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Purpose: Laparoscopic radical prostatectomy has become an accepted alternative to open surgery. However, there is still a lack of data concerning the oncological outcome., Materials and Methods: From March 1999 to July 2004, 1,078 patients underwent laparoscopic radical prostatectomy at our institution. Oncological results in the first 500 patients with a minimal followup of 23 months were analyzed, focusing on positive margins, prostate specific antigen (PSA) failure, clinical progression and survival., Results: Median followup was 40 months (range 23 to 65). Of the patients 417 underwent pelvic lymph node dissection, which revealed positive nodes in 6 (1.2%). Positive margins were documented in 22 of 296 pT2 tumors (7.4%), 27 of 107 pT3a tumors (25.2%) and 29 of 69 pT3b tumors (42.0%). PSA recurrence was diagnosed in 55 patients (11.0%) at a mean of 20.8 months (range 6 to 36) that is stages pT2a, pT2b, pT3a and pT3b/4 in 3.2%, 6.5%, 15.9% and 23.9%, respectively. PSA progression-free rates were 83.0% at 3 years and 73.1% at 5 years. Two patients died of disease and 6 died of other causes (99.2% overall survival). The clinical progression rate was to 4.1% at 3 years and 9.8% at 5 years. No port site metastasis was observed., Conclusions: At centers of expertise laparoscopic radical prostatectomy may provide an oncological outcome similar to that of the open procedure. However, it offers the advantages of minimally invasive surgery.

Purpose: There is an ongoing debate about the benefits of laparoscopic radical prostatectomy compared to the open retropubic approach. We compared the last 219 patients treated with open retropubic prostatectomy with 438 patients treated with laparoscopic radical prostatectomy at our institution, focusing on operative data, complications and mid-term outcome., Materials and Methods: From December 1994 to November 1999 a total of 219 patients were treated with open prostatectomy and pelvic lymph node dissection (group 1). From March 1999 to September 2002, 219 patients underwent early (group 2) and 219 underwent late (group 3) laparoscopic radical prostatectomy and pelvic lymph node dissection. The same surgeons performed both operations. All 3 groups were similar with respect to mean patient age, mean prostate specific antigen value, median Gleason score, previous transurethral resection of the prostate and neoadjuvant treatment, although there was a slight stage shift in favor of the 2 laparoscopic groups., Results: Mean operating time was significantly shorter after open surgery (196 minutes) compared to the early laparoscopic group (288) but it did not differ significantly from the late laparoscopic group (218). Mean blood loss (1,550 versus 1,100 versus 800 cc) and transfusion rates (55.7% versus 30.1% versus 9.6%) in groups 1 to 3 favored the laparoscopic groups. The complication rate in groups 1 to 3 was lower for laparoscopy (19.2% versus 13.7% versus 6.4%), but the spectrum differed. The early laparoscopic group had a higher incidence of rectal injuries (1.8% versus 3.2% versus 1.4% in groups 1 to 3, respectively) and urinary leakage (0.5% versus 2.3% versus 0.9%), whereas more lymphoceles (6.9% versus 0% versus 0%), wound infection (2.3% versus 0.5% versus 0%), embolism/pneumonia (2.3% versus 0.5% versus 0.5%) and anastomotic strictures (15.9% versus 6.4% versus 4.1%) occurred after open surgery. The amount of postoperative analgesia was significantly greater after open surgery (50.8 versus 33.8 versus 30.1 mg. in groups 1 to 3, respectively). Median catheter time was longer after open retropubic prostatectomy (12 versus 7 versus 7 days in groups 1 to 3, respectively) but the continence rates were similar in all 3 groups at 12 months (89.9% versus 90.3% versus 91.7%). The rate of positive margins did not differ significantly in groups 1 to 3 (28.2% versus 21.0% versus 23.2%), prostate specific antigen recurrence was equivalent related to the different observation periods., Conclusions: Laparoscopic radical prostatectomy is technically demanding, with an initially longer operative time, higher incidence of rectal injuries and urinary leakage. The overall outcome after 219 cases favors the laparoscopic approach. Consequently, at our institution laparoscopic radical prostatectomy has become the method of choice.

Purpose: In 1998 Guillonneau and Vallancien introduced laparoscopic radical prostatectomy with primary access to the seminal vesicle. In 1999 we developed a different laparoscopic technique similar to the classic retropubic radical prostatectomy. We focus on early results and the learning curve of the procedure in the first 180 patients., Materials and Methods: A transperitoneal approach is used with immediate access to Retzius' space. After the dorsal vein complex is endoscopically sutured, the urethra is incised and distal pedicles of the prostate with or without the neurovascular bundle transected. The apex is then pulled ventrally followed with incision at the bladder neck, and transvesical access to vas deferens and seminal vesicle. After completing the posterior wall of the urethrovesical anastomosis with 5 interrupted endoscopic sutures, the Foley catheter is placed, bladder neck closed and specimen extracted via the umbilical incision. From March 1999 to December 2000 we have performed 180 procedures, including 3 for stage pT1 tumor, 88 pT2, 82 pT3 and 7 pT4. Mean preoperative PSA was 13.3 ng./ml. (range 1.4 to 148), mean specimen weight 37.4 gm. (10 to 125) and median Gleason score 6 (3 to 9). For evaluation of the learning curve a separate analysis of 3 groups with 60 patients in each was done. Differences between groups 1 (first 60 patients) and 3 (last 60) were analyzed for statistically significant differences., Results: Mean operating time was 271 minutes (range 150 to 500) and transfusion rate 31%. The reintervention rate was 4.4% and complication rate 18.8%. Of the patients 92% did not require any analgesia on postoperative day 2. Positive margins were found in 16% of the patients. The rate of positive margins in pT2 tumors was 2.3%, pT3a 15% and pT3b 34%. After a median followup of 12 months (range 3 to 23) in 9 (5%) patients a prostate specific antigen relapse was observed. The anastomosis was tight after removal of the catheter in 83% of patients, with a median time of 7 days (range 5 to 30). An anastomotic stricture had to be treated with laser incision in 3.3% of patients. On discharge from the hospital 33% of patients were continent, after 6 months 74% and after 12 months 97%. Analysis of the learning curve revealed significant differences in operating time (324 versus 265 minutes), conversion rate to open surgery (8.1% versus 1.7%), complication rate (23.3% versus 11.7%) and rate of prolonged catheterization (31.6% versus 10%, respectively), whereas the percentage of positive margins and continence rates showed no influence., Conclusions: Laparoscopic radical prostatectomy requires significant laparoscopic expertise with an ongoing learning curve. Morbidity is low, oncological control similar to results of open surgery and functional results are promising. The procedure should be performed only at dedicated centers with adequate training and expertise.

Purpose: A retroperitoneal access is commonly used for open urological procedures. Since the introduction of the balloon dissecting technique by Gaur this anatomical route has also been used for laparoscopic surgery. We present our experience with retroperitoneoscopy in 200 cases., Materials and Methods: From December 1992 to October 1997 a total of 200 retroperitoneoscopic procedures were performed in 197 patients 4 to 82 years old, comprising 78 nephrectomies, 50 renal cyst resections, 14 nephropexies, 11 ureterolyses, 8 retroperitoneal lymph node dissections, 8 renal biopsies, 6 adrenalectomies, 6 heminephrectomies, 6 pyeloplasties, 5 ureterolithotomies, 6 ureterocutaneostomies and 2 others. Of the patients 38 (19%) and 22 (11%) had undergone previous abdominal surgery, and kidney and ureter operations, respectively. Dissection of the retroperitoneal space was enabled by the use of a balloon catheter in 14, balloon trocar system in 93 and finger dissection technique in 93 cases., Results: We classified 76 procedures (38%) as simple (renal biopsy, renal cyst resections, ureterocutaneostomy), 102 (51%) as difficult (adrenalectomy, nephrectomy, nephropexy) and 22 (11%) as very difficult (pyeloplasty, heminephrectomy, lymphadenectomy). There was a significant learning curve during the first 50 cases reflected by longer operating time, and higher complication, conversion to open surgery and open reintervention rates (14, 10 and 6%, respectively). In addition to the learning curve, mean operating time depended on the difficulty of the procedure, averaging 45 to 100 minutes for a simple, 95 to 185 for a difficult and 185 to 240 for a very difficult retroperitoneoscopy. In the last 50 cases the complication, conversion and reintervention rates (2, 4 and 2%, respectively) were acceptable for routine clinical application., Conclusions: After experience with more than 200 cases of retroperitoneoscopy the access technique has been significantly simplified. The procedure is standardized, safe and reproducible.

Purpose: We describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups., Materials and Methods: The patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag., Results: The procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients. Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease., Conclusions: Our preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).