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Radical prostatectomy versus watchful waiting in early prostate cancer.  Bill-Axelson A,  Holmberg L,  Ruutu M et al.  N Engl J Med 2005;  352:  1977-1984. 

Radical prostatectomy is becoming one of the post common major surgical procedures in many Western countries. However, there have been few randomised trials quantifying the benefit of this surgical procedure.  The aim of this study was to assess whether the relative reduction in the risk of death due to prostate cancer after surgery increases with time and to assess whether radical surgery significantly improves survival.  Between 1989 and 1999, 695 men with early prostate cancer (mean age = 65 years) were randomly assigned to radical prostatectomy (n=347) or watchful waiting (n=348).  The follow-up was complete through 2003, with blinded evaluation of the causes of death.  The primary endpoint was death due to prostate cancer.  The secondary end points were death from any cause, metastasis and local progression.  During a median follow-up of 8.2 years, 83 men in the surgery group and 106 men in the watchful waiting group died (p=0.04). In 30 of the 347 men assigned to surgery (8.6%) and 50 of the 348 men assigned to watchful weighting (14.4%) death was due to prostate cancer.  The difference in the cumulative incidence of death due to prostate cancer increased from 2.0% after 5 years to 5.3% after 10 years, for a relative risk of 0.56 (95% CI 0.36-0.88. p=0.01).  For distant metastasis the corresponding increase was from 1.7% to 10.2% for a relative risk in the surgery group of 0.60 (95% CI 0.42-0.86. p=0.004).  For local tumour progression the corresponding increase was from 19.1% to 25.1% for a relative risk in the surgery group of 0.33 (95% CI 0.25-0.44. p<0.001).  It was concluded that radical prostatectomy reduces disease-specific mortality, overall mortality and the risks of metastasis and local progression.  The absolute reduction in the risk of death after 10 years is small, but the reduction in risk of metastasis and local tumour progression are substantial.

Randomised clinic trial of laparoscopic vs. open donor nephrectomy.  Nicholson M L,  Kaushik M,  Lewis G R R et al.  Br J Surg 2010;  97:  21-28.

This randomized controlled trial was designed to determine the safety and efficacy of laparoscopic donor nephrectomy (LDN) in comparison with short-incision open donor nephrectomy (ODN). Eighty-four live kidney donors were randomized in a 2:1 ratio to LDN (56 patients) or short-incision ODN without rib resection (28).  Primary endpoints were pain relief and duration of inpatient stay. There was no donor death or allograft thrombosis in either group. The first warm ischaemic time median (range) 4 (2-7) versus 2 (1-5) min; p = 0001) and the duration of operation (160 (110-250)  versus 150 (90-200); p = 0004) were longer for LDN. LDN led to a reduction in parenteral morphine requirement 59 (6-136) versus 90 (35-312) mg; p = 0001) and hospital stay (4 (2-6) versus 6 (2-9) days; p = 0001), and earlier return to employment (42 (14-84) versus 665 (14-112) days; P = 0004). Postoperative respiratory function was improved after LDN. There were more postoperative complications per donor in the ODN group (06(07) versus 03(05); p = 0033). At a median follow-up of 74 months, there were no differences in renal function or allograft survival between the groups. It was concluded that LDN removes some of the disincentives to live donation without compromising the outcome of the recipient transplant.

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