Reply by the Authors
1
2. Protogerou V, Argyropoulos V, Patrozos K, et al. Transvesical pros- tatectomy through a 3 cm incision: the minimal invasive technique for benign prostate hyperplasia for large prostates (80 cc): Iaso General Hospital, Athens, Greece. Eur Urol Meet. 2008;3:91. Reply by the Authors TO THE EDITOR: Our article reports on the technical feasibility of single- port transvesical prostatectomy and the outcomes for the initial 3 cases. Clearly, and we have noted this in our report, this is a technique in evolution, and the drawbacks mentioned by Protogeru are mostly valid. However, we would like to respond to some of the points he has raised. Although the operative time in our first 3 cases was relatively long, one must realize that the current experience represents the very early part of the learning curve and the operative time is likely to become shorter. The single most important advantage of our technique is that it is performed under pneumovesicum, thereby conferring tamponade to venous bleeding, a major problem with open simple prostatectomy. Also, most of the enucleation is per- formed under direct laparoscopic visualization, in con- trast to most open techniques. Finally, after comple- tion of enucleation and extraction of the adenoma, we can readily inspect the prostatic fossa to confirm the final hemostasis. Although we have used finger assis- tance in some cases, this was done after enucleating the base and controlling most of the vascular supply to the adenoma so that the distal apical dissection could be performed in a relatively bloodless manner. We are also exploring alternative methods of apical dissection such as the use of transurethral bipolar enucleation to facilitate the procedure. Only time will tell whether our technique demonstrates a benefit compared with other more established techniques of treating large- volume benign prostatic hyperplasia. We have significant reservations about the “minilap” techniques that Protogeru mentions. Such “mini” inci- sion, open procedures have been tried across surgical disciplines and generally have not stood the test of time. Unfortunately, the report that Protogeru refers to in his letter is in abstract form and not published as a full report and thus no further comment can be made. We would be interested in knowing more details about this technique in the future. Mihir Desai, M.D. David Canes, M.D. Department of Urology Cleveland Clinic Foundation Cleveland, Ohio Re: Finley et al.: Hypothermic Nerve- sparing Radical Prostatectomy: Rationale, Feasibility, and Effect on Early Continence. (Urology 2009;73:691-696) TO THE EDITOR: Finley et al. 1 report on an interesting nuance to robotic radical prostatectomy. Postulating that cooling the pros- tate and periprostatic tissues would decrease postopera- tive inflammation, they examined the effect of such cool- ing on the recovery of urinary continence. The surgeons used a combination of an endorectal cooling balloon and local irrigation with cold saline to cool the prostate to 25°C. Although they did not prove that this decreased inflammation, they did find that 88% of patients under- going the hypothermic procedure were pad free at 3 months compared with 69% of the historic controls. The return of continence was significantly quicker (median 39 days) in the “cool”(ed) group. The data presented are impressive, but the controls were historic. The authors state that the evidence they present is level 1B. Strictly speaking, the continence data with pelvic cooling can be considered level 1B evidence, but the comparison to historic controls is not. Although showing that no evidence was found of a learning curve, ideally a randomized trial would be necessary to show that the difference in outcomes is related to pelvic cool- ing. This we learned to our dismay. In a study examining the effects of a 2-layer anastomotic technique on urinary continence, a cohort analysis led us to predict a 30% im- provement in outcomes. 2 However, this improvement dis- appeared when the hypothesis was tested through a random- ized trial. Having said this, the data presented are fascinating. The use of hypothermia to reduce postoperative inflam- mation has also intrigued us, although we confess that we did not think of it in terms of urinary continence. A decrease in inflammation should, in theory, also help erectile function. To test this, a few months ago, we started cooling the prostate by injecting ice-cold saline directly into the periprostatic tissues. Although our tech- nique is different from that reported, did Findley et al. note improvements in erectile function with pelvic cool- ing? If so, this study would be a true landmark in the surgical treatment of prostate cancer. Mani Menon, M.D. Vattikuti Urology Institute Henry Ford Hospital Detroit, Michigan Case Western Reserve School of Medicine Cleveland, Ohio New York University School of Medicine New York, New York and University of Toledo School of Medicine Toledo, Ohio 1426 UROLOGY 73 (6), 2009
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Transcript of Reply by the Authors
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. Protogerou V, Argyropoulos V, Patrozos K, et al. Transvesical pros-tatectomy through a 3 cm incision: the minimal invasive techniquefor benign prostate hyperplasia for large prostates (�80 cc): IasoGeneral Hospital, Athens, Greece. Eur Urol Meet. 2008;3:91.
eply by the Authors
O THE EDITOR:
ur article reports on the technical feasibility of single-ort transvesical prostatectomy and the outcomes forhe initial 3 cases. Clearly, and we have noted this inur report, this is a technique in evolution, and therawbacks mentioned by Protogeru are mostly valid.owever, we would like to respond to some of the
oints he has raised. Although the operative time inur first 3 cases was relatively long, one must realizehat the current experience represents the very earlyart of the learning curve and the operative time isikely to become shorter. The single most importantdvantage of our technique is that it is performednder pneumovesicum, thereby conferring tamponadeo venous bleeding, a major problem with open simplerostatectomy. Also, most of the enucleation is per-ormed under direct laparoscopic visualization, in con-rast to most open techniques. Finally, after comple-ion of enucleation and extraction of the adenoma, wean readily inspect the prostatic fossa to confirm thenal hemostasis. Although we have used finger assis-ance in some cases, this was done after enucleatinghe base and controlling most of the vascular supply tohe adenoma so that the distal apical dissection coulde performed in a relatively bloodless manner. We arelso exploring alternative methods of apical dissectionuch as the use of transurethral bipolar enucleation toacilitate the procedure. Only time will tell whetherur technique demonstrates a benefit compared withther more established techniques of treating large-olume benign prostatic hyperplasia.We have significant reservations about the “minilap”
echniques that Protogeru mentions. Such “mini” inci-ion, open procedures have been tried across surgicalisciplines and generally have not stood the test of time.nfortunately, the report that Protogeru refers to in his
etter is in abstract form and not published as a full reportnd thus no further comment can be made. We would benterested in knowing more details about this techniquen the future.
Mihir Desai, M.D.David Canes, M.D.
Department of UrologyCleveland Clinic Foundation
Cleveland, Ohio
426
e: Finley et al.: Hypothermic Nerve-paring Radical Prostatectomy: Rationale,easibility, and Effect on Earlyontinence. (Urology 2009;73:691-696)
O THE EDITOR:
inley et al.1 report on an interesting nuance to roboticadical prostatectomy. Postulating that cooling the pros-ate and periprostatic tissues would decrease postopera-ive inflammation, they examined the effect of such cool-ng on the recovery of urinary continence. The surgeonssed a combination of an endorectal cooling balloon andocal irrigation with cold saline to cool the prostate to5°C. Although they did not prove that this decreasednflammation, they did find that 88% of patients under-oing the hypothermic procedure were pad free at 3onths compared with 69% of the historic controls. The
eturn of continence was significantly quicker (median 39ays) in the “cool”(ed) group.The data presented are impressive, but the controls
ere historic. The authors state that the evidence theyresent is level 1B. Strictly speaking, the continence dataith pelvic cooling can be considered level 1B evidence,ut the comparison to historic controls is not. Althoughhowing that no evidence was found of a learning curve,deally a randomized trial would be necessary to showhat the difference in outcomes is related to pelvic cool-ng. This we learned to our dismay. In a study examininghe effects of a 2-layer anastomotic technique on urinaryontinence, a cohort analysis led us to predict a 30% im-rovement in outcomes.2 However, this improvement dis-ppeared when the hypothesis was tested through a random-zed trial.
Having said this, the data presented are fascinating.he use of hypothermia to reduce postoperative inflam-ation has also intrigued us, although we confess that we
id not think of it in terms of urinary continence. Aecrease in inflammation should, in theory, also helprectile function. To test this, a few months ago, wetarted cooling the prostate by injecting ice-cold salineirectly into the periprostatic tissues. Although our tech-ique is different from that reported, did Findley et al.ote improvements in erectile function with pelvic cool-
ng? If so, this study would be a true landmark in theurgical treatment of prostate cancer.
Mani Menon, M.D.Vattikuti Urology Institute
Henry Ford HospitalDetroit, Michigan
Case Western Reserve School of MedicineCleveland, Ohio
New York University School of MedicineNew York, New York
and University of Toledo School of Medicine
Toledo, OhioUROLOGY 73 (6), 2009
