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Clavijo R, Carmona O, De Andrade R, Garza R, Fernandez G, Sotelo R. Robot-Assisted Intrafascial Simple Prostatectomy: Novel Technique. J Endourol 2013; 27:328-32. [DOI: 10.1089/end.2012.0212] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Rafael Clavijo
- Robotic and Minimally Invasive Surgery Center, Instituto Médico La Floresta, Caracas, Venezuela
| | - Oswaldo Carmona
- Robotic and Minimally Invasive Surgery Center, Instituto Médico La Floresta, Caracas, Venezuela
| | - Robert De Andrade
- Robotic and Minimally Invasive Surgery Center, Instituto Médico La Floresta, Caracas, Venezuela
| | - Roberto Garza
- Robotic and Minimally Invasive Surgery Center, Instituto Médico La Floresta, Caracas, Venezuela
| | - Golena Fernandez
- Robotic and Minimally Invasive Surgery Center, Instituto Médico La Floresta, Caracas, Venezuela
| | - Rene Sotelo
- Robotic and Minimally Invasive Surgery Center, Instituto Médico La Floresta, Caracas, Venezuela
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Functional outcomes following robotic prostatectomy using athermal, traction free risk-stratified grades of nerve sparing. World J Urol 2013; 31:471-80. [DOI: 10.1007/s00345-012-1018-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/20/2012] [Indexed: 11/25/2022] Open
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Anatomic and technical considerations for optimizing recovery of sexual function during robotic-assisted radical prostatectomy. Curr Opin Urol 2013; 23:88-94. [DOI: 10.1097/mou.0b013e32835b6602] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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54
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Hinata N, Sejima T, Takenaka A. Progress in pelvic anatomy from the viewpoint of radical prostatectomy. Int J Urol 2012. [DOI: 10.1111/iju.12021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nobuyuki Hinata
- Department of Urology; Tottori University; Yonago; Tottori; Japan
| | - Takehiro Sejima
- Department of Urology; Tottori University; Yonago; Tottori; Japan
| | - Atsushi Takenaka
- Department of Urology; Tottori University; Yonago; Tottori; Japan
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Choi D, Kim D, Kyung YS, Lim JH, Song SH, You D, Jeong IG, Kim CS. Clinical experience with limited lymph node dissection for prostate cancer in Korea: single center comparison of 247 open and 354 robot-assisted laparoscopic radical prostatectomy series. Korean J Urol 2012. [PMID: 23185666 PMCID: PMC3502733 DOI: 10.4111/kju.2012.53.11.755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE There are limited data on the role of limited pelvic lymph node dissection (PLND) in patients with prostate cancer in Korea. The objective of this study was to demonstrate our clinical experience with limited PLND and the difference in its yield between open retropubic radical prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer patients in Korea. MATERIALS AND METHODS We retrospectively analyzed 601 consecutive patients undergoing radical prostatectomy and bilateral limited PLND by either RRP (n=247) or RALP (n=354) in Asan Medical Center. All patients were divided into three groups according to the D'Amico's risk stratification method. Clinicopathologic data, including the yield of lymph nodes, were thoroughly reviewed and compared among the three risk groups or between the RRP and RALP subjects. RESULTS The mean patient age was 64.9 years and the mean preoperative prostate-specific antigen was 9.8 ng/ml. The median number of removed lymph nodes per patient was 5 (range, 0 to 20). The numbers of patients of each risk group were 167, 199, and 238, and the numbers of patients with tumor-positive lymph nodes were 1 (0.6%), 4 (2.0%), and 17 (7.1%) in the low-, intermediate-, and high-risk groups, respectively. In the high-risk group, the lymph node-positive ratio was higher in RRP (14.9%) than in RALP subjects (2.4%). CONCLUSIONS We speculate that limited PLND may help in prostate cancer staging in intermediate- and high-risk prostate cancer groups. RRP is a more effective surgical modality for PLND than is RALP, especially in high-risk prostate cancer groups.
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Affiliation(s)
- Daeheon Choi
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ou YC, Yang CK, Wang J, Hung SW, Cheng CL, Tewari AK, Patel VR. The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria. Eur J Surg Oncol 2012; 39:107-13. [PMID: 23085148 DOI: 10.1016/j.ejso.2012.10.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/02/2012] [Accepted: 10/03/2012] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND To analyze the trifecta outcome (continence, potency, and cancer control) in 300 cases of robotic-assisted laparoscopic radical prostatectomy (RARP). METHODS A prospective assessment of outcomes in 300 consecutive patients that underwent a RARP performed by a single surgeon. Patients were grouped according to D'Amico risk criteria: Group I consisted of 'low-risk' cases (n = 64), Group II consisted of 'intermediate-risk' cases (n = 88), and Group III consisted of 'high-risk' cases (n = 148). Patients were evaluated for perioperative complications and the trifecta outcome. RESULTS The operation time, blood loss, post-operative stay, duration of urethral catheterization, and perioperative complication rate were similar among all groups. The incidence of bilateral neurovascular bundle (NVB) preservation was significantly decreased with the increasing risk of cases (P < 0.001). The continence rates at the 1-week, 1-month, 3-month, 6-month, and 12-month follow-ups did not differ significantly between groups. The potency rates at the 12-month follow-up were not significantly different. The positive surgical margin and positive lymph node metastasis rate increased with the increasing risk of cases (P < 0.001). The biochemical recurrence rate (BCR, PSA >0.2 ng/mL) was 3.1, 11.36, and 19.59% in Groups I, II and III, respectively (P = 0.004). The trifecta outcome for RARP with bilateral NVB preservation showed no significant differences among groups. CONCLUSIONS Undergoing a RARP is safe and feasible in high-risk prostate cancer patients. Compared to low-risk and intermediate-risk groups, the high-risk group had a significant higher incidence of positive surgical margin, positive lymph node metastasis, and BCR rate.
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Affiliation(s)
- Y C Ou
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, National Yang-Ming University, Taiwan.
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Hoshi A, Usui Y, Shimizu Y, Tomonaga T, Kawakami M, Nakajima N, Hanai K, Nomoto T, Terachi T. Dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy. Int J Urol 2012; 20:493-500. [PMID: 23039276 PMCID: PMC3664026 DOI: 10.1111/j.1442-2042.2012.03181.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 09/04/2012] [Indexed: 11/30/2022]
Abstract
Objectives To describe a novel dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and to evaluate its postoperative outcomes. Methods A total of 109 patients who underwent laparoscopic radical prostatectomy by a single surgeon were evaluated, including 44 patients with dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy, 20 patients with conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and 45 patients with non-nerve-sparing laparoscopic radical prostatectomy. Functional outcomes were evaluated using a self-administered questionnaire (Expanded Prostate Cancer Index Composite). Continence was defined as zero to one security pad per day. Oncological outcomes were evaluated based on positive surgical margin. Results In the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group, the continence rate was 57%, 77% and 95% at 1, 3 and 12 months, respectively. The continence rate in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy group was 37%, 63% and 90%, and in the non-nerve-sparing laparoscopic radical prostatectomy group it was 23%, 57% and 82% at 1, 3, and 12 months, respectively. The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group showed a significantly earlier recovery from incontinence compared with that in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and non-nerve-sparing laparoscopic radical prostatectomy groups (log–rank test, P = 0.044 and P < 0.001). Similarly, the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group tended to show a more early recovery in relation to urinary function of the Expanded Prostate Cancer Index Composite. Regarding sexual function, there were no significant differences between the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and conventional intrafascial nerve-sparing laparoscopic radical prostatectomy groups. In pT2 patients, the positive surgical margin rate of the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group (11%) was similar to that of the other two groups (conventional intrafascial nerve-sparing laparoscopic radical prostatectomy 7%; non-nerve-sparing laparoscopic radical prostatectomy 11%). Conclusions The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome.
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Affiliation(s)
- Akio Hoshi
- Department of Urology, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
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Finley DS, Ellingson BM, Natarajan S, Zaw TM, Raman SS, Schulam P, Reiter RE, Margolis D. Diffusion tensor magnetic resonance tractography of the prostate: feasibility for mapping periprostatic fibers. Urology 2012; 80:219-23. [PMID: 22748877 DOI: 10.1016/j.urology.2012.03.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 02/23/2012] [Accepted: 03/19/2012] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the feasibility of diffusion tensor imaging (DTI) tractography of the prostate for mapping of periprostatic neurovascular anatomy. METHODS Eight men with prostate cancer scheduled to undergo nerve-sparing robot-assisted radical prostatectomy (RARP) underwent endorectal multiparametric magnetic resonance imaging (MRI) of the prostate with DTI. Tract mapping was accomplished by positioning spherical regions of interest contiguously along the prostatic capsule at the prostatic apex, midgland, and base. RESULTS DTI tractography of the prostate effectively visualized periprostatic fiber tract anatomy. There was no significant correlation between total tract number and prostate size, however (Spearman's coefficient = 0.33, P = .42). Variation in tract distribution existed. The total fiber mass was highest in the lower prostate hemisphere at the base of the prostate (mean = 36.9 vs 21.1, P = .0004) and in the upper hemisphere at the apex (mean = 41.6 vs 57.9, P = .006). CONCLUSION DTI tractography successfully visualized fiber tracts around the prostate. Gold standard anatomic correlation is needed.
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Affiliation(s)
- David S Finley
- Department of Urology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA 90027, USA.
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Butet Y, Villers A, Delmas V, Piechaud T. Bases anatómicas quirúrgicas de la prostatectomía radical con o sin conservación nerviosa. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/s1761-3310(12)62106-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ko WJ, Hruby GW, Turk AT, Landman J, Badani KK. Pathological confirmation of nerve-sparing types performed during robot-assisted radical prostatectomy (RARP). BJU Int 2012; 111:451-8. [PMID: 22900712 DOI: 10.1111/j.1464-410x.2012.11393.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Incremental nerve-sparing techniques (NSTs) improve postoperative erectile function after robot-assisted radical prostatectomy (RARP). However, there are no studies to date that histologically confirm the surgeon intended NST. Thus, in the present study, we histologically confirmed that the surgeon performed the nerve preservation as his intended NSTs during RARP. Also, we found that there was more variability in fascia width outcome on the left side compared with the right. Therefore, when performing nerve preservation on the surgeon's non-dominant side, we need to pay more close attention. OBJECTIVES To confirm that the surgeon achieved true intended histological nerve sparing during robot-assisted radical prostatectomy (RARP) by studying RP specimens. To aid the novice robotic surgeon to develop the skills of RARP. PATIENTS AND METHODS Between June 2008 and May 2009, 122 consecutive patients underwent RARP by a single surgeon (K.K.B.). The degree of nerve sparing (wide resection [WR], interfascial nerve sparing [ITE-NS], intrafascial nerve sparing [ITR-NS]) on both sides was recorded. The posterior sectors of RP specimens from distal, mid, and proximal parts were evaluated. Fascia width (FW) of each position in RP specimens were compared across nerve-sparing types (NSTs). FW was recorded at 15 ° intervals (3-9 o'clock position), measured as the distance between the outermost prostate gland and surgical margin. The slides were reviewed by an experienced uropathologist who was 'blinded' to the NST. RESULTS In all, 93 men were included. The overall mean (sd) FW was the greatest in the order of WR, ITE-NS, and ITR-NS, at 2.42 (1.62), 1.71 (1.40) and 1.16 (1.08) mm, respectively (P < 0.001). FW was statistically significantly correlated with the surgical technique used. When the surgeon intended to perform various levels of nerve sparing, these were reflected in the FW. Interestingly, the left-side FW showed more variability than the right side. We suspect that this was a result of the surgeon's right-hand dominance. Erectile function (EF) recovery rate according to NST was 88.9%, 77.3%, 65.6%, 56.3%, and 0% in bilateral ITR-NS, ITR-NS/ITE-NS, bilateral ITE-NS, ITE-NS/WR, and bilateral WR, respectively. To further validate and confirm these preliminary findings, additional studies involving multicentre cohorts would be required. CONCLUSIONS The surgeon intended dissection and FW correlate, with ITR-NS providing the narrowest FW and the EF recovery rate was the highest in bilateral ITR-NS. There was more variability in FW outcome on the left side than the right. The novice robotic surgeon should consider this variability when performing RARP. It may have implications for technique improvement on nerve preservation for EF.
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Affiliation(s)
- Woo Jin Ko
- Department of Urology, National Health Insurance Corporation Ilsan Hospital, Goyang, South Korea.
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Tewari A, Pham A, Srivastava A, Leung R, Sooriakumaran P, Bloch D, Seshadri-Kreaden U, Hebert AE, Wiklund P. Reply from Authors re: Quoc-Dien Trinh, Khurshid R. Ghani, Mani Menon. Robot-assisted Radical Prostatectomy: Ready To Be Counted? Eur Urol 2012;62:16–8. Eur Urol 2012. [DOI: 10.1016/j.eururo.2012.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol 2012; 62:368-81. [PMID: 22763081 DOI: 10.1016/j.eururo.2012.05.057] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/25/2012] [Indexed: 11/20/2022]
Abstract
CONTEXT Radical retropubic prostatectomy (RRP) has long been the most common surgical technique used to treat clinically localized prostate cancer (PCa). More recently, robot-assisted radical prostatectomy (RARP) has been gaining increasing acceptance among patients and urologists, and it has become the dominant technique in the United States despite a paucity of prospective studies or randomized trials supporting its superiority over RRP. OBJECTIVE A 2-d consensus conference of 17 world leaders in prostate cancer and radical prostatectomy was organized in Pasadena, California, and at the City of Hope Cancer Center, Duarte, California, under the auspices of the European Association of Urology Robotic Urology Section to systematically review the currently available data on RARP, to critically assess current surgical techniques, and to generate best practice recommendations to guide clinicians and related medical personnel. No commercial support was obtained for the conference. EVIDENCE ACQUISITION A systematic review of the literature was performed in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. EVIDENCE SYNTHESIS The results of the systematic literature review were reviewed, discussed, and refined over the 2-d conference. Key recommendations were generated using a Delphi consensus approach. RARP is associated with less blood loss and transfusion rates compared with RRP, and there appear to be minimal differences between the two approaches in terms of overall postoperative complications. Positive surgical margin rates are at least equivalent with RARP, but firm conclusions about biochemical recurrence and other oncologic end points are difficult to draw because the follow-up in existing studies is relatively short and the overall experience with RARP in locally advanced PCa is still limited. RARP may offer advantages in postoperative recovery of urinary continence and erectile function, although there are methodological limitations in most studies to date and a need for well-controlled comparative outcomes studies of radical prostatectomy surgery following best practice guidelines. Surgeon experience and institutional volume of procedures strongly predict better outcomes in all relevant domains. CONCLUSIONS Available evidence suggests that RARP is a valuable therapeutic option for clinically localized PCa. Further research is needed to clarify the actual role of RARP in patients with locally advanced disease.
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Abstract
PURPOSE OF REVIEW Much of the progress in improving potency outcomes after radical prostatectomy has been achieved due to a better visualization of the neurovascular bundle responsible for erectile function. We review the current literature evaluating the existing imaging modalities to image the neurovascular bundle around the prostate pre, intra, and postoperatively, thereby enabling development of surgical techniques for better preservation of nerve function. RECENT FINDINGS Imaging modalities like multiphoton microscopy, optical coherence tomography, Coherent anti-Raman spectroscopy, exogenous fluoroscopy using prostate-specific membrane antigen, and so on have led to a better appreciation of the neurovascular bundle, thus encouraging novel techniques in nerve preservation during radical prostatectomy. SUMMARY In an age of heightened patient expectations and increasing life expectancy, better visualization of the neurovascular bundle around the prostate using novel imaging modalities may provide breakthroughs in improving potency outcomes after radical prostatectomy.
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The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy. Eur Urol 2012; 61:571-6. [DOI: 10.1016/j.eururo.2011.12.047] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 12/20/2011] [Indexed: 11/18/2022]
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Chopra S, Srivastava A, Tewari A. Robotic radical prostatectomy: The new gold standard. Arab J Urol 2012; 10:23-31. [PMID: 26558001 PMCID: PMC4442908 DOI: 10.1016/j.aju.2011.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/21/2011] [Accepted: 12/24/2011] [Indexed: 11/15/2022] Open
Abstract
Objectives Open radical prostatectomy (RP) has been the standard and primary treatment for focal prostate cancer. However, in recent years this view has changed, as robot-assisted laparoscopic RP has gained acceptance among urologists. In this review we evaluate the importance and place of robotics in laparoscopic urological surgery, discussing several techniques that are currently being used and potentially new techniques that might be used in the future. Methods We systematically reviewed papers published between 1998 and 2011 using the keywords ‘robotic prostatectomy’ ‘gold standard’ and the Medline database. In addition, after selecting relevant reports we searched ‘related citations’ of the documents to find further supporting published papers. Results In all, 50 original papers were identified using the search criteria; we also found 28 through ‘related citations’ browsing. Papers were selected according to their relevance to the current topic (i.e. RP, original articles) and incorporated into this review. These papers were used for their information on the advantages of using robotics, as well as innovative ideas being used in the field of robotic urological surgery. Conclusion Almost a decade after the first robotic RP many reports show the benefits and advantages of incorporating robotics into urological surgery. Robotic surgery decreases the learning curve necessary for surgeons when compared with laparoscopic techniques. In addition, patients prefer robotics, as the procedure is less invasive, diminishes the duration of hospitalisation and speeds the return to function.
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Affiliation(s)
- Sameer Chopra
- LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, NY, USA
| | - Abhishek Srivastava
- LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, NY, USA
| | - Ashutosh Tewari
- LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, NY, USA
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Takenaka A, Tewari AK. Anatomical basis for carrying out a state-of-the-art radical prostatectomy. Int J Urol 2011; 19:7-19. [DOI: 10.1111/j.1442-2042.2011.02911.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tewari AK, Srivastava A, Sooriakumaran P, Grover S, Desir S, Dev H, Yadav R, Leung R, Shevchuk M. Pathological outcomes and strategies to achieve optimal cancer control during robotic radical prostatectomy in Asian-Indian men. Indian J Urol 2011; 27:326-30. [PMID: 22022054 PMCID: PMC3193731 DOI: 10.4103/0970-1591.85428] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES There is a paucity of information in the literature about the characteristics of prostate cancer in the Asian-Indian population. We wanted to evaluate the oncological outcomes of Asian-Indians and Caucasians. We also derived a nomogram for prediction of extraprostatic extension (EPE) and presented biochemical recurrence (BCR) rates in the Asian-Indian population. MATERIALS AND METHODS A total of 2367 D'Amico low-risk patients underwent robotic-assisted radical prostatectomy (RARP) for clinically localized prostate cancer between January 2005 and July 2010 by a single surgeon. Of these 56 (2.4%) patients were Asian-Indians and 2025 were Caucasians (85.6%). Univariate and multivariate models were created for predicting EPE. A multivariate logistic regression model was used to develop a predictive nomogram. BCR was defined as a prostate-specific antigen ≥0.2 at any postoperative time point. Kaplan-Meier survival analysis was used to investigate BCR rates. RESULTS A significantly greater percentage of Asian-Indians compared to Caucasians had EPE (32.3 vs. 16.5; P = 0.01). In multivariate analysis adjusted for significant variables from univariate analyses, Asian-Indian race (P = 0.028), age (P = 0.050), maximum percentage cancer on biopsy (P < 0.001), and pathology prostate weight (P = 0.047) were independent predictors of EPE. Kaplan-Meier analysis demonstrated BCR free rates of 94.6% and 95.4%, for Asian-Indians and Caucasians, respectively, at a median follow-up of 16 months (range 2-70 months). There was no statistically significant difference in BCR rates across the two cohorts (log-rank P-value = 0.405). CONCLUSIONS This study highlights that while Asian-Indians have more advanced cancer variables, their risk of BCR after surgery is similar to Caucasian patients. Further work is required to better understand the social, genetic and environmental factors that affect the biology of prostate cancer in men of Asian-Indian descent.
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Affiliation(s)
- Ashutosh K Tewari
- Department of Urology, Lefrak Center of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation, Weill Medical College of Cornell University, New York Presbyterian Hospital, NY, USA
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Tewari AK, Srivastava A, Huang MW, Robinson BD, Shevchuk MM, Durand M, Sooriakumaran P, Grover S, Yadav R, Mishra N, Mohan S, Brooks DC, Shaikh N, Khanna A, Leung R. Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP). BJU Int 2011; 108:984-92. [PMID: 21917101 DOI: 10.1111/j.1464-410x.2011.10565.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES • To report the potency and oncological outcomes of patients undergoing robot-assisted radical prostatectomy (RARP) using a risk-stratified approach based on layers of periprostatic fascial dissection. • We also describe the surgical technique of complete hammock preservation or nerve sparing grade 1. PATIENTS AND METHODS • This is a retrospective study of 2317 patients who had robotic prostatectomy by a single surgeon at a single institution between January 2005 and June 2010. • Included patients were those with ≥ 1 year of follow-up and who were potent preoperatively, defined as having a sexual health inventory for men (SHIM) questionnaire score of >21; thus, the final number of patients in the study cohort was 1263. • Patients were categorized pre-operatively by a risk-stratified approach into risk grades 1-4, where risk grade 1 patients received nerve-sparing grade 1 or complete hammock preservation and so on for risk grades 2-4, as long as intraoperative findings permitted the planned nerve sparing. • We considered return to sexual function post-operatively by two criteria: i) ability to have successful intercourse (score of ≥ 4 on question 2 of the SHIM) and ii) SHIM >21 or return to baseline sexual function. RESULTS • There was a significant difference across different NS grades in terms of the percentages of patients who had intercourse and returned to baseline sexual function (P < 0.001), with those that underwent NS grade 1 having the highest rates (90.9% and 81.7%) as compared to NS grades 2 (81.4% and 74.3%), 3 (73.5% and 66.1%), and 4 (62% and 54.5%). • The overall positive surgical margin (PSM) rates for patients with NS grades 1, 2, 3, and 4 were 9.9%, 8.1%, 7.2%, and 8.7%, respectively (P = 0.636). • The extraprostatic extension rates were 11.6%, 14.3%, 29.3%, and 36.2%, respectively (P < 0.001). • Similarly, in patients younger than 60, intercourse and return to baseline sexual function rates were 94.9% and 84.3% for NS grade 1 as compared to 85.5% and 77.2% for NS grades 2, 76.9% and 69% for NS grades 3, and 64.8% and 57.7% for NS Grade 4 (P < 0.001). CONCLUSIONS • The risk-stratified approach and anatomical technique of neural-hammock sparing described in the present manuscript was effective in improving potency outcomes of patients without compromising cancer control. • Patients with greater degrees of NS had higher rates of intercourse and return to baseline sexual function without an increase in PSM rates.
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Affiliation(s)
- Ashutosh K Tewari
- LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York, NY 10065, USA.
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Ou YC, Hung SW, Wang J, Yang CK, Cheng CL, Tewari AK. Retro-apical transection of the urethra during robot-assisted laparoscopic radical prostatectomy in an Asian population. BJU Int 2011; 110:E57-63. [DOI: 10.1111/j.1464-410x.2011.10660.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kowalczyk KJ, Huang AC, Hevelone ND, Lipsitz SR, Yu HY, Ulmer WD, Kaplan JR, Patel S, Nguyen PL, Hu JC. Stepwise Approach for Nerve Sparing Without Countertraction During Robot-Assisted Radical Prostatectomy: Technique and Outcomes. Eur Urol 2011; 60:536-47. [DOI: 10.1016/j.eururo.2011.05.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/02/2011] [Indexed: 10/18/2022]
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Yamaguchi K, Kobayashi M, Kato T, Akita K. Origins and distribution of nerves to the female urinary bladder: new anatomical findings in the sex differences. Clin Anat 2011; 24:880-5. [PMID: 21538568 DOI: 10.1002/ca.21186] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 11/01/2010] [Accepted: 03/03/2011] [Indexed: 11/08/2022]
Abstract
The development of nerve-sparing procedures is important in preventing bladder dysfunction following radical hysterectomy. In this study, we dissected 14 halves of 7 female pelvises (age range: 46-86 years; mean age: 74 years) to examine the origins, courses, and distributions of nerve branches to the bladder in females in detail, and 6 halves of 3 male pelvises (age range: 71-85 years, mean age: 78 years) to compare with the female specimens. Nerve branches to the bladder originated mainly from the inferior hypogastric plexus, but independent direct branches running along the ureter from the hypogastric nerve were also distributed particularly to the trigone in all female specimens. We classified these independent branches into four types according to their relationship to the ureter. In males the numbers of the independent branches were small and they were difficult to find. The present observations indicate that nerve distribution patterns to the bladder differ between females and males. In nerve sparing procedures for radical hysterectomy, the area between the ureter and the hypogastric nerve is important.
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Affiliation(s)
- Kumiko Yamaguchi
- Unit of Clinical Anatomy, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
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72
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Clarebrough EE, Challacombe BJ, Briggs C, Namdarian B, Weston R, Murphy DG, Costello AJ. Cadaveric Analysis of Periprostatic Nerve Distribution: An Anatomical Basis for High Anterior Release During Radical Prostatectomy? J Urol 2011; 185:1519-25. [DOI: 10.1016/j.juro.2010.11.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Indexed: 11/27/2022]
Affiliation(s)
- Emma E. Clarebrough
- Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Christopher Briggs
- Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin Namdarian
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Robin Weston
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Declan G. Murphy
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Urological Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Australian Prostate Cancer Research Centre at Epworth, Melbourne, Victoria, Australia
| | - Anthony J. Costello
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Australian Prostate Cancer Research Centre at Epworth, Melbourne, Victoria, Australia
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Reis LO, Zani EL, Billis A, Prudente A, Denardi F, Ferreira U. The triple clinicopathologic features to seminal vesicle-sparing radical prostatectomy. J Endourol 2011; 24:1535-9. [PMID: 20804433 DOI: 10.1089/end.2009.0655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE With the widespread early detection programs for prostate cancer, there has been a downward stage migration and a marked decrease in the percentage of men with seminal vesicle invasion (SVI) compared with previous data. We evaluated clinicopathologic findings that are associated with SVI to select patients for potential seminal vesicle-sparing surgery. PATIENTS AND METHODS We reviewed our radical prostatectomy database from 1997 to 2006 to evaluate the incidence and clinical correlates of SVI. Variables analyzed included serum prostate-specific antigen (PSA) level, clinical stage, percentage of positive cores with cancer, Gleason score on biopsy, age, prostate weight, and urethral and vesical surgical margins. Statistical analysis included univariate and multivariate logistic regressions. RESULTS Of 267 patients, 32 (12%) had SVI. Preoperative PSA level, biopsy Gleason score, and percentage of positive cores were highly predictive of SVI on multivariate analysis. SVI was present in only 1/98 patients (1.02 %) with biopsy Gleason score ≤6, 0/23 patients (0%) with serum PSA level <4 ng/mL, and only 1 patient with ≤12.8% of positive cores on biopsy. In all cases of distal SVI, there was proximal involvement. CONCLUSION Serum PSA level, Gleason score, and percentage of positive cores on biopsy are statistically significant predictors of SVI on multivariate analysis. Seminal vesiculectomy does not benefit almost 99% of patients with biopsy Gleason score ≤6, PSA level <4 ng/mL, and with <12% cores with cancer. In cases of seminal vesicle-sparing surgery, frozen section of the proximal portion may be of adjunct usefulness for the triple.
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Affiliation(s)
- Leonardo Oliveira Reis
- Department of Surgery (Urology), School of Medicine, University of Campinas (UNICAMP), Campinas, Sao Paolo, Brazil.
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Neuroanatomic basis for traction-free preservation of the neural hammock during athermal robotic radical prostatectomy. Curr Opin Urol 2011; 21:49-59. [DOI: 10.1097/mou.0b013e32834120e9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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75
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Tewari AK, Srivastava A, Mudaliar K, Tan GY, Grover S, El Douaihy Y, Peters D, Leung R, Yadav R, John M, Wysock J, Vaughan ED, Muir S, Amin MB, Rubin M, Tu J, Akthar M, Shevchuk M. Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy. BJU Int 2010; 106:1364-73. [PMID: 20377582 DOI: 10.1111/j.1464-410x.2010.09318.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P = 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥ pT3a) documented on final specimen pathology (16% vs 10%, P = 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.
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Affiliation(s)
- Ashutosh K Tewari
- Lefrak Center of Robotic Surgery, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY 10065, USA.
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76
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Costello AJ, Dowdle BW, Namdarian B, Pedersen J, Murphy DG. Immunohistochemical study of the cavernous nerves in the periprostatic region. BJU Int 2010; 107:1210-5. [DOI: 10.1111/j.1464-410x.2010.09711.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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77
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Samadi DB, Muntner P, Nabizada-Pace F, Brajtbord JS, Carlucci J, Lavery HJ. Improvements in Robot-Assisted Prostatectomy: The Effect of Surgeon Experience and Technical Changes on Oncologic and Functional Outcomes. J Endourol 2010; 24:1105-10. [DOI: 10.1089/end.2010.0136] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David B. Samadi
- Department of Urology, The Mount Sinai Medical Center, New York, New York
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John Carlucci
- Department of Urology, The Mount Sinai Medical Center, New York, New York
| | - Hugh J. Lavery
- Department of Urology, The Mount Sinai Medical Center, New York, New York
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Chauhan S, Coelho RF, Rocco B, Palmer KJ, Orvieto MA, Patel VR. Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy. Int Braz J Urol 2010; 36:259-72. [DOI: 10.1590/s1677-55382010000300002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2010] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Rafael F. Coelho
- University of Central Florida School of Medicine, USA; University of Sao Paulo, Brazil; European Institute of Oncology, Italy
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79
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Sung W, Lee S, Park YK, Chang SG. Neuroanatomical study of periprostatic nerve distributions using human cadaver prostate. J Korean Med Sci 2010; 25:608-12. [PMID: 20358006 PMCID: PMC2844592 DOI: 10.3346/jkms.2010.25.4.608] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 08/12/2009] [Indexed: 11/20/2022] Open
Abstract
We investigated the distribution and navigation of periprostatic nerve fibers and constructed a 3-dimensional model of nerve distribution. A total of 5 cadaver specimens were serially sectioned in a transverse direction with 0.5 cm intervals. Hematoxylineosin staining and immunohistochemical staining were then performed on whole-mount sections. Three representative slides from the base, mid-part, and apex of each prostate were subsequently divided into 4 sectors: two lateral, one ventral, and one dorsal (rectal) part. The number of nerve fibers, the distance from nerve fiber to prostate capsule, and the nerve fiber diameters were analyzed on each sector from the representative slides by microscopy. Periprostatic nerve fibers revealed a relatively even distribution in both lateral and dorsal parts of the prostate. There was no difference in the distances from the prostate capsule to nerve fibers. Nerve fibers in the ventral area were also thinner as compared to other areas. In conclusion, periprostatic nerve fibers were observed to be distributed evenly in the periprostatic area, with the exception of the ventral area. As the number of nerve fibers on the ventral part is fewer in comparison, an excessive high up incision is insignificant during the nerve-sparing radical prostatectomy.
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Affiliation(s)
- Wooseuk Sung
- Department of Urology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sun Lee
- Department of Pathology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Yong-Koo Park
- Department of Pathology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung-Goo Chang
- Department of Urology, School of Medicine, Kyung Hee University, Seoul, Korea
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80
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Tewari AK, Patel ND, Leung RA, Yadav R, Vaughan ED, El-Douaihy Y, Tu JJ, Amin MB, Akhtar M, Burns M, Kreaden U, Rubin MA, Takenaka A, Shevchuk MM. Visual cues as a surrogate for tactile feedback during robotic-assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients. BJU Int 2010; 106:528-36. [PMID: 20192955 DOI: 10.1111/j.1464-410x.2009.09176.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyse consecutive cases of robotic-assisted laparoscopic prostatectomy (RALP), present the incidence of nerve-sparing-related positive surgical margins (SM+), include visual cues that might assist in smoothly changing to the robotic platform, and discuss the scientific rationale for 'intersensory integration' which might explain the 'reverse Braille' phenomenon, i.e. the ability to feel when vision is greatly enhanced, as the lack of tactile feedback during RALP is often cited as a disadvantage of robotic surgery, interfering with a surgeon's ability to make intraoperative oncological decisions. PATIENTS AND METHODS Data from 1340 consecutive patients undergoing RALP from one institution were analysed and trends for positive posterolateral SM+ (PLSM+) were correlated with oncological variables before and after RALP. A sample of patient slides were reviewed by a extramural pathologist. Multivariate regression modelling was used to compare the projected rates of PLSM+ vs the actual rate, given the effect of a conscious effort to use visual cues. Finally, video recordings of the procedure were systematically reviewed and correlated with anatomical and histopathological images in an integrated session involving the surgeon and the pathology team. RESULTS The incidence of PLSM+ was 2.1%, which gradually declined to 1.0% in the last 100 patients. The reduction in PLSM+ occurred despite an increased rate of high-risk tumours operated on during this period. Forecasting analysis showed that the actual PLSM+ rate declined by half in the most recent 1000 patients, due to an integrated effort involving the use of visual cues during surgery. The following visual cues were considered important; appreciation of periprostatic (lateral prostatic) fascial compartments; colour and texture of the tissue; periprostatic veins as a landmark for athermal dissection; signs of inflammation; and a freely separating bloodless plane showing loose shiny areolar tissue. CONCLUSION Adapting to the robotic platform is easy and there is no compromise of the oncological safety of this procedure. Experienced surgeons can use visual cues to assist during nerve-sparing RALP and achieve low PLSM+ rates.
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Affiliation(s)
- Ashutosh K Tewari
- Lefrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology,Weill Medical Collage, Cornell University, 525 East 68th Street, Starr 900, New York, NY 10065, USA.
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81
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Walz J, Burnett AL, Costello AJ, Eastham JA, Graefen M, Guillonneau B, Menon M, Montorsi F, Myers RP, Rocco B, Villers A. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol 2009; 57:179-92. [PMID: 19931974 DOI: 10.1016/j.eururo.2009.11.009] [Citation(s) in RCA: 304] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 11/02/2009] [Indexed: 01/20/2023]
Abstract
CONTEXT Detailed knowledge of the anatomy of the prostate and adjacent tissues is mandatory during radical prostatectomy to ensure reliable oncologic and functional outcomes. OBJECTIVE To review critically and to summarize the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control, erectile function, and urinary continence. EVIDENCE ACQUISITION A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis, and sphincter. Relevant articles and textbook chapters were reviewed, analyzed, and summarized. EVIDENCE SYNTHESIS Anatomy of the prostate and the adjacent tissues varies substantially. The fascia surrounding the prostate is multilayered, sometimes either fused with the prostate capsule or clearly separated from the capsule as a reflection of interindividual variations. The neurovascular bundle (NVB) is situated between the fascial layers covering the prostate. The NVB is composed of numerous nerve fibers superimposed on a scaffold of veins, arteries, and variable amounts of adipose tissue surrounding almost the entire lateral and posterior surfaces of the prostate. The NVB is also in close, cage-like contact to the seminal vesicles. The external urethral sphincter is a complex structure in close anatomic and functional relationship to the pelvic floor, and its fragile innervation is in close association to the prostate apex. Finally, the shape and size of the prostate can significantly modify the anatomy of the NVB, the urethral sphincter, the dorsal vascular complex, and the pubovesical/puboprostatic ligaments. CONCLUSIONS The surgical anatomy of the prostate and adjacent tissues involved in radical prostatectomy is complex. Precise knowledge of all relevant anatomic structures facilitates surgical orientation and dissection during radical prostatectomy and ideally translates into both superior rates of cancer control and improved functional outcomes postoperatively.
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Affiliation(s)
- Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Center, 232, Bd Ste. Marguerite, 13009 Marseille, France.
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Abstract
PURPOSE OF REVIEW To review the recent urologic literature with a focus on refinements of surgical technique in robot-assisted laparoscopic prostatectomy (RALP) and to discuss the impact of these developments on the 'trifecta' of prostate cancer management: oncologic, continence, and potency outcomes. RECENT FINDINGS Refinements in the surgical technique during the established steps of radical prostatectomy have led to improved functional outcomes following RALP. Early continence rates have increased, and potency, with evolving respect for the neurovascular bundle and neural anatomy, has further promise. 'Long-term' outcomes demonstrate favorable results in continence and potency. Oncologic outcomes, specifically low positive margin rates, have been maintained and even improved in many series during the evolution of this widely accepted procedure. SUMMARY RALP has continued to rapidly disseminate through the urologic community, but the ultimate impact remains under scrutiny. The procedure has seen birth from open and laparoscopic prostatectomy, and its success has been measured against contemporary open prostatectomy series during its infancy. Short and long-term oncologic outcomes must be followed carefully. The assessment of functional outcomes of continence and potency requires honest and, as best possible, objective analysis. Prospective, randomized clinical trials with long-term follow-up utilizing validated instruments are necessary to evaluate RALP and all associated technical modifications.
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83
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Finley DS, Rodriguez Jr E, Skarecky DW, Ahlering TE. Quantitative and qualitative analysis of the recovery of potency after radical prostatectomy: effect of unilateral vs bilateral nerve sparing. BJU Int 2009; 104:1484-9. [DOI: 10.1111/j.1464-410x.2009.08546.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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84
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Anatomical description of the periprostatic nerves in the male rhesus monkey (Macaca mulatta). World J Urol 2009; 29:375-80. [PMID: 19760222 DOI: 10.1007/s00345-009-0473-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 08/27/2009] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Recent publications have revealed a variable course of the periprostatic nerves in humans. It is unclear to what extent nerves outside the dorsolateral region of the prostate are involved in the physiology of erectile function. As functional studies in humans are limited by ethical aspects investigations in animal models could provide further insight. The intention of this study was to give a detailed description of the topographical anatomy of autonomic nerves along the seminal vesicles and the prostate in male rhesus monkeys (Macaca mulatta) to investigate its suitability as an animal model for future physiological studies. METHODS Wholemount serial sections of pelvic organ blocks of ten male rhesus monkeys were investigated. Autonomic nerves were stained with an antibody against S100. RESULTS Autonomic nerves were dispersed along the dorsolateral to the ventrolateral aspect of the capsule of the prostate within a layer of connective tissue. There was no accumulation of vessels and nerves in the dorsolateral position of the prostate. The prostate is located dorsally to the urethra and does not encircle it. No adjacent nerves were found in the cranial two-thirds of the seminal vesicles. CONCLUSIONS The male rhesus monkey is limited suitable as an animal model for studies on the periprostatic nerves provided the following differences to humans are considered: the special topography of the prostate, the nerve course along the seminal vesicles and the missing nerve accumulation dorsolaterally to the prostate.
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85
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Song LJ, Lu HK, Wang JP, Xu YM. Cadaveric study of nerves supplying the membranous urethra. Neurourol Urodyn 2009; 29:592-5. [DOI: 10.1002/nau.20768] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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86
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Challacombe BJ, Costello AJ. Editorial comment. Nerve quantification and computerized planimetry to evaluate periprostatic nerve distribution--does size matter? Urology 2009; 74:403-4; author reply 404-5. [PMID: 19646625 DOI: 10.1016/j.urology.2009.01.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 01/13/2009] [Accepted: 01/14/2009] [Indexed: 11/27/2022]
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Juan Gardiner Monzó I, Herranz Amo F, Cabello Benavente R, Bun M, Gómez Muñoz J, González Enguita C. [Controversies in the prostate surgical anatomy. A literature review]. Actas Urol Esp 2009; 33:228-34. [PMID: 19537059 DOI: 10.1016/s0210-4806(09)74135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Radical prostatectomy technique has improved in the last years based on accumulated surgical experience and new anatomical findings. We think it is time to update anatomical concepts to standardized the criteria formentioning structures related with radical prostatectomy MATERIAL AND METHOD With the followings key words: "cavernosal nerves, prostatectomy, anatomy, neurovascular bundle" we search in Medline/PubMed database selecting papers fulfilling the search criteria. CONCLUSIONS The prostate does not have a true capsule but rather an incomplete fibromuscular band as an intrinsic part of the gland. Periprostatic fascia seems to be a different structure from this fibromuscular band. Histologically Denonvilliers's fascia is formed by two thin layers that cannot be separated during surgery. The longitudinal smooth muscle fibres located beneath the posterior bladder neck corresponds to the posterior longitudinal fascia of the detrusor muscle. Cavernosal nerves are located between the two layers of the endopelvic fascia, the inner layer could be named periprostatic fascia and the outer, levator ani fascia. Cavernosal nerves merged from the pelvic plexus running within a neurovascular bundle around the prostate that could be found as a singular bundle or spread all around the anterolateral surface of this gland. There are overlapping terms to designate the pelvic fascia, therefore it could be useful for Urologists to standardized them.
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88
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Gofrit ON, Zorn KC, Shikanov SA, Zagaja GP, Shalhav AL. Is seminal vesiculectomy necessary in all patients with biopsy Gleason score 6? J Endourol 2009; 23:709-13. [PMID: 19335331 DOI: 10.1089/end.2008.0577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low-risk prostate cancer. However, these glands are routinely removed in every radical prostatectomy. Dissection of the SVs can damage the pelvic plexus, compromise trigonal, bladder neck, and cavernosal innervation, and contribute to delayed gain of continence and erectile function. In this study we evaluated the oncological benefit of routine removal of the SVs in currently operated patients. MATERIALS AND METHODS A total of 1003 patients (mean age, 59.7 years) with prostate cancer underwent robot-assisted radical prostatectomy between February 2003 and July 2007. RESULTS Seminal vesicle invasion (SVI) was found in 46 of the operated patients (4.6%). Biopsy Gleason score (BGS), preoperative serum PSA, clinical tumor stage, percent of positive cores, and maximal percentage of cancer in a core had all a significant impact on the risk of SVI. Only 4/634 patients (0.6%) with BGS < or =6 suffered from SVI, as opposed to 42/369 (11.4%) with higher Gleason scores. CONCLUSIONS Seminal vesiculectomy does not benefit more than 99% of the patients with BGS < or =6. Considering the potential neural and vascular damage associated with seminal vesiculectomy, we suggest that routine removal of these glands during radical prostatectomy in these cases is not necessary.
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Affiliation(s)
- Ofer N Gofrit
- Section of Urology, Department of Surgery, University of Chicago Hospitals, Chicago, Illinois 60637, USA.
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89
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Pelvic neuroanatomy and radical prostatectomy with neurovascular preservation: quo vadis? Eur Urol 2009; 56:1092-3. [PMID: 19473750 DOI: 10.1016/j.eururo.2009.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 05/05/2009] [Indexed: 11/23/2022]
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90
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Brown JA, Rodin DM, Harisinghani M, Dahl DM. Impact of preoperative endorectal MRI stage classification on neurovascular bundle sparing aggressiveness and the radical prostatectomy positive margin rate. Urol Oncol 2009; 27:174-9. [DOI: 10.1016/j.urolonc.2008.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 04/01/2008] [Accepted: 04/02/2008] [Indexed: 11/28/2022]
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91
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Rosenberg S, Pode D, Shapiro A, Zorn KC, Shalhav AL, Gofrit ON. The fate of the seminal vesicle remnant after proximal transection or ligation: an animal model. J Urol 2009; 181:1483-6. [PMID: 19157442 DOI: 10.1016/j.juro.2008.10.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Dissection of the seminal vesicles during radical prostatectomy has the potential to damage the pelvic plexus, thus compromising trigonal, bladder neck and cavernous innervation, and contributing to delayed gain of continence and erectile function. The rate of prostate cancer invasion into the seminal vesicles in currently operated patients is low and in most it may be predicted preoperatively. This situation calls for seminal vesicle sparing radical prostatectomy in select patients, leaving a distal remnant of the seminal vesicles in place. We investigated the fate of the seminal vesicle remnant after proximal transection or ligation in an animal model. MATERIALS AND METHODS The right seminal vesicle in 36 anesthetized male rats was divided by suture ligation or by transection. The left seminal vesicle served as a control. Six rats per group were sacrificed 1, 2 and 4 weeks after division, respectively. Seminal vesicle morphology was evaluated macroscopically and microscopically. RESULTS All rats tolerated surgery well and gained weight postoperatively. Transected seminal vesicles were similar in weight and morphology to control contralateral glands. One week after seminal vesicle ligation the remnants became significantly heavier and showed balloon dilatation of the hollow spaces, while the lining epithelium became significantly flattened. Two and 4 weeks after ligation half of the animals showed gland shrinkage and half demonstrated persistent dilatation. CONCLUSIONS Seminal vesicle transection preserves the gland remnant in a relatively normal morphology, while ligation leads to severe and inconsistent morphological changes. When considering seminal vesicle sparing radical prostatectomy, seminal vesicle transection may be preferred to ligation.
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Affiliation(s)
- Shilo Rosenberg
- Department of Urology, Hadassah-Hebrew University Medical Center Jerusalem, Israel
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[Significance of residual hyperplastic cells after radical prostatectomy. A literature review]. Actas Urol Esp 2009; 32:873-8. [PMID: 19044296 DOI: 10.1016/s0210-4806(08)73954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Radical prostatectomy represents a standard surgical treatment for clinically localized prostate cancer. Classically pathologist and urologist worried about positive surgical margin, but not to the presence of surgery residual hyperplastic cells able to generate prostate specific antigen (PSA) and difficult the follow up of the patients that underwent surgery. We reviewed the literature looking for the incidence, the potential etiology and the influence of these hyperplastic cells in the biochemical evolution of the disease. MATERIAL AND METHOD The information for this review was compiled by searching the Pubmed database. We used "Mesh", Prostatectomy" and "Prostatic Neoplasms" and "Prostate-Specific Antigen" terms, and we added "biochemical failure" and/or "hyperplasic cells" and/or "benign cells". Furthermore, we select the work in English, Spanish and German, review articles that referenced this work and include the series with more than 50 patients, letters to the editor, editorials and overall reviews. CONCLUSIONS Benign hyperplasic cells left behind after radical prostatectomy are frequent and probably under-rated. The influence of those cells in the biochemical outcome is a controversial issue. Positive margins for benign cells can come from apex or neck of the bladder, where the prostatic capsule is not well defined, but no from dorso-lateral area, this would imply a technical mistake. We recommend the inspection of the specimen by the surgeon, after prostatectomy in order to detect apex integrity, cranial and dorso-lateral capsule.
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Abstract
Robotic-assisted laparoscopic prostatectomy (RALP) has emerged as an important treatment option for localized prostate cancer. As such, methods to improve instrumentation, technique, outcomes, and cost require continued investigation. For example, a recently introduced four-armed robotic system has limited the need for bedside assistants, while an enhanced understanding of pelvic anatomy as visualized robotically has led to valuable modifications in operative technique. Increased surgeon experience has decreased perioperative morbidity, and has resulted in short-term pathologic and functional outcomes that compare favorably with open radical prostatectomy. Meanwhile, quality-of-life studies using validated instruments are helping to define the time course of patient recovery. Nevertheless, costs associated with robotic surgery remain daunting. As the follow-up of patients treated with RALP matures, future studies, ideally with a prospective, randomized design, will be needed to establish the long-term oncologic efficacy of the procedure and to evaluate the overall advantages of RALP compared with open surgery.
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Gallina A, Salonia A, Briganti A, Suardi N, Dehò F, Zanni G, Saccà A, Abdollah F, Cestari A, Guazzoni G, Rigatti P, Montorsi F. Prevention and Management of Postprostatectomy Erectile Dysfunction. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.eursup.2008.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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95
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Wexner SD, Bergamaschi R, Lacy A, Udo J, Brölmann H, Kennedy RH, John H. The current status of robotic pelvic surgery: results of a multinational interdisciplinary consensus conference. Surg Endosc 2008; 23:438-43. [PMID: 19037694 DOI: 10.1007/s00464-008-0202-8] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 10/13/2008] [Indexed: 01/07/2023]
Abstract
BACKGROUND Despite the significant benefits of laparoscopic surgery, limitations still exist. One of these limitations is the loss of several degrees of freedom. Robotic surgery has allowed surgeons to regain the two lost degrees of freedom by introducing wristed laparoscopic instruments. METHODS At the first Pelvic Surgery Meeting held in Brescia in June 2007, the participants focused on the role of robotic surgery in pelvic operations surgery for malignancy including prostate, rectal, uterine, and cervical carcinoma. All members of the interdisciplinary panel were asked to define the role of robotic surgery in prostate, rectal, and uterine carcinoma. All key statements were reformulated until a consensus within the group was achieved (Murphy et al., Health Technol Assess 2(i-v):1-88, 1998). For the systematic review, a comprehensive literature search was performed in Medline and the Cochrane Library from January 1997 to June 2007. The keywords used were Da Vinci, telemonitoring, laparoscopy, neoplasms for urology, colorectal, gynecology, visceral surgery, and minimally invasive surgery. The pelvic surgery meeting was supported by Olympus Medical Systems Europa. RESULTS As of December 31, 2007, there were 795 unit shipments worldwide of the Da Vinci((R)): 595 in North America, 136 in Europe, and 64 in the rest of the world (http://investor.intuitivesurgical.com/phoenix.zhtml?c=122359&p=irol-faq#22324 ). It was estimated that, during 2007, approximately 50,000 radical prostatectomies were performed with the Da Vinci robot system in the USA, reflecting market penetration of 60% of radical prostatectomies in the USA. This utilization represents 50% growth as in 2006 only 42% of all radical prostatectomies performed in the USA employed robotics. CONCLUSION While robotic prostatectomy has become the most widely accepted method of prostatectomy, robotic hysterectomy and proctectomy remain far less widely accepted. The theoretical benefits of the increased degrees of freedom and three-dimensional visualization may be outweighed in these areas by the loss of haptic feedback, increased operative times, and increased cost.
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Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA.
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96
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Cozzi P. Improving cancer control and recovery of potency after radical prostatectomy: nerve sparing versus nerve resection with grafting. ANZ J Surg 2008; 78:834-5. [PMID: 18959630 DOI: 10.1111/j.1445-2197.2008.04674.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Paul Cozzi
- Department of Surgery, University of New South Wales, Sydney Prostate Cancer Centre, Continuum Health Care Group, St George Hospital, Sydney, New South Wales, Australia
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97
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Zorn KC, Gofrit ON, Steinberg GP, Taxy JB, Zagaja GP, Shalhav AL. Planned nerve preservation to reduce positive surgical margins during robot-assisted laparoscopic radical prostatectomy. J Endourol 2008; 22:1303-9. [PMID: 18484875 DOI: 10.1089/end.2008.0009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The main objective of radical prostatectomy (RP) is optimal oncologic resection with preservation of sexual function (SF). During our initial experience with robot-assisted laparoscopic radical prostatectomy (RLRP), we noted a high rate of posterolateral location of positive surgical margins (PSM) with nerve preservation (NP). With its magnified view of the surgical field and improved instrument precision, one potential advantage of RLRP is the ability to tailor the degree of NP. We evaluated the effect of a protocol for side-specific NP based on preoperative variables on PSM rates and SF outcomes. METHODS Between June and November 2006, 150 consecutive RLRPs were performed using a surgical protocol to select side-specific NP techniques (interfascial [IF], partial extrafascial [pEF], and wide extrafascial resection [WEFR]) based on preoperative risk factors (clinical stage, biopsy Gleason score, percentage of positive cores and maximal core cancer percentage, and preoperative PSA). Pathologic and SF outcomes in these patients were compared with those of a control group of 245 consecutive RLRPs in whom non-selective IF dissection was performed. All data were prospectively collected. RESULTS Mean patient age, PSA, clinical stage, biopsy Gleason score and positive core involvement, pathologic Gleason score, and stage were comparable among the two groups. The overall PSM rate (12.6% nu 20.4%; P = 0.04) and posterolateral location of PSMs (37% nu 70%; P = 0.04) were significantly lower in the study group. At 12 months, potency was reported in 80%, 67%, and 11% of men undergoing bilateral IFNP, partial extrafascial nerve preservation (pEFNP), and WEFR, respectively (P = 0.27). CONCLUSIONS Planning side-specific NP during RLRP, according to selected preoperative variables, can significantly reduce overall and posterolateral PSM rates. Furthermore, partial nerve sparing (pEFNP) also appears to confer favorable early SF outcomes.
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Affiliation(s)
- Kevin C Zorn
- Section of Urology, University of Chicago, Pritzker School of Medicine, Chicago, Illinois 60637, USA.
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98
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Mandhani A, Dorsey, Jr. PJ, Ramanathan R, Salamanca JI, Rao S, Leung R, Berryhill Jr. R, Tewari AK. Real Time Monitoring of Temperature Changes in Neurovascular Bundles During Robotic Radical Prostatectomy: Thermal Map for Nerve-Sparing Radical Prostatectomy. J Endourol 2008; 22:2313-7. [DOI: 10.1089/end.2008.9712] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anil Mandhani
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Philip J. Dorsey, Jr.
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Rajan Ramanathan
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Juan I. Salamanca
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Sandhya Rao
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Robert Leung
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Roy Berryhill Jr.
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
| | - Ashutosh K. Tewari
- New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021
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Tewari A, Rao S, Mandhani A. Catheter-less robotic radical prostatectomy using a custom-made synchronous anastomotic splint and vesical urinary diversion device: report of the initial series and perioperative outcomes. BJU Int 2008; 102:1000-4. [DOI: 10.1111/j.1464-410x.2008.07875.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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100
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Martinez-Salamanca JI, Rao S, Ramanathan R, Leung R, Mandhani A, Tewari A. The case for robot-assisted radical prostatectomy. J Endourol 2008; 22:2039-43; discussion 2049. [PMID: 18811534 DOI: 10.1089/end.2008.9749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Juan I Martinez-Salamanca
- Department of Urology, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021, USA
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