Retrograde Extraperitoneal Laparoscopic Prostatectomy (RELP). A Prospective Study about 1,000 Consecutive Patients, with Oncological and Functional Results.

PURPOSE: Usual laparoscopic surgery of localized prostate cancer uses antegrade dissection. We describe and evaluate the original RELP (Retrograde Extraperitoneal Laparoscopic Prostatectomy). MATERIALS AND METHODS: A prospective cohort of 1005 patients with clinical localized cancer prostate were operated from December 1999 to September 2013, in Lyon (France), and followed up to 172 months (median: 60 months). Patients encountered a RELP procedure, a totally extra-peritoneal approach with a retrograde dissection from the apex to the bladder neck, and ascending dissection of the erectile neurovascular bundles, facilitated by the 30° optic telescope. Adjunctive treatments were: immediate radiotherapy (9.2%), salvage radiotherapy (13.4%), androgen deprivation therapy (10.8%), chemotherapy (1.4%), no treatment (75.8%). Results The mean age was 63.4, the Gleason score was 4+3 or worse in 24.9%, there were 2.3% unifocal tumors. The pathology stages were pT2A (8.71%), pT2B (2.80%), pT2C (69.0%), pT3A (13.1%), and pT3B (6.41%). There were 60.8% negative margins (R0) in total (90.1% for basal locations, and 75.8% for apical locations). The mean operating time was 115 minutes for the last 100 patients. The BPFSR (biological progression free survival rate, PSA≤0.10 ng/ml) was 71.9% at 5 years, and 61.4% at 10 years. The cancer specific survival rate was 99.4% at 5 years, and 98.3% at 10 years. After 12 months, 88.6% of patients did not require an incontinence pad, and 67.0% retained the pre-operative quality of their erection. CONCLUSION: RELP yields good oncologic results and quality of life, as good as robot-assisted surgery.

Mid-term biochemical recurrence-free outcomes following robotic versus laparoscopic radical prostatectomy.

We compared 5-year biochemical recurrence (BCR)-free rates for robotic-assisted laparoscopic prostatectomy (RALP) and laparoscopic radical prostatectomy (LRP). Three hundred and twelve consecutive patients who underwent RALP from 2003 to 2008 were compared to 97 consecutive LRP patients from 1999 to 2004. All laparoscopic surgeries were performed by one surgeon and robotic surgeries were performed by this surgeon or a laparoscopically naïve surgeon. Both groups were evaluated for perioperative outcome, pathologic status, and mid-term oncologic outcomes (5-year BCR-free rates at prostate-specific antigen [PSA] cutoffs of <0.4, <0.2, or <0.1 ng/ml). Baseline characteristics were equivalent except for age (61.9 years vs. 65.1 years, P < 0.0001). RALP operating time was shorter (215.5 min vs. 305.3, P < 0.0001), and resulted in fewer complications (3.8% vs. 10.3%, P = 0.0214) and blood transfusions (2.9% vs. 13.4%, P = 0.0003). Positive surgical margins were equivalent (pT2 20.9% vs. 28.8%, P = 0.1818). Overall 5-year BCR-free rates were comparable for RALP (97.6, 93.4, and 85.1%) and LRP (97.7, 89.7, and 79.7%) at PSA cutoff levels of <0.4, <0.2, and <0.1 ng/ml, respectively. There was a significant difference in BCR-free rates between the RALP and LRP groups for patients with organ-confined (pT2) disease at 0.2 ng/ml (96.4% vs. 88.7%, P = 0.0373) and 0.1 ng/ml (91.0% vs. 83.0%, P = 0.0470). We report lower morbidity, comparable pathologic outcome and improved mid-term oncologic results in patients with organ-confined disease after RALP in comparison to LRP.

[Retrograde extraperitoneal laparoscopic prostatectomy (R.E.I.P). Simplified technique (based on a series of 143 cases]. / Prostatectomie extrapéritonéale rétrograde laparoscopique (P.E.R.L.) Technique simplifiée (à propos d'une série de 143 cas).

Since the first laparoscopic prostatectomies, performed via an intraperitoneal approach in Bordeaux, France, in November 1997 (Gaston et al.) and then via an extraperitoneal approach in Belgium in September 1999 (BOLLENS et al.), several French (Montsouris and Mondor) and European teams have adopted and amplified these approaches, but much late and more discreetly in the case of the extraperitoneal approach. A multidisciplinary collaboration initiated in Lyon in 1999 has led to the development of an original retrograde extraperitoneal laparoscopic technique (R.E.L.P.) which exactly reproduces the conventional open operation and which allows primary access and dissection of the erectile neurovascular pedicles and the prostatic-urethral sphincter junction, followed by retrograde prostato-rectal dissection. This technique, based on a series of 143 operations at the end of 2002, which exclusively uses an oblique vision scope, comprises the following steps: 1. Access to and exposure of the surgical field, an essential step which determines the success of the rest of the operation. 2. Primary or secondary pelvic lymphadenectomy. 3. Primary access to the erectile neurovascular pedicles and prostatic-urethral sphincter junction, which, together with the following step, represents the original feature of this technique. 4. Urethral section and retrograde prostato-rectal and seminal dissection. 5. Vesico-prostatic cleavage, and antegrade dissection of the seminal vesicles and vesico-prostatic attachments. 6. Vesicourethral anastomosis by interrupted sutures tied extracorporeally. The still limited preliminary results are very encouraging and will soon be reviewed with a longer follow-up, which should show that the retrograde extraperitoneal approach is a technique of choice for laparoscopic radical prostatectomy.