Patient Outcome

With carefully planned strategies, advanced urologic laparoscopy in a community setting can yield results comparable to major academic centers (9). The importance of balancing the complexity of procedures with the experience of the surgeon cannot be overemphasized.

Operative time, an important factor in the private practice setting (10), has become very reasonable (Table 4). In many cases, the operative time matches that expected for the equivalent open procedure. As shown in Figure 1, procedure time decreases with experience. Hospital stay has averaged less than 1.2 days, ranging from the same day to 32 days. Even when including total hospital days for related readmissions, the average remains below 1.2 days. The fairly consistent next-day discharge is felt to be a result of the predominantly extraperitoneal or retroperitoneal approach.

A total of 12 open conversions occurred during 5 nephrectomies, 3 partial nephrectomies, 2 prostatectomies, and two pyeloplasties. This low conversion rate (1.1%) is the result of careful patient selection and attempts toward detailed repro-ducibility of all procedural steps. The failure to progress in accordance with standard surgical principles was the typical reason for conversion. Emergent conversion for bleeding was never required. A global complication rate of 7% as detailed in Table 5 is comparable to previously published series (11-15). As a result of careful case selection, this rate remained stable from year to year (Fig. 2). Neither of the two deaths was related directly to an intraoperative issue. One patient expired from an acute myocardial infarction on postoperative day three. The other death was a result of a multitude of comorbid conditions including near end-stage renal disease, malignant hypertension, and severe vascular disease.

Increased operative time for laparoscopic versus open procedures is a common criticism. The three positional complications were defined as any new muscu-loskeletal or sensorimotor complaint, separate from the operative sites, lasting greater than two weeks. All three eventually resolved. When including thrombotic events (5) and pneumonia (6), all possibly time-related complications comprise only 1.3% of the total number of patients. One patient with a postoperative urinoma underwent both a stent placement and a percutaneous drain placement, thereby

TABLE S ■ Miscellaneous Procedures

Procedure

No.

Procedure

No.

Kidney

132

Vagina

35

Biopsy

41

Urethropexy

8

Pexy

39

Sacrocolpopexy

22

Diverticulectomy

34

Vesicovaginal fistula

5

Cyst decortication

25

Other

28

Cryotherapy

24

RPLND

5

Bladder

4

Limited RPLND

5

Repair

7

Ureteral repair

2

Partial cystectomy

3

Ureterolysis

3

Reimplant ± Boari

6

Conduit

2

Augmentation

3

Stone

8

Cystectomy

3

Lymphocele

3

Abbreviation: RPLND, retroperitoneal lympth node dissection.

Abbreviation: RPLND, retroperitoneal lympth node dissection.

TABLE 4 ■ Operative Time

Procedure

Time (min)

Nephrectomy

105

Prostatectomy

230

Pyeloplasty

185

Adrenalectomy

95

RPLND

285

Abbreviation: RPLND, retroperitoneal lymph node dissection.

FIGURE 1 ■ Operative time with experience.

OPERATtVE TIME WITH EXPERIENCE

FIGURE 1 ■ Operative time with experience.

OPERATtVE TIME WITH EXPERIENCE

1 2 3 4 5 6 7 3 Year
TABLE S ■ Complications

Complications

No.

Intraoperative

Rectal injury

2

Other bowel injury

4

Early postoperative (<48 hr)

Transfusion

12

Acute renal insufficiency

5

Position

3

Late postoperative

Return to surgery

7

Myocardial infarction

3

Thrombosis

5

Pneumonia

6

Urinoma

3

Ileus/small bowel obstruction

10

Wound

10

Mortality

2

accounting for two of the seven returns to surgeries. Following failed laparoscopic pyeloplasty, one patient underwent laparoscopic nephrectomy, and three others were managed endoscopically. In addition, one patient required urethrorectal fistula repair following failed laparoscopic rectal repair during laparoscopic prostatectomy. One bowel injury required open conversion, but the others were managed laparo-scopically. All patients with postoperative ileus or partial small bowel obstruction were managed nonoperatively.

As shown in Table 6, of the 459 patients with presumed renal cell carcinoma, 23 were actually benign and 19 were lost to follow-up. Overall disease-free survival is 96%. Of the 107 patients with greater than five-year follow-up, 91% are disease free. An additional 10 patients five years beyond surgery have not undergone radiographic imaging within the last 12 months. At least 6 of these 10 patients are known to be alive. These results are comparable to historical open and laparoscopic data (16-19).

Cancer control following nephroureterectomy and prostatectomy is also outlined in Table 6. Although a significant volume of long-term data has not yet accumulated, early outcome compares well with historical open data (20-22). Cancer control following nephrourcterectomy and prostatectomy is also outlined in Table 6. Although a significant volume of long-term data has not yet accumulated, early outcome compares well with historical open data (20-22). The overall prostatectomy positive margin rate was 13%, but this fell below 11% in the last 100 patients. Thus far, only three patients have a detectable prostate-specific antigen.

The pyeloplasty success rate is outlined in Table 7, Similar to other centers, success in this category is defined as resolution of symptoms and postdiuretic half-time clearance of less than 15 minutes during nuclear renogram beyond 6 months (23-25). Asymptomatic failures with improved drainage were followed expectantly. All other failures underwent subsequent corrective procedures.Functional outcomes following laparoscopic radical prostatectomy (Tables 8 and 9) compare favorably to previously reported open and laparoscopic data (26,27). Erectile function was defined as a sexual health inventory for men score (28) of at least 18. Patients less than 12 months following surgery with lower sexual health inventory for men scores were excluded from this data. In addition, patients with a preoperative sexual health inventory for men score less than 23 were also excluded. Of course, the data continue to mature. Due to excellent visualization and precise suture placement, patency rates following laparoscopic anastamoses are excellent. No bladder

FIGURE 2 ■ Complications over time.

FIGURE 2 ■ Complications over time.

TABLE 6 ■ Cancer Control

Outcome

No.

Outcome

No.

Presumed renal cell carcinoma

Upper tract transitional cell carcinoma

No evidence of disease

389

No evidence of disease

36

Nodal involvement

4

Nodal involvement

3

Local recurrence

3

Distant metastasis

2

Initial distant metastasis

3

Concurrent bladder

8

Subsequent distant metastasis

7

Subsequent bladder

12

Benign

23

Bladder cuff

1

Unrelated death

11

Prostatic adenocarcinoma

Unknown

19

Organ-confined

146

Extracapsular extension

12

Seminal vesicle

3

Nodal involvement

3

Positive margins

27

neck contractures occurred following laparoscopic radical prostatectomy. All ureteroileal anastomoses and ureteroneocystostomies were successful.

Cost considerations are always difficult to assess. The hospital charges of two predominant procedures are evaluated in Table 10 for both open and laparoscopic methods at a single institution. Minimal difference exists between the two groups. When looking at previously reported data (29-31), a decreasing trend in cost for laparoscopic procedures makes the value-added benefits of this approach economically reasonable.

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