Training in laparoscopic urology

PURPOSE OF REVIEW: Training in laparoscopy has become an important issue in the current surgical scenario. In this overview we aim to update the current knowledge in the field of laparoscopic urological training and to highlight the potential dangers of using simulation for accreditation and selection purposes at this stage. RECENT FINDINGS: Physical simulators are widely available and seem to be equally efficient as virtual reality simulators. Transfer of training has been proven to be beneficial in randomized controlled trials for virtual reality and cholecystectomy. A model for the vesico-urethral suture has been described and integrated in a skills laboratory program. The program has construct validity and can discriminate at least between beginners and advanced laparoscopists. Efforts have still to be made in defining appropriate tools to assess competence and evidence for reliability, and validity must be obtained before including simulators in accreditation programs. SUMMARY: In spite of the abundant literature there is still little evidence about the learning mechanism involved in acquiring laparoscopic skills. Physical and virtual reality simulators have been proven to be efficient in improving dexterity and some evidence exists of a positive transfer from virtual reality to the operating room in cholecystectomy. Very few models, however, have been described for reconstructive urology, and effective transfer to the operating room has not yet been proven, although validation work is in progress in the field of urolog

Gleason score and margin status are the strongest predictors for benefit of radiotherapy after radical prostatectomy.

Introduction and Objective: A randomized trial (EORTC 22911) recently showed that postoperative radiotherapy after radical prostatectomy showing pT3a/b with or without positive margins reduces the risk of biochemical and local recurrence. A pathological review of prostatectomy specimens was performed to analyse predictors of this beneficial effect. Methods: After radical prostatectomy 503 patients were randomly assigned to a control arm and 502 to immediate postoperative radiotherapy. All eligible patients had pN0M0 disease and local pathology had shown pT3a/b disease and/or positive surgical margins. A total of 552 prostatectomy specimens (280 control arm, 272 test arm) of 12 major centers was reviewed by a single pathologist for stage, margins and Gleason score. The findings of review were related to biochemical recurrence in each of the trial arms by log-rank test for heterogeneity (α=0.05). Results: Agreement of local pathologists and review pathologist was high (kappa 0.83) for seminal vesicle involvement, but low (kappa 0.33, resp. 0.45) for extracapsular extension and margin status. Review pathology of surgical margins was a stronger predictor of biochemical recurrence than local pathology (HR=2.16, P=0.0002 versus HR=1.08, P>0.1). The data also suggested that the margin status assessed by the review pathologist was a stronger predictive factor of treatment benefit than the local pathology. These data confirm earlier findings that the margin status modulates the extent of the treatment benefit. We also developed a multivariate prognostic model in the control arm that showed Gleason sum, margin positivity assessed by the review pathologist and post operative PSA value (> 2 ng/ml vs <=2 ng/ml) to be the three strongest predictors of biochemical PFS. A prognostic classification could be derived from the model, that was predictive of treatment benefit (P=0.04) and suggested that the “good risk” patients might not truly benefit from post-operative irradiation. Those patients are essentially patients with pT2a-pT3 disease, Gleason sum <8, negative margins and post-operative PSA <= 2 ng/ml. Conclusions: Gleason score, margin status, and post-operative PSA are the strongest predictors of outcome and radiotherapy benefit after radical prostatectomy. Review pathology assessment of the margins, however, is needed

Duration of androgen suppression in the treatment of prostate cancer.

International audienceBACKGROUND: The combination of radiotherapy plus long-term medical suppression of androgens (> or = 2 years) improves overall survival in patients with locally advanced prostate cancer. We compared the use of radiotherapy plus short-term androgen suppression with the use of radiotherapy plus long-term androgen suppression in the treatment of locally advanced prostate cancer. METHODS: We randomly assigned patients with locally advanced prostate cancer who had received external-beam radiotherapy plus 6 months of androgen suppression to two groups, one to receive no further treatment (short-term suppression) and the other to receive 2.5 years of further treatment with a luteinizing hormone-releasing hormone agonist (long-term suppression). An outcome of noninferiority of short-term androgen suppression as compared with long-term suppression required a hazard ratio of more than 1.35 for overall survival, with a one-sided alpha level of 0.05. An interim analysis showed futility, and the results are presented with an adjusted one-sided alpha level of 0.0429. RESULTS: A total of 1113 men were registered, of whom 970 were randomly assigned, 483 to short-term suppression and 487 to long-term suppression. After a median follow-up of 6.4 years, 132 patients in the short-term group and 98 in the long-term group had died; the number of deaths due to prostate cancer was 47 in the short-term group and 29 in the long-term group. The 5-year overall mortality for short-term and long-term suppression was 19.0% and 15.2%, respectively; the observed hazard ratio was 1.42 (upper 95.71% confidence limit, 1.79; P=0.65 for noninferiority). Adverse events in both groups included fatigue, diminished sexual function, and hot flushes. CONCLUSIONS: The combination of radiotherapy plus 6 months of androgen suppression provides inferior survival as compared with radiotherapy plus 3 years of androgen suppression in the treatment of locally advanced prostate cancer. (ClinicalTrials.gov number, NCT00003026.