Diapositive 1

1
EXTRAPERITONEAL RADICAL PROSTATECTOMY AND
PREVIOUS HISTORY OF HERNIA REPAIR EVALUATION OF
RESULTS SELCUK KESKIN, GUILLAUME GUICHARD,
ÁNDRAS HOZNEK , ALEXANDRE DE LA TAILLE, RENE
YIOU,DIMITRI VORDOS, CLEMENT-CLAUDE ABBOU and
LAURENT SALOMON Department of Urology, Henri
Mondor Hospital, Créteil, France.

INTRODUCTION
Abstract
Successful reports of subsequent transperitoneal
laparoscopic radical prostatectomy(TPLP) with a
previous history of hernia operation have been
recently reported1, 2. During the
extraperitoneal laparoscopic prostatectomy
(EPLP), conversion to transperitoneal route was
required in patients with a previous hernia
operation with the placement of a graft3. Since
the initial step of extraperitoneal technique is
creating a workspace in the Space of Retzius,
previous history of operation in this area may
complicate this step. To address this question,
we reviewed our results in 500 extraperitoneal
laparoscopic prostatectomies (EPLP) with or
without previous history of inguinal or
preperitoneal hernia operation.
CONCLUSION
RESULTS
PURPOSE To evaluate the results of
extraperitoneal laparoscopic prostatectomy in
patients with a previous history of hernia
repair METHODS Between 2001 and 2005, 500
consecutive extraperitoneal laparoscopic were
performed for localized prostate cancer. Patients
were classified into three groups group 1 no
previous history of surgery for hernia, group 2
unilateral or bilateral open surgery for inguinal
hernia with or without graft, group 3 previous
extraperitoneal laparoscopic hernia surgery. For
each patients, preoperative datas (age, PSA
level, clinical stage, Gleason score of positive
biopsies), per operative datas (length of
procedure, blood loss and transfusion rate),
medical and surgical complications, bladder
catheterization and hospitalisation stay,
prostate weight Gleason score of prostate
specimen, pathological staging according to TNM
2002 and positive surgical margins were noted. We
compared the 3 groups using t-Student and chi
square test RESULTS There were 472, 16 and 12
patients in groups I, II, III, respectively.
There were no differences in terms of age,
clinical stage, mean PSA, Gleason score and
prostate weight. For group I, group II and group
III, respectively, length of procedure was 191,
194 and 223mn (p0.04). blood loss was 738, 696
and 1008 cc (pgt0,05), transfusion rate were 4,
0 and 8 (pgt0.05). There was only one patient
who required transfusion in group III. There
were no difference in terms of medical and
surgical complications. Bladder catheterization,
hospitalization stays were similar in all groups.
(6.7, 5.4 and 6 days for length of
hospitalization and 5.9, 6.0 and 5.3 days for
catheterization in groups I, II and III
respectively)(pgt0.05) No difference was noted
between three groups in terms of pathological
results. CONCLUSION Extraperitoneal
laparoscopic radical prostatectomy can be
performed safely in patients with a history of
extraperitoneal surgery for hernia repair.
Group I N 472 Group II N 16 Group III N 12
Operative time (min) 191 194,6 223,7
Transfusion rate n() 23(4) 0(0) 1(8)
Medical complications 10(2) 0(0) 0(0)
Surgical complications 18(3) 0(0) 0(0)
Mean hospital stay (days) 6.7 5,4 6,0
From our results, it is evident that, there is
no difference between groups I and II. This is
not surprising since the patients in group II do
not have a profound fibrosis in the
extraperitoneal area and do not require any
specific attempt for the creation of the
workspace. The only difference in group III was
the length of operation time. We believe that a
similar amount of an additional time is required
for the dissection of the graft, also in the open
surgery. Since the initial step in EPLP is
dissection through the posterior sheath of rectus
muscles, although in the presence of a big graft,
this virgin plane allows creation of a space at
least to the level of arcuate line. With enough
experience, it is possible to perform EPLP in
patients with a history of previous
extraperitoneal herniorrhapphy operation with
graft. There is no difference in terms of
complications and oncological outcomes when
compared with patients without history of
previous surgery. The removal of the prostate and
uretrovesical anastomosis is not a major
consideration. A special attention should be paid
for epigastric vessels since the visualization of
these structures are hampered because of the
graft.
Patients and Methods
21.
Pathological results
Without previous hernia operation (Group I) With previous hernia operation graft in the inguinal area (Group II) With previous hernia operation graft in the preperitoneal space (Group III)
N 472 16 12
Age (years) 62,4 63,5 62,4
PSA (ng/ml) 10,4 ?0,2 9,8 ?5,3 10,1 ?6,5
Gleason Score of biopsies 2-6 7 8-10 311 (66) 138 (29) 23 (5) 7 (80.4) 6 (38) 3 (18) 9(759 2(17) 1(8)
References
Group I Group II Group III
Gleason score 6.9 ? 0.6 7,1 ? 0.7 6,8 ?1,1
2-6 103 (22) 1(7) 3(25)
7 316(66) 12 (75) 7(58)
8-10 54 (12) 3 (18) 2(17)
1- Erdogru, T., Teber, D., Frede, T. et al. The
effect of previous transperitoneal laparoscopic
inguinal herniorrhaphy on ransperitoneal
laparoscopic radical prostatectomy. J Urol, 173
769, 2005 2- Brown, J. A., Dahl, D. M.
Transperitoneal laparoscopic radical
prostatectomy in patients after laparoscopic
prosthetic mesh inguinal herniorrhaphy. Urology,
63 380, 2004 3- Rozet, F., Arroyo, C.,
Cathelineau, X. et al. Extraperitoneal standard
laparoscopic radical prostatectomy. J Endourol,
18 605, 2004
Clinical stage
Positive margins
Group I Group II Group III
Positive margins pT2 146 (31,3) 44 (17) 7 (43,75) 1 (33) 3 (25) 1 (10)