The Australian laparoscopic non robotic radical prostatectomy experience - analysis of 2943 cases (USANZ supplement).

OBJECTIVES: To analyse the Australian experience of high-volume Fellowship-trained Laparoscopic Radical Prostatectomy (LRP) surgeons. MATERIALS AND METHODS: 2943 LRP cases were performed by nine Australian surgeons. The inclusion criteria were a prospectively collected database with a minimum of 100 consecutive LRP cases. The surgeons' LRP experience commenced at various times from July 2003 to September 2009. Data were analysed for demographic, peri-operative, oncological and functional outcomes. RESULTS: The mean age of patients were 61.5 years and mean preoperative PSA 7.4 ng/ml. Mean operating time was 168 minutes with conversion to open surgery in 0.5% and a blood transfusion rate of 1.1%. Overall mean length of stay was 2.5 days. 73.6% of pathological specimens were pT2 and 86.3% had Gleason Score >7. Overall positive surgical margins (PSM) occurred in 15.9% with pT2 PSM 9.8%, pT3a PSM 30.8% and pT3b PSM 39.2%. Mean urinary continence at 12 months was 91.4% (data available from five surgeons). Mean 12 months potency after bilateral nerve spare was 47.2% (data available from four surgeons). Biochemical recurrence occurred in 10.6% (mean follow up 17 months). CONCLUSION: The Australian experience of Fellowship trained surgeons performing LRP demonstrates favourable peri-operative, oncological and functional outcomes in comparison to published data for open, laparoscopic and robotic assisted radical prostatectomy. In our Australian centres, LRP remains an acceptable minimally invasive surgical treatment for prostate cancer despite the increasing use of robotic assisted surgery.

A randomised controlled trial comparing use of lignocaine periprostatic nerve block alone and combined with diclofenac suppository for patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy.

OBJECTIVE: To examine whether or not the combination of diclofenac suppository with peri-prostatic nerve block (PPNB) was effective in reducing the degree of pain experienced during transrectal ultrasound (TRUS)-guided prostate biopsy in a randomised single-blind placebo-controlled trial. PATIENTS AND METHODS: In all, 96 patients having a planned TRUS-guided prostate biopsy were randomised into one of the following arms on a 1:1 basis: 10 mL 1% lignocaine PPNB and placebo suppository (control) or 10 mL 1% lignocaine PPNB and 100 mg diclofenac suppository (treatment). Pain scores were recorded using the Numerical Rating Scale for pain (0-10) at the following time-points: (i) introduction of probe, (ii) during biopsy, (iii) 1 h after biopsy, (iv) later that evening (≈6 h after biopsy) and (v) 1 day after biopsy. Patients were asked about their preferred method for pain control if a repeat TRUS-guided prostate biopsy was required: local anaesthetic (LA) again or intravenous sedation. RESULTS: There were no significant differences in age (P = 0.653) or PSA level (P = 0.584) between either study arm. The differences in pain scores between the control and treatment groups were not significant at Time 1 (probe insertion; P = 0.299), Time 2 (biopsy; P = 0.983), Time 4 (evening after; P = 0.231) and Time 5 (1 day after biopsy; P = 0.384). At Time 3 (1 h after biopsy), the control pain scale scores were statistically significantly higher than the treatment pain scale scores (P = 0.044). There was no difference between treatment (87%) and control (80%) groups as to whether they would prefer to repeat the biopsy under LA (P = 0.373). CONCLUSION: The use of a diclofenac suppository with PPNB did not show any clinically meaningful effect in decreasing pain or improving tolerability of TRUS-guided prostate biopsy and is not recommended. PPNB TRUS-guided biopsy is extremely well tolerated, with >80% of patients electing for subsequent LA biopsy if required.

Comparison of the thermal and histopathological effects of bipolar and monopolar electrosurgical resection of the prostate in a canine model.

OBJECTIVES: To compare the thermal and histopathological effects of two commercially available bipolar systems and conventional monopolar transurethral resection of the prostate (TURP) in a canine model. Bipolar TURP is an alternative to monopolar electrosurgery for treating benign prostatic hyperplasia and has several potential clinical advantages, including the ability to use normal saline irrigation, enhanced haemostasis and less collateral thermal damage. MATERIAL AND METHODS: In all, 12 adult male beagles were studied. After midline laparotomy and exposure of the bladder and prostate, two fibre-optic thermosensors were placed to record tissue temperatures; one sensor was placed into the substance of the prostate 2 cm from the urethra and the second in the prostatic-rectal groove on the capsular surface of the prostate to measure temperatures in the region of the neurovascular bundles. Through a midline cystotomy, antegrade TURP was performed using two different bipolar systems (Gyrus PlasmaKinetic and Vista, both from Gyrus-ACMI Corporation, Maple Grove, MN, USA) or a monopolar device (Force(TM) 2, Valleylab, Boulder, CO, USA). TURP was performed in each lateral lobe using 24 F resection loops. The dogs were humanely killed acutely and the prostates excised for histopathological assessment. RESULTS: When comparing intraprostatic temperature data, the mean (sem) temperature changes recorded for the monopolar group were significantly higher than in either the Gyrus or Vista bipolar groups, at 24.2 (3.9) degrees C vs 8.1 (1.5) degrees C and 6.8 (1.8) degrees C, respectively (P < 0.001). No measurable temperature elevations were recorded near the neurovascular bundles with any of the electrosurgery devices. The depth of thermal damage was greatest in the monopolar group at 0.59 (0.27) mm compared with the Gyrus and Vista groups at 0.07 (0.08) mm and 0.15 (0.02) mm, respectively (P < 0.001). CONCLUSION: Bipolar TURP generated significantly less heat and histopathological evidence of thermal damage compared with monopolar TURP in the present canine model.

Free-beam and contact laser soft-tissue ablation in urology.

The ablation of tissue by laser has several applications in urology. Most of the published research has been concerned with the treatment of benign prostatic hyperplasia (BPH). Other applications studied include superficial upper- and lower-tract transitional-cell carcinoma, urethral and ureteral strictures, ureteropelvic junction stenosis, and posterior urethral valves. The attraction of laser ablation for the treatment of BPH lies with the decreased morbidity in comparison with standard transurethral electrocautery resection of the prostate and the ability to remove tissue immediately and therefore allow a more rapid progression to catheter removal and early voiding. The three main laser wavelengths used in urology for tissue ablation are the neodymium:yttrium-aluminum-garnet when used with contact tips or high-density power settings, the potassium-titanyl-phosphate, and the holmium:YAG. This article reviews the published literature on the use of these laser wavelengths in soft-tissue ablation, focusing on the treatment of BPH.

Holmium laser prostatectomy: current techniques.

INTRODUCTION: During the past 7 years, holmium laser prostatectomy has evolved into an enucleation procedure, incorporating the use of established surgical planes. Holmium laser enucleation of the prostate (HoLEP) uses the excellent incisional and hemostatic properties of the holmium laser wavelength. Clinical outcomes with this may be superior to transurethral resection of prostate. HoLEP is also a minimally invasive therapy for larger glands that have traditionally been treated by open prostatectomy. TECHNICAL CONSIDERATIONS: There are four steps to performing HoLEP: (a) creation of bladder neck incisions, (b) enucleation of the median lobe, (c) enucleation of the lateral lobes off the prostatic capsule, and (d) transurethral morcellation. In most cases, postoperative irrigation is not needed and the catheterization time is less than 24 hours. CONCLUSIONS: HoLEP is an emerging technique in the surgical management of benign prostatic hyperplasia. There is a learning curve with this procedure, because the technique is very different from transurethral resection of prostate.