Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ≥ 1 year of follow-up.

BACKGROUND: Robot-assisted laparoscopic radical prostatectomy (RARP) has become the main surgical option for localized prostate cancer. We recently developed a new approach for RARP, passing through the pouch of Douglas and avoiding all the Retzius structures involved in continence and potency preservation. OBJECTIVE: To report the functional and oncologic results of our first 200 patients operated on using this new approach. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective, noncontrolled case series including the first 200 consecutive patients undergoing this kind of surgery (January the 1st, 2010 to December the 31st, 2011). SURGICAL PROCEDURE: Retzius-sparing RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: All perioperative, oncologic, and functional data were prospectively recorded. Potency was defined as an International Index of Erectile Function-5 questionnaire score >17; continence was defined as use of no pad or of one safety liner. Oncologic results were reported as positive surgical margins (PSM) and 1-yr biochemical disease-free survival (1y-bDFS). Recurrence was defined as a repeated prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo system. The first 100 patients (group 1) were compared with the second 100 (group 2) to evaluate the learning curve effects. RESULTS AND LIMITATIONS: The median patient age was 65 yr. Comparing the two groups, transfusions were needed in 8% versus 4% of cases in groups 1 and 2, respectively (p=0.02). There was one Clavien-Dindo grade 3b in group 1 versus one grade 3a complication in group 2. In patients with pT2 disease, PSMs were recorded in 22.4% of those in group 1 versus 10.1% in group 2 (p=0.045). 1y-bDFS was 89% in group 1 versus 92% in group 2. For groups 1 and 2, respectively, immediate continence was reached in 92% versus 90% of patients, and the 1-yr continence rate was 96% versus 96%. Considering the 77 potent patients aged <65 yr who underwent bilateral intrafascial nerve-sparing surgery, 40.4% of those in group 1 versus 40% of those in group 2 reached their first intercourse within 1 mo; at 1 yr of follow-up, these figures had increased to 81% versus 71%, respectively (p=0.162). The main limitation of this study is its noncontrolled nature. CONCLUSIONS: We demonstrated Retzius-sparing RARP to be oncologically safe and to result in high early continence and potency rates. Long-term, prospective, comparative, and possibly randomized studies are needed.

A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery.

Robot-assisted laparoscopic prostatectomy (RALP) has been disseminated widely, changing the knowledge of surgical anatomy of the prostate. The aim of our study is to demonstrate the feasibility of a new, purely intrafascial approach. The Bocciardi approach for RALP passes through the Douglas space, following a completely intrafascial plane without any dissection of the anterior compartment, which contains neurovascular bundles, Aphrodite's veil, endopelvic fascia, the Santorini plexus, pubourethral ligaments, and all of the structures thought to play a role in maintenance of continence and potency. In this case series, we present our first five patients undergoing the Bocciardi approach for RALP. We report the results of our technique in three patients following two unsuccessful attempts. No perioperative major complication was recorded. Pathologic stage was pT2c in two patients and pT2a in one patient, with no positive surgical margin. The day after removing the catheter, two of the three patients reported use of a single, small safety pad, and one patient was discharged without any pad. One patient reported an erection the day after removing the catheter. The anatomic rationale for better results compared with traditional RALP is strong, but well-designed studies are needed to evaluate the advantages of our technique.

Gastrointestinal stromal tumor presenting as a large abdominal mass.

OBJECTIVE: We report on a male patient operated on for a mesenchymal tumor of the digestive tract presenting a mega cyst-like abdominal mass. MATERIAL AND METHODS: The size of the lesion was magnum, the mass presented as unilocular, the wall thickness was not uniform (0.1 to 1 cm) with hemorragic areas, the lesions were multiple measuring 3x2 cm and less, the mitotic index was borderline. The diagnosis was histologically defined as GIST borderline (low mitotic count and tumor size < 5 cm). The ultrasonography and TAC were unable to diagnostic information. CONCLUSION: The GIST presents no specific signs and the most frequent symptoms are abdominal pain and abdominal mass, the CT scan and ultrasonography are sensitive in the evaluation of location, size, invasion of adjacent organs but not for diagnosis. Prognostic predictions are on the basis of mitotic index and tumor size (1). The precise cellular origin of GIST (2) has recently been proposed to be the interstitial cell of Cajal, an intestinal pacemaker cell. The gain-of function mutation of c-kit (receptor tyrosine kinase--KIT positive tumor) proto-oncogene has been detected in GIST and its role in molecular pathogenesis has been established. The treatment of unresectable and metastatic lesion is Imatinib mesylate, inhibitor of tyrosine-kinase activity (Gleevec, Novartis).