since 1997 when the schuessler and colleagues , after performing the first 9 cases of endoscopic extraperitoneal radical prostatectomy , questioned the desirability of the development of this procedure due to the long duration and the scale of difficulty , lpr has undergone massive modifications .
guilloneau and vallancien described a technique ( lpr montsouris technique ) which allowed to perform surgery in less than three hours . in order to avoid complications associated with the transperitoneal route [ 3 , 4 ] ,
raboy and colleagues proposed preperitoneal access , which found its use and justification in a series of 42 cases performed by bollens and co - workers in 2001 .
the advantage of laparoscopic procedures when compared with open procedures are less postoperative pain , shorter postoperative hospital stay , faster return to physical activity and through advanced optical systems , better vision of the operative field .
it has been shown that the laparoscopic procedures generate less activity of acute - phase reaction ( measured through , for example c - reactive protein , il-65 , il-10 ) when compared with open surgery , which results in intraoperative patient s safety and shorter postoperative period of convalescence .
lpr has become a first line treatment for patients with localized prostate cancer , in many centers around the world .
to meet the general trend in european urology , interests and expectations of patients associated with laparoscopic procedures , as well as , the growing importance of laparoscopy in poland , we started to implement laparoscopic procedures in our department .
one of our urologists completed a six - month fellowship at the center of l'institut mutualiste montsouris in paris . during the fellowship he assisted prostatectomies , completed a simulator training
after the fellowship finished , we launched in our center the initial cases of endoscopic extraperitoneal radical prostatectomy . in the period from august 2014 to december 2015 , a group of 30 patients with organ confined prostate cancer , underwent endoscopic extraperitoneal radical prostatectomy , according to the montsouris technique .
the mean age of the patients was 65.3 years ( 4373 years ) , the mean preoperative prostate specific antigen ( psa ) was 7.2 ng / ml ( 49.8 ng / ml ) , the mean prostate volume measured in trus ( transrectal ultrasound ) was 41 cm ( 2580 cm ) .
all patients were classified as the low risk group ( damico ) so we did not perform lymph node dissection .
all the procedures were completed using the montsouris 2 technique [ 2 , 11 ] in which the patient is laid on his back in the trendelenburg position ( inclination approx .
20 ) , with legs spread , which enables a digital rectal examination during surgery .
1 cm , under the umbilicus in the midline . incision of rectus fascia is performed and then the location of the linea alba , through which using pean and then a finger we get under the rectus muscle to the preperitoneal space .
after insufflation ( 12 mmhg ) , we introduced optics 0 and then , under visual control , an additional four ports ( 5 mm and 10 mm for the operator and 2x5 mm for assistance ) . during the procedure we used only bipolar tools , including the biclamp forceps for the operator s left hand .
we found this tool comfortable for both preparation and coagulation . in the first stage , after the release of the adhesions and fat tissue , we located the bladder neck .
a useful maneuver is pulling on the foley catheter inserted before the procedure or deflating and refilling the catheter balloon which allows the precise location and incision of the bladder neck .
assistance pulled the catheter upward , towards the pubic symphysis so that the posterior wall of the urethra could be cut off . gently pulling down on the posterior wall of the bladder
it was important to stay close to the bladder s wall at this stage in order not to enter the prostate . by getting into the adenoma
next by pulling the prostate upward , in the direction of the pubic symphysis , we were able to uncover vertical fibers of the anterior layer of the denonvilliers ' fascia .
its incision showed the retrovesical space in which the vas deferens was located and then showed where the more laterally lying seminal vesicles were located . during preparation of the seminal vesicles we advised a good hemostasis of the medially situated vessels .
lifting by the aid of the assistance , we cut off the vas deferens and dissected the seminal vesicles unveiling the posterior layer of the denonvilliers ' fascia .
this maneuver enabled the preparation and safe sectioning of the prostate pedicles in a further step . in a next step ,
after sectioning and local hemostasis with both biclamp forceps and hem - o - lok plastic clips , the prostate pedicles were sectioned by moving close to the prostate , as far as the pericapsular fatty space in which neurovascular bundles are located . after the sectioning of the pedicles ,
limitation of the thermal trauma ( excessive coagulation ) helps to keep the bundles in good condition . before sectioning the apex of the prostate , we control the dorsal vein complex ( dvc ) with 2 zero resorbable sutures .
the needle was passed from the right side of the complex to the left . in case of the suture
being located too close to the prostate , the hemostasis of dorsal vein complex ( dvc ) might not be effective after incision .
in this situation in order to prevent excessive bleeding , we decided to increase the insufflations pressure up to 16 mmhg and to introduce an additional suture after freeing the prostate . introducing to the urethra the benique catheter allowed for the tactile perception of the urethral wall and precise dissection near the apex .
the incision of the urethra is performed and after the withdrawal of the benique catheter , the sectioning of the posterior urethral wall is completed . dissecting and cutting the urthro - rectal fibres completely releases the prostate specimen .
the urethrovesical anastomosis was performed using a running suture v - lock. we found this suture easy to handle thanks to the one needle system and because of its construction a watertight effect of the anastomosis was achieved , even for a non - experienced surgeon . the first suture is placed at the 5 oclock position , running the outside in the bladder .
the second and following sutures were placed at the 7 , 9 , 11 , 1 and 3 oclock position , running the outside in the bladder and inside out of the urethra . the foley catheter was inserted and its position was checked in the bladder between the 9 and 11 oclock sutures . in series of last 10 cases we decided to insert the catheter earlier , after the 7 oclock suture . the balloon was inflated and the bladder was filled to check the watertight anastomosis .
the 10 mm port used initially for the camera needed to be sometimes enlarged by up to 3 cm , depending on the prostate volume , to get the specimen out of the operation field . in the preperitoneal space , two drains of redon 's type were left .
all the procedures were completed using the montsouris 2 technique [ 2 , 11 ] in which the patient is laid on his back in the trendelenburg position ( inclination approx .
20 ) , with legs spread , which enables a digital rectal examination during surgery .
1 cm , under the umbilicus in the midline . incision of rectus fascia is performed and then the location of the linea alba , through which using pean and then a finger we get under the rectus muscle to the preperitoneal space .
after insufflation ( 12 mmhg ) , we introduced optics 0 and then , under visual control , an additional four ports ( 5 mm and 10 mm for the operator and 2x5 mm for assistance ) . during the procedure we used only bipolar tools , including
we found this tool comfortable for both preparation and coagulation . in the first stage , after the release of the adhesions and fat tissue , we located the bladder neck .
a useful maneuver is pulling on the foley catheter inserted before the procedure or deflating and refilling the catheter balloon which allows the precise location and incision of the bladder neck .
assistance pulled the catheter upward , towards the pubic symphysis so that the posterior wall of the urethra could be cut off . gently pulling down on the posterior wall of the bladder
it was important to stay close to the bladder s wall at this stage in order not to enter the prostate . by getting into the adenoma
next by pulling the prostate upward , in the direction of the pubic symphysis , we were able to uncover vertical fibers of the anterior layer of the denonvilliers ' fascia .
its incision showed the retrovesical space in which the vas deferens was located and then showed where the more laterally lying seminal vesicles were located . during preparation of the seminal vesicles we advised a good hemostasis of the medially situated vessels . lifting by the aid of the assistance , we cut off the vas deferens and dissected the seminal vesicles unveiling the posterior layer of the denonvilliers ' fascia .
this maneuver enabled the preparation and safe sectioning of the prostate pedicles in a further step . in a next step ,
after sectioning and local hemostasis with both biclamp forceps and hem - o - lok plastic clips , the prostate pedicles were sectioned by moving close to the prostate , as far as the pericapsular fatty space in which neurovascular bundles are located .
limitation of the thermal trauma ( excessive coagulation ) helps to keep the bundles in good condition . before sectioning the apex of the prostate
, we control the dorsal vein complex ( dvc ) with 2 zero resorbable sutures .
the needle was passed from the right side of the complex to the left . in case of the suture
being located too close to the prostate , the hemostasis of dorsal vein complex ( dvc ) might not be effective after incision .
in this situation in order to prevent excessive bleeding , we decided to increase the insufflations pressure up to 16 mmhg and to introduce an additional suture after freeing the prostate . introducing to the urethra the benique catheter allowed for the tactile perception of the urethral wall and precise dissection near the apex .
the incision of the urethra is performed and after the withdrawal of the benique catheter , the sectioning of the posterior urethral wall is completed .
the urethrovesical anastomosis was performed using a running suture v - lock. we found this suture easy to handle thanks to the one needle system and because of its construction a watertight effect of the anastomosis was achieved , even for a non - experienced surgeon .
the first suture is placed at the 5 oclock position , running the outside in the bladder . then the benique catheter helped to guide the needle in the urethra inside out .
the second and following sutures were placed at the 7 , 9 , 11 , 1 and 3 oclock position , running the outside in the bladder and inside out of the urethra .
the foley catheter was inserted and its position was checked in the bladder between the 9 and 11 oclock sutures . in series of last 10 cases we decided to insert the catheter earlier , after the 7 oclock suture . the balloon was inflated and the bladder was filled to check the watertight anastomosis .
the 10 mm port used initially for the camera needed to be sometimes enlarged by up to 3 cm , depending on the prostate volume , to get the specimen out of the operation field . in the preperitoneal space , two drains of redon 's type were left .
from august 2014 until december 2015 we performed 30 cases of endoscopic extraperitoneal radical prostatectomy .
the mean operative time was 3 h 55 min ( 3 h 15 min  5 h 30 min ) ; however , during the first 15 cases the mean operative time was 4 h 25 min and during the second 15 cases it was 3 h 35 min ( table 3 ) .
the negative margin , shown in histopathology , was achieved in 86% of patients ( 26/30 patients ) .
the positive margin in most cases concerned the apex of the prostate , which prompted us to closer dissection of this structure during the final stage of the procedure .
two months postoperatively 13 patients ( 43% ) were completely continent , with no need for pads , 16 ( 35% ) presented moderate stress incontinence with occasional urine leakage during normal activity and 1 patient ( 3% ) presented severe stress incontinence ( table 1 ) .
initial results and complications after laparoscopy for prostate cancer in 30 patients in seven cases ( 23% ) transfusions were necessary ( table 2 ) .
such a situation was observed in 5 cases in initial stage of learning ( first 15 cases ) , and was related to the insufficient supply of the santorini s plexus before preparation of the prostate apex and bleeding at this stage of the procedure . in three cases ( 10% )
the injury was supplied laparoscopically . in one case due to the size of injury ,
in one case , rectal injury occurred after dissecting and cutting the urethra near the apex of the prostate , during the preparation of urethro - rectal fibers and in two cases during the preparation of the posterior surface of the prostate .
all three cases were observed during the first 15 cases . in two cases , during the creation of preperitoneal space an opening of the peritoneum was observed .
the procedures were completed ; however , we suffered from the limitation of the space in the operation field .
the majority of patients ( 65% ) were discharged from a hospital on the fifth day after surgery .
the last three patients in our series were discharged home on the fourth day after surgery . in two cases ( 7% ) , we observed a prolongation of hospitalization , due to the continued leakage of urine from the drains .
in cystography we found an anastomotic leak , caused probably by drains being placed directly on the anastomosis . after pulling the drains we observed thediminution of the leak followed by a complete watertight effect .
endoscopic extraperitoneal radical prostatectomy for many years has been the first line treatment in organ confined cancers of the prostate , in many urological centers . on the european stage , as well as , all over the world , it is more and more frequently being performed with the use of the da vinci surgical system ( ralrp  robot assisted laparoscopic radical prostatectomy ) [ 9 , 10 ] .
despite such a significant popularization of this method , initial cases , performed especially in centers having no experience in this matter , is a major challenge .
first of all , we found it very helpful to have at least one member of the laparoscopic team complete a practical fellowship in a center having an extensive experience in lpr ( laparoscopic radical prostatectomy ) . finding the appropriate habits and theoretical knowledge in the sequence of stages of the procedure , gained while assisting operations , facilitated the initial operations .
lpr ( laparoscopic radical prostatectomy ) is a time consuming procedure and any additional technical difficulties prolong operation , sometimes beyond a rational framework .
our observation was that the length of the procedure , in addition to the growing experience of the operator , was dependent on several components .
first of all , proper and careful trocar placement plays a huge role ensuring good visibility throughout the operation and giving surgeons the necessary working space .
injured at this stage peritoneum , which inflates , significantly reduces the working space , hampering visibility and causing more frequent soiling of the camera which results in the need for interrupting the procedure .
our advice is to start with patients without any previous abdominal surgery , such as appendectomy or inguinal hernia repair .
we believe that useful maneuver is placing the patient in deep trendelenburg position ( up to 25 ) in order to push the peritoneum cephalically .
unfortunately , in our center , especially during the initial cases , this maneuver was met with strong disapproval from anaesthesiologists .
another important issue was the ability of the operator to perform a time - consuming urethrovesical anastomosis . at this stage of operation
therefore , trained skills could have an impact on how quick and successful the ending of the procedure could be .
we found the running suture easy to control and advised it for the beginners ; however , we have no experience with other techniques . we believe that sewing the anastomosis is an activity that can and should be trained in the conditions of a simulation .
modification to the montsouris technique [ 2 , 11 ] applied in the last ten cases was controlling the dvc ( dorsal vein complex ) with a suture after cutting off the prostate .
our observation was that the suture was sometimes placed too close to the prostate and after sectioning the apex it did not work in a hemostatic manner . in four cases , we observed the prolongation of time of the urethrovesical anastomosis because of the catheter being inserted under the bladder , between 5 and 7 oclock sutures .
our modification in last ten cases was inserting the catheter earlier during the anastomosis just after the 7 oclock suture , to easily guide it to the bladder .
as far as urinary continence goes , we believe that the improval in incontinence rate between groups of patients 015 and 1630 comes from more precise bladder s neck preservation as well as from limitation of coagulation during sectioning of the prostate apex and during cutting off the prostate next to the apex
. when starting with lpr ( laparoscopic radical prostatectomy ) procedure , we must be aware of possible complications .
prostatitis , multiple biopsies or local inflammation after a biopsy , affect the strong adhesion of the prostate to the rectum making rectal injury more probable . in case of a difficult dissection of the posterior surface of the prostate
we believe that inserting a finger into the rectum becomes a helpful maneuver ( finger assisted laparoscopy ) , in order to improve anatomical orientation . in our opinion preoperative mri gives very helpful knowledge about the potential adhesion allowing the surgeon to avoid unnecessary mistakes .
the ability of suturing in a single or double layered manner , enables the successful completion of the case without the need for a conversion into open surgery . despite increasing the skills of the operator and team involved after our 30 cases , the execution of the lpr ( laparoscopic radical prostatectomy ) procedure still took us around 3 h 30 min .
i believe that this is the best proof as to how lpr ( laparoscopic radical prostatectomy ) is initially a difficult operation to master .
despite many years of experience and the global spread of endoscopic radical prostatectomy , many centers , especially in poland , have just started their initial operations in daily clinical work . representing the second department of urology in d , we are one of these centers in poland that have shown our observation in this process , which is that the learning and launching of the lpr ( laparoscopic radical prostatectomy ) is a difficult , time - consuming and sometimes daunting process
. it requires experience with laparoscopy , good surgical equipment , support of co - workers , thorough knowledge of anatomy and subsequent steps of the procedure and patience . in spite of the initial obstacles , we are aware that minimally invasive procedures , including lpr ( laparoscopic radical prostatectomy ) , is the state of art and its development and evolution will help shaping present urology .
 introductionto present initial observations after the first 30 cases of endoscopic extraperitoneal radical prostatectomy carried out at our department , which so far has had no experience with this surgical procedure.material and methodsin the period of 15 months a group of 30 patients with organ confined prostate cancer , underwent endoscopic extraperitoneal radical prostatectomy using montsouris technique . 
 all procedures were performed by the same team of two urologists and one resident.resultsthe mean age of the patients was 65.3 years ( 4373 years ) , the mean preoperative prostate specific antigen ( psa ) was 7.2 ng / ml ( 49.8 ng / ml ) , the mean prostate volume measured in trus was 41 cm ( 2580 cm ) . 
 the mean operative time was 3 h 55 min ( 3 h 15 min  5 h 30 min ) . 
 the negative margin was achieved in 26 patients ( 86% ) . in seven patients ( 23% ) 
 blood transfusion was required . 
 three patients had intraoperative rectal injury . in two cases trauma 
 was supplied laparoscopically , and in one case it was decided to perform diverting colostomy . 
 the majority of patients ( 65% ) were discharged home on the fifth day after surgery . 
 two months postoperatively 13 patients ( 43% ) were continent , 16 ( 35% ) presented moderate stress incontinence with occasional urine leakage during normal activity and 1 patient ( 3% ) presented severe stress incontinence.conclusionsendoscopic extraperitoneal radical prostatectomy during the early phase of learning is technically difficult , requiring from the operator the laparoscopic skills , determination and a thorough knowledge of the theoretical basis of the subsequent stages of the procedure . 
 urologists who start performing this procedures must be aware of possible intra as well as postoperative complications . 
INTRODUCTION
MATERIAL AND METHODS
Surgical technique of endoscopic extraperitoneal radical prostatectomy
RESULTS
DISCUSSION
CONCLUSIONS
CONFLICTS OF INTEREST