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.

[Can we prevent prostatic cancer: role of nutrition?]. / Peut-on prevenir le cancer de la prostate: role de la nutrition?

The present paper gives a comprehensive overview of recent data, especially prospective randomized trials, which support an important role for nutrition in the development of prostate cancer. Prostate cancer seems to be an ideal candidate for chemoprevention, in order to interfere by modification of nutritional habits with its onset, its incidence and ultimately with its progression, especially in high risk groups.

Is one set of sextant biopsies enough to rule out prostate Cancer? Influence of transition and total prostate volumes on prostate cancer yield.

PURPOSE: Although the sextant biopsy technique has been widely used, concern has arisen that this method may not include an adequate sampling of the prostate, especially for large prostate volumes. We conducted a multicenter study in patients with PSA levels <10 ng/ml to determine the influence of the total and transition zone (TZ) volumes of the prostate for predicting whether one single set of biopsies was sufficient to rule out prostate cancer (PCa). These parameters were evaluated in patients in whom PCa was found after one set of systematic sextant biopsies and those in whom PCa was found after a repeat biopsy. MATERIALS AND METHODS: A total of 1,018 patients were included in this study. All underwent transrectal ultrasound-guided needle sextant and two TZ biopsies of the prostate. Total and TZ volumes of the prostate were measured (prolate ellipsoid method). From this cohort, all patients in whom a benign disease was found after the first set of biopsies underwent a second similar set of biopsies within 6 weeks. Only patients with PCa were included in this study, whether diagnosed on first or repeat biopsy. Uni- and multivariate statistical analysis using the SAS system (Cary, N.C., USA) and ROC curves were used to compare patients in whom the diagnosis was performed after the first set of biopsies and those who required a second set. RESULTS: Of the 1,018 patients, 344 (33.8%) had PCa diagnosed, 285 (28%) after the first set of biopsies, and 59 (8.1%) on repeat biopsy. As compared to patients diagnosed with PCa after the first set of biopsies, patients diagnosed after the second set had larger total prostate and TZ volumes (43.1+/-13.0 vs. 32.5+/-10.6 cm(3), p<0.0001 and 20.5+/-8.3 vs. 12.8+/-6.0 cm(3), p<0.0001). ROC curves showed that total and TZ volumes of 45 and 22. 5 cm(3), respectively, provided the best combination of sensitivity and specificity for discriminating between patients diagnosed with PCa after the first from those diagnosed after a second set. CONCLUSION: In patients with total prostate volume >45 cm(3) and TZ >22.5 cm(3), a single set of sextant biopsies may not be sufficient to rule out PCa. In these patients, a repeat biopsy should be considered in case of a negative first biopsy.

[Urinary lithiasis: epidemiology and physiopathology]. / Lithiase urinaire: épidemiologie et physiopathologie.

Urolithiasis has an incidence of about 12% in men and about 5% in women before the age of 70 years. Several epidemiological factors are involved in the predisposition to the urinary stone disease, notably: age, sex, race, climate, geography, profession, social class, nutritional factors and inherent genetic particularities. A number of physicochemical mechanisms govern lithogenesis, passing from saturation and supersaturation of urine to nucleation, crystallization and crystal growth to clinically significant sizes when the inhibition mechanisms are overwhelmed or absent. Generally urinary stone are of diverse aetiologies, that can essentially be grouped in calcium, uric acid, cystine and magnesium ammonium phosphate stones with subgroups in relation to the varied pathophysiological mechanisms involved in each case.

[A metabolic approach to patients with calculi]. / Approche métabolique du patient lithiasique.

Metabolic evaluation remains cornerstones in the treatment and prevention of recurrence in patients with urolithiasis. The various chrystallographic, biological and radiological investigation should be done only in patients presenting recurrence and/or given risks factor of recurrences. The choice of the investigation is guided by the knowledge of the pathophysiological phenomena and should thus be adapted to each patient. Results should be analyzed by a multidisciplinary team. This aspect will be developed in the next paragraph.

[Abscess of the rectovaginal wall in women. Apropos of a case]. / Abcès de la cloison recto-vaginale chez la femme. A propos d'un cas.

Recto-vaginal septum abscess is a rare entity in women. The authors report a rare clinical observation of a recto-vaginal septum abscess in a 40 year old woman, hospitalized and treated in the Surgical Unit of the Yaounde General Hospital. Medical literature was reviewed and surgical indications discussed.

[Postoperative necrotizing fasciitis in infants. Apropos of a case]. / Fasciite nécrosante post-opératoire chez le nourrisson. A propos d'un cas.

A case of postoperative necrotizing fasciitis after a right incarcerated inguinal hernia repair is reported in a six week old baby hospitalized in the paediatric surgical unit of the Yaounde General Hospital. Treatment consisted in a medical reanimation, surgical debridement and an appropriate antibiotherapy. Medical literature was reviewed and therapeutic indications discussed.

[Late exterioration of a postoperative cecal fistula in children. Apropos of a rare clinical case]. / Fistule caecale postopératoire tardivement extériorisée chez l'enfant. A propos d'une observation clinique rare.

The authors report a rare clinical observation of a post-appendectomy caecal fistula retardedly exteriorized, in a 18 year old adolescent, managed in the surgical service of the Yaounde General Hospital. The radical treatment was surgical and consisted in right hemicolectomy. Literature was reviewed and therapeutic indications discussed.