1
|
Wang X, Wu Y, Guo J, Chen H, Weng X, Liu X. Oncological safety of intrafascial nerve-sparing radical prostatectomy compared with conventional process: a pooled review and meta-regression analysis based on available studies. BMC Urol 2019; 19:41. [PMID: 31133039 PMCID: PMC6537360 DOI: 10.1186/s12894-019-0476-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 05/13/2019] [Indexed: 11/11/2022] Open
Abstract
Background Intrafascial prostatectomy was a modified technique from the conventional nerve-sparing surgery in order to improve patients’ post-surgical continence and erectile function; however, ongoing controversy exists regarding the oncological safety of this technique. In this study we aimed to provide a critical and pooled analysis based on published literatures regarding the oncological outcomes after intrafascial nerve-sparing prostatectomy. Methods Database searches were performed for published articles till June 2018 on PubMed. Three reviewers screened fulfilled papers and extracted data independently. Main outcome was the positive surgical margins (PSMs) rates stratified by pathological stages. We performed both one-arm and comparative meta-analysis to evaluate the oncological safety of intrafascial technique. Moreover, we built meta-regression models to assess the confounding factors. Results We retrieved a total of 117 records after electronic search, of which 21 studies were finally included in this review. There were 15 controlled studies and 6 surgical series. Our one-arm meta-analysis demonstrated that the total PSM rates after intrafascial techniques ranging from 2.2 to 35%, with a pooled rate of 14.5% on average (480 of 3151 patients, 95% confidence interval[CI]: 11.2–17.5%). Meta-regression model showed that patients’ age, pT2 cancer percentage and Selection Score of Oncological Safety (SSOS) were significantly associated with total PSM rate; moreover, each 1 point of SSOS could decrease the total PSM rate by 1.3% on average. Comparative meta-analysis demonstrated that there was no significant difference between intra- and inter-fascial group regarding PSM rates. Conclusions With stringent case selection and when performed by experienced surgeons, intrafascial prostatectomy could offer an acceptable or, at least, equivalent PSM rate compared with the conventional interfascial approach. Preoperative SSOS more than 7 points could be considered as an indication of intrafascial radical prostatectomy. Electronic supplementary material The online version of this article (10.1186/s12894-019-0476-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Xiao Wang
- Department of Urology, Renmin Hospital of Wuhan University, 238Jiefang Road, Wuhan, 430060, People's Republic of China
| | - Yiqi Wu
- Department of Urology, Renmin Hospital of Wuhan University, 238Jiefang Road, Wuhan, 430060, People's Republic of China
| | - Jia Guo
- Department of Urology, Renmin Hospital of Wuhan University, 238Jiefang Road, Wuhan, 430060, People's Republic of China
| | - Hui Chen
- Department of Urology, Renmin Hospital of Wuhan University, 238Jiefang Road, Wuhan, 430060, People's Republic of China
| | - Xiaodong Weng
- Department of Urology, Renmin Hospital of Wuhan University, 238Jiefang Road, Wuhan, 430060, People's Republic of China
| | - Xiuheng Liu
- Department of Urology, Renmin Hospital of Wuhan University, 238Jiefang Road, Wuhan, 430060, People's Republic of China.
| |
Collapse
|
2
|
Clarebrough E, Christidis D, Lindner U, Fernandes K, Fleshner N, Lawrentschuk N. Analysis of a practical surgical skills laboratory for nerve sparing radical prostatectomy. World J Urol 2018; 37:799-804. [PMID: 30191394 DOI: 10.1007/s00345-018-2472-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE With the rapidly expanding anatomical and technical knowledge surrounding nervesparing radical prostatectomy (NSRP), anatomical and operative textbooks have failed to keep pace with the literature. A surgical skill laboratory (SSL) was designed to educate urology trainees on surgical anatomy and techniques for NSRP. The objective was to assess the validity of a SSL program. METHODS A low-fidelity, anatomically accurate prostate model with its appropriate fascial coverings and location of the neurovascular bundle was created. Participants were surveyed prior to a SSL workshop for their knowledge of NSRP focusing on clinical and anatomical considerations. An interactive 2-h tutorial and workshop was then undertaken outlining the clinical and anatomical nuances for NSRP, with participants then practising an intra and inter-fascial NSRP on the model. Participants were resurveyed immediately after the workshop and at 6 months. RESULTS Thirty participants completed the NSRP workshop. Significant differences (p < 0.0001) in anatomical and clinical knowledge were noted after the workshop with improvements for both junior and senior trainees. The knowledge was retained at 6 months following the workshop. CONCLUSIONS A low-fidelity bench-top model is a feasible and reproducible technique for improving the understanding of periprostatic anatomy and the different surgical approaches for NSRP. The SSL is useful and knowledge gained appears to be retained by workshop participants. SSL workshops are a valid hands-on approach to teaching surgical skills and should remain an integral part of urology training.
Collapse
Affiliation(s)
- Emma Clarebrough
- Department of Surgery, Royal Melbourne Hospital, Melbourne, VIC, Australia. .,Young Urology Researchers Organisation (YURO), Melbourne, VIC, Australia.
| | - Daniel Christidis
- Young Urology Researchers Organisation (YURO), Melbourne, VIC, Australia.,Department of Surgery, Austin Health, Melbourne, VIC, Australia
| | - Uri Lindner
- Department of Urology and Surgical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Kimberly Fernandes
- Department of Urology and Surgical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Neil Fleshner
- Department of Urology and Surgical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Nathan Lawrentschuk
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia.,Olivia Newton John Cancer Research Institute, Austin Health, Melbourne, VIC, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| |
Collapse
|
3
|
Wang X, Wu Y, Guo J, Chen H, Weng X, Liu X. Intrafascial nerve-sparing radical prostatectomy improves patients' postoperative continence recovery and erectile function: A pooled analysis based on available literatures. Medicine (Baltimore) 2018; 97:e11297. [PMID: 30024505 PMCID: PMC6086530 DOI: 10.1097/md.0000000000011297] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Intrafascial nerve-sparing prostatectomy has been currently applied based on the updated anatomic understanding of periprostatic cavernous nerves, in order to provide patients better postoperative recovery of continence and potency. The aim of our study is to perform a pooled analysis of available literatures regarding the functional outcomes following intrafascial nerve-sparing technique. METHODS The authors performed database searches of articles published till October 2017 on PubMed using following keywords across the "title" and "abstract" field of the records: intrafascial, veil, curtain dissection, high anterior release, incremental nerve sparing, and radical prostatectomy. Fulfilled papers were screened and data were extracted independently by 3 reviewers. Main outcome was the postoperative continence and potency rate stratified by follow-up durations. Both 1-arm and comparative meta-analyses were performed and meta-regression models were conducted to evaluate the confounding factors. RESULTS Using the electronic search strategy, a total of 71 records were retrieved and 20 studies were finally included, of which 6 were surgical series and 14 were controlled studies. Our 1-arm meta-analysis summarized the pooled continence rates after intrafascial prostatectomy were 59.4%, 76.2%, 89.9%, and 92.2% at postoperative follow-up of 1, 3, 6, and 12 months, respectively. Regardless of the variance in potency definition, the pooled potency rates after intrafascial prostatectomy were 42.2%, 54.2%, and 72.2% at 3, 6, and 12 months, respectively. Comparative analysis showed that the intrafascial group offered better continence rates at 1, 3, and 6 months with an odds ratio (OR) of 2.38 (95% confidence interval [CI]: 1.73-3.26), 1.82 (95% CI: 1.18-2.82), and 2.19 (95% CI: 1.43-3.34) as compared with the interfascial group. Moreover, potency rate in the intrafascial group was higher at 12 months than in the interfascial group, with an OR of 2.44 (95% CI: 1.35-4.42). CONCLUSION Based on the limited evidence, our study demonstrated that intrafascial nerve-sparing prostatectomy could provide patients with earlier recovery of continence and better erectile function compared with conventional interfascial approach, but physiological mechanisms about this technique still need further study.
Collapse
|
4
|
Comparison of intrafascial and non-intrafascial radical prostatectomy for low risk localized prostate cancer. Sci Rep 2017; 7:17604. [PMID: 29242503 PMCID: PMC5730549 DOI: 10.1038/s41598-017-17929-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 11/03/2017] [Indexed: 02/06/2023] Open
Abstract
In this meta-analysis study, we compared the oncological and functional outcomes of intrafascial radical prostatectomy (IFRP) with non-intrafascial radical prostatectomy (NIFRP) in the treatment of patients with low risk localized prostate cancer (PCa). Relevant articles were identified by searching PubMed, EMBASE, Cochrane Library, Ovid, and the ISI Web of Knowledge databases. A total of 2096 patients were included from 7 eligible studies. Results of the pooled data showed that the oncological outcomes including gleason score, positive surgical margin and biochemical free survival rates were similar between the two groups. IFRP was superior to NIFRP with lower postoperative complication rates (RR 0.57, 95% CI 0.38, 0.85, p = 0.006), higher continence rates at 3 months post-operation (RR: 1.14; 95% CI, 1.04, 1.26; p = 0.006), and higher potency rates at 6 months (RR: 1.53; 95% CI, 1.07, 2.18; p = 0.02) and 12 months post-operation (RR: 1.38; 95% CI, 1.11, 1.73; p = 0.005). Additionally, there was a tendency towards higher potency rate in patients ≤65 years old compared with patients >65 years old after IFRP. Overall, these findings suggest that IFRP in young patients with low risk localized PCa had less postoperative complications, shortened time to return to continence and improved potency rate without compromising complete tumor control.
Collapse
|
5
|
Favorito LA. Editorial in this issue - Bladder Neck Reconstruction in Radical Prostatectomy: What we still can learn and improve? Int Braz J Urol 2015. [PMID: 26200531 PMCID: PMC4752129 DOI: 10.1590/s1677-5538.ibju.2015.03.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
6
|
Lott FM, Favorito LA. Is previous experience in laparoscopic necessary to perform robotic radical prostatectomy? A comparative study with robotic and the classic open procedure in patients with prostate cancer. Acta Cir Bras 2015; 30:229-34. [DOI: 10.1590/s0102-8650201500300000011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/18/2015] [Indexed: 11/22/2022] Open
|
7
|
Isgoren AE, Saitz TR, Serefoglu EC. Erectile Function Outcomes after Robot‐Assisted Radical Prostatectomy: Is It Superior to Open Retropubic or Laparoscopic Approach? Sex Med Rev 2014; 2:10-23. [DOI: 10.1002/smrj.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
8
|
Andino L, Davis JW, Wei W, Prokhorova IN, Troncoso P, Matin SF. Correlation of histomorphologic findings and partial neurovascular bundle preservation during laparoscopic and robotic radical prostatectomy. J Robot Surg 2013; 7:1-8. [PMID: 27000885 DOI: 10.1007/s11701-011-0323-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 10/23/2011] [Indexed: 10/15/2022]
Abstract
The objective of this work was to compare the amount of residual periprostatic tissue for radical prostatectomy performed by the partial NS (PNS) technique with that performed by the nerve-sparing (NS) or wide-resection (WR) techniques. Retrospective histomorphologic evaluation of radical prostatectomy specimens (RPSs) from patients undergoing laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) was performed. The posterolateral regions corresponding to the neurovascular bundle in RPSs from 48 patients who had undergone NS, PNS, or WR during LRP (n = 30) or RARP (n = 18) were examined by two pathologists unaware of the technique used. The RPSs were evaluated at the base, mid-gland, and apex. The amount of periprostatic tissue at each site was recorded. Measurements were analyzed by use of a linear mixed model. For both LRP and RARP, each gradation of nerve-preservation was associated with periprostatic tissue, except PNS and WR did not differ for LRP at the apex and base or for RARP at the apex, mid-gland, and base. For LRP, a greater amount of tissue was on the left side of the prostate than on the right at the mid-gland level (P = 0.004) whereas for RARP the opposite was found (P = 0.024). Of 18 separate analyses, 13 were significantly associated. The study is limited by its retrospective design. The amount of periprostatic tissue in the neurovascular bundle area correlates well with the nerve-preservation approach used during LRP and RARP, providing anatomic evidence supporting the PNS approach. We also describe a novel finding of laterality bias at the mid-gland level in LRP and RARP specimens.
Collapse
Affiliation(s)
- Lizmarie Andino
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John W Davis
- Department of Urology, Unit 1373, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Wei Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ina N Prokhorova
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patricia Troncoso
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Surena F Matin
- Department of Urology, Unit 1373, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| |
Collapse
|
9
|
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
| |
Collapse
|
10
|
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.
Collapse
Affiliation(s)
- David S Finley
- Department of Urology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA 90027, USA.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Alemozaffar M, Duclos A, Hevelone ND, Lipsitz SR, Borza T, Yu HY, Kowalczyk KJ, Hu JC. Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function. Eur Urol 2012; 61:1222-8. [DOI: 10.1016/j.eururo.2012.02.053] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 02/29/2012] [Indexed: 11/30/2022]
|
12
|
Open Complete Intrafascial Nerve-sparing Retropubic Radical Prostatectomy: Technique and Initial Experience. Urology 2012; 79:717-21. [DOI: 10.1016/j.urology.2011.11.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 11/02/2011] [Accepted: 11/29/2011] [Indexed: 11/20/2022]
|
13
|
Dal Moro F, Secco S, Valotto C, Artibani W, Zattoni F. Specific learning curve for port placement and docking of da Vinci® Surgical System: one surgeon’s experience in robotic-assisted radical prostatectomy. J Robot Surg 2011; 6:323-7. [DOI: 10.1007/s11701-011-0315-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 09/12/2011] [Indexed: 01/22/2023]
|
14
|
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]
|
15
|
Abstract
PURPOSE OF REVIEW New insights in the anatomy of the prostate and the surrounding tissue evolve the technique of radical prostatectomy for the treatment of prostate cancer. RECENT FINDINGS Regarding the course of the erectile nerves along the prostate, recent studies confirmed the presence of parasympathetic pro-erectile nerve fibers at the anterolateral aspect of the prostate. Another study of intraoperative electrostimulation of those nerves confirmed an increase in intracavernosal pressure by stimulations between the 1 and 3 o'clock position. Therefore, it is very likely that these anterior nerve fibers have an effect on erectile function. Regarding the urethral sphincter in the male, a study showed no attachment of the external sphincter to the levator ani muscle, probably resulting in an absence of a levator ani support to the continence mechanism. The male urinary sphincter seems to be in isolation responsible for urinary continence. SUMMARY The nerve fibers at the anterolateral aspect of the prostate seem to participate in erectile function, which renders the concept of a high anterior release during nerve sparing beneficial. The isolated urinary sphincter mechanism results in the need to conserve as much urethral length as possible during radical prostatectomy to avoid urinary incontinence.
Collapse
|
16
|
Cathelineau X, Sanchez-Salas R, Barret E, Rozet F, Galiano M, Benoist N, Stakhovsky O, Vallancien G. Radical prostatectomy: evolution of surgical technique from the laparoscopic point of view. Int Braz J Urol 2011; 36:129-39; discussion 140. [PMID: 20450497 DOI: 10.1590/s1677-55382010000200002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2009] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To review the literature and present a current picture of the evolution in radical prostatectomy from the laparoscopic point of view. MATERIALS AND METHODS We conducted an extensive Medline literature search. Articles obtained regarding laparoscopic radical prostatectomy (LRP) and our experience at Institut Montsouris were used for reassessing anatomical and technical issues in radical prostatectomy. RESULTS LRP nuances were reassessed by surgical teams in order to verify possible weaknesses in their performance. Our basic approach was to carefully study the anatomy and pioneer open surgery descriptions in order to standardized and master a technique. The learning curve is presented in terms of an objective evaluation of outcomes for cancer control and functional results. In terms of technique-outcomes, there are several key elements in radical prostatectomy, such as dorsal vein control-apex exposure and nerve sparing with particular implications in oncological and functional results. Major variations among the surgical teams' performance and follow-up prevented objective comparisons in radical prostatectomy. The remarkable evolution of LRP needs to be supported by comprehensive results. CONCLUSIONS Radical prostatectomy is a complex surgical operation with difficult objectives. Surgical technique should be standardized in order to allow an adequate and reliable performance in all settings, keeping in mind that cancer control remains the primary objective. Reassessing anatomy and a return to basics in surgical technique is the means to improve outcomes and overcome the difficult task of the learning curve, especially in minimally access urological surgery.
Collapse
Affiliation(s)
- Xavier Cathelineau
- Department of Urology, Institut Montsouris, Université Paris Descartes, Paris, France.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Freire MP, Choi WW, Lei Y, Carvas F, Hu JC. Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy. Urol Clin North Am 2010; 37:37-47, Table of Contents. [PMID: 20152518 DOI: 10.1016/j.ucl.2009.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors' RALP technique, and concludes with tips to overcome the learning curve.
Collapse
Affiliation(s)
- Marcos P Freire
- Division of Urology, Brigham & Women's Hospital, 45 Francis Street ASB II-3, Boston, MA 02115, USA
| | | | | | | | | |
Collapse
|
18
|
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.
Collapse
Affiliation(s)
- Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Center, 232, Bd Ste. Marguerite, 13009 Marseille, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Lawrentschuk N, Lindner U, Fleshner N. CURRENT TEXTBOOKS AND ANATOMY OF THE PROSTATE - A CASE FOR AN UPDATE. BJU Int 2009; 103:1319-22. [DOI: 10.1111/j.1464-410x.2009.08426.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
Sievert KD, Hennenlotter J, Laible IA, Amend B, Nagele U, Stenzl A. The Commonly Performed Nerve Sparing Total Prostatectomy Does Not Acknowledge the Actual Nerve Courses. J Urol 2009; 181:1076-81. [DOI: 10.1016/j.juro.2008.10.154] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Indexed: 10/21/2022]
Affiliation(s)
| | | | - Ines A. Laible
- Department of Urology, University of Tuebingen, Tuebingen, Germany
| | - Bastian Amend
- Department of Urology, University of Tuebingen, Tuebingen, Germany
| | - Udo Nagele
- Department of Urology, University of Tuebingen, Tuebingen, Germany
| | - Arnulf Stenzl
- Department of Urology, University of Tuebingen, Tuebingen, Germany
| |
Collapse
|
21
|
[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.
Collapse
|
22
|
Sievert KD, Hennenlotter J, Laible I, Amend B, Schilling D, Anastasiadis A, Kuehs U, Nagele U, Stenzl A. The Periprostatic Autonomic Nerves—Bundle or Layer? Eur Urol 2008; 54:1109-16. [DOI: 10.1016/j.eururo.2008.06.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
|
23
|
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.
Collapse
Affiliation(s)
- Kevin C Zorn
- Section of Urology, University of Chicago, Pritzker School of Medicine, Chicago, Illinois 60637, USA.
| | | | | | | | | | | |
Collapse
|
24
|
Chabert CC, Merrilees DA, Neill MG, Eden CG. Curtain dissection of the lateral prostatic fascia and potency after laparoscopic radical prostatectomy: a veil of mystery. BJU Int 2008; 101:1285-8. [DOI: 10.1111/j.1464-410x.2008.07595.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
Zorn KC, Gallina A, Hutterer GC, Walz J, Shalhav AL, Zagaja GP, Valiquette L, Gofrit ON, Orvieto MA, Taxy JB, Karakiewicz PI. External validation of a nomogram for prediction of side-specific extracapsular extension at robotic radical prostatectomy. J Endourol 2008; 21:1345-51. [PMID: 18042028 DOI: 10.1089/end.2007.0044] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Several staging tools have been developed for open radical prostatectomy (ORP) patients. However, the validity of these tools has never been formally tested in patients treated with robot-assisted laparoscopic radical prostatectomy (RALP). We tested the accuracy of an ORP-derived nomogram in predicting the rate of extracapsular extension (ECE) in a large RALP cohort. PATIENTS AND METHODS Serum prostate specific antigen (PSA) and side-specific clinical stage and biopsy Gleason sum information were used in a previously validated nomogram predicting side-specific ECE. The nomogram-derived predictions were compared with the observed rate of ECE, and the accuracy of the predictions was quantified. Each prostate lobe was analyzed independently. As complete data were available for 576 patients, the analyses targeted 1152 prostate lobes. Median age and serum PSA concentration at radical prostatectomy were 60 years and 5.4 ng/mL, respectively. RESULTS The majority of side-specific clinical stages were T(1c) (993; 86.2%). Most side-specific biopsy Gleason sums were 6 (572; 49.7%). The median side-specific percentages of positive cores and of cancer were, respectively, 20.0% and 5.0%. At final pathologic review, 107 patients (18.6%) had ECE, and side-specific ECE was present in 117 patients (20.3%). The nomogram was 89% accurate in the RALP cohort v 84% in the previously reported ORP validation. CONCLUSIONS The ORP side-specific ECE nomogram is highly accurate in the RALP population, suggesting that predictive and possibly prognostic tools developed in ORP patients may be equally accurate in their RALP counterparts.
Collapse
Affiliation(s)
- Kevin C Zorn
- Minimal Invasive Urology Department, University of Chicago, Chicago, Illinois, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Zorn KC, Gofrit ON, Orvieto MA, Mikhail AA, Zagaja GP, Shalhav AL. Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation. Eur Urol 2006; 51:755-62; discussion 763. [PMID: 17084520 DOI: 10.1016/j.eururo.2006.10.019] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2006] [Accepted: 10/16/2006] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Robotic-assisted laparoscopic radical prostatectomy (RLRP) is increasingly becoming an alternative to open and laparoscopic radical prostatectomy in the treatment of localized prostate cancer. RLRP has been associated with low morbidity, short convalescence and comparable oncologic and functional outcomes. We report our initial experience of 300 consecutive cases with selective use of interfascial nerve preservation (IFNP). METHODS Between February 2003 and September 2005, 300 consecutive men underwent RLRP at our institution. Patients were followed prospectively with validated questionnaires. RESULTS Mean operative time was 282 minutes with an estimated blood loss of 273 ml. The intra-operative complication rate was 2.3% with no mortality. Return to baseline (RTB) urinary function and subjective continence at 12 months were 71% and 90.2%, respectively. RTB sexual function and subjective potency at 12 months were 53% and 80.4%, respectively. Overall, the positive surgical margin (PSM) rate was 20.9%: 15.1% for pT2 and 52.1% for pT3 disease and 93.1% had an undetectable PSA (<0.1 ng/mL) with a mean follow-up of 17.3 months. Fifty-four percent of PSMs occured in a poster-lateral (PL) location. Retrospectively, IFNP was performed in 86.5% and 62.5% of pT2 and pT3 PSMs, respectively. Pathologic-T3 PSMs were found to occur significantly more often in a PL location when ipsilateral IFNP was performed when compared to non-IFNP (73% vs 33%, p=0.05). CONCLUSIONS IFNP appears to result in favorable return of potency, however, postero-lateral PSMs appear to occur more frequently with this technique. Proper patient selection for robotic surgery and nerve-preservation appears to be critical in order to reduce PSM and optimize the oncologic efficacy of this technology.
Collapse
Affiliation(s)
- Kevin C Zorn
- Section of Urology, University of Chicago, Pritzker School of Medicine, Chicago, Illinois 60637, United States.
| | | | | | | | | | | |
Collapse
|