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Kumagai S, Muraki O, Yoshimura Y. Evaluation of the effect of levator ani muscle contraction on post-prostatectomy urinary incontinence using cine MRI. Neurourol Urodyn 2021; 41:616-625. [PMID: 34962308 DOI: 10.1002/nau.24861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/08/2022]
Abstract
AIM Post-prostatectomy urinary incontinence (PPI) is the greatest concern for urologists after radical prostatectomy (RP). It is thought that PPI is composed of multiple factors including static and dynamic components. The purpose of this study is to show visually levator ani muscle (LAM) contraction during pelvic floor muscle contraction and to evaluate the dynamic differences in its contraction between men with and without PPI. METHODS This study was a case-control study of the urinary continent or incontinent men. It investigated whether LAM contraction was involved in urinary leakage based on examination of LAM contraction by cine magnetic resonance imaging. RESULTS The LAM contracted from the coccyx to the pubis in the same manner before and after surgery. The degree of contraction of the LAM in post-prostatectomy groups was smaller than that in the healthy adult group. The contraction distances of each part of the pelvic floor were decreased by 50%-70% in the incontinence group compared to those in the continence group. The bladder neck moved 2.5-fold further in the continence group and the direction of movement was more vertical than in the incontinence group. Urethral compression was attenuated by about 40% in the incontinence group compared to that in the continence group. CONCLUSIONS RP can cause damage to the LAM. LAM contraction is reduced after RP compared with that in healthy adult men. In men with PPI, the reduced muscle contraction might not compress the urethra sufficiently when abdominal pressure is raised. Pelvic floor muscle training might provide a meaningful method for the recovery of LAM contraction in patients with PPI.
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Affiliation(s)
- Shin Kumagai
- Department of Urology, Fujita General Hospital, Fukushima, Japan
| | - Osamu Muraki
- Department of Urology, Fujita General Hospital, Fukushima, Japan
| | - Yasukuni Yoshimura
- Department of Urology, Showa University Northern Yokohama Hospital Female Pelvic Health Center, Yokohama, Japan
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Vogt K, Netsch C, Becker B, Oye S, Gross AJ, Rosenbaum CM. Perioperative and Pathological Outcome of Nerve-Sparing Radical Cystectomy With Ileal Neobladder. Front Surg 2021; 8:652958. [PMID: 33869270 PMCID: PMC8044882 DOI: 10.3389/fsurg.2021.652958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/26/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: So far, it has not been described whether the perioperative course and the pathologic outcome of patients who undergo radical cystectomy (RC) with orthotopic bladder substitution differs if nerve sparing (NS) is performed or not. Material and Methods: In all, there were 472 patients who underwent RC between 2012 and 2019 at our department. We performed a retrospective analysis of 116 patients who underwent RC with ileal neobladder. We analyzed perioperative complications according to the Clavien-Dindo classification system, as well as the pathological outcome. Results: Of 116 patients, 68 (58.6%) underwent RC, and 48 (41.4%) underwent NS RC. Clavien-Dindo complications ≥3b occurred in 15 (12.9%) of all patients. Only infectious complications differed among the groups [NS RC: 25 patients (52.1%) vs. RC: 20 patients (29.4%); p = 0.02]. There was no significant difference concerning tumor stage. Concomitant Cis was present in 24 patients (35.3%) of the RC group and in 27 patients (56.3%) of the NS RC group (p = 0.036). Nodal status and positive surgical margin status of the bladder tumor did not differ among the groups. In all, 42 of all male patients (45.7%) had an incidental prostatic carcinoma. Positive surgical margins concerning the prostate carcinoma occurred in six patients, with all cases in the RC group (p = 0.029). Conclusions: Our data suggest that performing NS during RC in carefully selected patients is a safe procedure and does not impair perioperative outcome. Pathological outcome of NS RC is comparable as well.
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Affiliation(s)
- Katharina Vogt
- Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
| | | | - Benedikt Becker
- Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Sebastian Oye
- Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Andreas J Gross
- Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
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3
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Li P, Wang C, Tang M, Han P, Meng X. Holmium laser enucleation of prostate by using en-bloc and bladder neck preservation technique: technical consideration and influence on functional outcomes. Transl Androl Urol 2021; 10:134-142. [PMID: 33532303 DOI: 10.21037/tau-20-852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background This study aimed to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) by using en-bloc and bladder neck preservation technique on benign prostatic hyperplasia (BPH) and assess the influence of this procedure on urinary and sexual functional outcomes. Methods A total of 704 patients with BPH undergoing HoLEP were retrospectively analysed. Amongst them, 213 who met the sexual function assessment criteria were further assessed the influence of the technique on sexual functional outcomes. Results The mean operative time, resected prostate weight and mean estimated blood loss were 69.3±14.8 min, 53.4±17.6 g and 62.1±23.7 mL, respectively. The mean duration of catheterization after surgery and mean hospital stay were 2.1±1 and 5.4±3.6 days, respectively. The post-void residual volume, maximum urinary flow rate, international prostate symptom score and quality of life score were all significantly improved postoperation (P<0.05). Amongst the 213 patients with normal antegrade ejaculation before surgery, postoperative international index of erectile function scores slightly improved, although the difference was insignificant (P>0.05). The difference in the Erection Hardness Grading Scale before and after surgery was statistically insignificant (P>0.05). A total of 25 (11.7%) patients had retrograde ejaculation after surgery. Conclusions HoLEP by an en-bloc and bladder neck preservation technique can obtain good functional outcome with small injury and high efficiency, especially for patients who need to preserve normal sexual function and anterograde ejaculation.
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Affiliation(s)
- Pu Li
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chengming Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Tang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Peng Han
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoxin Meng
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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4
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Krausewitz P, Ritter M. [Pre-, intra- and postoperative predictors of functional outcome following radical prostatectomy]. Aktuelle Urol 2020; 51:463-468. [PMID: 32588414 DOI: 10.1055/a-1185-8330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Maintaining continence and erectile function is crucial for quality of life after radical prostatectomy. This review provides an overview of available evidence concerning preoperative risk stratification as well as intra- and postoperative factors determining functional outcomes after radical prostatectomy.Current data indicate that patient factors including age, baseline erectile function, prostate size, body-mass index and comorbidity status are valid predictors of functional outcome after prostatectomy. While surgical methods do not seem to have any influence, intraoperative procedures like nerve-sparing techniques, the extent of pelvic floor reconstruction as well as surgeons' experience have a significant impact on postoperative potency and continence. Rehabilitation consisting of pelvic floor training and use of PDE-5 inhibitors also contributes significantly to the recovery of erectile function and urinary continence.In summary, numerous adjustments of treatment can help to improve functional results and thus the quality of life after prostatectomy. A careful preoperative selection of suitable patients by urologists and integration of knowledge of periprostatic nerve and fascial structures into the surgical procedure are decisive factors.
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Affiliation(s)
- Philipp Krausewitz
- Universitätsklinikum Bonn, Klinik und Poliklinik für Urologie und Kinderurologie, Bonn
| | - Manuel Ritter
- Universitätsklinikum Bonn, Klinik und Poliklinik für Urologie und Kinderurologie, Bonn
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5
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Kumar A, Patel VR, Panaiyadiyan S, Seetharam Bhat KR, Moschovas MC, Nayak B. Nerve-sparing robot-assisted radical prostatectomy: Current perspectives. Asian J Urol 2020; 8:2-13. [PMID: 33569267 PMCID: PMC7859364 DOI: 10.1016/j.ajur.2020.05.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
Robotic-assisted radical prostatectomy (RARP) is the current standard of care with long term cure in organ-confined disease. The introduction of nerve-sparing (NS) to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes. This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes, the neurovascular bundle (NVB), various NS techniques and postoperative functional outcomes. A non-systematic review was done using PubMed, Embase and Medline databases to retrieve and analyse articles in English, with following keywords "prostate cancer", "robotic radical prostatectomy", "nerve-sparing". The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies. The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other. Variables such as preoperative risk assessments, baseline potency, surgical anatomy of individual patients and surgeons' expertise play a major role in the outcomes. A tailored approach for each patient is required for applying the NS approach during RARP.
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Affiliation(s)
- Anup Kumar
- Department of Urology,Robotics and Renal Transplant, Vardhman Mahaveer Medical College and Safdarjang Hospital, New Delhi, India
| | - Vipul R Patel
- Department of Robotic Surgery, AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Sridhar Panaiyadiyan
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Marcio Covas Moschovas
- Department of Robotic Surgery, AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Brusabhanu Nayak
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
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6
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Zattoni F, Artibani W, Patel V, Montorsi F, Porpiglia F, Hampton LJ, Rocco B, Dasgupta P, Hemal AK, Mottrie A, Tewari A, Dal Moro F. Technical innovations to optimize continence recovery after robotic assisted radical prostatectomy. MINERVA UROL NEFROL 2019; 71:324-338. [DOI: 10.23736/s0393-2249.19.03395-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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7
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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.
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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.
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8
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Manfredi M, Fiori C, Amparore D, Checcucci E, Porpiglia F. Technical details to achieve perfect early continence after radical prostatectomy. MINERVA CHIR 2019; 74:63-77. [DOI: 10.23736/s0026-4733.18.07761-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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9
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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.
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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
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10
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KleinJan GH, Sikorska K, Korne CM, Brouwer OR, Buckle T, Tillier C, van der Roest RCM, de Jong J, van Leeuwen FWB, van der Poel HG. A prediction model relating the extent of intraoperative fascia preservation to erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy. J Robot Surg 2018; 13:455-462. [PMID: 30178300 DOI: 10.1007/s11701-018-0867-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/26/2018] [Indexed: 11/30/2022]
Abstract
Robot-assisted radical prostatectomy (RARP) is performed in patients with prostate cancer. Unfortunately, 10-46% of patients may still suffer from limited erectile function (EF) after RARP. This study aimed to develop a prediction model based on the extent of fascia preservation (FP) and postoperative EF after RARP. A previously developed FP score quantizing the extent and regions of nerve-preservation was determined in a cohort of 1241 patients who underwent RARP. The predictive value of the FP score for post-prostatectomy EF (following the international index erectile function (IIEF) score, EF domain) was analyzed. To increase the predictive value of the scoring system, the FP regions were related to postoperative EF, nerve distribution and co-morbidity factors. Finally, a prediction model for EF was developed based on the studied cohort. When corrected for the preoperative IIEF-EF, the FP score was shown to be a significant denominator for IIEF (p = 2.5 × 10- 15) with an R2 of 35%. Variable selection performed using the Akaike information criterion led to a final prediction model for postoperative IIEF after nerve-preservation based on the FP score. Furthermore, patient's age, preoperative IIEF score, CCIS and use of clips for nerve sparing were significantly associated with postoperative IIEF-EF. More anterior fascia preservation was correlated with better EF outcome and age was a strong independent predictor of EF outcome. In older men, the relative benefit of more extensive fascia preservation was at least similar to younger men, despite a lower baseline IIEF-EF score. Quantitative nerve-sparing FP scoring could be related to the postoperative IIEF-EF and integrated into a multivariate prediction model, which includes with age, use of surgical clips, the Charlson Comorbidity Index Score (CCIS), and preoperative IIEF-EF. When further validated the prediction model could provide patients and care-givers a qualitative estimation of EF outcome after RARP.
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Affiliation(s)
- G H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - K Sikorska
- Department of Biometrics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - C M Korne
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - O R Brouwer
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - T Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - C Tillier
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - R C M van der Roest
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - J de Jong
- Department of Pathology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - F W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center (LUMC), Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - H G van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AvL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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11
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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.
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12
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Grivas N, van der Roest RC, de Korne CM, KleinJan GH, Sikorska K, Schoots IG, Tillier C, van der Broek B, Jalink K, Heijmink SWTJP, Buckle T, van Leeuwen FWB, van der Poel HG. The value of periprostatic fascia thickness and fascia preservation as prognostic factors of erectile function after nerve-sparing robot-assisted radical prostatectomy. World J Urol 2018; 37:309-315. [PMID: 29936567 DOI: 10.1007/s00345-018-2387-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/19/2018] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To determine the correlation of preoperative fascia thickness (FT) and intraoperative fascia preservation (FP) with erectile function (EF) after nerve-sparing robot-assisted radical prostatectomy (RARP). METHODS Our analysis included 106 patients, with localized prostate cancer and no erectile dysfunction (ED) before RARP, assessed with preoperative 3 Tesla (3 T) multiparametric magnetic resonance imaging (MRI). FP score was defined as the extent of FP from the base to the apex of the prostate, quantitatively assessed by the surgeon. Median fascia thickness (MFT) per patient was defined as the sum of the median FT of 12 MRI regions. Preserved MFT (pMFT) was the sum of the saved MFT. The percentage of pFMT (ppMFT) was also calculated. Fascia surface (FS) was measured on MRI and it was combined with FP score resulting in preserved FS (pFS) and percentage of pFS (ppFS). RESULTS FP score, pMFT, ppMFT, pFS and ppFS were significantly lower (p < 0.0001) in patients with ED. In the multivariate regression analysis, lower FP score [odds ratio (OR) 0.721, p = 0.03] and lower ppMFT (OR 0.001, p = 0.027) were independent predictors of ED. ROC analysis showed the highest area under the curve for ppMFT (0.787) and FP score (0.767) followed by pMFT (0.755) and ppFS (0.743). CONCLUSIONS MRI-determined periprostatic FT combined with intraoperative FP score are correlated to postprostatectomy EF. Based on the hypothesis that a thicker fascia forms a protective layer for the nerves, we recommend assessing FT preoperatively to counsel men for the odds of preserving EF after RARP.
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Affiliation(s)
- Nikolaos Grivas
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - Rosanne C van der Roest
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Clarize M de Korne
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Gijs H KleinJan
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Karolina Sikorska
- Department of Biometrics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ivo G Schoots
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Corinne Tillier
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Bram van der Broek
- Department of Cell Biology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Kees Jalink
- Department of Cell Biology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Stijn W T J P Heijmink
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Tessa Buckle
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Fijs W B van Leeuwen
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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13
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Wu YP, Xu N, Wang ST, Chen SH, Lin YZ, Li XD, Zheng QS, Wei Y, Xue XY. The efficacy and feasibility of total reconstruction versus nontotal reconstruction of the pelvic floor on short-term and long-term urinary continence rates after radical prostatectomy: a meta-analysis. World J Surg Oncol 2017; 15:228. [PMID: 29262863 PMCID: PMC5738806 DOI: 10.1186/s12957-017-1296-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 12/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background Recently, total pelvic floor reconstruction (TR) has been the treatment of choice for improving urinary incontinence (UI) after radical prostatectomy (RP). However, the superiority of TR with respect to urinary continence recovery following RP remains controversial. This study identified the effect of TR versus nonTR of the pelvic floor on short-term and long-term continence rates after RP. Methods A literature search was performed in November 2017 using the PubMed, Embase, and Web of Science databases. Only comparative research or clinical studies reporting urinary continence outcomes was included in the meta-analysis, and the quality of evidence was evaluated using the 2011 Level of Evidence for therapy research. Results We analyzed ten studies reporting urinary continence rates after RP at one or more postoperative time points (1, 2, 4, 12, 24, and 52 weeks). TR was associated with significantly better urinary continence outcomes at 1 week (OR 2.76, 95% CI 1.58–4.84, P < 0.001), 2 weeks (OR 2.57, 95% CI 1.74–3.80, P < 0.001), 4 weeks (OR 2.61, 95% CI 1.56–4.38, P < 0.001), 12 weeks (OR 4.33, 95% CI 2.01–9.33, P < 0.001), 24 weeks (OR 3.83, 95% CI 1.54–9.55, P = 0.004), 52 weeks (OR 4.10, 95% CI 1.80–9.38, P < 0.001) after RP. There was no difference in the rate of complications between the two arms (OR 0.54, 95% CI 0.19–1.54, P = 0.25). Conclusions Compared with nonTR, TR is significantly and positively associated with a return to continence but not with complication rate in men following RP, suggesting that TR may be useful for decreasing the urinary incontinence rate after surgery.
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Affiliation(s)
- Yu-Peng Wu
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Ning Xu
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Shi-Tao Wang
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Shao-Hao Chen
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Yun-Zhi Lin
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Xiao-Dong Li
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Qing-Shui Zheng
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Yong Wei
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
| | - Xue-Yi Xue
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China.
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14
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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.
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15
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Xu Z, Chapuis PH, Bokey L, Zhang M. Nature and Architecture of the Puboprostatic Ligament: A Macro- and Microscopic Cadaveric Study Using Epoxy Sheet Plastination. Urology 2017; 110:263.e1-263.e8. [PMID: 28847689 DOI: 10.1016/j.urology.2017.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/21/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the nature and the architecture of the puboprostatic ligament (PPL) and its relationship with surroundings. MATERIALS AND METHODS Six adult male cadaveric pelvises (age range, 46-87 years) were prepared as serial transverse (2 sets), coronal (1 set), or sagittal (3 sets) plastinated sections, and were examined under a stereoscope and a confocal microscope. The thickness of the section was 2.5 mm, the interval between 2 adjacent sections was about 0.9 mm, and a total of about 70 serial sections per set were collected. RESULTS First, the musculotendinous sheet of the pubococcygeus contributed to the visceral endopelvic fascia, decussated in front of the detrusor apron, and fixed to the pubis. Second, anteriorly to the prostate, the detrusor apron split up into anterior, middle, and posterior layers, which contributed to the PPL, the fascial sheaths of the dorsal vascular complex, and the anterior fibromuscular stroma of the prostate, respectively. Third, the PPL originated from both the detrusor apron and the decussated and undecussated fibers of the pubococcygeus, and inserted onto the pubis. CONCLUSION This study revealed the nature and the architecture of the PPL and its relationship with surroundings. These findings provide new insights in the "suspensory system" involving the urinary continence and may incite for future surgical techniques that aim to preserve the decussated pubococcygeus and the intactness of a pubococcygeus-detrusor apron complex during radical retropubic prostatectomy.
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Affiliation(s)
- Zhaoyang Xu
- Department of Anatomy, Anhui Medical University, Hefei, China
| | - Pierre H Chapuis
- Department of Colorectal Surgery, Concord Hospital and Discipline of Surgery, Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Les Bokey
- Department of Colorectal Surgery, Liverpool Hospital and School of Medicine, University of Western Sydney, New South Wales, Australia
| | - Ming Zhang
- Department of Anatomy, University of Otago, Dunedin, New Zealand.
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16
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Tavukçu HH, Aytac O, Atug F. Nerve-sparing techniques and results in robot-assisted radical prostatectomy. Investig Clin Urol 2016; 57:S172-S184. [PMID: 27995221 PMCID: PMC5161020 DOI: 10.4111/icu.2016.57.s2.s172] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/23/2016] [Indexed: 11/24/2022] Open
Abstract
Nerve-sparing techniques in robot-assisted radical prostatectomy (RARP) have advanced with the developments defining the prostate anatomy and robotic surgery in recent years. In this review we discussed the surgical anatomy, current nerve-sparing techniques and results of these operations. It is important to define the right and key anatomic landmarks for nerve-sparing in RARP which can demonstrate individual variations. The patients' risk assessment before the operation and intraoperative anatomic variations may affect the nerve-sparing technique, nerve-sparing degree and the approach. There is lack of randomized control trials for different nerve-sparing techniques and approaches in RARP, therefore accurate preoperative and intraoperative assessment of the patient is crucial. Current data shows that, performing the maximum possible nerve-sparing using athermal techniques have better functional outcomes.
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Affiliation(s)
| | - Omer Aytac
- Department of Urology, Istanbul Bilim University, Istanbul, Turkey
| | - Fatih Atug
- Department of Urology, Istanbul Bilim University, Istanbul, Turkey
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17
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Capogrosso P, Sanchez-Salas R, Salonia A, Cathala N, Mombet A, Sivaraman A, Barret E, Montorsi F, Cathelineau X. Recovery of urinary continence after radical prostatectomy. Expert Rev Anticancer Ther 2016; 16:1039-52. [PMID: 27636115 DOI: 10.1080/14737140.2016.1233818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting. AREAS COVERED This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient's clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the 'preservation' or the 'reconstruction' of the anatomical elements responsible for urinary continence. Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI. Expert commentary: A comprehensive pre-operative patient's clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.
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Affiliation(s)
- Paolo Capogrosso
- a Università Vita-Salute San Raffaele , Milan , Italy.,b Division of Experimental Oncology/Unit of Urology, URI , IRCCS Ospedale San Raffaele , Milan , Italy.,c Department of Urology , L'Institut Mutualiste Montsouris , Paris , France
| | | | - Andrea Salonia
- a Università Vita-Salute San Raffaele , Milan , Italy.,b Division of Experimental Oncology/Unit of Urology, URI , IRCCS Ospedale San Raffaele , Milan , Italy
| | - Nathalie Cathala
- c Department of Urology , L'Institut Mutualiste Montsouris , Paris , France
| | - Annick Mombet
- c Department of Urology , L'Institut Mutualiste Montsouris , Paris , France
| | - Arjun Sivaraman
- c Department of Urology , L'Institut Mutualiste Montsouris , Paris , France
| | - Eric Barret
- c Department of Urology , L'Institut Mutualiste Montsouris , Paris , France
| | - Francesco Montorsi
- a Università Vita-Salute San Raffaele , Milan , Italy.,b Division of Experimental Oncology/Unit of Urology, URI , IRCCS Ospedale San Raffaele , Milan , Italy
| | - Xavier Cathelineau
- c Department of Urology , L'Institut Mutualiste Montsouris , Paris , France
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18
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Salomon L, Droupy S, Yiou R, Soulié M. [Functional results and treatment of functional dysfunctions after radical prostatectomy]. Prog Urol 2016; 25:1028-66. [PMID: 26519966 DOI: 10.1016/j.purol.2015.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 07/30/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer. MATERIAL AND METHOD Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta. RESULTS Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach. CONCLUSION Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.
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Affiliation(s)
- L Salomon
- Service d'urologie et de transplantation rénale et pancréatique, CHU Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
| | - S Droupy
- Service d'urologie et d'andrologie, CHU de Nîmes, place du Professeur-Robert-Debré, 30029 Nîmes cedex 09, France
| | - R Yiou
- Service d'urologie et de transplantation rénale et pancréatique, CHU Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - M Soulié
- Département d'urologie-andrologie-transplantation rénale, CHU Rangueil, 1, avenue Jean-Poulhès, 31059 Toulouse cedex 9, France
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Dalpiaz O, Anderhuber F. The fascial suspension of the prostate: A cadaveric study. Neurourol Urodyn 2016; 36:1131-1135. [PMID: 27459892 DOI: 10.1002/nau.23073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/24/2016] [Indexed: 11/08/2022]
Abstract
AIMS Analysis and description of the supporting fascial structure around the prostate and urethra, which needs to be preserved or restored during radical prostatectomy (RP). METHODS Anatomical dissection of 10 male cadavers was performed and the supporting fascial structures of bladder neck, prostate, and proximal urethra were investigated. The cadavers were embalmed according to Thiel's method, which preserves a natural texture and color of tissues. RESULTS Anteriorly, the puboprostatic ligament (PL), the dorsal vein complex, and the urethropelvic ligament form an integral structure that suspends and stabilizes the prostatic apex. Laterally, the fascia originates from the fascial tendinous arch of the pelvis and stabilizes the prostate in the central position. In the posterolateral aspect, we could demonstrate a tendineous dorsal raphe, which represents an important stabilization structure of the urethra. CONCLUSIONS The anterior and posterior pelvic fascial structure seems to be important stabilizer for the prostate and proximal urethra. Their preservation or reconstruction during RP is mandatory to restore the anatomic and functional continuity of the bladder neck and urethra. Neurourol. Urodynam. 36:1131-1135, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Orietta Dalpiaz
- Department of Urology, Medical University of Graz, Graz, Austria.,Institute of Anatomy, Medical University of Graz, Graz, Austria
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20
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Salomon L, Rozet F, Soulié M. La chirurgie du cancer de la prostate : principes techniques et complications péri-opératoires. Prog Urol 2015; 25:966-98. [DOI: 10.1016/j.purol.2015.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 08/06/2015] [Indexed: 11/25/2022]
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21
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Ganzer R, Stolzenburg JU, Neuhaus J, Weber F, Fuchshofer R, Burger M, Bründl J. Anatomical Study of Pelvic Nerves in Relation to Seminal Vesicles, Prostate and Urethral Sphincter: Immunohistochemical Staining, Computerized Planimetry and 3-Dimensional Reconstruction. J Urol 2015; 193:1205-12. [DOI: 10.1016/j.juro.2014.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Roman Ganzer
- Department of Urology, University of Leipzig, Leipzig, Germany
| | | | - Jochen Neuhaus
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Florian Weber
- Department of Pathology, University of Regensburg, Regensburg, Germany
| | - Rudolf Fuchshofer
- Institute of Human Anatomy and Embryology, University of Regensburg, Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
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22
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Good DW, Stewart GD, Laird A, Stolzenburg JU, Cahill D, McNeill SA. A Critical Analysis of the Learning Curve and Postlearning Curve Outcomes of Two Experience- and Volume-Matched Surgeons for Laparoscopic and Robot-Assisted Radical Prostatectomy. J Endourol 2015; 29:939-47. [PMID: 25630790 DOI: 10.1089/end.2014.0810] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE There remains equipoise with regard to whether laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) has any benefit over the other. Despite this, there is a trend for the increasing adoption of RARP at great cost to health services across the world. The aim was to critically analyze the learning curve and outcomes for LRP and RARP for two experience- and volume-matched surgeons who have completed the learning curve for LRP and RARP. PATIENTS AND METHODS Two experience- and volume-matched LRP and RARP surgeons who have completed the learning curve were compared with respect to their learning curve and outcomes for RARP and LRP. There were 531 RARP and 550 LRPs analyzed from April 2003 until January 2012 at two relatively high-volume United Kingdom centers. Outcome measures included operative time, blood loss, complication rate (Clavien-Dindo grade III), positive surgical margin (PSM) rate, and early continence rate. RESULTS Learning curves for blood loss, operative times, and complication rate were similar between groups. The overall PSM rate and pT2 PSM rate learning curves were longer for RARP compared with LRP but shorter for early continence. Apical PSM showed no learning curve for RARP; however, a long learning curve for LRP and the rate was lower for RARP than for LRP (P=<0.001). CONCLUSIONS This study of RARP and LRP identified that both modalities had long learning curves. Despite the long learning curve for RARP, significant benefits in lower PSM rates and better early continence in comparison with LRP exist. There are benefits to patients with RARP over LRP, especially those linked to better apical dissection (apical PSM and early continence).
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Affiliation(s)
- Daniel W Good
- 1 Department of Urology, Western General Hospital , NHS Lothian, Edinburgh, United Kingdom .,2 Edinburgh Urological Cancer Group, University of Edinburgh , Edinburgh, United Kingdom
| | - Grant D Stewart
- 1 Department of Urology, Western General Hospital , NHS Lothian, Edinburgh, United Kingdom .,2 Edinburgh Urological Cancer Group, University of Edinburgh , Edinburgh, United Kingdom
| | - Alexander Laird
- 1 Department of Urology, Western General Hospital , NHS Lothian, Edinburgh, United Kingdom .,2 Edinburgh Urological Cancer Group, University of Edinburgh , Edinburgh, United Kingdom
| | | | - Declan Cahill
- 4 Department of Urology, Guy's and St. Thomas' NHS Trust , London, United Kingdom
| | - S Alan McNeill
- 1 Department of Urology, Western General Hospital , NHS Lothian, Edinburgh, United Kingdom .,2 Edinburgh Urological Cancer Group, University of Edinburgh , Edinburgh, United Kingdom
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24
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Hoshi A, Nitta M, Shimizu Y, Higure T, Kawakami M, Nakajima N, Hanai K, Nomoto T, Usui Y, Terachi T. Total pelvic floor reconstruction during non-nerve-sparing laparoscopic radical prostatectomy: impact on early recovery of urinary continence. Int J Urol 2014; 21:1132-7. [PMID: 24976517 DOI: 10.1111/iju.12539] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 05/22/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To develop a modified technique of "total pelvic floor reconstruction" during non-nerve-sparing laparoscopic radical prostatectomy, and to determine its effect on postoperative urinary outcomes. METHODS A total of 128 patients who underwent non-nerve-sparing laparoscopic radical prostatectomy were evaluated, including 81 with total pelvic floor reconstruction and 47 with non-total pelvic floor reconstruction. Nerve-sparing cases were excluded. Urinary outcomes were assessed with self-administrated questionnaires (Expanded Prostate Cancer Index Composite) at 1, 3, 6 and 12 months after laparoscopic radical prostatectomy. The total pelvic floor reconstruction technique included two concepts involving posterior and anterior reconstructions. In posterior reconstruction, Denonvilliers' fascia was approximated to the bladder neck and the median dorsal raphe by slipknot. The anterior surface of the bladder-neck was approximated to the anterior detrusor apron and the puboprostatic ligament collar for anterior reconstruction. RESULTS There were no significant differences between the two groups in the patients' characteristics, and in perioperative and oncological outcomes. In the total pelvic floor reconstruction group, the continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy were 45.7%, 71.4%, and 84.6%, respectively. In the non-total pelvic floor reconstruction group, the continence rates were 26.1%, 46.8% and 60.9%, respectively. The total pelvic floor reconstruction technique resulted in significantly higher continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy, respectively (all P < 0.05). The mean interval to achieve continence was significantly shorter in the total pelvic floor reconstruction group (mean 7.7 months) than in the non-total pelvic floor reconstruction group (mean 9.8 months; P = 0.0003). CONCLUSION The total pelvic floor reconstruction technique allows preservation of the blood supply to the urethra and physical reinforcement of the pelvic floor. Therefore, this technique is likely to improve urinary continence outcomes after laparoscopic radical prostatectomy.
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Affiliation(s)
- Akio Hoshi
- Department of Urology, Tokai University School of Medicine, Isehara, Japan
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25
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Park YH, Jeong CW, Lee SE. A comprehensive review of neuroanatomy of the prostate. Prostate Int 2013; 1:139-45. [PMID: 24392437 PMCID: PMC3879050 DOI: 10.12954/pi.13020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/05/2013] [Indexed: 12/24/2022] Open
Abstract
Although oncologic efficacy is the primary goal of radical prostatectomy, preserving potency and continence is also important, given the indolent clinical course of most prostate cancers. In order to preserve and recover postoperative potency and continence after radical prostatectomy, a detailed understanding of the pelvic anatomy is necessary to recognize the optimal nerve-sparing plane and to minimize injury to the neurovascular bundles. Therefore, we reviewed the most recent findings from neuroanatomic studies of the prostate and adjacent tissues, some of which are contrary to the established consensus on pelvic anatomy. We also described the functional outcomes of radical prostatectomies following improved anatomical understanding and development of surgical techniques for preserving the neurovascular bundles.
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Affiliation(s)
- Yong Hyun Park
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Eun Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
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26
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Good DW, Stewart GD, Stolzenburg JU, McNeill SA. Analysis of the pentafecta learning curve for laparoscopic radical prostatectomy. World J Urol 2013; 32:1225-33. [PMID: 24326782 DOI: 10.1007/s00345-013-1198-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 10/19/2013] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Laparoscopic radical prostatectomy (LRP) has a long learning curve; however, little is known about the pentafecta learning curve for LRP. We analysed the learning curve for a fellowship trained surgeon with regard to the pentafecta with up to 6-year follow-up. METHODS A retrospective review was performed in 550 cases, by dividing these cases into 11 groups of 50 patients. Outcomes analysed were the following: (1) the pentafecta (complication rate, positive surgical margin (PSM) rate, continence, potency and biochemical recurrence); (2) operative time and blood loss; and (3) overall pentafecta attainment. RESULTS The mean complication rate for the entire series was 9 %; this plateaued after 150 cases. The overall PSM rate for the series was 23.5 %, 16.3 % for pT2 and 40.5 % for pT3. PSM plateaued after 200 cases. Excluding the first 100 cases, the overall PSM rate for pT2 was 10.9 % and 37.8 % for pT3. The continence rate stabilised after approximately 250 cases. The rate of male sling/artificial urinary sphincter plateaued after 200 cases. The potency learning curve continues to improve after 250 cases of nerve-sparing (ns) endoscopic extraperitoneal radical prostatectomy (EERPE) as does the pentafecta learning curve which closely follows the pattern of the potency learning curve. The last group of nsEERPE achieved pentafecta in 63 %. CONCLUSION This study shows multiple learning curves: an initial for peri-operative outcomes, then stabilisation of oncologic outcomes and the final for stabilisation of functional outcomes. In this series over 250 cases were required to achieve the learning curve.
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Affiliation(s)
- D W Good
- Department of Urology, Western General Hospital, NHS Lothian, Crewe Road South, Edinburgh, EH2 4XU, UK,
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McNeill SA, Good DW, Stewart GD, Stolzenburg JU. Five-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) for prostate cancer: results from a medium-volume UK centre. BJU Int 2013; 113:449-57. [PMID: 23980640 DOI: 10.1111/bju.12260] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the 5-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) from a medium-volume centre, thereby providing much needed data on outcomes from the UK. PATIENTS AND METHODS From January 2006 to January 2012, 575 patients underwent EERPE for localized prostate cancer, performed by a single surgeon who had completed a modular training programme. Follow-up was as per local hospital policy and data were collected in our prospective database. A retrospective review of patient demographics, prostate-specific antigen (PSA) levels, pathological T stages, Gleason scores, surgical margin status and biochemical recurrence (BCR) data was performed. BCR was defined as PSA >0.2 μg/L. RESULTS The mean (range) patient age was 62 (40.3-76.5) years and the mean (range) follow-up was 30 (12-72) months. The median (interquartile range [IQR]) operating time was 135 (120-170) min and the median (IQR) blood loss was 200 (100-250) mL. Of the 575 patients, 135 (23.5%) had positive surgical margins (PSMs). The PSM rate for pT2 disease was 66/406 patients (16.3%) and for pT3 disease it was 68/168 patients (40.5%). Overall BCR-free survival at 5-years was 81.5%. Multivariate Cox analysis showed that PSMs, Gleason score, D'Amico risk category and pT stage were independent predictors of BCR-free survival. CONCLUSIONS This assessment of the oncological results of EERPE, which included the surgical learning curve, shows that the adoption of EERPE after mentored fellowship training translates into mid-term oncological outcomes in line with those of retropubic/transperitoneal laparoscopic approaches and with large-volume centres worldwide which have pioneered laparoscopic radical prostatectomy. The study shows that EERPE in a medium-volume second generation laparoscopic centre (that introduced EERPE after adequate training in pioneering centres) produces results with good 5-year oncological outcomes, similar to those of other major series, for patients in the UK.
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Affiliation(s)
- S Alan McNeill
- Department of Urology, Western General Hospital, Edinburgh, UK
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Gao X, Pang J, Si-tu J, Luo Y, Zhang H, Li LY, Zhang Y. Single-port transvesical laparoscopic radical prostatectomy for organ-confined prostate cancer: technique and outcomes. BJU Int 2013; 112:944-52. [PMID: 23826929 DOI: 10.1111/bju.12225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report a novel technique for performing single-port transvesical laparoscopic radical prostatectomy (STLRP) and to evaluate the oncological and functional outcomes in 16 patients with organ-confined prostate cancer. PATIENTS AND METHODS In total, 16 consecutive patients with clinical stage T1-2aN0M0 were scheduled for STLRP, and their continence and erectile status were investigated preoperatively. The patients' mean age was 62 years, mean prostate volume 42 mL and mean prostate-specific antigen (PSA) 7.5 ng/mL. The STLRP procedures were performed by a single surgeon, and all the operating procedures were conducted transvesically and laparoscopically. Intra-operative and postoperative complications, assessed according to the modified Clavien system, were recorded and peri-operative and functional outcome data were analysed. All patients were followed up for a minimum of 12 months postoperatively through PSA detection, daily pads, the International Index of Erectile Function (IIEF)-6 score and urography. RESULTS All of the 16 STLRP procedures were successfully completed. The mean (range) operation duration was 105 (75-180) min, and the mean (range) estimated blood loss was 130 (75-500) mL. No patients had positive surgical margins. Postoperative complications occurred in five patients, including three cases of urinary infection and two cases of haematuria (grade II). Catheters were removed after a mean (range) time of 11.2 (9-14) days with cystography. The mean (range) hospital stay was 12.7 (10-15) days. Of the 16 patients, 13 were immediately continent (0 pads/day), and three had mild incontinence (2-3 pads/day) after catheter removal. All patients were observed as continent 3 months postoperatively. In total, 10/16 and 12/16 patients achieved a satisfactory erection at 6 and 12 months follow-up postoperatively, respectively, with an IIEF-6 score ≥ 18. The mean postoperative PSA levels at 3, 6 and 12 months were 0.015 ng/mL, 0.017 ng/mL and 0.016 ng/mL, respectively. No patients were identified with biochemical recurrence in this series. No patients demonstrated vesico-urethral stricture during follow-up for 12-24 months. CONCLUSIONS We conclude that STLRP is technically feasible for patients with low-risk organ-confined prostate cancer and demonstrates promising functional outcomes regarding continence and potency.
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Affiliation(s)
- Xin Gao
- Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy. Asian J Androl 2013; 15:513-7. [PMID: 23708458 DOI: 10.1038/aja.2012.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 11/11/2012] [Accepted: 12/04/2012] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1:2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤ 65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.
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Stolzenburg JU, Qazi HA, Holze S, Mende M, Nicolaus M, Franz T, Ho Thi P, Dietel A, Liatsikos E, Do M. Evaluating the Learning Curve of Experienced Laparoscopic Surgeons in Robot-Assisted Radical Prostatectomy. J Endourol 2013; 27:80-5. [PMID: 22834963 DOI: 10.1089/end.2012.0262] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Hasan A.R. Qazi
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Sigrun Holze
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Meinhard Mende
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Martin Nicolaus
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Toni Franz
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Phuc Ho Thi
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Anja Dietel
- Department of Urology, University of Leipzig, Leipzig, Germany
| | | | - Minh Do
- Department of Urology, University of Leipzig, Leipzig, Germany
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Choi YH, Lee JZ, Chung MK, Ha HK. Preliminary results for continence recovery after intrafascial extraperitoneal laparoscopic radical prostatectomy. Korean J Urol 2012; 53:836-42. [PMID: 23301127 PMCID: PMC3531636 DOI: 10.4111/kju.2012.53.12.836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/25/2012] [Indexed: 11/24/2022] Open
Abstract
Purpose We present our initial experience and surgical outcomes for the most recent refinement of bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy (nsELRP). Materials and Methods Among 62 patients who underwent laparoscopic radical prostatectomy, 50 patients underwent intrafascial nsELRP by a single surgeon at Pusan National University Hospital from November 2011 to April 2012. As part of the intrafascial technique, the dissection plane is directly on the prostatic capsule to preserve most of the periprostatic fascia containing small vessels and nerves, endopelvic fascia, neurovascular bundle, and puboprostatic ligament. Postoperative continence recovery was established by daily consumption of pads. Follow-up was done at 2 weeks, 6 weeks, and 3 months after surgery. Results The patients' mean age was 66.5±6.2 years. The mean operation time and mean blood loss were 149.3±28.1 minutes and 155.4±168.1 ml, respectively. The mean hospitalization time and mean catheterization time were 6.3±5.1 days and 5.5±4.7 days, respectively. Two weeks after the operation, a total of 14 patients (28.0%) were pad-free but the other incontinent patient group used on average 2.3 pads per day. After 6 weeks, 35 patients (70.0%) achieved pad-free status and 7 patients (14.0%) required more than 2 pads per day. At 3 months after surgery, a total of 31 patients were available for follow-up, and 26 patients (83.9%) were pad-free. Conclusions Compared with conventional laparoscopic prostatectomy, the intrafascial nsELRP procedure enables the preservation of periprostatic structures that are essential to the recovery of surgical structures related to continence. As a result, early postoperative continence can be achieved.
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Affiliation(s)
- Young Hoon Choi
- Department of Urology, Pusan National University Hospital, Busan, Korea
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32
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Ganzer R, Stolzenburg JU, Wieland WF, Bründl J. Anatomic Study of Periprostatic Nerve Distribution: Immunohistochemical Differentiation of Parasympathetic and Sympathetic Nerve Fibres. Eur Urol 2012; 62:1150-6. [DOI: 10.1016/j.eururo.2012.03.039] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 03/20/2012] [Indexed: 11/30/2022]
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33
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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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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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Mattei A, Di Pierro GB, Rafeld V, Konrad C, Beutler J, Danuser H. Positioning injury, rhabdomyolysis, and serum creatine kinase-concentration course in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection. J Endourol 2012; 27:45-51. [PMID: 22770120 DOI: 10.1089/end.2012.0169] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND PURPOSE During robot-assisted radical prostatectomy (RARP), patients remain in a steep Trendelenburg position. This can cause positioning injuries as well as rhabdomyolysis. The primary diagnostic indicator of rhabdomyolysis is elevated serum creatine kinase (CK). We investigate whether RARP with extended pelvic lymph node dissection (ePLND) in a prolonged extreme Trendelenburg position can cause positioning injuries and rhabdomyolysis. PATIENTS AND METHODS We performed a prospective study of the first 60 patients undergoing RARP and ePLND for organ-confined prostate cancer at our institute. Positioning injuries were graded according to three degrees of clinical severity. Serum-CK, serum-pH, and base excess (BE) were measured before, during, and for 5 days after surgery. Rhabdomyolysis was defined by serum-CK levels >5000 IU/L. RESULTS Median operative time was 317 minutes (range 200-475 min); median time in the Trendelenburg position was 282 minutes (range 170-470 min). Serum-CK was significantly elevated 6 hours postoperatively, peaking at 18 hours postoperatively. Serum-CK levels did not correlate with pH, BE, and perioperative creatinine values. Serum-CK course shows weak correlation with body mass index (BMI), operative time, Trendelenburg position time, and medium correlation with positioning injuries of any degree. Twenty-one of the 60 (35%) patients showed positioning-related injuries: 16 (27%) patients degree I, 2 (3%) patients degree II, and 3 (5%) patients degree III. Rhabdomyolysis developed in 10 patients. Postoperative renal failure did not develop in any patient receiving postoperative hypervolemic diuretic therapy nor any patient with injuries degrees I, II, or III. conclusion: Clinically relevant positioning injuries and rhabdomyolysis can occur in patients who are subjected to prolonged extreme Trendelenburg position during RARP and ePLND, especially at the beginning of the learning curve. Serum-CK increases significantly after surgery, peaking 18 hours postoperatively. Serum-CK elevation alone is not predictive of positioning injury. By very long operative and Trendelenburg times as well as high BMI with visible position injuries, we recommend serum-CK measurement 6 and 18 hours postoperatively followed by hypervolemic therapy to prevent possible renal injury from rhabdomyolysis if serum-CK >5000 IU/L.
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Affiliation(s)
- Agostino Mattei
- Klinik für Urologie und, Luzerner Kantosspital, Lucerne, Switzerland.
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Mortezavi A, Hermanns T, Seifert HH, Wild PJ, Schmid DM, Sulser T, Eberli D. Intrafascial dissection significantly increases positive surgical margin and biochemical recurrence rates after robotic-assisted radical prostatectomy. Urol Int 2012; 89:17-24. [PMID: 22738925 DOI: 10.1159/000339254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 05/04/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Improved visualization and magnification in robot-assisted laparoscopic radical prostatectomy (RALRP) has tempted many urologists to dissect the neurovascular bundle closer to the prostate following the layers of the pseudo-capsule of the prostate. This might bear a higher risk of decreased tumor control. MATERIALS AND METHODS An analysis of a consecutive series of 186 patients who underwent RALRP at our institution was performed. The outcome of patients with intrafascial nerve-sparing (INS) was compared with the outcome of patients who underwent interfascial, extrafascial or no nerve-sparing (non-INS). RESULTS A total of 80 patients (43.0%) received INS. The overall R1 rate was 27.9%. For pT2 tumors the rate of R1 was 33.8% in INS versus 14.8% in non-INS (odds ratio 2.936, 95% confidence interval 1.338-6.443, p = 0.007). Recurrence-free survival was significantly shorter in INS (p = 0.05; hazard ratio 3.791). CONCLUSION The intrafascial dissection technique for RALRP bears a high risk of incomplete resection in localized prostate cancer resulting in unfavorable outcome.
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Affiliation(s)
- Ashkan Mortezavi
- Department of Urology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
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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]
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Prevention and management of postprostatectomy sexual dysfunctions. Part 1: choosing the right patient at the right time for the right surgery. Eur Urol 2012; 62:261-72. [PMID: 22575909 DOI: 10.1016/j.eururo.2012.04.046] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 04/23/2012] [Indexed: 02/03/2023]
Abstract
CONTEXT Sexual dysfunction is common in patients following radical prostatectomy (RP) for prostate cancer (PCa). OBJECTIVE To review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics and intra- and postoperative factors that may influence EF recovery. EVIDENCE ACQUISITION A literature search was performed using Google and PubMed database for English-language original and review articles either published or e-published up to November 2011. EVIDENCE SYNTHESIS The literature demonstrates great inconsistency in what constitutes normal EF before surgery and what a man may consider a normal erection after RP. The use of validated psychometric instruments with recognised cut-offs for normalcy and severity during the pre- and postoperative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative erectile dysfunction (ED), the concept of spontaneous or pharmacologically assisted erections, and the difference between "back to baseline" EF and "erections adequate enough to have successful intercourse" clearly emerge as key issues in the eventual understanding of the prevention of ED and promotion of satisfactory EF recovery post-RP. Patient factors (including age, baseline EF, and status of comorbid conditions), cancer selection (unilateral vs bilateral nerve sparing), type of surgery (ie, intra- vs inter- vs extrafascial surgeries), surgical techniques (ie, open, laparoscopic, and robot-assisted RP), and surgeon factors (ie, surgical volume and surgical skill) represent the key significant contributors to EF recovery. CONCLUSIONS The complexity of the issues discussed throughout this review culminates in the simple concept that optimal outcomes are achieved by the careful choice of the correct patient for the correct type of surgery.
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Jeong CW, Oh JJ, Jeong SJ, Hong SK, Byun SS, Choe G, Lee SE. Novel posterior reconstruction technique during robot-assisted laparoscopic prostatectomy: Description and comparative outcomes. Int J Urol 2012; 19:683-7. [DOI: 10.1111/j.1442-2042.2012.02988.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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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]
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41
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Stolzenburg JU, Andrikopoulos O, Kallidonis P, Kyriazis I, Do M, Liatsikos E. Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE): technique and outcome. Asian J Androl 2011; 14:278-84. [PMID: 22179509 DOI: 10.1038/aja.2011.53] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Endoscopic extraperitoneal radical prostatectomy (EERPE) is a well-established and standardized technique for treating patients with localized prostate cancer. Nevertheless, the procedure is continuously being refined with the expansion of anatomical knowledge. The development of a nerve-sparing approach and improvements in currently used equipment are expected to yield better results in cosmesis and convalescence without sacrificing the procedure's established benefits in terms of potency, continence and oncological management. In this study, the technique and its evolution are presented in detail, along with an analysis of its clinical efficacy. We also consult the literature to compare EERPE to transperitoneal laparoscopic radical prostatectomy, and we also discuss new technical advancements regarding the use of robotic assistance during EERPE.
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Influence of bladder neck suspension stitches on early continence after radical prostatectomy: a prospective randomized study of 180 patients. Asian J Androl 2011; 13:806-11. [PMID: 21909121 DOI: 10.1038/aja.2011.82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Several techniques have been introduced to improve early postoperative continence. In this study, we evaluated the impact of bladder neck (vesicourethral anastomosis) suspension on the outcome of extraperitoneal endoscopic radical prostatectomy (EERPE). In this research, a total of 180 patients underwent EERPE. Group 1 included patients who underwent nerve-sparing EERPE (nsEERPE) (n=45), and Group 2 included patients who underwent nsEERPE with bladder neck suspension (BNS, n=45). Groups 3 (n=45) and 4 (n=45) included patients who received EERPE and EERPE with BNS, respectively. Patients were randomly assigned to receive BNS with their nsEERPE or EERPE procedure. Perioperative parameters were recorded, and continence was evaluated by determining the number and weight of absorbent pads (pad weighing test) on the second day after catheter removal and by a questionnaire 3 months postoperatively. Two days after catheter removal, 11.1% of Group 1, 11.1% of Group 2, 4.4% of Group 3 and 8.9% of Group 4 were continent. The average urine loss was 80.4, 70.1, 325.0 and 291.3 g for the each of these groups, respectively. At 3 months, 76.5% of Group 1 and 81.3% of Group 2 were continent. The continence figures for Group 3 and 4 were 48.5% and 43.8%, respectively. Similar overall rates were observed in all groups. In conclusion, although there are controversial reports in the literature, early continence was never observed to be significantly higher in the BNS groups when compared with the non-BNS groups, regardless of the EERPE technique performed.
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Soga H, Takenaka A, Murakami G, Haraguchi T, Miyake H, Tanaka K, Fujisawa M. Distribution of the lymphatic vessels in the prostatic fascia. Prostate 2011; 71:1294-8. [PMID: 21308710 DOI: 10.1002/pros.21343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 01/04/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prostatic fascia-preserving procedure is effective for the early recovery of erectile function after radical prostatectomy; however, the long-term influence of on cancer control was unknown. This study clarified the distribution of lymphatic vessels in the prostatic fascia. MATERIAL AND METHODS The lymphatic vessels were analyzed in 10 prostates obtained from fixed Japanese cadavers (aged, 71-90 years old). Specimens were taken from the apex, the middle part, and the base of the right-hand side of the prostate. Lymphatic vessels were detected by immunohistochemical stain using an antibody specific for the lymphatic endothelial cells (clone D2-40). The lymphatic vessels were counted in the prostate capsule and the prostatic fascia of each section by light microscopy at low power (100×). RESULTS The median number of lymphatic vessels in the prostatic capsule per prostatic half was 21.0, 14.0, and 21.0 in the apex, middle, and base part of the prostate, respectively. In the prostatic facia the median number of lymphatic vessels per prostatic half was 8.0, 3.0, and 13.0 in the apex, middle, and the base part of the prostate, respectively. In the apex and the middle part the lymphatic vessels in the prostatic fascia were fewer than those in the prostatic capsule. However, in the base part the number of lymphatic vessels in the prostatic fascia was similar to that in the prostatic capsule. CONCLUSIONS The present study suggested the surgeon to pay more attention for the dissection of the fascia at the base of the prostate.
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Affiliation(s)
- Hideo Soga
- Department of Surgery Related, Kobe University Graduate School of Medicine, Chuou-ku, Kobe, Japan
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44
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Stewart GD, El-Mokadem I, McLornan ME, Stolzenburg JU, McNeill SA. Functional and oncological outcomes of men under 60 years of age having endoscopic surgery for prostate cancer are optimal following intrafascial endoscopic extraperitoneal radical prostatectomy. Surgeon 2011; 9:65-71. [DOI: 10.1016/j.surge.2010.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 06/17/2010] [Accepted: 07/08/2010] [Indexed: 11/29/2022]
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45
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Do M, Liatsikos EN, Kallidonis P, Wedderburn AW, Dietel A, Turner KJ, Stolzenburg JU. Hernia Repair During Endoscopic Extraperitoneal Radical Prostatectomy: Outcome After 93 Cases. J Endourol 2011; 25:625-9. [DOI: 10.1089/end.2010.0406] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Minh Do
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Evangelos N. Liatsikos
- Department of Urology, University of Leipzig, Leipzig, Germany
- Department of Urology, University of Patras Medical School, Patras, Greece
| | | | | | - Anja Dietel
- Department of Urology, University of Leipzig, Leipzig, Germany
| | - Kevin J. Turner
- Department of Urology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
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Classification of the distribution of cavernous nerve fibers around the prostate by intraoperative electrical stimulation during laparoscopic radical prostatectomy. Int J Impot Res 2011; 23:56-61. [PMID: 21390045 DOI: 10.1038/ijir.2011.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We investigated the distribution of cavernous nerve (CN) fibers around the prostate by electrical nerve stimulation during laparoscopic radical prostatectomy to classify the distribution of the CN fibers. Electrical stimulation was performed on 30 consecutive patients with localized prostate cancer; middle of the neurovascular bundle (NVB, point A), base of the NVB (point B), the rectal wall 1 cm posterolateral to the NVB (point C) and the lateral aspect of the prostate (point D). We measured the intraurethral pressure at the midportion to detect the changes in intracavernosal pressure. The mean maximum changes were 10.5 ± 7.9, 11.6 ± 8.8, 9.6 ± 7.4 and 6.7 ± 7.0 cm H(2)O at points A, B, C and D, respectively. The patterns of CN fiber distribution were divided into four groups: type 1 (23%), the bundle corresponding to the NVB; type 2 (7%), the bundle from the rectal wall to the prostate; type 3 (27%), the plate including NVB and posterolateral to NVB; and type 4 (43%), the plate between the rectal wall posterolateral to the NVB and the lateral aspect of the prostate. Distribution of the CNs in a bundle-like formation was considered to account for 30%, whereas a plate-like formation accounted for 70%. Understanding these four patterns of CN fiber distribution should facilitate accurate CN-sparing radical prostatectomy.
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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.
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Affiliation(s)
- Xavier Cathelineau
- Department of Urology, Institut Montsouris, Université Paris Descartes, Paris, France.
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Sammon JD, Menon M. Editorial comment. Urology 2011; 77:506-7. [PMID: 21295258 DOI: 10.1016/j.urology.2010.07.484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 07/27/2010] [Accepted: 07/29/2010] [Indexed: 10/18/2022]
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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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Greco F, Hoda MR, Wagner S, Reichelt O, Inferrera A, Magno C, Fornara P. Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients. BJU Int 2010; 108:583-7. [PMID: 21091973 DOI: 10.1111/j.1464-410x.2010.09836.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Study Type - Therapy (case series). LEVEL OF EVIDENCE 4. What's known on the subject? and What does the study add? Bilateral nerve-sparing radical prostatectomy still represents an issue for urologists as the indications to perform it depend oft from the personal clinical experience. Moreover, until now data concerning bilateral and unilateral laparoscopic nerve-sparing radical prostatectomy have been limited. This study states that bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes when compared with unilateral nsLRP and it suggests to prefer a bilateral nerve-sparing technique in younger patients with low-risk, organ-confined prostate cancer. OBJECTIVE To evaluate the surgical and functional outcomes in bilateral and unilateral nerve-sparing laparoscopic radical prostatectomy (nsLRP). PATIENTS AND METHODS Between January 2005 and May 2009, 457 nsLRP were performed at our clinic. In all, 250 patients underwent a bilateral nsLRP and 207 patients underwent an unilateral nsLRP. One surgeon performed all the operations. All patients presented at biopsy a localized prostate cancer. Demographic data and perioperative and postoperative measurements and outcomes were compared. RESULTS The operative times for bilateral nsLRP and unilateral nsLRP were 165 ± 45 min and 130 ± 25 min, respectively. The mean intra-operative blood loss was 450 ± 300 mL and 270 ± 160 mL in the bilateral and unilateral nsLRP groups with a transfusion rate of 3% and 1%, respectively (P = 0.013). Conversion to open surgery was never deemed necessary. Postoperatively, the mean Gleason Score after nsLRP and distribution of tumour stages was similar in the two groups, and the frequency of positive margins in both groups did not present any statistically significant difference. At 12 months, a complete continence was reported in 97% of patients who underwent a bilateral nsLRP and in 88% of patients of the unilateral nsLRP group. At that time, 69% in the bilateral nsLRP and 43% in the unilateral nsLRP groups reported the ability to engage in sexual intercourse. CONCLUSION The bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes with regard to urinary continence and sexual potency, when compared with unilateral nsLRP, reporting similar oncological outcomes.
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Affiliation(s)
- Francesco Greco
- Department of Urology and Kidney Transplantation, Martin Luther University, Halle-Wittenberg, Germany.
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