There is no difference between open and laparoscopic prostatectomy as far as patient selection is concerned. However, during a surgeon's initial experience with this operation, it is recommended that patients be selected with early cancers that do not require laparoscopic pelvic lymph node dissection. This is suggested to limit the operating time, which is likely to be prolonged during the early patients. In the first 20 patients we have selected patients with prostate specific antigen (PSA) less than 10 and a Gleason score of 6 or below.
Patients that should be avoided during the learning curve include those with the following: obesity; history of radiotherapy to the prostate; transurethral resection of the prostate; and previous bladder and prostate surgery, and laparoscopic inguinal hernia repair. Neoadjuvant hormonal treatment can make surgery difficult due to periprostatic adhesions and fibrosis. The nerve-sparing technique is difficult during a surgeon's early experience. We would, therefore, recommend that patients with preoperative erectile dysfunction be chosen and that the nerve-sparing technique should not be attempted initially. Patients with prostates that are larger than 80 g and less than 20 g would also be relatively difficult initially. As experience is gained, indications for laparoscopic prostatectomy should include all patients who are candidates for radical prostatectomy. A large median lobe can make bladder neck preservation difficult and would necessitate bladder neck reconstruction.
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