early detection of prostate cancer has significantly improved , and a rapid increase in 
 prostate cancer incidence during the past two decades has been noted in many countries . radical retropubic prostatectomy ( rp ) 
 provides excellent long - term disease control for patients with clinically localized prostate 
 cancer but has a negative impact on quality of life .
initially , laparoscopic surgery was used mostly for diagnostic support and for 
 benign lesions , but it is now widely applied for malignancies in many institutions . between 
 september 1991 and may 1995 , schuessler et al .
performed the first series 
 of lrp on nine patients with clinically localized prostate cancer , and since report of the first 10 cases at two french 
 institutions , this procedure has spread all over the world .
these investigators demonstrated that lrp 
 can be performed with reasonable operative outcomes and that the approach offers an 
 alternative form of surgical treatment for prostate cancer with reduced patient morbidity . 

nowadays , laparoscopic radical cystectomy and urinary diversion using the gastrointestinal 
 tract is routine .
even robotic - assisted laparoscopic surgery is now spreading worldwide . 
 however , laparoscopic procedures are relatively difficult , and it can take considerable time 
 to obtain sufficient experience for a good outcome . in this study
, we analyzed the outcome 
 of lrp in initial 30 cases performed by a single surgeon .
from june 2004 to may 2006 , patients with clinically localized prostate cancer underwent 
 lrp at nagoya city university graduate school of medical sciences and anjo kosei hospital . 
 from these cases , we retrospectively selected the initial 30 cases receiving this 
 operation performed by a single surgeon , and these cases
were then divided into three 
 groups ( 10 cases each ) according to the time period ( groups 1 , 2 and 3 included cases 1 to 
 10 , 11 to 20 and 21 to 30 , respectively ) .
the average age was 65.7 years ( range , 46 to 
 75 ) , and the average preoperative serum psa level was 11.57 ng / ml ( range , 4 to 22 ng / ml ) . 

preoperative staging of the tumor included magnetic resonance imaging , computed tomography 
 and bone scintigraphy .
the preoperative clinical stages were as follows : ct1c : ct2a : 
 ct2b : ct3a = 11 : 11 : 7 : 1 .
the clinical characteristics are listed in table 1table 1 clinical and pathologic characteristics of 30 patientsclinical characteristicscases 110cases 1120cases 2130mean age ( y)66.767.462.9mean psa ( ng / ml)11.411.711.7gleason score at biopsy464357534810031unknown110clinical stagect1c523ct2a , b486ct3a100there were no significant differences among the three groups .. there were no significant differences among the three groups . for 
 comparison of peri- and post - surgical parameters among these groups ,
the oncologic results 
 were evaluated by staging of the operative specimens according to the tnm 1997 
 classification and according to the last serum psa level after surgery .
the median 
 follow - up period was 49.7 weeks ( range , 17.3 to 87.3 weeks ) .
we used the student s 
 t test for comparison of values , with p<0.05 
 considered to be significant .
intervals to pad free and incontinence rates all the laparoscopic operative procedures were performed by a single surgeon with 13 
 years experience in open surgery who received instruction from surgeons with more than 7 
 years experience in laparoscopic surgery .
we were unable to determine who assisted in the 
 procedures because the procedures took place at two separate institutions .
the surgical 
 technique was the intraperitoneal approach reported by guillonneau and vallancien as the 
 montsouris technique . in this 
 technique
, the patient is positioned at a 30 degree decline in the trendelenburg position 
 with the pneumoperitoneal pressure maintained at 10 mmhg .
one 12-mm trocar ( blunt tip 
 type ) for optical system use is placed under the umbilicus , and another is located 
 inferior to the umbilicus at the lateral border of the right rectus muscle .
three 5-mm 
 trocars are then placed in the lower abdomen , one at the lateral border of the left rectus 
 muscle and one each on the left and right lateral clavicular lines just superior to the 
 anterior superior iliac crest .
the surgeon stands to the left of the patient with 
 assistants on the other side .
transperitoneal dissection of the vas deferentia and seminal 
 vesicles is performed through the pouch of douglas .
denonvilliers fascia is incised 
 transversely at the base of the prostate , and the bladder is dissected away from the 
 anterior abdominal wall by dividing the median umbilical ligaments and urachus .
the 
 retzius space is accessed , the endopelvic fascia is incised and santorini s venous plexus 
 is ligated using 2 - 0 vicryl on a ctb1 needle ( ethicon ) .
the catheter is grasped , and 
 the prostate is lifted anteriorly to expose the posterior bladder for dissection .
dissection of 
 the lateral pedicles of the prostate , which are selectively coagulated for control of 
 bleeding , is performed as far as the apex .
a vesicourethral anastomosis is performed by 
 running suture with 2 - 0 vicryl on a ur-6 needle ( ethicon ) .
the final two anterior sutures 
 are placed but not tied until a 20-f foley catheter has been positioned in the bladder 
 under direct vision .
the operative specimen is extracted with a laparoscopy bag from the 
 12-mm umbilicus trocar .
a suction drain is inserted into the retropubic space , and the 
 incisions are closed . in each case , once the prostate had been removed , the specimen was fixed in 10% buffered 
 formaldehyde .
after removal of the apex and the bladder neck resection margins , the 
 prostate was sectioned axially at regular intervals of 5 mm or less , yielding serial 
 slices of tissue . on each slide ,
from june 2004 to may 2006 , patients with clinically localized prostate cancer underwent 
 lrp at nagoya city university graduate school of medical sciences and anjo kosei hospital . 
 from these cases , we retrospectively selected the initial 30 cases receiving this 
 operation performed by a single surgeon , and these cases
were then divided into three 
 groups ( 10 cases each ) according to the time period ( groups 1 , 2 and 3 included cases 1 to 
 10 , 11 to 20 and 21 to 30 , respectively ) .
the average age was 65.7 years ( range , 46 to 
 75 ) , and the average preoperative serum psa level was 11.57 ng / ml ( range , 4 to 22 ng / ml ) . 

preoperative staging of the tumor included magnetic resonance imaging , computed tomography 
 and bone scintigraphy .
the preoperative clinical stages were as follows : ct1c : ct2a : 
 ct2b : ct3a = 11 : 11 : 7 : 1 .
the clinical characteristics are listed in table 1table 1 clinical and pathologic characteristics of 30 patientsclinical characteristicscases 110cases 1120cases 2130mean age ( y)66.767.462.9mean psa ( ng / ml)11.411.711.7gleason score at biopsy464357534810031unknown110clinical stagect1c523ct2a , b486ct3a100there were no significant differences among the three groups .. there were no significant differences among the three groups . for 
 comparison of peri- and post - surgical parameters among these groups ,
the oncologic results 
 were evaluated by staging of the operative specimens according to the tnm 1997 
 classification and according to the last serum psa level after surgery .
the median 
 follow - up period was 49.7 weeks ( range , 17.3 to 87.3 weeks ) .
we used the student s 
 t test for comparison of values , with p<0.05 
 considered to be significant .
all the laparoscopic operative procedures were performed by a single surgeon with 13 
 years experience in open surgery who received instruction from surgeons with more than 7 
 years experience in laparoscopic surgery .
we were unable to determine who assisted in the 
 procedures because the procedures took place at two separate institutions .
the surgical 
 technique was the intraperitoneal approach reported by guillonneau and vallancien as the 
 montsouris technique . in this 
 technique
, the patient is positioned at a 30 degree decline in the trendelenburg position 
 with the pneumoperitoneal pressure maintained at 10 mmhg .
one 12-mm trocar ( blunt tip 
 type ) for optical system use is placed under the umbilicus , and another is located 
 inferior to the umbilicus at the lateral border of the right rectus muscle .
three 5-mm 
 trocars are then placed in the lower abdomen , one at the lateral border of the left rectus 
 muscle and one each on the left and right lateral clavicular lines just superior to the 
 anterior superior iliac crest .
the surgeon stands to the left of the patient with 
 assistants on the other side .
transperitoneal dissection of the vas deferentia and seminal 
 vesicles is performed through the pouch of douglas .
denonvilliers fascia is incised 
 transversely at the base of the prostate , and the bladder is dissected away from the 
 anterior abdominal wall by dividing the median umbilical ligaments and urachus .
the 
 retzius space is accessed , the endopelvic fascia is incised and santorini s venous plexus 
 is ligated using 2 - 0 vicryl on a ctb1 needle ( ethicon ) .
the catheter is grasped , and 
 the prostate is lifted anteriorly to expose the posterior bladder for dissection .
dissection of 
 the lateral pedicles of the prostate , which are selectively coagulated for control of 
 bleeding , is performed as far as the apex .
a vesicourethral anastomosis is performed by 
 running suture with 2 - 0 vicryl on a ur-6 needle ( ethicon ) .
the final two anterior sutures 
 are placed but not tied until a 20-f foley catheter has been positioned in the bladder 
 under direct vision .
the operative specimen is extracted with a laparoscopy bag from the 
 12-mm umbilicus trocar .
a suction drain is inserted into the retropubic space , and the 
 incisions are closed . in each case , once the prostate had been removed , the specimen was fixed in 10% buffered 
 formaldehyde .
after removal of the apex and the bladder neck resection margins , the 
 prostate was sectioned axially at regular intervals of 5 mm or less , yielding serial 
 slices of tissue . on each slide ,
there was no postoperative mortality , and only one conversion to open surgery was necessary 
 to repair a sigmoid colon serosal injury ( 10th case ) .
the operation times are described in 
 figure 1figure 1 operation times for the three groups .
* p<0.05 .. the average operating times were 280 min ( group 1 ) , 229.5 min ( group 2 ) and 243.1 
 min ( group 3 ) . the difference between group 1 and group 2 was statistically significant .
the average 
 blood losses were 1498 ml ( group 1 ) , 852.3 ml ( group 2 ) and 1203 ml ( group 3 ; figure 2figure 2 blood loss with sucked urine .
perioperative complications were encountered in 5 patients , four of which were in 
 the initial 10 cases .
two of the 30 cases ( 6.7% ) required a blood transfusion ( first case 
 and 11th case ) .
the catheter duration after lrp was reduced in the later cases ( figure 3figure 3 catheter duration .
the catheter duration after lrp was reduced in the later cases , 
 but there was no statistical significance among the groups . ) .   catheter duration .
the catheter duration after lrp was reduced in the later cases , 
 but there was no statistical significance among the groups .
the frequencies tended to be decreased in the late phase group , 
 but without statistical significance .
sm : surgical margin .. the total positive surgical margin rate was 20.7% ( 6 of 29 cases ) , and the total psa 
 recurrence rate was 23.3% ( 7 of the 30 cases ) .
the frequencies tended to be decreased in the 
 late phase group , but without statistical significance .  
the frequencies tended to be decreased in the late phase group , 
 but without statistical significance .
all patients had their continence status assessed at final follow - up , and 67% ( 20 of the 30 
 cases ) were completely continent ( no need for a pad ) .
when the recovery period was divided 
 into three groups ( <3 months , 3 months to < 6 months , 6 months ) , the number of 
 patients with delayed recovery of continence was slightly increased across the groups , but 
 again without statistical significance ( figure 
 5figure 5 urinary continence recovery .
the number of patients with delayed recovery of 
 continence was slightly increased across the groups , but without statistical 
 significance . ) .  
the number of patients with delayed recovery of 
 continence was slightly increased across the groups , but without statistical 
 significance .
the majority of lrps are performed in high volume centers , allowing for intensive learning 
 of complex procedures . in japan
, the procedure is performed by expert urological 
 laparoscopic surgeons , rather than regular urological surgeons , who have expertise in 
 conventional rp . to some extent
, our results for our institutions suggest that the 
 laparoscopic approach to radical prostatectomy is a safe and reasonable therapeutic option 
 for treatment of localized prostate cancer .
major complications were concentrated in the 
 initial cases , so that it is important to conduct this operation very carefully under the 
 supervision of teaching staff until a great deal of experience has been obtained . the post - operative catheter duration , margin positivity rate , and psa recurrence rate 
 showed a tendency to improve over time , but there was no significant correlation among the 
 three groups .
limited data are available 
 regarding the initial learning curves for lrp , but ghavamian et al . reported
their initial learning curve was 
 overcome after approximately 35 cases , as the mean operation time reached a plateau after 
 that number ( mean operation time of 4 hours or less ) , so we might have to experience further 
 cases . a few reports about the importance of assistants have been published .
stressed the 
 importance of one assistant and the placement of ports for maximal benefit in 
 robotic - assisted lrp .
certainly , a single team approach would be optimal , but in our 
 institution this was not always possible .
in postoperative review , this may be a 
 part because of frequent use of monopolar electrocautery for the control of bleeding . as a 
 result ,
a better view and less positive surgical margin specimens were obtained , but the 
 recovery of continence might thereby have been delayed .
we must standardize specific 
 instruments for particular portions of the operation as more experience is gained .
blood 
 loss with sucked urine was worse in group 3 compared with group 2 .
we might have to pursue a single team , and further 
 investigation is necessary . from our experience with one surgeon ,
with whom perioperative complications were 
 concentrated in the initial 10 cases and catheter duration was reduced in the later cases , 
 we conclude that this kind of operation should be performed by experienced surgeons after 
 intensive training .
 objective : we carried out this study to clarify whether operative methods of laparoscopic 
 prostatectomy ( lrp ) could become a standard therapy . 
 the purpose was to evaluate the 
 technical feasibility , oncologic effectiveness and perioperative and postoperative 
 morbidity of lrp performed by a general urologist.patients and methods : between june 2004 and may 2006 , 30 
 patients with clinically localized prostate cancer consecutively underwent lrp by a single 
 surgeon . 
 oncologic data were assessed by histopathological examination and by 
 postoperative prostate - specific antigen ( psa ) levels.results : complete laparoscopic removal of the 
 prostate and seminal vesicles was achieved in all 30 patients . 
 the average operation time 
 was 250.9 min ( range , 168 to 394 min ) . 
 the total positive surgical margin rate was 20.7% 
 ( 6 of 29 cases ) , with a total psa recurrence rate was 23.3% ( 7 of 30 cases ) , but the 
 frequencies tended to be decreased in the later phase cases . 
 perioperative complications 
 were encountered in 5 patients ; four of these patients were in the initial 10 cases . 
 two 
 of the 30 cases ( 6.7% ) required a blood transfusion ( first case and 11th case ) . 
 there were 
 three surgical complications , one ureter injury , one rectal injury and one sigmoid serosal 
 injury . 
 the catheter duration intervals were reduced in the later cases.conclusions:from our 
 experience with one surgeon , with whom perioperative complications were concentrated in 
 the initial 10 cases , we conclude that lrp should be performed by experienced surgeons 
 after intensive training . 
Introduction
Patients and Methods
Study population
Investigated parameters
LRP procedure and histopathological estimation
Results
Discussion