Laurent Salomon

L’analyse de la pièce opératoire après prostatectomie radicale fournit des critères d’agressivité tumorale qui peuvent suggérer que la chirurgie seule n’est pas suffisante pour contrôler la maladie. L’hormonothérapie adjuvante ne trouve sa place que chez les patients présentant un envahissement ganglionnaire, où elle apporte un gain en termes de survie spécifique. Dans les autres cas, ce traitement n’apporte qu’une amélioration de la survie sans progression biologique mais ne permet pas d’améliorer la survie spécifique. Elle ne doit être réservée donc que pour les patients N+. Hormonal treatment combined with radical prostectomy has shown clinical benefits in patients with localized prostate cancer. However, hormone therapy as adjuvant treatment provides significant survival advantages only in patients with lymph nodes involvement. In others, this treatment is associated with an improvement in survival without biochemical progression but it does not improve specific survival. Consequently, the use of adjuvant hormone therapy should be restricted to patients with lymph node invasion.

The objective of the study was to evaluate the long-term results of retroperitoneal laparoscopic radical prostatectomy (LRP). From 2001 to 2005, 550 consecutive patients underwent a laparoscopic extraperitoneal prostatectomy in our department. Continence and erectile function were analysed prospectively by a self-administrated questionnaire. Mean operating time was 188 min, mean bladder catheterisation time 5.9 days, mean hospital stay 4.6 days Pathological stage was pT2 in 55.8%, pT3a in 29.6%, pT3b in 9.1% and pT4a in 5.4% tumours. Positive surgical margins were 17.9% for pT2, 44.8% for pT3 tumours and 71.4% for pT4a tumours. Five years survival without biochemical progression was 78.8%. After 24 months of follow-up, diurnal continence rate was 91%, and potency rate was 64% when both neurovascular bundles were preserved, 78.6% when the patients were younger than 60 years. LRP is now a standardised procedure. An extraperitoneal approach combines the advantages of a laparoscopic procedure with those of an extraperitoneal approach.

Nephrectomy was one of the very first urological procedures to be performed by laparoscopy. The objective of this study was to evaluate the results of retroperitoneal laparoscopic simple nephrectomy. From 1995 to 2002, 88 retroperitoneal laparoscopic simple nephrectomies were performed in 87 patients with a mean age of 45.3 years (range: 18 to 77 years). The intraoperative and postoperative complications, conversion rate, blood loss, operating time and length of hospital stay were studied for each patient. The mean operating time was 114 min (range: 35 to 280 min), mean blood loss was 97.6 ml (range: 0 to 300 ml), there were 3 conversions (3.4%) and the mean length of hospital stay was 4.7 days (range: 2 to 13 days). The main postoperative complications were 2 cases of haematoma and one abscess of the nephrectomy site requiring surgical revision and 3 intraoperative thromboses of arteriovenous fistulas in 3 patients with polycystic kidney disease. Due to its low morbidity, laparoscopic simple nephrectomy has probably become the, reference technique for all indications for nephrectomy for benign disease.

The results of radical prostatectomy (cancer control, continence and sexual potency) are currently presented separately, while the success of this surgery depends on a combination of good cancer control with maintenance of continence and erections. We propose a score to jointly evaluate and report cancer control and functional results. The results of 205 radical prostatectomies were studied at one year. Cancer control was evaluated by PSA and continence and sexual potency were evaluated by a self-administered questionnaire. Each patient was attributed 0 or 4 points according to the presence or absence of biochemical progression (PSA > 0.2 ng/ml), 0 or 2 points according to the presence or absence of urinary incontinence (use of pads) and 0 or 1 point according to the presence or absence of impotence (no erections). The sum of these points provided a socre classifying the patient into 8 distinct categories, from 0 to 7, each corresponding to a specific status (from 0 (0 + 0 + 0): no cancer control-incontinence-impotence to 7 (4 + 2 + 1): cancer control-continence-sexual potency). One year after the operation, 175 (85%) of patients had a PSA less than 0.2 ng/ml, 135 (65.8%) were continent and 64 (32.7%) reported erections. All patients with a score > or = 4 had good cancer control, wit no functional disorders for a score of 7 (4 + 2 + 1) (92%), no disorders of continence for a score of 6 (4 + 2 + 1) (31.5%), no disorders of erection for a score of 5 (4 + 0 + 1) (8.3%), or with incontinence and impotence for a score of 4 (4 + 0 + 0) (21.9%). All patients with a score < 4 had a PSA > 0.2 ng/ml, but with no functional disorders for a score for 3 (0 + 2 + 1) (2.4%), no incontinence for a score of 2 (0 + 2 + 0) (8.3%), and no impotence for a score of 1 (0 + 0 + 1) (1.9%). 1.9% of patients were incontinent, impotent and showed signs of biochemical progression (socre 0 = 0 + 0 + 0). This score allows analysis of the global (cancer control and functional) results of radical prostatectomy and would facilitate comparisons between various surgical techniques (type of approach, nerve-sparing techniques) and various centres.