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COMMENTARY

Guy Vallancien

Institut Montsouris, Université Pierre et Marie Curie, Paris, France

The paper presented by Jens Rassweiler and the group at Heilbron is an excellent review on the state of the art of transperitoneal laparoscopic radical prostatectomy. The author gives accurate results of the different techniques for this procedure.

As Rassweiler highlights, it is difficult to provide an accurate measure of potency and successful sexual intercourse in this patient population. It is, indeed, impossible to compare results between academic groups. Accurate results of sexual function and urinary incontinence can only be obtained if an academic group evaluates another group's patient population by the International Continence Society questionnaire and the IIEF5 questionnaire. Furthermore, to help minimize any potential bias, only questionnaires filled in at the patient's home should be used to evaluate these outcomes. Nevertheless, potency results are improving every year. These improvements are the result of both bilateral nerve sparing and oral phosphodiesterase-5 inhibitor therapy started a few days after surgery.

Laparoscopy, despite its technical difficulty, material investment, and longer operating times, provides patients with less pain and a rapid recovery. These are the reasons surgeons learn to be laparoscopists. In urology, we have no validated outcome measures to compare open versus laparoscopic prostatectomy. However, an excellent clinical observation can be made. With open surgery, our patients are unable to mobilize without a pillow on their abdomen and someone to help them. They cannot laugh or cough without pain. After laparoscopy, however, when you knock at the door, the patient gets up from his chair, and with a large smile comes to greet and congratulate you.

As for technical training, it is important that young surgeons understand that a laparoscopic prostatectomy should not be attempted after participating in a postgraduate course and watching the operation on video. Laparoscopic skills can only be acquired at a significant laparoscopic center where these procedures are performed on a daily basis. The young surgeon needs to practice for hours to master knot tying and suturing. These skills can be acquired on cadavers, animal models, or the pelvitrainer. Only then will he or she have the skills to operate successfully on patients. Furthermore, in my opinion, a successful laparoscopic prostatectomy requires only scissors, two graspers, two bipolars, and one aspirator. There is no need for additional instruments.

As for the future of urologic surgery, I expect within the next 10 years, most surgeries will be done laparoscopically. This movement will be driven by the next generation of urologists who have understood the benefits of laparoscopy and its future in urologic surgery and who are ready to make the commitment to excellent surgical training.

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