Analysis of PI-RADS 4 cases: Management recommendations for negatively biopsied patients.

PURPOSE: To evaluate if subgroups of patients assigned to MRI category PI-RADS 4 regarding clinical and MRI imaging aspects have distinct risks of prostate cancer (PCa) to facilitate adequate clinical management of this population, especially after negative targeted biopsy. METHODS: This prospective, IRB approved single center cross-sectional study includes 931 consecutive patients after mp-MRI at 3 T for PCa detection. 193 patients with PI-RADS assessment category 4 received subsequent combined targeted MRI/US fusion-guided and systematic 12-core TRUS-guided biopsy as reference standard and were finally analyzed. The primary endpoint was PCa detection of PI-RADS 4 with MRI subgroup analyses. Secondary endpoints were analyses of clinical data, location of PCa, and detection of targeted biopsy cores. RESULTS: PCa was detected in 119 of 193 patients (62%) including clinically significant PCa (csPCa; Gleason score ≥3 + 4 = 7) in 92 patients (48%). MRI subgroup analysis revealed 95% PCa (73% csPCa) in unambiguous PI-RADS 4 index lesions without additional, interfering signs of prostatitis in the peripheral zone or overlaying signs of severe stromal hyperplasia in the transition zone according to PI-RADS v2. Transition zone confined PI-RADS-4-lesions with overlaying signs of stromal hyperplasia showed PCa only in 11% (4% csPCa). Targeted biopsy cores missed the csPCa index lesion in 7% of the patients. PSA density (PSAD) was significantly higher in PCa patients. CONCLUSIONS: Small csPCa can reliably be detected with mp-MRI by experienced readers, but can be missed by targeted MR/US fusion biopsy alone. Targeted re-biopsy of unambiguous (peripheral) PI-RADS-4-lesions is recommended; whereas transition zone confined PI-RADS-4-lesions with overlaying signs of stromal hyperplasia might be followed-up by re-MRI primarily.

Influence of arterial input function (AIF) on quantitative prostate dynamic contrast-enhanced (DCE) MRI and zonal prostate anatomy.

PURPOSE: Reproducibility of quantitative perfusion analysis of DCE requires a standardized AIF acquisition. However, there are many different approaches for AIF assessment so that the absolute values of perfusion parameters may vary depending on the used method. This study analyzes the influence of the method of AIF determination on quantitative DCE-MRI. METHODS: In this retrospective, single-center, cohort study three different methods of AIF determination in 50 consecutive patients with multiparametric MRI of the prostate were conducted. As a reference, AIF was selected manually by defining a region of interest in an artery manually (AIFm). The second method (AIFa), based on an automated algorithm and the third, population-derived AIFp where then compared. Primary endpoint were differences in the performance of the perfusion parameters Ktrans, ve and kep regarding the AIF acquisition methods, secondary endpoints consisted of the evaluation of differences in the peripheral and transition zone of the prostate (PZ, TZ). RESULTS: In all three methods, Ktrans, ve, and kep were significantly higher in PZ than in TZ with Ktrans showing least overlapping. There were no significant differences for Ktrans determined with AIFm and AIFa (0.3 ±â€¯0.2 min-1 for PZ for both and 0.5 ±â€¯0.3 min-1 for TZ in AIFm and 0.4 ±â€¯0.3 min-1 in AIFa), while there were great differences between AIFa and AIFp and AIFm and AIFp (0.1 ±â€¯0.03 min-1 for TZ and PZ in AIFp). Spearman test demonstrated good correlation of values for Ktrans and kep in all 3 methods (ρ ≥ 0.76). AIFa showed a success rate of 98% in finding the artery. CONCLUSION: AIFa is a recommendable user-independent automatical method to determine quantitative perfusion parameters allowing an objective measurement and saving interactive time for the radiologist. AIFp may be applied as second alternative method.

Hyoscine butylbromide significantly decreases motion artefacts and allows better delineation of anatomic structures in mp-MRI of the prostate.

OBJECTIVES: To prospectively evaluate the effect of hyoscine butylbromide (HBB) on visualisation of anatomical details and motion-related artefacts in mp-MRI of the prostate at 3.0 Tesla. METHODS: One hundred and three consecutive patients (65 ± 10 years) were included in this trial, powered to demonstrate an improvement of image quality after HBB administration, assessed on a 5-point scale by two blinded readers. All patients received high-spatial resolution axial T2-weighted TSE sequences at 3.0 T without spasmolytic agent, repeated after application of 40 mg HBB and followed by routine mp-MRI. Secondary endpoints were (1) susceptibility to side effects, (2) dependence of spasmolytic effect on patients´ weight, and (3) prostate volume. RESULTS: In 68% of patients, HBB significantly improved the anatomic score (mean 3.4 ± 0.9 before and 4.4 ± 0.7 after HBB for both readers, p = <0.001). In 67%, HBB significantly enhanced the artefact score (mean 3.2 ± 1 before and 4.2 ± 0.8 after HBB for reader 1, p = <0.001; 3.2 ± 1 and 4.1 ± 0.8 for reader 2, p = <0.001). Subgroup analysis revealed no statistically significant difference between patients with different bodyweight or prostate volume. Inter-reader agreement was excellent (k = 0.95-0.98). CONCLUSIONS: Hyoscine butylbromide significantly improves image quality and reduces motion-related artefacts in mp-MRI of the prostate independent of bodyweight or prostate volume. No side effects were reported. KEY POINTS: • Hyoscine butylbromide (HBB) improved image quality in over 2/3 of patients. • Severe artefacts were reduced after HBB in more than 20%. • The number of non-diagnostic MRI was reduced to <1% after HBB. • HBB effect was independent of bodyweight and prostate volume. • No side effects of HBB were reported in this study population.

Magnetic resonance imaging of the prostate at 1.5 versus 3.0T: A prospective comparison study of image quality.

OBJECTIVES: This study prospectively evaluates objective image quality (IQ), subjective IQ, and PI-RADS scoring of prostate MRI at 3.0T (3T) and 1.5T (1.5T) within the same patients. METHODS: Sixty-three consecutive patients (64±9years) were prospectively included in this non-inferiority trial, powered at 80% to demonstrate a ≤10% difference in signal-to-noise (SNR) and contrast-to-noise ratio (CNR) of T2-weighted and diffusion-weighted imaging (T2WI, DWI) at 1.5T compared to 3T. Secondary endpoints were analysis of subjective IQ and PI-RADS v2 scoring. RESULTS: All patients received multi-parametric prostate MRI on a 3T (T2WI, DWI, DCE) and bi-parametric MRI (T2WI, DWI) on a 1.5T scanner using body coils, respectively. SNR and CNR of T2WI were similar at 1.5T and 3T (p=0.7-1), but of DWI significantly lower at 1.5T (p<0.01). Subjective IQ was significantly better at 3T for both, T2WI and DWI (p<0.01). PI-RADS scores were comparable for both field strengths (p=0.05-1). Inter-reader agreement was excellent for subjective IQ assessment and PI-RADS scoring (k=0.9-1). CONCLUSION: Prostate MRI at 1.5T can reveal comparable objective image quality in T2WI, but is inferior to 3T in DWI and subjective IQ. However, similar PI-RADS scoring and thus diagnostic performance seems feasible independent of the field strength even without an endorectal coil.

Targeted MRI-guided prostate biopsy: are two biopsy cores per MRI-lesion required?

PURPOSE: This study evaluates the feasibility of performing less than two core biopsies per MRI-lesion when performing targeted MR-guided in-bore prostate biopsy. METHODS: Retrospectively evaluated were 1545 biopsy cores of 774 intraprostatic lesions (two cores per lesion) in 290 patients (66 ± 7.8 years; median PSA 8.2 ng/ml) regarding prostate cancer (PCa) detection, Gleason score, and tumor infiltration of the first (FBC) compared to the second biopsy core (SBC). Biopsies were acquired under in-bore MR-guidance. RESULTS: For the biopsy cores, 491 were PCa positive, 239 of 774 (31 %) were FBC and 252 of 771 (33 %) were SBC (p = 0.4). Patient PCa detection rate based on the FBC vs. SBC were 46 % vs. 48 % (p = 0.6). For clinically significant PCa (Gleason score ≥4 + 3 = 7) the detection rate was 18 % for both, FBC and SBC (p = 0.9). Six hundred and eighty-seven SBC (89 %) showed no histologic difference. On the lesion level, 40 SBC detected PCa with negative FBC (7.5 %). Twenty SBC showed a Gleason upgrade from 3 + 3 = 6 to ≥3 + 4 = 7 (2.6 %) and 4 to ≥4 + 3 = 7 (0.5 %). CONCLUSION: The benefit of a second targeted biopsy core per suspicious MRI-lesion is likely minor, especially regarding PCa detection rate and significant Gleason upgrading. Therefore, a further reduction of biopsy cores is reasonable when performing a targeted MR-guided in-bore prostate biopsy. KEY POINTS: • Higher PI-RADS overall score (IV-V) correlated well with PCa detection rate • In more than 80 % SBC was concordant regarding overall PCa detection • In almost 90 % there was no Gleason upgrading by the SBC • Only 2/54 (3.7 %) csPCa was missed when the SBC was omitted • For IB-GB a further reduction of biopsy cores is reasonable.

Predictive power of the ESUR scoring system for prostate cancer diagnosis verified with targeted MR-guided in-bore biopsy.

PURPOSE: This study evaluates the diagnostic value of the ESUR scoring system (PI-RADS) regarding prostate cancer detection using MR-guided in-bore biopsies (IB-GB) as the reference standard. METHODS: 566 lesions in 235 consecutive patients (65.7 ± 7.9 years, PSA 9.9 ± 8.5 ng/ml) with a multiparametric (mp)-MRI (T2WI, DWI, DCE) of the prostate at 3T were scored using the PI-RADS scoring system. PI-RADS single (PSsingle), summed (PSsum), and overall (PSoverall) scores were determined. All lesions were histologically verified by IB-GB. RESULTS: Lesions with a PSsum below 9 contained no prostate cancer (PCa) with Gleason score (GS) ≥ 4+3=7. A PSsum of 13-15 (PSoverall V) resulted in 87.8% (n=108) in PCa and in 42.3% (n=52) in GS ≥ 4+3=7. Transition zone (TZ) lesions with a PSsum of 13-15 (PSoverall V) resulted in 76.3% (n=36) in PCa and in 26.3% (n=10) in GS ≥ 4+3=7, whereas for peripheral zone (PZ) lesions cancer detection rate at this score was 92.9% (n=79) and 49.4% (n=42) for GS ≥ 4+3=7. Using a threshold of PSsum ≥ 10, sensitivity was 86.0%, and negative predictive value (NPV) was 86.2%. For higher grade PCa sensitivity was 98.6%, and NPV was 99.5%. CONCLUSION: A PSsum below 9 excluded a higher grade PCa, whereas lesions with a PSsum ≥ 13 (PSoverall V) represented in 88% PCa, and in 42% higher grade PCa. The PSsum or PSoverall demonstrated a better diagnostic value for PZ lesions with higher detection rates for higher grade PCa compared to TZ lesions.

Inter-reader agreement of the ESUR score for prostate MRI using in-bore MRI-guided biopsies as the reference standard.

OBJECTIVES: The recent European Society of Urogenital Radiology (ESUR) guidelines for evaluation and reporting of prostate multiparametric magnetic resonance imaging (mp-MRI) include the Prostate Imaging Reporting and Data System (PI-RADS). The aim of this study was to investigate the inter-reader agreement of this scoring system. METHODS: One hundred and sixty-four lesions in 67 consecutive patients with elevated prostate-specific antigen and previously negative trans-rectal ultrasound (TRUS)-guided biopsy were scored retrospectively by three blinded readers using PI-RADS. Mp-MRI was performed at 3 T using T2-weighted, diffusion-weighted and dynamic contrast-enhanced imagings (T2WI, DWI, DCE-MRI). Histology of all lesions was obtained by in-bore MRI-guided biopsy. Cohen's kappa statistics were calculated for all readers. RESULTS: Inter-reader agreement for all lesions was good to moderate (T2WI, κ = 0.55; DWI, κ = 0.64; DCE-MRI, κ = 0.65). For tumour lesions it was good (T2WI, κ = 0.66; DWI, κ = 0.80; DCE-MRI, κ = 0.63) and for benign lesions moderate to good (T2WI, κ = 0.46; DWI, κ = 0.52; DCE-MRI, κ = 0.67). Using an overall PI-RADS score with a threshold of ≥10, we achieved a sensitivity of 85.7 %, and negative predictive value of 90.1 % for biopsied lesions. CONCLUSION: PI-RADS score shows good to moderate inter-reader agreement and enables standardised evaluation of prostate mp-MRI, with high sensitivity and negative predictive value. KEY POINTS: • The European Society of Urogenital Radiology recently published guidelines for prostate MRI. • We have evaluated inter-reader agreement of ESUR scoring for multiparametric prostate MRI. • PI-RADS shows good to moderate inter-reader agreement and is clinically applicable. • PI-RADS achieves in our series high sensitivity and negative predictive value for biopsied lesions. • PI-RADS can be used as standardised scoring system in prostate cancer detection.

Holmium laser ablation of the prostate (HoLAP): intermediate-term results of 144 patients.

PURPOSE: To retrospectively analyse the intermediate-term outcome of holmium laser ablation of the prostate (HoLAP) of up to 4 years postoperatively in one of the largest series and to define the selection criteria for patients who benefit from potentially lower complications associated with HoLAP. METHODS: Between June 2006 and November 2010, 144 patients with benign prostatic obstruction were treated at two centres with standardised HoLAP (2.0 J/50 Hz or 3.2 J/25 Hz with Versapulse(®) 80-100 W laser Lumenis(®)). Median follow-up was 21 months (range, 1-54). International prostate symptom score and quality of life (IPSS-QoL), PSA, prostate volume, maximal flow rate (Qmax), postvoiding residual volume (Vres) were evaluated pre- and postoperatively. All complications were graded according to CTCAE (v4.03). RESULTS: Mean patient age was 70.1 ± 7.7 years (range, 46-90). With a preoperative median prostate volume of 40 ml (range, 10-130), the median operation time was 50 min (range, 9-138). We observed a median catheterisation time of 1 day (range, 0-12) and hospitalisation time of 2 days (range, 1-16). IPSS-QoL, Qmax and Vres were significantly improved after 3 months, and all parameters remained unchanged after 12, 24 and 36 months. The rate of re-operation was significantly lower in patients with prostate volume <40 ml, compared to patients with prostates ≥ 40 ml (9.1 vs. 25 %, p = 0.04). CONCLUSIONS: HoLAP is a safe and effective procedure for the treatment of prostates <40 ml. Patients benefit from HoLAP because of a low bleeding rate and short hospital stay. Due to high recurrence rates, HoLAP should be avoided in prostates >40 ml.

[Standardised scoring of a multi-parametric 3-T MRI for a targeted MRI-guided prostate biopsy]. / Standardisierung des multiparametrischen 3-T-MRT zur zielgerichteten Biopsie der Prostata.

BACKGROUND: The use of multi-parametric MRI and MRI-guided biopsy for the detection of prostate cancer is rapidly increasing. This is a pilot study to evaluate the consensus-based international MRI scoring system as decision criterion for targeted MRI-guided prostate biopsy. MATERIAL AND METHODS: After a multi-parametric 3-T MRI (T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast-enhanced MRI) in 23 consecutive patients a total of 47 lesions were scored according to a 5-point scale for each MRI sequence. A total score of ≥ 10 points was considered to be suspicious for prostate cancer. All 47 lesions were histologically assessed after MRI-guided biopsy. RESULTS: At the cut-off score of 10 points, sensitivity, specificity, negative predictive value and positive predictive value of multi-parametric MRI were 94.1, 43.3, 92.9 and 48.5%, respectively. CONCLUSIONS: A standardised scoring of lesions on multi-parametric MRI is feasible. The cut-off value leads to excellent values for sensitivity and negative predictive value. The values for specificity and positive predictive value are modest. Lesions with a total score <10 points are very unlikely to be malignant.

[Robot-assisted radical cystectomy: do we actually need a robot?]. / Roboterassistierte radikale Zystektomie : Brauchen wir den Roboter tatsächlich?

Compared to radical prostatectomy robotic surgery is far from becoming the standard of care for radical cystectomy. Concerns about perioperative and oncological safety as well as patient's benefit from this procedure may be a reason.In current publications no differences of perioperative morbidity and mortality were observed between patients undergoing open or robot-assisted radical cystectomy. Interestingly, older patients or patients with impaired health status might even profit from this technique. Though long-term data are missing, oncological results of robot-assisted radical cystectomy are encouraging. Extended lymphadenectomy is possible and positive margins are not seen more frequently. Concerning functional results (continence, potency) only little information is evaluable.In summary, operative and oncological outcomes do not seem to be impaired by robot assistance in radical cystectomy. However, whether patients or patient subgroups truly benefit from robot-assisted cystectomy needs to be elucidated in the future.

[Quality control in the implementation of new surgical procedures: Da Vinci robot-assisted systems]. / Qualitätssicherung in der Einführung neuer operativer Methoden : Da Vinci-Robotersysteme.

Robot assistance in the surgical treatment of urological malignancies is gaining increasing importance. As is the case in already established surgical procedures, the quality of robot-assisted surgery needs to be controlled and evaluated by appropriate measures. Baseline-parameters of treated patients should be documented precisely. General and operation type-specific parameters should be evaluated in short- as well as in mid-term follow-up. Appropriate and validated instruments should be used. Only by using these measures will it be possible to compare robot-assisted procedures of different institutions and historical data of conventional surgery with regard to oncological and functional efficacy.

[Robot-assisted radical cystectomy. Pilot study for the prospective evaluation of perioperative parameters compared to open radical cystectomy]. / Roboterassistierte radikale Zystektomie. Pilotstudie zur prospektiven Erfassung der operativen Ergebnisse im Vergleich zur offenen Zystektomie.

BACKGROUND: For robot-assisted radical cystectomy prospective assembly and evaluation of peri- and postoperative parameters within a national database is planned. This pilot study evaluated which parameters should be assessed and which problems might occur for assembly and interpretation of data. PATIENTS AND METHODS: Of 84 patients with radical cystectomy, 14 underwent RARC. Evaluable patients were compared to patients with open radical cystectomy (ORC) regarding perioperative parameters. In addition, a literature review on published single-center RARC series and comparative investigations (RARC vs ORC) was performed. Published data were compared to results of our own series. RESULTS: RARC patients received less packed red blood cells [RARC: 0 (0-2), ORC 2 (0-12), p=0.009] and hospitalization was shorter [RARC: 14 (8-18) days, ORC: 18 (11-97) days, p=0.015]. Comorbidities as assessed by the Charlson Comorbidity Index were less common in RARC patients [RARC: 4 (3-8), ORC: 6 (3-11), p=0.11]. No major differences between our own and published results were observed. The rate of continent urinary diversions in the Düsseldorf RARC cohort was, apart from one study, larger. Problems in the assembly and interpretation of operation time, blood loss, transfusion rate, and postoperative recovery were observed. CONCLUSIONS: Even in this small cohort results of published studies were confirmed. Potential problems in data assembly were identified. Appropriate solutions will be implemented in the national database.

[Fornix rupture caused by a ureteral stone during pregnancy: non-contrast-enhanced MR urography]. / Harnleitersteinbedingte Fornixruptur in der Schwangerschaft : Kontrastmittelfreie MR-Urographie.

Fornix rupture during pregnancy is rare. To be able to initiate the optimal therapy it is important to distinguish the spontaneous fornix rupture from the rupture caused by an obstruction. We report on a patient in the 18th week of pregnancy with strong flank pain on the left side. By means of MR urography the diagnosis of a left fornix rupture due to an obstructive stone could be made. A double-J catheter was placed in the left ureter and the patient received oral antibiotics.

[Significance of residual hyperplastic cells after radical prostatectomy. A literature review]. / Trascendencia de células hiperplásicas residuales a la prostatectomía radical. Revisión de la literatura.

INTRODUCTION: Radical prostatectomy represents a standard surgical treatment for clinically localized prostate cancer. Classically pathologist and urologist worried about positive surgical margin, but not to the presence of surgery residual hyperplastic cells able to generate prostate specific antigen (PSA) and difficult the follow up of the patients that underwent surgery. We reviewed the literature looking for the incidence, the potential etiology and the influence of these hyperplastic cells in the biochemical evolution of the disease. MATERIAL AND METHOD: The information for this review was compiled by searching the Pubmed database. We used "Mesh", Prostatectomy" and "Prostatic Neoplasms" and "Prostate-Specific Antigen" terms, and we added "biochemical failure" and/or "hyperplasic cells" and/or "benign cells". Furthermore, we select the work in English, Spanish and German, review articles that referenced this work and include the series with more than 50 patients, letters to the editor, editorials and overall reviews. CONCLUSIONS: Benign hyperplasic cells left behind after radical prostatectomy are frequent and probably under-rated. The influence of those cells in the biochemical outcome is a controversial issue. Positive margins for benign cells can come from apex or neck of the bladder, where the prostatic capsule is not well defined, but no from dorso-lateral area, this would imply a technical mistake. We recommend the inspection of the specimen by the surgeon, after prostatectomy in order to detect apex integrity, cranial and dorso-lateral capsule.

Trascendencia de células hiperplásicas residuales a la prostatectomía radical. Revisión de la Literatura / Significance of residual hyperplastic cells after radical prostatectomy. A literature review

Introducción: La Prostatectomía radical es el tratamiento estándar para el cáncer de próstata órgano confinado. Clásicamente se presta atención a los márgenes positivos para células tumorales, pero no a la presencia de células hiperplásicas residuales a la cirugía capaces de generar antígeno prostático específico (PSA) y dificultar el seguimiento de los pacientes intervenidos. Esta situación nos lleva a plantear una revisión de la literatura, donde evaluemos la frecuencia de esta presencia, las posibles causas que lo justifiquen y la influencia de estas células en la evolución bioquímica de la enfermedad. Material y Método: Realizamos una búsqueda bibliográfica a través de la base de datos 'Pubmed' utilizando los términos 'Mesh' 'Prostatectomy' y 'Prostatic Neoplasms' y 'Prostate-Specific Antigen' a los que añadimos los términos 'biochemical failure' y/o 'hyperplasic cells' y/o 'benign cells' . Así mismo, seleccionamos los trabajos en lengua inglesa, española y alemana, revisamos los artículos que dichos trabajos referencian e incluimos las series con más de 50 pacientes, cartas al editor, editoriales y revisiones de conjunto. Conclusiones: La presencia de células hiperplásicas microscópicas residuales a la cirugía prostática radical, es un hecho frecuente que probablemente esté infra-evaluado. Los márgenes positivos para células benignas procederán de lápex o del cuello vesical donde la cápsula prostática no está bien definida, en ningún caso de la zona dorsolateral de la próstata, lo que traduciría un defecto de la técnica quirúrgica. La capacidad de estas células para generar PSA en cantidad suficiente para interferir en el seguimiento de los pacientes operados es controvertida. Recomendamos la inspección macroscópica de la pieza por el cirujano, tras la prostatectomía, para evaluar la integridad del ápex, zona craneal y cápsula dorsolateral (AU)

Introduction: Radical prostatectomy represents a standard surgical treatment for clinically localized prostate cancer. Classically pathologist and urologist worried about positive surgical margin, but not to the presence of surgery residual hyperplastic cells able to generate prostate specific antigen (PSA) and difficult the follow up of the patients that underwent surgery. We reviewed the literature looking for the incidence, the potential etiology and the influence of these hyperplastic cells in the biochemical evolution of the disease. Material and Method: The information for this review was compiled by searching the Pubmed database. We used 'Mesh', 'Prostatectomy' and 'Prostatic Neoplasms' and 'Prostate-Specific Antigen' terms, and we added 'biochemical failure' and/or 'hyperplasic cells' and/or 'benign cells'. Furthermore, we select the work in English, Spanish and German, review articles that referenced this work and include the series with more than 50 patients, letters to the editor, editorials and overall reviews. Conclusions: Benign hyperplasic cells left behind after radical prostatectomy are frequent and probably under-rated. The influence of those cells in the biochemical outcome is a controversial issue. Positive margins for benign cells can come from apex or neck of the bladder, where the prostatic capsule is not well defined, but no from dorso-lateral area, this would imply a technical mistake. We recommend the inspection of the specimen by the surgeon, after prostatectomy in order to detect apex integrity, cranial and dorso-lateral capsule (AU)

Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter?

The treatment of prostate cancer has undergone a fundamental change in the last decade. New surgical and nonsurgical minimal invasive methods have evolved. As the methodology of the different treatments is commonly known to urologists, this article focuses on oncological and functional outcome of open retropubic (ORP), trans- or extraperitoneal endoscopical (LRP), and robot-assisted radical prostatectomy (RALP), based on personal experience and review of the literature. A MEDLINE search was performed to review the literature on LRP and RALP between 1982 and 2007 with special emphasis on oncological and functional results, technical considerations, comparison of LRP and RALP to ORP, laparoscopic training, historical aspects, and cost-efficiency of the techniques. Based on diligent training and proctoring programs, a continuous dissemination of laparoscopic techniques takes place. There is a trend towards the extraperitoneal access in most of the minimal invasive programs at least in the European community. Mid-term outcomes of LRP and short-term outcomes of RALP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower transfusion rates, shorter convalescence, and better cosmetics. In contrast to RALP, LRP reaches cost-equivalence with open surgery in selected centers. LRP and RALP reproduce the short-term results of open surgery while providing the advantages of a minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow, but the discussion about the longer learning curve for laparoscopy handling remains. The future will show if European centers adopt the use of robots comparable to the United States.

[Laparoscopic surgery in urology: Taining and education]. / Laparoskopische Chirurgie in der Urologie: Training und Ausbildung.

Relatively long learning curves and, therefore, initially longer operating times compared to conventional procedures are still a matter of debate. Today, there are numerous possibilities for learning laparoscopic techniques and establishing one's own laparoscopic programs, including various pelvitrainers and virtual reality computer programs. One useful and realistic way involves "wet lab" training programs for ablative and reconstructive procedures using the pig model. Today, laparoscopic urological surgery includes procedures with low (e.g. laparoscopy for undescended testicles), intermediate (laparoscopic pyeloplasty) and high level (laparoscopic/endoscopic prostatectomy) complexity. Therefore, laparoscopy should be an integral part of training in urology. A defined number of possibly multi-institutional training centers with well structured educational programs are needed. The main goal should be the standardization of surgical procedures as well as educational training programs in order to shorten individual learning curves and generate common quality standards.

[Laparoscopic extraperitoneal radical prostatectomy: changes in time and updated results]. / Prostatectomía radical extraperitoneal laparoscópica: evolución en el tiempo y resultados actualizados.

Laparoscopic radical prostatectomy has been established and adopted by specialized urologic centers around the world as the primary approach to the surgical management of localized prostate cancer. Urologists are on a continuous search for development of technical modifications and refinements, to reduce morbidity and ameliorate clinical and quality of life outcome. In 2002 we have initially reported our technique and experience with the totally extraperitoneal endoscopic radical prostatectomy (EERPE). In the present review paper we present the evolution of the technique and the latest results.

Prostatectomía radical extraperitoneal laparoscópica: evolución en el tiempo y resultados actualizados / Laparoscopic extraperitoneal radical prostactectomy: evolution in time and updated results

La prostatectomía radical laparoscópica ha sido establecida y adoptada por centros urológicos especializados de todo el mundo como el método fundamental de tratamiento quirúrgico del cáncer de próstata localizado. Los urólogos mantienen una búsqueda constante de desarrollo de modificaciones y refinamientos técnicos, para reducir la morbilidad y mejorar el resultado clínico y de calidad de vida. En 2002, comunicamos inicialmente nuestra técnica y experiencia con la prostatectomía radical endoscópica totalmente extraperitoneal (PRETE). En este artículo de revisión presentamos la evolución de la técnica y los últimos resultados

Laparoscopic radical prostatectomy has been established and adopted by specialized urologic centers around the world as the primary approach to the surgical management of localized prostate cancer. Urologists are on a continuous search for development of technical modifications and refinements, to reduce morbidity and ameliorate clinical and quality of life outcome. In 2002 we have initially reported our technique and experience with the totally extraperitoneal endoscopic radical prostatectomy (EERPE). In the present review paper we present the evolution of the technique and the latest results