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      Posterior Reconstruction and Outcomes of Laparoscopic Radical Prostatectomy in a High-Risk Setting

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          Abstract

          Posterior reconstruction was found to be associated with lower degree of anastomotic leakage and enhanced urinary continence at one and three months after extrafascial laparoscopic radical prostatectomy.

          Abstract

          Background and Objectives:

          To detail the technique and evaluate the impact of a personal modified posterior reconstruction technique (PDR) on the outcomes of extrafascial laparoscopic radical prostatectomy (eLRP) in a consecutive series of 52 patients affected by high-risk prostate cancer (HRPCa).

          Methods:

          From October 2007 to March 2012, 52 patients underwent PDR during eLRP for HRPCa. Fifty-four patients who underwent eLRP for HRPCa with no PDR were considered as historical controls. Mean operative time (MOT), mean catheterization time (MCT), % continence and quality of life (QoL) at a scheduled follow-up, % anastomotic leakage, % adjuvant therapy were compared between the groups. Percentage of continence and QoL were prospectively assessed by self-administered validated questionnaires (ICI-Q-SF; SF-36) at 1, 3, 6, and12 months.

          Results:

          PDR was associated wither higher continence rates at 1 and 3 mo ( P = .028, P = .006), a lower incidence of cystographic leakage ( P = .002), and an increased adjuvant radiotherapy rate ( P = .008). At 1- and 3-mo interval, in the PDR group, we found a higher number of patients reporting better general health, ( P = .01, P = .03) reduced role limitations due to physical health, ( P = .02, P = .001), and emotional problems ( P = .001, P = .02).

          Conclusions:

          PDR is associated with a lower degree of anastomotic leakage, and it significantly enhances urinary continence at 1 and 3 mo. The increased adjuvant radiotherapy rate and quality of life after surgery observed with our technique suggest that in the high-risk setting an early functional recovery may substantially influence the oncologic outcome of eLRP.

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          Most cited references 19

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          EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer.

          Our aim is to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC). The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and the levels of evidence (LEs) and/or grades of recommendation (GR) were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews. Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). Although LHRH antagonists decrease testosterone without any testosterone surge, their clinical benefit remains to be determined. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation (IAD) results in equivalent oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values >0.2 ng/ml following radical prostatectomy (RP) and >2 ng/ml above the nadir after radiation therapy (RT). Therapy for PSA relapse after RP includes salvage RT at PSA levels 20 ng/ml. Follow-up after ADT should include screening for the metabolic syndrome and an analysis of PSA and testosterone levels. Treatment of castration-resistant prostate cancer (CRPC) includes second-line hormonal therapy, novel agents, and chemotherapy with docetaxel at 75 mg/m(2) every 3 wk. Cabazitaxel as a second-line therapy for relapse after docetaxel might become a future option. Zoledronic acid and denusomab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications. The knowledge in the field of advanced, metastatic, and CRPC is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice. A full version is available at the EAU office or online at www.uroweb.org. Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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            Laparoscopic radical prostatectomy: the Montsouris technique.

            Laparoscopic radical prostatectomy has become standard at our institution based on experience with 260 consecutive cases operated on between January 1998 and December 1999. In view of the favorable short-term outcomes we describe our standardized laparoscopic radical prostatectomy technique. Two urologists trained in open retropubic radical prostatectomy and laparoscopy combined their experience to develop a specific technique of nonincisional radical prostatectomy for localized prostate cancer. Patients presented with clinical stages T1b to T2 prostate cancer and tumor size was approximately 18 to 130 gm. Operations were performed by 1 senior surgeon and 1 assistant, with the help of a voice controlled robot and with the patient under general anesthesia. The 2, 10 mm. ports and 3, 5 mm. ports were placed in the umbilicus and iliac fossa. The laparoscopic procedure was performed transperitoneally, combining anterograde and retrograde approaches in 7 standardized steps. Urethrovesical anastomosis was performed with 3-zero interrupted sutures tied intracorporeally. Technical details were compiled, summarized and illustrated with schematic views. Operating time was approximately 3 hours for the last 120 cases. Estimated average blood loss was 250 ml. with a transfusion rate of less than 1%. The conversion rate was 0%. Postoperative pain was minimal and analgesics were generally not required by postoperative day 2. The accuracy of dissection and sutures allowed patients to be discharged home without urethral catheterization starting on postoperative day 3. Laparoscopic radical prostatectomy is now not only feasible, but more importantly reproducible. Each step has been checked and validated, and the procedure is standardized and has definitively replaced the retropubic approach in our practice.
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              Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes.

              The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation. A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months. We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature. A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy.
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                Author and article information

                Contributors
                Policlinico Tor Vergata, Department of Urology, Rome, Italy
                S. Camillo-Forlanini Hospital, Department of Urology, Rome, Italy.
                S. Camillo-Forlanini Hospital, Department of Urology, Rome, Italy.
                S. Camillo-Forlanini Hospital, Department of Urology, Rome, Italy.
                Journal
                JSLS
                JSLS
                jsls
                jsls
                JSLS
                JSLS : Journal of the Society of Laparoendoscopic Surgeons
                Society of Laparoendoscopic Surgeons (Miami, FL )
                1086-8089
                1938-3797
                Oct-Dec 2013
                : 17
                : 4
                : 535-542
                Affiliations
                Policlinico Tor Vergata, Department of Urology, Rome, Italy
                S. Camillo-Forlanini Hospital, Department of Urology, Rome, Italy.
                S. Camillo-Forlanini Hospital, Department of Urology, Rome, Italy.
                S. Camillo-Forlanini Hospital, Department of Urology, Rome, Italy.
                Author notes

                Drs. Anceschi U, Gaffi M, Molinari C, Anceschi C have no conflicts of interest to disclose.

                Acknowledgments to Mrs. Michela Cangani and Mr. Alessandro Bove for providing illustrations of our work; to Mrs. Francesca Ercoli for her strong and continuous support.

                Address correspondence: to Umberto Anceschi, MD, Department of Urology, Viale dei Colli Portuensi 579 - CAP 00151 Rome (Italy). Policlinico Tor Vergata, Viale Oxford 81 00133- Rome – Italy. Telephone: +39–0665744402; Mobile: +39–3395836431, E-mail: umberto.anceschi@ 123456alice.it
                Article
                MN-11-12-186
                10.4293/108680813X13794522666365
                3866056
                © 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/us/), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

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