overall 211.8 vs. 197.1 minutes mean operative time (p = 0.328) and 21.9 +/- 15.4 mg vs. 26.3 +/- 15.8 mg narcotic analgesic requirements (p = 0.111) did not differ significantly in both groups. However, mean operating time was significantly longer in the extraperitoneal group when performing pelvic lymphadenectomy (244.5 vs. 209.6 minutes, p = 0.017). There was no statistical difference of complication rate (4% vs. 2%) and median catheter time (7 vs. 7 days), positive surgical margins (22.6% vs. 20.7%) and 12 months continence (86.7% vs. 84.9%). CONCLUSIONS: There was no significant difference between the extraperitoneal and transperitoneal approaches using the Heilbronn technique regarding all important parameters. In addition to the preference and experience of the individual surgeon, previous abdominal surgery, gross obesity and requirement of simultaneous inguinal hernia repair may be considered as selective indications for extraperitoneal laparoscopic radical prostatectomy.

Aged↗

PubMed2004

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery?

OBJECTIVE: In 1991, laparoscopic nephroureterectomy has been introduced as a treatment option for upper tract transitional cell carcinoma. Based on the review of the current literature and personal experience we want to analyze the actual results of this technique in comparison to open surgery. MATERIALS AND METHODS: We performed a MEDLINE/PubMed search and reviewed the literature on laparoscopic and open nephroureterectomy between 1991 and 2004 (n = 1365 patients) including the results of 45 patients who underwent either laparoscopic (n = 23) or open nephroureterectomy (n = 21) during the same period of time at the Klinikum Heilbronn. Demographic, perioperative and follow-up data were compared. RESULTS: The analysis revealed a slightly longer OR-time (276.6 vs. 220.1 min), and significantly lower blood loss (240.9 vs. 462.9 ml) in the laparoscopic series. No differences of minor (12.9 vs. 14.1%) or major complication rate (5.6 vs. 8.3%) were observed. All nine comparative studies revealed a significant dose reduction of the morphine-equivalents after laparoscopy. In all ten comparative series the hospital stay was shorter after laparoscopy, but only in 6 series the difference was statistically significant. The frequency of bladder recurrence (24.0 vs. 24.7%), local recurrence (4.4 vs. 6.3%), and distant metastases (15.5% vs. 15.2) did not differ significantly in both groups. The actual disease-free two-year survival rates (75.2 vs. 76.2%) were similar. The five-year survival rates averaged 81.2% in the three laparoscopic (n = 113 pat.) and 61% in the ten open series (n = 681 pat.) Six port site metastases were reported in 377 (1.6%) analyzed patients occurring 3 to 12 months following laparoscopy. CONCLUSION: Open radical nephroureterectomy still represents the golden standard for the management of upper tract transitional cell carcinoma, however, laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome. In case of advanced tumors (pT3,N+) open surgery is still recommended.

Adult↗

PubMed2004

Laparoscopic radical prostatectomy: functional and oncological outcomes.

PURPOSE OF REVIEW: Laparoscopic radical prostatectomy has become an accepted alternative to open surgery, however data on the functional and oncological outcome are still lacking. In this study we present an analysis based on a survey of the current literature and the first 500 patients treated with the Heilbronn technique. Additionally, we compare the results of laparoscopy with those of open radical prostatectomy. RECENT FINDINGS: We conducted an extensive MEDLINE search of laparoscopic and open radical prostatectomy from 1999 through 2003, focusing on the last 3 years. The articles as well as our own results were analyzed with respect to continence, potency, positive margins, prostatic specific antigen failure, and clinical progression. No significant differences were found between the laparoscopic and open approach with respect to overall continence at 12 months (60-94% versus 61-98%) or at 3 months (51-63% versus 62-69%), varying from 4.1% at pT2, 12% at pT3 to 19% at pT4 stages. We found no significant differences between the two techniques in the recovery of potency (34-67% versus 31-79%), if one excludes the selected series of Walsh with a mean age of 57 years. Furthermore, we did not detect any significant differences in positive margins and short-term prostatic specific antigen recurrence (3 years). SUMMARY: At centers of expertise, laparoscopic radical prostatectomy is able to provide similar functional and oncological results as its open counterpart, however with the advantages of minimally invasive surgery.

Follow-Up Studies↗

PubMed2003

Technical evolution of laparoscopic radical prostatectomy after 450 cases.

BACKGROUND AND PURPOSE: In 1998, laparoscopic radical prostatectomy with primary access to the seminal vesicles was introduced. In 1999, we developed a laparoscopic technique similar to the classic retropubic radical prostatectomy. We focus here on the continuous technical evolution of our technique. PATIENTS AND METHODS: From March 1999 to May 2002, we performed 450 laparoscopic radical prostatectomies. All important data of the patients; data concerning the performance of the procedure, including technical modifications, conversion, reintervention, and complication rate; as well as follow-up information were documented contemporaneously. The patients were divided into three groups of 150 individuals each in order to analyze the influence of the technical evolution of the procedure. Additionally, we studied the transferability of our technique, comparing the learning curves of the three surgeons involved in the program. RESULTS: The technical modifications included the routine use of a voice-controlled robot (AESOP) for the camera, exposure of the apex with 120 degrees retracting forceps, a free-hand suturing technique instead of the Endostitch device for the dorsal vein complex, 5-mm clipping instead of bipolar coagulation for the nerve-sparing technique, initial 6 o'clock suturing of the urethra before complete division, control of the prostatic pedicles by use of 12-mm Hemo-lok clips instead of the Ultracision or Endo-GIA, the bladder neck-sparing technique in cases of T(1c) and T(2a) tumors, and interrupted instead of continuous sutures for the vesicourethral anastomosis. All these modifications resulted in a significant decrease in operating time and the rates of transfusion, open conversion, and reintervention. The introduction of the nerve-sparing technique increased the number of tumor-positive margins. The mean operating time of the third surgeon was significantly less than that of the first surgeon, but the transfusion, conversion, and reintervention rates did not differ significantly among the surgeons. CONCLUSIONS: Laparoscopic radical prostatectomy has undergone continuous technical evolution resulting in a significant improvement of the operative results. Although we were able to demonstrate the transferability of this difficult procedure, we feel that it should be performed only at centers of expertise.

Adult↗

PubMed2003

Laparoscopic versus open radical prostatectomy: a comparative study at a single institution.

PURPOSE: There is an ongoing debate about the benefits of laparoscopic radical prostatectomy compared to the open retropubic approach. We compared the last 219 patients treated with open retropubic prostatectomy with 438 patients treated with laparoscopic radical prostatectomy at our institution, focusing on operative data, complications and mid-term outcome. MATERIALS AND METHODS: From December 1994 to November 1999 a total of 219 patients were treated with open prostatectomy and pelvic lymph node dissection (group 1). From March 1999 to September 2002, 219 patients underwent early (group 2) and 219 underwent late (group 3) laparoscopic radical prostatectomy and pelvic lymph node dissection. The same surgeons performed both operations. All 3 groups were similar with respect to mean patient age, mean prostate specific antigen value, median Gleason score, previous transurethral resection of the prostate and neoadjuvant treatment, although there was a slight stage shift in favor of the 2 laparoscopic groups. RESULTS: Mean operating time was significantly shorter after open surgery (196 minutes) compared to the early laparoscopic group (288) but it did not differ significantly from the late laparoscopic group (218). Mean blood loss (1,550 versus 1,100 versus 800 cc) and transfusion rates (55.7% versus 30.1% versus 9.6%) in groups 1 to 3 favored the laparoscopic groups. The complication rate in groups 1 to 3 was lower for laparoscopy (19.2% versus 13.7% versus 6.4%), but the spectrum differed. The early laparoscopic group had a higher incidence of rectal injuries (1.8% versus 3.2% versus 1.4% in groups 1 to 3, respectively) and urinary leakage (0.5% versus 2.3% versus 0.9%), whereas more lymphoceles (6.9% versus 0% versus 0%), wound infection (2.3% versus 0.5% versus 0%), embolism/pneumonia (2.3% versus 0.5% versus 0.5%) and anastomotic strictures (15.9% versus 6.4% versus 4.1%) occurred after open surgery. The amount of postoperative analgesia was significantly greater after open surgery (50.8 versus 33.8 versus 30.1 mg. in groups 1 to 3, respectively). Median catheter time was longer after open retropubic prostatectomy (12 versus 7 versus 7 days in groups 1 to 3, respectively) but the continence rates were similar in all 3 groups at 12 months (89.9% versus 90.3% versus 91.7%). The rate of positive margins did not differ significantly in groups 1 to 3 (28.2% versus 21.0% versus 23.2%), prostate specific antigen recurrence was equivalent related to the different observation periods. CONCLUSIONS: Laparoscopic radical prostatectomy is technically demanding, with an initially longer operative time, higher incidence of rectal injuries and urinary leakage. The overall outcome after 219 cases favors the laparoscopic approach. Consequently, at our institution laparoscopic radical prostatectomy has become the method of choice.

Adult↗