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3. Cooperberg MR, Downs TM, Carroll PR. Radical retropubic pros-tatectomy frustrated by prior laparoscopic mesh herniorrhaphy.Surgery. 2004;135:452-453.

4. Rassweiler J, Sentker L, Seemann O, Hatzinger M, Rumpelt HJ.Laparoscopic radical prostatectomy with the Heilbronn technique:an analysis of the first 180 cases. J Urol. 2001;166:2101.

5. Joseph JV, Madeb R, Wu G, Vicente I, Erturk E. Laparoscopicradical prostatectomy following laparoscopic bilateral mesh herniarepair. JSLS. 2005;9:368-369.

6. Brown JA, Dahl DM. Transperitoneal laparoscopic radical prosta-tectomy in patients after laparoscopic prosthetic mesh inguinalherniorrhaphy. Urology. 2004;63:380.

7. Erdogru T, Teber D, Frede T, et al. The effect of previous trans-peritoneal laparoscopic inguinal herniorrhaphy on transperitoneallaparoscopic radical prostatectomy. J Urol. 2005;173:769-772.

8. Stolzenburg J, Anderson C, Rabenalt R, et al. Endoscopic extra-peritoneal radical prostatectomy in patients with prostate cancerand previous laparoscopic inguinal mesh placement for herniarepair. World J Urol. 2005;23:295-299.

9. Saint-Elie DT, Marshall FF. Impact of laparoscopic inguinal herniarepair mesh on open radical retropubic prostatectomy. Urology.2010; . 2010 3.

10. Neff D, See WA. Laparoscopic mesh herniorrhaphy: impact onoutcomes associated with radical retropubic prostatectomy. UrolOncol. In press;2009.

doi:10.1016/j.urology.2010.10.029Published byUROLOGY 77: 967–968, 2011. © 2011

lsevier Inc.

REPLY

Hoang Minh Do, M.D., Kevin Turner, M.D.,Anja Dietel, M.D.,Andrew Wedderburn, M.D.,Evangelos Liatsikos, M.D.,Jens-Uwe StolzenburgOur series of 92 patients with prior extraperitoneal in-guinal hernia repair undergoing endoscopic extraperito-neal radical prostatectomy represents the largest experi-ence of its type. We have concluded that functional andprostatic margin data in this subset of patients is equiv-alent to our main dataset of more than 2000 patients.However, 86.3% (44/51) of patients who fulfilled criteriafor pelvic lymph node dissection (PLND) did not have itperformed on the side/sides of the mesh because of therisk of neurovascular injury. In 13.7% (7/51) of patients,

it was deemed safe to proceed to PLND. Does leaving

968

pelvic lymph nodes behind lead to an adverse oncologicaloutcome? Our 1-year biochemical recurrence rate for thissmall group is not statistically different from the 1-yeardata from our main series. As mentioned before, there isoncological evidence supporting our decision not to do aPLND on the side of the mesh.1

Would it be easier to remove the lymph nodes via thetransperitoneal route? Our belief is that the potential forneurovascular injury remains high without clear oncolog-ical benefit. However, long-term oncological outcomedata are not yet available for our subset of patients. Weagree that if PLND is attempted on the side of the meshthat the quality and extent of the PLND will be com-promised. Furthermore, if one considers the increasedoperative time and loss of the surgical advantage of theextraperitoneal approach2,3 then the potential oncologi-al benefit of PLND on the side of the mesh is doubtful.

Does robot-assisted laparoscopic prostatectomy facili-ate safe PLND on the side of extraperitoneal mesh repairithout compromising oncological and functional out-ome? This has yet to be proven, although there are theerceived advantages of three-dimensional vision, greateragnification, and precise instrument control. Lack ofaptic feedback and the range of camera movement are

imitations.In conclusion, it is worth mentioning that our out-

omes have been achieved by experienced surgeons in aigh-volume center of excellence. Surgeons on their

earning curve or in low-volume centers may have differ-nt outcomes from ours.

eferences1. DiMarco DS, Zincke H, Sebo TJ, Slezak J, Bergstralh EJ, Blute ML.

The extent of lymphadenectomy for pTXNO prostate cancer doesnot affect prostate cancer outcome in the prostate specific antigenera. J Urol. 2005;173:1121-1125.

2. Stolzenburg J-U, Truss MC, Bekos A, Do M, Robert R, Stief CG, etal. Does the extraperitoneal Laparoskopic approach improve theoutcome of radical prostatectomy? Curr Urol Rep. 2004;5:115-122.

3. Stolzenburg JU, Rabenalt R, Do M, Kallidonis P, Liatsikos. Endo-scopic extraperitoneal radical prostatectomy: the University ofLeipzig experience of 2000 cases. EN. J Endourol. 2008;22(10):2319-2325.

doi:10.1016/j.urology.2010.08.020

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