Comparison of laparoscopic radical prostatectomy techniques

Over the past years, laparoscopic radical prostatectomy has emerged as an attractive, exciting, and new approach for the surgical treatment of localized prostate cancer. Several centers in Europe and the United States have developed their own technique and have already published their first results. Two main routes have been used, namely, the transperitoneal and extraperitoneal approaches. Data from the literature and available experience demonstrate that this laparoscopic procedure is feasible and teachable and that oncologic and functional results seem comparable to those of classic open radical prostatectomy. Minimal bleeding, reduced blood transfusion rates, shorter hospitalization, and shorter recovery time are unquestionable advantages for laparoscopic procedures. Laparoscopic radical prostatectomy remains a difficult intervention and should be performed in selected centers with experienced teams who already have extensive laparoscopic experience and who recruit enough patients to grant them the proper amount of expertise. This is the only way to achieve excellence in terms of oncologic and functional results.     

Feasibility and usefulness of laparoscopic radical prostatectomy: Kobe University experience

OBJECTIVES: The objective of this study was to present the clinical outcomes of 26 patients who underwent laparoscopic radical prostatectomy at our institution. METHODS: We performed laparoscopic prostatectomy on patients who were clinical stage T1 or T2. The mean age was 70 years old (range: 52-76). The mean level of pre-treatment prostate-specific antigen (PSA) was 8.7 ng/mL (range: 3.3-45). The Gleason score of the needle biopsy was < 7 in 21 patients and > or = 7 in five patients. Clinical stage was T1c in 17 patients, T2a in 6 patients and T2b in 3 patients. Operative techniques followed those of the French groups. Five trocars were introduced into the peritoneal cavity. The vas deferens and seminal vesicles were dissected to reach the posterior wall of the prostate and the retroperitoneal space was dissected around the urinary bladder. Incision of endopelvic fascia and dorsal vein complex (DVC) ligation were performed. The bladder neck and prostate were divided, then the distal urethra was cut. The lateral pedicles of the prostate were cut and the entire prostate was removed. Vesico-urethral anastomosis was performed at eight points. RESULTS: Mean operation time was 7 h 30 min. Mean bleeding volume (including urine volume) was 850 mL (range: 32-3135). All patients underwent autologous blood transfusion. Only one patient required further blood transfusion. Gleason scores of resected specimens were < 7 in 10 patients, and > or = 7 in 16 patients. Pathological stage was T0 in 1 patient, T2a in 6 patients, T2b in 13 patients, T3a in 5 patients and T3b in 1 patient. The PSA value was undetectable in all patients one month after surgery. Ten patients who survived for 6 months after surgery had complete urinary continence without a pad. In 7 of the 12 patients who were potent before surgery, neurovascular bundles were preserved, and 5 of them (71%) achieved complete or incomplete erection 3 months after surgery. However, only one patient (14%) could have sexual intercourse. CONCLUSION: Although longer follow-up is necessary to evaluate this surgical technique, laparoscopic prostatectomy seems to be a reasonable option in the treatment of organ-confined prostate cancer.     

Utilization and efficacy of autologous blood predeposit in radical prostatectomy with lymphadenectomy: implications for blood conservation and physician education programs.

Autologous blood predeposit is a widely used transfusion practice that has become a standard of care for elective surgery. Despite the support for this practice there are unanswered questions in the usage and efficacy of autologous blood programs. This study is a prospective analysis of 52 consecutively audited urologic patients undergoing elective, radical prostatectomy with lymphadenectomy in which all 52 patients predonated autologous blood. Preoperative blood donation, blood transfused, surgical blood lost, and the "transfusion trigger" were evaluated for each of these patients. We conclude (1) the rate of homologous blood exposure (15%) despite preoperative autologous blood donation in every patient indicates a need for innovative blood conservation strategies to minimize homologous blood transfusion in this surgical group. (2) Unnecessary autologous transfusions could be identified in 8 (15%) of 52 patients, all of which were single unit autologous blood transfusions. (3) Physician education programs that emphasize increased procurement of autologous blood along with more conservative transfusion of this blood are needed to avoid necessary homologous blood and unnecessary autologous blood transfusion.     

Laparoscopic radical prostatectomy. Technical aspects and experience with 125 cases

PURPOSE: The laparoscopic access for radical prostatectomy offers an alternative to the open surgical procedure with less morbidity. We report on our experience with 125 laparoscopic prostatectomies, especially with respect to making the laparoscopic approach a routine procedure and with a view to the oncological and functional results. MATERIAL AND METHODS: From June 1999 to September 2000, we performed 125 laparoscopic prostatectomies. These included only patients with cancer stages T1 or T2. The mean PSA concentration was 10.5 ng/ml. Forty-four percent of the patients had undergone previous abdominal and 19% previous transurethral surgery. For our laparoscopic prostatectomies we used the descending technique. Free-hand laparoscopic suturing and in situ knot-tying technique were used for the urethrovesical anastomosis. The mobilized specimens were removed in an endobag via a muscle splitting incision. RESULTS: All 125 procedures could be completed successfully. No case required conversion to open surgery. The average operating time was 255 min, the last 40 procedures taking 200 min only. Mean blood loss was 185 ml. Two patients (2%) required postoperative blood transfusion. After an initial learning curve, catheter remained in place for an average of 5.5 days, and the average postoperative stay in hospital was 8 days. Intraoperative complications were seen in 5 patients (4%). In 13 patients (10.4%) postoperative complications were observed. 86% of the patients are continent 6 months postoperatively. Preservation of the neurovascular bundle and sexual potency is possible. CONCLUSION: Laparoscopic radical prostatectomy is an ambitious procedure with a steep learning curve, especially for the laparoscopic dissecting and suturing technique. The excellent sight for dissection results in a reduced blood loss and faster convalescence with an overall lower morbidity. Also with regard to oncological and functional (continence) results the minimally invasive access is at least equivalent to the open procedure. In our opinion, laparoscopic prostatectomy will be the future method of choice for radical prostatectomy.     

Laparoscopic radical prostatectomy: preliminary results

OBJECTIVES: To evaluate our preliminary experience with laparoscopic radical prostatectomy. The indications for laparoscopy are currently being extended to complex oncologic procedures. METHODS: Forty-three men underwent laparoscopic radical prostatectomy. We used five trocars. The surgical technique replicates the steps of traditional retropubic prostatectomy, except that the rectoprostatic cleavage plane is developed transperitoneally at the beginning of the procedure. In the first 10 patients, we performed the vesicourethral reconstruction with interrupted sutures; in the remaining 33 patients, we performed it with two hemicircumferential running sutures. The specimen was removed through the umbilical port site. RESULTS: Once the developmental phase with the first 10 patients was concluded, the median operating time was 4.3 hours without pelvic lymphadenectomy, and the median postoperative bladder catheterization was 4 days. Two (4.7%) of 43 patients underwent transfusion. Twelve patients (27.9%) had positive surgical margins; all patients had a postoperative prostate-specific antigen level of less than 0.1 ng/mL at 1 month. Rectal injury occurred in 1 patient, requiring colostomy, and 4 patients had urethrovesical anastomotic leakages requiring surgical repair. One month postoperatively, 36 patients (84%) were fully continent (no leakage). Six patients had had erections, and four stated they had had sexual intercourse. CONCLUSIONS: Laparoscopic radical prostatectomy has evolved to a fully standardized and reproducible procedure. The short-term oncologic and functional efficacy rates are equivalent to those for open surgery. The operating time is reasonable once the learning curve is over, and postoperative morbidity is diminished. Because of the improved visual accuracy, permitting more precise dissection, this technique has the potential to become an important advancement in urologic surgery.     

Early laparoscopic management of acute postoperative hemorrhage after initial laparoscopic surgery

BACKGROUND AND PURPOSE: The use of laparoscopic surgery has been well established for the management of abdominal emergencies. However, the value of this technique for postoperative hemorrhage in urology has not been characterized. We present our favorable experience with laparoscopic exploration after urologic surgery and suggest guidelines for laparoscopic management of post-laparoscopy bleeding. PATIENTS AND METHODS: Three patients who developed hemorrhage shortly after laparoscopic urologic surgery and were managed by laparoscopic exploration were identified from a series of 910 laparoscopic urologic procedures performed at our institution from October 2002 to June 2006. RESULTS: Three patients, who were hemodynamically stable (two after robot-assisted laparoscopic prostatectomy, one after laparoscopic radical nephrectomy), required prompt surgical exploration for postoperative hemorrhage not stabilized by blood transfusion (mean 2.7 units) at a mean of 19.4 hours after initial surgery. Clots were evacuated with a 10-mm suction-irrigator. Two patients were found to have abdominal-wall arterial bleeding and were managed with suture ligation. The third patient demonstrated diffuse bleeding from the prostatic bed, which was controlled with Surgicel and FloSeal. Bleeding was efficiently controlled in all patients, and none required post-exploration transfusion. The mean post-exploration hospital stay was 2.3 days. CONCLUSION: Significant hemorrhage after urologic laparoscopy is a rare event. We found laparoscopic exploration to be an excellent way to diagnose and correct such hemorrhage in certain patients. Early diagnosis with clinical and hematologic studies, a lowered threshold for surgical exploration, and specific operative equipment may decrease patient morbidity and the need for open surgical exploration.     

A direct comparison of robotic assisted versus pure laparoscopic radical prostatectomy: a single institution experience

PURPOSE: We compared a single institution experience with radical prostatectomy using a pure laparoscopic technique vs a robotically assisted technique with regard to preoperative, intraoperative or postoperative parameters. MATERIALS AND METHODS: From May 2003 to May 2005 we reviewed 133 consecutive patients who underwent extraperitoneal robot assisted radical prostatectomy and compared them to 133 match-paired patients treated with a pure extraperitoneal laparoscopic approach. The patients were matched for age, body mass index, previous abdominopelvic surgery, American Society of Anesthesiologists score, prostate specific antigen, pathological stage and Gleason score. Preoperative, perioperative and postoperative data, including complications and oncological results, were analyzed between the 2 groups. RESULTS: The 2 groups were statistically similar with respect to age, body mass index, prostate specific antigen, Gleason score and clinical stage. No statistical differences were observed regarding operative time, estimated blood loss, hospital stay or bladder catheterization between the 2 groups. The transfusion rate was 3% and 9.8% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.03). Conversion from robotic assisted laparoscopic prostatectomy to laparoscopic radical prostatectomy was necessary in 4 cases. None of the laparoscopic radical prostatectomy cases required conversion to an open technique. The percentage of major complications was 6.0% vs 6.8%, respectively (p = 0.80). The overall positive margin rate was 15.8% vs 19.5% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.43). CONCLUSIONS: We demonstrated that the laparoscopic extraperitoneal radical prostatectomy is equivalent to the robotic assisted laparoscopic prostatectomy in the hands of skilled laparoscopic urological surgeons at our institution with respect to operative time, operative blood loss, hospital stay, length of bladder catheterization and positive margin rate.     

The use of predeposited autologous blood transfusion for radical prostatectomy

PURPOSE: In reference to the cases in which radical prostatectomy was performed after storage of autologous blood, we retrospectively study the usefulness of this procedure and proper amount of blood stored. PATIENTS AND METHODS: The subjects included 62 cases in which radical prostatectomy was performed after storage of autologous blood from October, 1997 to March, 2000. As the amount of blood to be stored, either 800 ml or 1,200 ml was selected optionally as the amount of blood to be stored, and blood was stored at a rate of 400 ml once a week. Erythropoietin, 24,000 units was injected subcutaneously after storage of blood, and an iron preparation 200 mg/day was administered orally throughout the period. RESULTS: Homologous blood transfusion could be avoided in 58 out of 62 cases, the avoidance rate being 93.5%. With 200 ml of autologous blood as 1 unit, 104 units out of 330 units were discarded, the disposal rate being 31.5%. To lower the disposal rate, we studied whether there is any parameter that can predict the loss of blood preoperatively. As a result, we found a significant difference in the loss of blood between the body mass index of less than 24 and that of more than 24. Blood storage and transfusion produced no side-effects. CONCLUSION: Storing autologous blood in radical prostatectomy is considered useful since homologous blood transfusion can be avoided at a high percentage and no side-effects are produced. The body mass index is useful for predicting the loss of blood and determining a proper amount of blood to be stored.     

新辅助内分泌治疗联合腹腔镜根治性前列腺切除术治疗高危前列腺癌体会

目的 探讨先行新辅助内分泌治疗后行腹腔镜前列腺癌根治术治疗高危前列腺癌的可行性及效果.方法 收集2013年10月至2016年1月本院先行新辅助内分泌治疗后,再行腹腔镜根治性前列腺切除术治疗14例高危前列腺癌患者的临床资料,术前病检诊断明确,完成Gleason评分,MRI增强扫描完成临床分期,行骨扫描及相关辅助检查排除远处转移,术前辅助内分泌治疗3～6个月控制PSA＜4μg/L后行腹腔镜根治性前列腺切除术,术后观察患者排尿情况及PSA控制情况等.结果 大部分患者手术时间为130～290 min,无输血、无直肠穿孔患者,术后平均15 d拔除尿管,术后3个月均能自行控尿,术后3例病检切缘阳性,术后3个月复查PSA＜0.2μg/L.结论 高危前列腺癌患者经内分泌治疗后行腹腔镜根治性前列腺切除术是安全可行,但术前需充分评估风险及并发症情况.     

Extraperitoneal laparoscopic radical prostatectomy. Results after 50 cases

INTRODUCTION: After an initial experience using transperitoneal laparoscopic radical prostatectomy as described by Vallancien and Guillonneau, we developed a pure extraperitoneal approach. This approach seems more comparable to the open technique and avoid potential risks of specific complications due to the transperitoneal approach. We evaluated the perioperative parameters (blood loss, operating time, transfusion rate) and postoperative results (oncological results, continence and potency) after our first 50 cases. MATERIAL AND METHOD: Between September 1999 and September 2000, we performed 50 laparoscopic radical prostatectomy. On average, patients were 63.3 years old (range 47-71), had preoperative mean PSA values of 9.14 ng/ml (1.1-23). Median Gleason score was 6 (4-10) with 2.5 (1-6) positive biopsies for a mean prostate volume of 40 cm(3) (17.5-95.0). Clinical stage was T1, T2a, T2b and T3 in 46.3, 41.5, 9.8 and 2.4% of the cases, respectively. We used a pure extraperitoneal approach and we performed a descending technique starting with the dissection at the bladder neck. The seminal vesicles dissection is comparable to the open approach. RESULTS: 42 extraperitoneal and 8 transperitoneal procedures were performed (2 in the initial experience, 3 because of previous abdominal surgery and 3 because of incidental peritoneal opening). Mean operative time was 317 min, mean blood loss 680 cm(3), transfusion rate of 13%. 1 patient/50 was converted to an open procedure. Pathological stage was pT1a, pT2a, pT2b, pT2c, pT3a and pT3b in 2.2, 8.5, 42.5, 2.2, 34 and 10.6% of cases, respectively. Positive surgical margins were observed in 22% of cases. The potency rate after neurovascular bilateral bundle preservation was 43% at 3 months (n = 7) and 67% at 6 months and (n = 6) without any further treatment. The continence rate (no pad) was 39% at 3 months and 85% at 6 months. Detectable postoperative PSA at 3 month was observed in 2 patients only. Two major complications occurred: one acute transient renal failure one uretrorectal fistula at day 20. CONCLUSIONS: The extraperitoneal laparoscopic radical prostatectomy results seem comparable to transperitoneal laparoscopic radical prostatectomy or open surgery. This approach is reproducible and seems to avoid the potential risks of intraperitoneal injury. Long-term follow up and comparative series are however necessary to further evaluate these new techniques.     

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, respiratory and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.     

Japanese experience with radical prostatectomy

Laparoscopic prostatectomy has become an established treatment option for localized prostate cancer in France, where open prostatectomy is now the gold standard. The main purposes of treatment for prostate cancer are cancer control and preservation of urinary continence and sexual function. To become a standard treatment option for organ-confined prostate cancer, laparoscopic prostatectomy has to show equal or better clinical outcome in these areas than its open counterpart. Many institutes in other countries are now trying to perform this surgery. There are, however, some negative reports, mainly because of the difficulty of the procedure. In Japan, more than 250 patients have undergone this surgery. It seems that satisfactory results in terms of positive surgical margin rate, bleeding volume, recovery from surgery, and urinary continence have been obtained so far. We need longer follow-up to assess recurrence rate and sexual function. The main obstacles for this surgery are the long operative time and the difficulty of the procedures. Although it will take time until laparoscopic prostatectomy becomes an approved treatment modality, we are gradually conquering these problems. In this paper, we review the current situation facing laparoscopic prostatectomy in Japan.     

Anesthetic management of a patient with Evans syndrome--benefit of perioperative hemodilutional autologous blood transfusion

The combination of idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia is termed Evans syndrome. We experienced the anesthetic management of a patient with this syndrome undergoing laparoscopic splenectomy. After induction of general anesthesia using thiamylal, fentanyl and vecuronium, hemodilutional autologous transfusion was employed to minimize the immune hemolytic process against the transfused blood throughout the surgical procedure. The anesthetic course was uneventful, and neither massive hemorrhage nor any complications related to bleeding occurred. We therefore recommend the use of hemodilutional autologous transfusion for the anteshetic management of patients with Evans syndrome.     

Intraoperative autologous blood transfusion for hemoperitoneum resulting from ectopic pregnancy or ovarian bleeding during laparoscopic surgery.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of intraoperative autologous blood transfusion during laparoscopic surgery for hemoperitoneum in benign gynecologic disease. METHODS: The Cell Saver, Haemo Lite 2, an intraoperative autologous blood salvage device, was used in laparoscopic surgery on 18 patients with ectopic pregnancies or ovarian bleeding who had a large hemoperitoneum with/without severe anemia and hypovolemic shock. RESULTS: The blood loss was 1186 +/- 789 mL, and the volume of reinfused processed blood was 661 +/- 405 mL in ectopic pregnancy cases. The blood loss was 716 +/- 219 mL, and the volume of reinfused processed blood was 496 +/- 138 mL in ovarian bleeding. Laparoscopic surgery was performed and homologous blood transfusion was not required in any patient. No adverse reactions or procedural difficulties associated with the autologous blood transfusions occurred. CONCLUSIONS: Intraoperative autologous blood transfusion enabled the performance of laparoscopic surgery for large hemoperitoneum caused by ectopic pregnancies or ovarian bleeding without a homologous blood transfusion.     

Laparoscopic radical prostatectomy: current techniques

PURPOSE OF REVIEW: Laparoscopic radical prostatectomy is now considered the standard of care at many centers for the treatment of localized prostate cancer. As with other surgical approaches, there has been an evolution in surgical techniques. Critical evaluation of the effects of these changes on clinical and pathologic outcomes continues. RECENT FINDINGS: The technique of nerve sparing laparoscopic radical prostatectomy should attempt to mimic the techniques and outcomes of open surgery, while maintaining the advantages of reduced blood loss and morbidity, and greater visualization. Long-term functional and oncologic outcomes appear equivalent to open surgery. Surgical approaches based upon recent anatomic studies of the periprostatic neuroanatomy continue to spur both advances and debate. Athermal dissection near the neurovascular bundle, along with high release of the surrounding fascia, may hasten recovery of erectile function. Techniques of sparing or reconstructing the puboprostatic ligaments and support of the bladder are evolving in efforts to improve continence results. Debate over the merits of transperitoneal vs. extraperitoneal approaches to laparoscopic prostatectomy continues. SUMMARY: Nerve sparing laparoscopic radical prostatectomy, although technically challenging, has proven to be an excellent alternative for dedicated centers wishing to provide a minimally invasive surgical option to their patients with localized prostate cancer.     

Laparoscopic versus open radical prostatectomy: Urodynamic evaluation of vesicourethral function

Objectives:   To assess the impact of laparoscopic radical prostatectomy on vesicourethral function and compare it to that of open radical prostatectomy.
Methods:   Sixty-three patients undergoing laparoscopic radical prostatectomy for localized prostate cancer were included in this retrospective analysis. Urodynamic parameters, including maximum urethral closing pressure (MUCP), functional profile length (FPL), bladder compliance, maximum cystometric capacity (MCC) and detrusor overactivity, were considered. Continence status and changes in urodynamic findings before and after surgery were evaluated. In addition, postoperative urodynamic findings were compared with those in 58 patients undergoing open radical prostatectomy.
Results:   After laparoscopic radical prostatectomy, MUCP and FPL showed a significant postoperative decrease. Continence rates after surgery were 82% in the laparoscopic and 78% in the open group. Comparison of postoperative data between continent and incontinent patients in both surgical groups showed significantly lower MUCP, shorter FPL, lower bladder compliance and higher incidence of detrusor overactivity in incontinent patients. Although there was no significant difference in postoperative MUCP and FPL between the two groups, bladder compliance was significantly lower and incidence of detrusor overactivity was significantly higher in the open prostatectomy group.
Conclusions:   Laparoscopic radical prostatectomy has a negative impact on storage function by impairing function of the urethral sphincter and decreasing bladder compliance. There is no difference in postoperative urethral function between open and laparoscopic radical prostatectomy. Laparoscopic surgery might be associated with less impairment of bladder function than open surgery.     

Robotic radical prostatectomy: overview of our learning curve

ObjectiveWe present the first cases of our robotic radical prostatectomy with Da Vinci (RRPdaV) that corresponds to the learning curve (LC) of the surgeon that has initiated with this technique.MethodsWe reviewed the first 20 patients that underwent RRPdaV, performed by an expert surgeon, without previous laparoscopic training, but with a wide experience in retropubic and perineal prostatectomy (HV). We analyzed: Surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also: rates and location of surgical margins, as well as functional outcomes with an average follow up of 10 months.ResultsMean operating time was 140 minutes (100-211) and blood loss 180 mL (80-360), and none required a blood transfusion. There were no intraoperative complications and neither any conversion to open surgery. The only postoperative outstanding fact was mean hospital stay were 3,35 days. (3-5). We had 6 cases of positive surgical margins (30%). The most frequent location was postero-lateral. Eighteen out of 20 patients (90%) were early totally continent, 2 (10%) required the use of one pad during the first six months due slight stress incontinence that stopped spontaneously. From 20 cases, two of them (10%) had preoperative erectile dysfunction; 12 out of the remaining 18 (66.6%) preserved potency at review and 6 (33.4%) had postoperative erectile dysfunction.ConclusionsIt has been demonstrated that robotic surgery for radical prostatectomy is clearly an advantage technique (easy maneuver although it is a minimally invasive technique, comfortable and ergonomic position for the surgeon, 3D visualization and short learning curve). The RRPDAv learning curve is significantly shorter if the surgeon has a wide previous surgical experience in open and/or laparoscopic surgery.     

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.     

经腹膜外途径腹腔镜下前列腺癌根治术

目的 探讨经腹膜外途径腹腔镜下前列腺癌根治术的临床效果及安全性. 方法 临床局限性前列腺癌患者15例,均行经腹膜外途径腹腔镜下前列腺癌根治术.术前平均总PSA 8.1ng/ml,平均Gleason评分5.7±1.3.采用切开腹白线的"北京医院建立腹膜外操作间隙技术"建立腹膜外间隙.手术过程中分离,切割和止血均采用超声刀技术.记录患者手术时间,估计术中出血量、术中并发症、留置引流管时间、术后疼痛指数、术后住院时间、术后病理和PSA等临床资料,并对结果进行分析. 结果 15例手术14例腹腔镜完成,1例因吻合困难中转开放手术.手术时间(316±74)min;术中估计出血量(408±362)ml.5例(33%)患者接受了输血,无直肠及输尿管损伤.术后第1和2天疼痛指数分别为2.3和1.4分.术后留置导尿(14.1±2.9)d,平均住院时间(19.5±4.9)d.术后Gleason评分5.7±1.8.标本切缘阳性2例(13%).病理检查未发现淋巴结转移病例.随访1～12个月,完全控尿10例(67%),PSA<0.2 ng/ml 12例.结论 经腹膜外途径腹腔镜下前列腺癌根治术是一种安全可行的局限性前列腺癌的手术方式.     

Anesthesia for radical prostatectomy

Radical prostatectomy is one of most common treatment options currently recommended for clinically localized prostate cancer. Evaluation of intraoperative and postoperative complications is important in evaluation of relative morbidity of this treatment option. Furthermore, investigation of complications of surgical treatment in correlation with not only surgical technique, but comorbidity, ASA stage and anesthetic technique enables improvements in complete perioperative treatment and decrease of incidence of complications resulting from the procedure. Improvement of anesthetic techniques and use of new anesthetic agents contributes to better outcome of surgical treatment. For radical surgery, combined epidural analgesia and general anesthesia reduces postoperative complications and mortality. Benefits can be conferred most likely by altered coagulation activation in surgery, increased blood flow, reduction of operative stress response. Modalities for reduction of intraoperative blood loss during radical prostatectomy are normovolemic haemodilution, preoperative donation of blood for autologus transfusion and use of erythropoietin for increasing red cell mass.