Berlin—A laparoscopic preperitoneal approach cannot only serve as a teaching platform for laparoscopic skills for surgeons, but it also demonstrates reproducible outcomes in the treatment of BPH, according to Belgian researchers who presented their results at the European Association of Urology annual congress here.
Researchers from the Institut Jules Bordet, Universite Libre de Bruxelles in Brussels, conducted a 102-patient prospective study comparing a classical open Millin’s retropubic transcapsular adenectomy in 51 patients and a laparoscopic preperitoneal approach in 52 patients according to a step-by-step transposition of Millin’s procedure described in European Urology (2004; 45:103-9).
Preoperative characteristics were comparable between the groups with respect to age, prostate volume measured by trans-rectal ultrasonography, preoperative micturition, post-void residual volume, and International Prostate Symptom Score (IPSS).
For patients at low risk for developing the disease, Dr. Katz recommended using the term “active holistic surveillance” instead of “watchful waiting.” This involves instructing patients to adhere to the following dietary modifications:
* Switch to a low-fat diet.
* Increase intake of fresh vegetables and lycopene.
* Supplement your diet with soy products, vitamin E, and selenium.
* Drink pomegranate juice and two to four cups of green tea daily.
Community urologists who want to learn this must have an adequate volume of cases, at least 20 prostatectomies a year, and it probably will take 20 or 30 procedures before they are comfortable. For someone doing less than 20 cases a year, it doesn’t make much sense. You have to do this procedure with some regularity to keep up your skills.
Pruthi: I hesitate to suggest a number because of the different issues we have mentioned. In the Henry Ford experience, when they looked at complications, the learning curve was 200 cases.
2 At Vanderbilt, the surgeon-reported learning curve was 250 cases.
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They conclude that surgical volume is a determinant of treatment-failure when evidenced by the use of secondary therapies. Surgeons performing 24 RPs per year had the lowest rate of secondary treatment use.
This is robot-assisted surgery — and some say it’s the future of surgery. Miriam Hospital is the first hospital in the state to acquire the robot, called the da Vinci Surgical System, which makes it easier to operate in the tighter corners of the human body.
Between the years1995 and 2004, 1,252 cases of CaP were diagnosed; 810 in the screening arm and 442 in the control arm. Men randomized to active screening had a 1.83-fold increased risk of being diagnosed with CaP compared to men in the control group. Most screened men had localized disease. The number of participants with metastatic CaP at the time of diagnosis (or with a PSA >100ng/ml) was 24 in the screening group compared to 47 in the control group (p=0.0084). This represents a 49% reduction in the risk of being diagnosed with metastatic CaP by screening over a 10-year period.
The study minimized selection bias as men were randomized without any prior information. A study limitation is that men had only sextant biopsy, although the biopsies were directly laterally.
The 1st quarter of 2007 was my busiest for da Vinci Prostatectomies (dvP) for prostate cancer (52 operations), as well as my busiest total robotic surgery 3 month period (60 operations).
My dvP volume increased 63% from the previous year and 24% from the previous quarter, which was then a record.
My total robotic surgery volume increased 50% from the previous year and 15% from the previous quarter, which was then a record as well.
The mean follow-up was 20 months. A total of 4% of patients who were continent pre-procedure were incontinent after therapy. A total of 39% of patients reported being potent pre-treatment and all men were impotent immediately after cryotherapy. The probability for a man potent prior to treatment to regain his ability to have intercourse with or without PDE-5 inhibitor assistance at 1, 2, and 4 years was 29%, 49%, and 51%, respectively. Nearly 80% of men achieved a PSA nadir of less than 0.4ng/mlwith a 4-year biochemical freedom from disease rate of 80%. In those experiencing disease failures, the mean time to failure was 4.2 months. Of 168 patients who underwent a prostate biopsy, 10% had CaP at a mean of 10 months after treatment.
Interestingly, in prostate volumes less than 30gm, lap RP was associated with a PSM in 44%, while no such association existed for open RP.
I have never thought of this before, but a quick look at my robotic data shows that 4 of my 18 prostates that were 30 gm or less had positive margins. This 22% figure is higher than the rest for me as well compared to my 11.8% overall for T2 cancers. It may be with minimally invasive surgery the smaller prostates may be less well defined. I will pay closer attention to these in the future.