Purpose
Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS ...performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR).
Methods
We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications.
Results
From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP.
Conclusions
In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.
To evaluate the feasibility of robotic salvage prostatectomy for local recurrence after permanent brachytherapy implants for prostate cancer.
Seven patients were operated by robotic salvage ...prostatectomy with or without pelvic lymph node dissection between October 2007 and March 2012, for a local recurrence after iodine 125 permanent brachytherapy implants. Local recurrence was proved by prostate biopsies, once biochemical relapse was diagnosed and imaging assessment performed.
The average age of a patient at the time of diagnosis was 66 years (62–71 years). The median nadir prostate specific antigen (PSA) serum concentration after brachytherapy was 1.29ng/mL (0.6–2.1ng/mL), obtained after a median of 12 months (7–21 months). The average PSA before robotic salvage prostatectomy was 6.60ng/mL (4.17–13.80ng/mL). PSA at 1 and 3 months after prostatectomy was less than 0.05ng/mL in five patients. PSA remained below 0.05ng/mL for six patients at 12 and 24 months. One month after robotic salvage prostatectomy, all patients had at least partial urinary incontinence. At 12 and 24 months after robotic salvage prostatectomy four patients have regained full urinary continence. In terms of erectile function at 24 months, three patients retained erectile function with possible sexual intercourse.
Robotic salvage prostatectomy appears to be a reliable treatment in terms of oncological outcome with convincing results both for urinary continence and erectile function for selected patients with local recurrence after permanent brachytherapy implants.
Évaluer la faisabilité d’une prostatectomie de rattrapage robotisée pour une rechute locale après une curiethérapie de prostate initiale par implants permanents.
D’octobre 2007 à mars 2012, sept patients pris initialement en charge par curiethérapie de prostate par iode 125, en situation de rechute locale, ont bénéficié d’une prostatectomie robotisée avec ou sans curage pelvien ganglionnaire. Les patients étaient en situation de rechute biologique selon la concentration sérique de d’antigène spécifique de la prostate et avaient eu un bilan d’imagerie complet. Le diagnostic de rechute locale a été confirmé par les biopsies prostatiques.
L’âge moyen des patients au moment du diagnostic était de 66 ans (62–71). Le nadir médian de la concentration sérique de d’antigène spécifique de la prostate à un an de la curiethérapie était de 1,29ng/mL (0,6–2,1mg/mL). La concentration moyenne d’antigène spécifique de la prostate lors du traitement de rattrapage par prostatectomie robotisée était de 6,60ng/mL (4,17–13,80ng/mL). La concentration sérique de d’antigène spécifique de la prostate était à 1 et 3 mois de la prostatectomie de moins de 0,05ng/mL pour cinq patients. À 12 et 24 mois, elle est restée inférieure à 0,05ng/mL pour six patients. Un mois après la chirurgie, tous les patients souffraient d’une incontinence urinaire partielle. À 12 et 24 mois, cinq patients avaient une continence parfaite. Pour ce qui concerne la fonction érectile, à 24 mois, trois patients ont conservé une fonction érectile permettant les rapports.
La prostatectomie de rattrapage robotisée réalisée pour des patients sélectionnés en situation de rechute locale après curiethérapie est une option thérapeutique à considérer, avec des résultats fiables et des résultats fonctionnels probants en termes de continence et de conservation érectile.
Objective
To evaluate the accuracy in histologic grading of MRI/US image fusion biopsy by comparing histopathology between systematic biopsies (SB), targeted biopsies (TB) and the combination of both ...(SB + TB) with the final histopathologic outcomes of radical prostatectomy specimens.
Materials and methods
Retrospective, multicentric study of 443 patients who underwent SB and TB using MRI/US fusion technique (Urostation
®
and Trinity
®
) prior to radical prostatectomy between 2010 and 2017. Cochran’s
Q
test and McNemar test were conducted as a post hoc test. Uni-multivariable analyses were performed on several clinic-pathological variables to analyze factors predicting histopathological concordance for targeted biopsies.
Results
Concordance in ISUP (International Society of Urological Pathology) grade between SB, TB and SB + TB with final histopathology was 49.4%, 51.2%, and 63.2% for overall prostate cancer and 41.2%, 48.3%, and 56.7% for significant prostate cancer (ISUP grade ≥ 2), respectively. Significant difference in terms of concordance, downgrading and upgrading was found between SB and TB (ISUP grade ≥ 2 only), SB and SB + TB, TB and SB + TB (overall ISUP grade and ISUP grade ≥ 2) (
p
< 0.001). Total number of cores and previous biopsies were significant independent predictive factors for concordance with TB technique.
Conclusion
In this retrospective study, combination of SB and TB significantly increased concordance with final histopathology despite a limited additional number of cores needed.
To describe our technique of nerve sparing laparoscopic radical prostatectomy (LRP). We present the oncological and functional results (potency and urinary continence).
LRP has become standard at our ...institution based on experience with more than 2800 consecutive cases operated on between 1997 and 2005. From May 2003 to March 2005 a total of 677 LRP were performed, 425 consecutive patients candidates for a nerve sparing technique have been operated using the intrafascial approach. The challenge of our technique is to remove the prostate without any thermic and mechanic traumatism, avoiding dissection of outer layer. Oncological data were assessed by pathological examination and post-operative PSA level. Functional results were assessed with a self questionnaire.
By pathological stage, 2 pT2a specimens (7.4%), 7 pT2b specimens (21%), 44 pT2c specimens (24%), 63 pT3a specimens (43%), 11 pT3b specimens (46%) were found to have positive surgical margins (SMs). In 86 specimen (59%) positive SMs were focal inframillimetric. Median follow-up was 11 months (range 1–22). The continence rate (no leakage/no pad) was 95% at 6 months, confirmed at 12 months among 202 patients. For 137 patients, potency rate was 58.5% at 12 months.
Intrafascial LRP provides satisfactory results in regard to recovery of continence and sexual function. Long-term progression and survival outcome are necessary before this procedure should be offered as a replacement for interfascial nerve sparing technique.
In case of a single renal cell carcinoma strictly located in the kidney, the radical nephrectomy remains the treatment of choice. However, it has been estimated that nearly 30 to 40 % of renal cell ...carcinoma are about to recur after primitive surgery. In certain cases, conservative surgery can be discussed as an alternative to radical treatment, especially in case of exophytic renal tumour or less than 4 cm in diameter. New ablative techniques (radiofrequency and cryoablation) have shown promising results but the follow-up is still very limited. French national recommendation regarding kidney cancer have been updated in 2007 and following the development of clinical trials using antiangiogenic agents. Regarding the use of antiangiogenic agents, several points have to be taken into account: existence of renal cell carcinoma, presence of metastasis, number of metastasis, location and risk factor prognosis determination.
To assess the accuracy of targeted and systematic biopsies for the detection of prostate cancer (PCa) and clinically significant PCa (csPCa) in the everyday practice, evaluating the need for ...additional systematic biopsies at the time of targeted biopsy.
From our multicentric database gathering data on 2,115 patients who underwent fusion biopsy with Koelis™ system between 2010 and 2017, we selected 1,119 patients who received targeted biopsies (a median of 3 for each target), followed by systematic sampling of the prostate (12 to 14 cores). Overall and clinically significant cancer detection rate (CDR) of Koelis™ fusion biopsies were assessed, comparing target and systematic biopsies. Secondary endpoint was the identification of predictors of PCa detection.
The CDR of targeted biopsies only was 48% for all cancers and 33% for csPCa. The performance of additional, systematic prostate sampling improved the CDR of 15% for all cancers and of 12% for csPCa. PCa was detected in 35%, 69%, and 92% of patients with lesions scored as PI-RADS 3, 4 and 5, respectively. Elevated PI-RADS score and positive digital rectal examination were predictors of PCa, whereas biopsy-naïve status was associated with csPCa.
In the everyday practice target biopsy with Koelis™ achieves a good CDR for all PCa and csPCa, which is significantly improved by subsequent systematic sampling of the prostate. The outstanding outcomes of fusion biopsy are confirmed also in biopsy-naïve patients. Elevated PI-RADS score and positive digital rectal examination are strongly associated with presence of PCa.
Laparoscopic promontofixation often remains possible whatever the previous history of pelvic surgery, including the placing of prosthetic material. Preoperative care is standardized and is ...accompanied by antibiotic prophylaxis, preventive antithrombotic treatment and in the event of a history of pelvic surgery, a digestive preparation. Positioning of the patient must plan a 30 degrees Trendelenbourg position. After the introduction of trocars, initial surgery comprises interrectovaginal dissection to free the whole posterior surface of the vagina. This is followed by the installation of a posterior mesh pre-cut in an arch. The anterior face of the promontory is then freed after incision of the posterior peritoneum with the patient placed beforehand in a Trendelenbourg position. After intervesical vaginal dissection, the anterior prosthesis comprising a precut polyester mesh is fixed avoiding excess traction. The end of the surgery involves careful reperitonization of all the prosthetic parts. Possible specific surgical complications are vascular and visceral wounds. Postoperative secondary haemorrhage and gastrointestinal occlusion may occur. Occurrence of an inflammatory syndrome and low back pain suggests spondylodicitis and MRI should be performed. Vaginal erosion on the prosthesis (1.6 to 10% depending on the series) may occur after several months and seems relatively independent of the prosthetic material used.
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