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Yu C, Yao J, He Y, Huang J, Chen M, Qian M, Lou D, Zhou Z, Chen F. Effects of surgery versus radiotherapy in patients with localized prostate cancer in terms of urinary, bowel, and sexual domains. Cancer Med 2023; 12:18176-18188. [PMID: 37519062 PMCID: PMC10524086 DOI: 10.1002/cam4.6395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND The health-related quality of life (HRQoL) of patients with localized prostate cancer (LPCa) after treatment mainly surgery and radiotherapy (RT) has received increasing attention. The aim of this study is to compare the HRQoL of LPCa after surgery and RT. METHODS Web of Science, Embase, PubMed and Cochrane databases were searched after January 2000 to observe the HRQoL scores after surgery and RT at different treatment time points. RESULTS A total of 28 studies were included in this study, and the results showed that LPCa received surgery had better bowel scores than RT at ≤3 (weighted mean differences [WMD] = 4.18; p = 0.03), 3-6 (WMD = 4.16; p < 0.001), 6-12 (WMD = 2.99; p = 0.004), 24-60 (WMD = 1.87; p = 0.06), and ≥60 (WMD = 4.54; p = 0.02) months. However, LPCa received RT had higher urinary scores at ≤3 (WMD = -7.39; p = 0.02), 3-6 (WMD = -6.03; p = 0.02), 6-12 (WMD = -4.90; p < 0.001), 24-60 (WMD = -3.96; p < 0.001), ≥60 (WMD = -2.95; p < 0.001) months and had better sexual scores at ≤3 (WMD = -13.58; p = 0.09), 3-6 (WMD = -12.32; p = 0.06), 6-12 (WMD = -12.03; p = 0.002), 24-60 (WMD = -11.29; p < 0.001), and ≥60 (WMD = -3.10; p = 0.46) months than surgery. The scores difference between surgery and RT decreased over time. CONCLUSION Overall, for LPCa, surgery was associated with better HRQoL in the bowel domain, whereas RT was associated with better HRQoL in the urinary and sexual domains, with the difference between surgery and RT narrowing over time.
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Affiliation(s)
- Chao Yu
- Department of Urology, Ningbo Medical Center LiHuiLi HospitalNingbo UniversityNingboChina
| | - Jie Yao
- School of Public HealthZhejiang Chinese Medical UniversityHangzhouChina
| | - Yujing He
- The Second Clinical Medical CollegeZhejiang Chinese Medical UniversityHangzhouChina
| | - Jianing Huang
- School of Public HealthZhejiang Chinese Medical UniversityHangzhouChina
| | - Meiling Chen
- School of Public HealthZhejiang Chinese Medical UniversityHangzhouChina
| | - Mingxia Qian
- School of Public HealthShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Dandi Lou
- The First Clinical Medical CollegeZhejiang Chinese Medical UniversityHangzhouChina
| | - Zhizhen Zhou
- School of Public HealthZhejiang Chinese Medical UniversityHangzhouChina
| | - Feng Chen
- Urology DepartmentNingbo Yinzhou No. 2 HospitalNingboChina
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Bravi CA, Gandaglia G, Mazzone E, Fossati N, Gallina A, Stabile A, Scuderi S, Barletta F, Nocera L, Rosiello G, Martini A, Pellegrino F, Cucchiara V, Dehò F, Capitanio U, Scattoni V, Salonia A, Briganti A, Montorsi F. Impact of Early Dorsal Venous Complex Ligation on Urinary Continence Recovery after Robot-assisted Radical Prostatectomy: Results from a Phase 3 Randomized Controlled Trial. Eur Urol Focus 2023; 9:83-88. [PMID: 36154808 DOI: 10.1016/j.euf.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/08/2022] [Accepted: 09/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Whether early ligation of the dorsal venous complex (DVC) might improve recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) has never been investigated in a prospective randomized study. OBJECTIVE To assess whether early DVC ligation might affect UC recovery after RARP. INTERVENTION DVC ligation (early vs standard). DESIGN, SETTING, AND PARTICIPANTS A total of 312 patients with prostate cancer underwent primary RARP at a tertiary care institution. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was UC recovery at 1 and 4 mo after RARP. UC was defined as 0 pads/1 safety pad per day. All patients completed the International Prostate Symptom Score (IPSS) and International Consultation of Incontinence Questionnaire (ICIQ)-Short Form questionnaires. Secondary outcomes were early (≤4 mo) erectile function recovery, the positive surgical margin (PSM) rate, 30-d Clavien-Dindo complications, and biochemical recurrence rates. Quality of life was assessed using the EQ-5D-5L questionnaire. The association between treatment arm and UC recovery was also tested using multivariable regression models. RESULTS AND LIMITATIONS After surgery, 23 patients withdrew their consent and 29 were lost to follow-up, leaving 261 patients available for per-protocol analyses. Of these, 32 patients (24%) in the experimental group and 37 (29%) in the control group used no pad/one safety pad at 1 mo after RARP, whereas 96 (72%) in the control group versus 83 (65%) in the control group were continent at 4-mo follow-up (both p = 0.3). Median ICIQ and IPSS scores did not differ between the groups at both time points. The results were confirmed on multivariable regression analyses. PSMs were observed for 32 patients (25%) in the experimental group versus 30 (22%) in the control group (p = 0.6). The incidence of postoperative complications (17% experimental vs 13% control) and the 1-yr biochemical recurrence-free survival did not differ between the groups. CONCLUSIONS In this randomized clinical trial, we did not find evidence that early ligation of the DVC during RARP was associated with better UC recovery after surgery in comparison to the standard technique. Given its safety in terms of surgical margins and complications, this technique may be considered as an option for surgical dissection according to the physician's preference. PATIENT SUMMARY Our trial showed that for patients undergoing robot-assisted surgical removal of the prostate, the timing of a specific step to control bleeding from a network of veins draining the prostate did not affect recovery of urinary continence after surgery. The results indicate that earlier control of these veins may be considered as an option according to the surgeon's preference.
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Affiliation(s)
- Carlo A Bravi
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium.
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Elio Mazzone
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicola Fossati
- Department of Urology, Ospedale Regionale di Lugano, Civico USI-Università della Svizzera Italiana, Lugano, Switzerland
| | - Andrea Gallina
- Department of Urology, Ospedale Regionale di Lugano, Civico USI-Università della Svizzera Italiana, Lugano, Switzerland
| | - Armando Stabile
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Simone Scuderi
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Barletta
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luigi Nocera
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giuseppe Rosiello
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Martini
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Pellegrino
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Vito Cucchiara
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federico Dehò
- Department of Urology, Ospedale di Circolo e Fondazione Macchi-ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Umberto Capitanio
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Vincenzo Scattoni
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Salonia
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
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Pedraza AM. ¿Cómo mejorar la función eréctil post-prostatectomía radical? UROLOGÍA COLOMBIANA 2022. [DOI: 10.1055/s-0042-1757160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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4
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Pedraza AM, Wagaskar V, Parekh S, Tewari A. Technical advances in nerve-sparing and continence preservation. Curr Opin Urol 2022; 32:204-210. [PMID: 34954705 DOI: 10.1097/mou.0000000000000958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Urinary incontinence and erectile dysfunction are common after radical prostatectomy. These side effects greatly impact patients' quality of life. Therefore, surgical techniques and technology tools are constantly being developed to optimize trifecta outcomes. Here we focus on advances in nerve-sparing (NS) and continence preservation. RECENT FINDINGS New surgical techniques dedicated to preservation rather than reconstruction have been developed to improve urinary continence (UC) and NS. On the other hand, intraoperative assessment of prostatic and periprostatic structures has shown promising outcomes toward NS whereas avoiding omission of extracapsular extension (ECE). Likewise, neural regeneration strategies are under research to improve return of erectile function and UC. SUMMARY Superb outcomes after Robot-Assisted Radical Prostatectomy require a proper balance between NS and risk of ECE. Detailed anatomic knowledge together with an accurate surgical planning are cornerstone for tailoring the approach in each case.
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Affiliation(s)
- Adriana M Pedraza
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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5
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Hoeh B, Wenzel M, Hohenhorst L, Köllermann J, Graefen M, Haese A, Tilki D, Walz J, Kosiba M, Becker A, Banek S, Kluth LA, Mandel P, Karakiewicz PI, Chun FKH, Preisser F. Anatomical Fundamentals and Current Surgical Knowledge of Prostate Anatomy Related to Functional and Oncological Outcomes for Robotic-Assisted Radical Prostatectomy. Front Surg 2022; 8:825183. [PMID: 35273992 PMCID: PMC8901727 DOI: 10.3389/fsurg.2021.825183] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 01/23/2023] Open
Abstract
Context Meticulous knowledge about the anatomy of the prostate and surrounding tissue represents a crucial and mandatory requirement during radical prostatectomy for reliable oncological and excellent replicable, functional outcomes. Since its introduction two decades ago, robotic-assisted laparoscopic radical prostatectomy (RALP) has evolved to become the predominant surgical approach in many industrialized countries. Objective To provide and highlight currently available literature regarding prostate anatomy and to help in improving oncological and functional outcomes in RALP. Methods/Evidence Acquiring PubMed database was searched using the following keywords: “robotic-assisted radical prostatectomy,” “anatomy,” “neurovascular bundle,” “nerve,” “periprostatic fascia,” “pelvis,” “sphincter,” “urethra,” “urinary incontinence,” and “erectile dysfunction.” Relevant articles and book chapters were critically reviewed and if eligible, they were included in this review. Results New evidence in regards to prostatic anatomy and surgical approaches in RALP has been reported in recent years. Besides detailed anatomical studies investigating the meticulous structure of the fascial structures surrounding the prostate and neurovascular bundle preservation, debate about the optimal RALP approach is still ongoing, inspired by recent publications presenting promising functional outcomes following modifications in surgical approaches. Conclusions This review provides a detailed overview of the current knowledge of prostate anatomy, its surrounding tissue, and its influence on key surgical step development for RALP.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
- *Correspondence: Benedikt Hoeh
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Lukas Hohenhorst
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Köllermann
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Haese
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Marina Kosiba
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Severine Banek
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A. Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Pierre I. Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Felix K. H. Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Felix Preisser
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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6
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Adamowicz J, Kluth LA, Pokrywczynska M, Drewa T. Tissue Engineering and Its Potential to Reduce Prostate Cancer Treatment Sequelae-Narrative Review. Front Surg 2021; 8:644057. [PMID: 34722618 PMCID: PMC8551715 DOI: 10.3389/fsurg.2021.644057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/19/2021] [Indexed: 01/08/2023] Open
Abstract
Tissue engineering offers the possibility to overcome limitations of current management for postprostatectomy incontinence and ED. Developed in recent years biotechnological feasibility of mesenchymal stem cell isolation, in vitro cultivation and implantation became the basis for new cell-based therapies oriented to induce regeneration of adult tissue. The perspective to offer patients suffering from post-prostatectomy incontinence or erectile dysfunction minimal invasive one-time procedure utilizing autologous stem cell transplantation is desired management.
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Affiliation(s)
- Jan Adamowicz
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Luis Alex Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marta Pokrywczynska
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Tomasz Drewa
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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7
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Wakamiya T, Yamashita S, Kikkawa K, Kohjimoto Y, Noda Y, Sonomura T, Hara I. Inverse planning in high-dose rate brachytherapy improves quality of life of prostate cancer patients compared with forward planning. Int J Clin Oncol 2021; 26:728-735. [PMID: 33486638 DOI: 10.1007/s10147-020-01851-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To understand differences in quality of life outcomes between cases with forward planning and cases with inverse planning, we examine patients undergoing high-dose rate brachytherapy combined with external beam radiotherapy for localized prostate cancer. METHODS We prospectively identified 283 patients with localized prostate cancer and divided them into forward planning and inverse planning groups. We extracted data on doses to the prostate, rectum and urethra that could potentially affect quality of life. We also evaluated quality of life using the Japanese version of Medical Outcome Study 8-Items Short Form Health Survey and Expanded Prostate Cancer Index Composite at pre-treatment and at 3, 6, 12 and 24 months after treatment. Wilcoxon signed rank test and Bonferroni correction were used to analyze the irradiation dose and any change in quality of life. RESULTS Doses to the prostate and rectum were not significantly different between the two groups. Notably, however, doses to the urethra were significantly lower in the inverse planning group than in the forward planning group. Patients in the forward planning group had significantly poorer physical component summary scores at 3 months according to survey results. In Expanded Prostate Cancer Index Composite, patients in the forward planning group had statistically significant poorer urinary, bowel and sexual scores than those in the inverse planning group. Quality of life related to decline in sexual function was significantly reduced in the inverse planning group. CONCLUSIONS Inverse planning in high-dose rate brachytherapy could significantly improve quality of life of patients with prostate cancer.
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Affiliation(s)
- Takahito Wakamiya
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Shimpei Yamashita
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kazuro Kikkawa
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Yasuo Kohjimoto
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Yasutaka Noda
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Isao Hara
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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Li X, Wu J, Cai Q, Pan J, Meng Q, Zhang P, Xu Y, Zhai L. The distribution pattern of periprostatic neurovascular bundles examined with successive celloidin slices. BMC Urol 2021; 21:6. [PMID: 33407368 PMCID: PMC7789796 DOI: 10.1186/s12894-020-00778-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/23/2020] [Indexed: 12/01/2022] Open
Abstract
Background Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused surgeons. The aim of this study was to describe the periprostatic neurovascular bundles and their relationship with the fascicles around prostate and provide the accurate morphologic knowledge of periprostatic tissue for prostate operation. Methods The pelvic viscera were obtained from 26 adult male cadavers. They were embedded in celloidin and cut into successive slices. The slices were explored with anatomic microscopy. 3-Dimensional reconstruction was achieved with celloidin sections and series software. Results The prostatic capsule which surrounded the dorsal, bilateral aspect of the prostate was attached ventrally to anterior fibrous muscular stroma (AFMS). The lower part of the striated sphincter completely embraced the urethral; the upper part of this muscle covered the lower ventral surface of prostate. The upper ventral surface of prostate is covered by the circular muscle of detrusor. The levator fascia and the capsule adhered on the most convex region of the lateral prostate, but separated on the other region. The pelvic neurovascular bundles (PNVB) divided into the anterior and posterior divisions. The anterior division continued as dorsal vascular complex (DVC). The distal part of DVC entered into penile hilum. The posterior division continued as neurovascular bundles, and then as the cavernous supply (CS). The distal part of CS joined into pudendal neurovascular bundles. Conclusions The capsule and AFMS formed a pocket like complex. There were anterior and posterior neurovascular approaches from PNVB to penile hilum.
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Affiliation(s)
- Xuemei Li
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, 300134, China
| | - Jianhui Wu
- Department of Urology, Tianjin First Central Hospital, Tianjin, 300192, China
| | - Qiliang Cai
- Department of Urology, the Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, 300211, China
| | - Janming Pan
- Department of Anatomy, School of Integrative Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Qingguo Meng
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, 22 Qixiangtai Road, Heping District, Tianjin, 300070, China
| | - Ping Zhang
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, 22 Qixiangtai Road, Heping District, Tianjin, 300070, China
| | - Yong Xu
- Department of Urology, the Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, 300211, China
| | - Lidong Zhai
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, 22 Qixiangtai Road, Heping District, Tianjin, 300070, China.
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Davis M, Egan J, Marhamati S, Galfano A, Kowalczyk KJ. Retzius-Sparing Robot-Assisted Robotic Prostatectomy: Past, Present, and Future. Urol Clin North Am 2020; 48:11-23. [PMID: 33218585 DOI: 10.1016/j.ucl.2020.09.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Radical prostatectomy has undergone many adaptations since its inception, including the Retzius-sparing robotic-assisted radical prostatectomy approach. In this article, we review the origins of radical prostatectomy, the theoretic basis for Retzius-sparing robotic-assisted radical prostatectomy, and outline the key steps of the procedure. To date, there have been 9 studies comparing the outcomes of Retzius-sparing robotic-assisted radical prostatectomy with standard robotic-assisted radical prostatectomy, which have demonstrated improved continence outcomes for Retzius sparing robotic assisted radical prostatectomy within the first year and equivalent oncologic efficacy out to 18 months. Further research is needed to evaluate sexual function outcomes as well as long-term oncologic outcomes.
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Affiliation(s)
- Meghan Davis
- Department of Urology, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA. https://twitter.com/MeghanFDavis1
| | - Jillian Egan
- Department of Urology, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA. https://twitter.com/JillianEganMD
| | - Shawn Marhamati
- Austin Hospital, Department of Urology, 145 Studley Rd, Heidelberg VIC 3084, Australia
| | - Antonio Galfano
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, Milano 20162, Italy
| | - Keith J Kowalczyk
- Department of Urology, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA.
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Pavone C, Abrate A, Agiato S, Billeci S, Tulone G, Vella M, Serretta V, Simonato A. Sildenafil orodispersible film in the treatment of erectile dysfunction after radical prostatectomy: A single-centre open-label uncontrolled trial. Andrologia 2020; 52:e13705. [PMID: 32501569 DOI: 10.1111/and.13705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 05/05/2020] [Accepted: 05/15/2020] [Indexed: 01/22/2023] Open
Abstract
Phosphodiesterase-5 inhibitors are the first-line therapy for erectile dysfunction (ED) after radical prostatectomy (RP). This single-centre open-label uncontrolled study evaluated the efficacy and safety of the new sildenafil orodispersible film (ODF) in ED treatment after RP. Sildenafil 100 mg ODF was administered twice a week for 3 months to patients under 75 years of age, with a Framingham cardiovascular risk score < 20% and a pre-operative International Index of Erectile Function (IIEF)-5 score ≥ 17, who had undergone open RP between 2016 and 2018. Erectile function was assessed pre-operatively, post-operatively and after treatment through the IIEF-5 score, the Sexual Encounter Profile Question (SEP-Q) 2 and SEP-Q3; adverse events (AE) were also investigated after 3 months. A total of 65 patients with a median (25th-75th percentile) post-operative IIEF-5 score of 8 (7-9) were treated. Nine (13.8%) patients reported AE of mild/moderate grade and discontinued treatment. A significant IIEF-5 score median (25th-75th percentile) increase of 10 (0-12) was found after treatment in the other 56 patients (p < .001). Sildenafil 100 mg ODF was effective in ED after RP in terms of improved IIEF-5 score and improved SEP-Q2 and SEP-Q3 in 67.9% of patients. It could represent a valid alternative for those patients with low compliance to tablet intake.
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Affiliation(s)
- Carlo Pavone
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Alberto Abrate
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Sonia Agiato
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Sandro Billeci
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Gabriele Tulone
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Marco Vella
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Vincenzo Serretta
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy
| | - Alchiede Simonato
- Department of Surgical, Oncological and Oral Sciences, Section of Urology, University of Palermo, Palermo, Italy.,Department of Surgery, Urology Unit, S. Croce e Carle Hospital, Cuneo, Italy
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Laucirica O, Gomez E, Hajianfar R, Vilanova JC, Muniesa M. Complete puborectalis, puboperinealis muscle and urethral rhabdomyosphincter preservation in laparoscopic radical prostatectomy: Anatomical landmarks to achieve early urinary continence. Int J Urol 2020; 27:525-536. [PMID: 32301194 PMCID: PMC7384200 DOI: 10.1111/iju.14228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/24/2020] [Indexed: 11/27/2022]
Abstract
Objectives To describe our surgical technique of “muscle‐sparing” laparoscopic radical prostatectomy and to review relevant anatomical landmarks during the procedure. Methods This was a prospective non‐controlled case series of 120 consecutive patients who underwent laparoscopic radical prostatectomy, always carried out by the same surgeon (OL). The median follow‐up period was 33 months. Dissection of the puboperinealis and puborectalis muscle consists of the precise dissection of the puborectalis and puboperinealis muscles from the periprostatic fascia. Rhabdomyo‐dissection consists of an approach that spares the external urethral sphincter from the ventral surface of the prostate and membranous urethra. Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications and outcomes of urinary continence were assessed. A descriptive statistical analysis was carried out. Results Continence rates were 70.8%, 83.3% and 92.5%, at 0–2, 3–4 and 5–8 weeks after removal of the urethral catheter, respectively; 96.6% and 98.3% at 6 and 12 months after surgery. The positive surgical margin rate associated with rhabdomyo‐dissection was 8.3%. Conclusions Laparoscopic radical prostatectomy with dissection of the puboperinealis and puborectalis muscle, and rhabdomyo‐dissection is an oncologically safe procedure, associated with very early recovery urinary continence in most patients. It is a technique that can be applied in most cases, as long as there is no invasion of the ventral side of the prostate.
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Affiliation(s)
- Oscar Laucirica
- Department of Urology, Moises Broggi Hospital, Barcelona, Spain
| | - Esther Gomez
- Department of Urology, Moises Broggi Hospital, Barcelona, Spain
| | - Ramin Hajianfar
- Department of Urology, Moises Broggi Hospital, Barcelona, Spain
| | - Joan C Vilanova
- Department of Radiology, Clinica Girona, Institute of Diagnostic Imaging, University of Girona, Girona, Spain
| | - Marta Muniesa
- Department of Urology, Moises Broggi Hospital, Barcelona, Spain
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12
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Kaiho Y, Ito J, Iwamura H, Anan G, Kuromoto A, Kudo T, Sato M. Nerves in the Areas Posterior to the Prostate Base Contribute to Erectile Function: An Intraoperative Electrical Stimulation Assessment. Urology 2019; 132:156-160. [DOI: 10.1016/j.urology.2019.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/25/2019] [Accepted: 05/10/2019] [Indexed: 11/25/2022]
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13
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Liu J, Huang P, Liang Q, Yang X, Zheng Z, Wei H. Preservation of Denonvilliers' fascia for nerve-sparing laparoscopic total mesorectal excision: A neuro-histological study. Clin Anat 2019; 32:439-445. [PMID: 30664277 DOI: 10.1002/ca.23336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/10/2019] [Accepted: 01/12/2019] [Indexed: 11/06/2022]
Abstract
Urogenital complications due to pelvic autonomic nerve damage frequently occur following rectal surgery. We investigated whether total mesorectal excision (TME) with preservation of the Denonvilliers' fascia (DVF) can effectively prevent the removal of pelvic autonomic nerves through microscopy. Twenty consecutive male patients with mid-low rectal cancer who received TME with preservation or resection of the Denonvilliers' fascia (P and R groups, respectively) were included. Serial transverse sections from surgical specimens were studied histologically. Nerve fibers at the surfaces of the mesorectum were counted. Clinical correlation between the amount of nerve fibers removed and post-operative sexual function was analyzed. Nerve fibers closely localized to the DVF in the R group displaying rich erectile activity (positive anti-nNOS immunostaining). At the anterior surface of the mesorectum, the mean numbers of nNOS-positive nerve fibers per specimen in the P group were significantly lower than the R group (3.0 ± 1.8 vs. 5.0 ± 2.3, P < 0.05). Compared to the R group, patients in the P group had higher IIEF scores and better erectile function at 3 and 6 months post-operatively. The DVF is a key risk zone for pelvic denervation during laparoscopic TME. Preservation of the DVF can prevent the removal of autonomic nerves and protect post-operative erectile function. Clin. Anat. 32:439-445, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Jianpei Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Pinjie Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiong Liang
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Yang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zongheng Zheng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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14
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Sievert KD, Hennenlotter J, Dillenburg T, Toomey P, Wöllner J, Zweers P, Pannek J, Andersson KE, Amend B. Extended periprostatic nerve distributions on the prostate surface confirmed using diffusion tensor imaging. BJU Int 2019; 123:995-1004. [DOI: 10.1111/bju.14508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Karl-Dietrich Sievert
- Department of Urology; Eberhard-Karls University Tuebingen; Tuebingen Germany
- PMU; Salzburg Austria
- Department of Urology; Medical University of Vienna; Vienna Austria
- Klinikum Lippe; Detmold Germany
| | - Jörg Hennenlotter
- Department of Urology; Eberhard-Karls University Tuebingen; Tuebingen Germany
| | - Thomas Dillenburg
- Department of Urology; Eberhard-Karls University Tuebingen; Tuebingen Germany
| | | | - Jens Wöllner
- Department of Urology; Medical University of Vienna; Vienna Austria
- Neuro-Urology; Swiss Paraplegic Center; Nottwil Switzerland
| | - Peter Zweers
- Klinikum Lippe; Detmold Germany
- Neuro-Urology; Swiss Paraplegic Center; Nottwil Switzerland
| | - Jürgen Pannek
- Klinikum Lippe; Detmold Germany
- Neuro-Urology; Swiss Paraplegic Center; Nottwil Switzerland
| | | | - Bastian Amend
- Department of Urology; Eberhard-Karls University Tuebingen; Tuebingen Germany
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15
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Surgical Management of Localized and Locally Advanced Prostate Cancer. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Local Treatment, Radical Cystectomy, and Urinary Diversion. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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17
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Furrer MA, Studer UE, Gross T, Burkhard FC, Thalmann GN, Nguyen DP. Nerve-sparing radical cystectomy has a beneficial impact on urinary continence after orthotopic bladder substitution, which becomes even more apparent over time. BJU Int 2018; 121:935-944. [DOI: 10.1111/bju.14123] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Marc A. Furrer
- Department of Urology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - Urs E. Studer
- Department of Urology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - Tobias Gross
- Department of Urology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - Fiona C. Burkhard
- Department of Urology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - George N. Thalmann
- Department of Urology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - Daniel P. Nguyen
- Department of Urology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
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18
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Local Treatment, Radical Cystectomy, and Urinary Diversion. Urol Oncol 2018. [DOI: 10.1007/978-3-319-42603-7_23-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Seikkula H, Janssen P, Tutolo M, Tosco L, Battaglia A, Moris L, Van den Broeck T, Albersen M, De Meerleer G, Van Poppel H, Everaerts W, Joniau S. Comparison of Functional Outcome after Extended versus Super-Extended Pelvic Lymph Node Dissection during Radical Prostatectomy in High-Risk Localized Prostate Cancer. Front Oncol 2017; 7:280. [PMID: 29214148 PMCID: PMC5702642 DOI: 10.3389/fonc.2017.00280] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/06/2017] [Indexed: 11/23/2022] Open
Abstract
Background Urinary continence and erectile function (EF) are best preserved when meticulous dissection of prostate and nerve sparing technique are used during radical prostatectomy (RP). However, extent of lymph node dissection (LND) may also adversely affect functional results. Objective To determine whether performing a super-extended LND (seLND) has a significant effect on recovery of urinary continence and EF after RP. Design, setting, and participants All patients who underwent RP from January 2007 until December 2013 were handed questionnaires assessing continence and EF. All patients in whom at least an extended LND (eLND) was performed were selected. This search yielded 526 patients. 172 of these patients had filed out 2 or more questionnaires and were included in our analysis. Outcome measurements and statistical analysis All questionnaires were reviewed. We used Kaplan–Meier analyses and multivariate Cox analysis to assess the difference in recovery of continence and EF over time for eLND/seLND. Primary endpoints were full recovery of continence (no loss of urine) and full recovery of EF (successful intercourse possible). Patients who did not reach the endpoint when the last questionnaire was filled out were censored at that time. Median follow-up was 12.43 months for continence, and 18.97 months for EF. Results and limitations Patients undergoing seLND have a lower chance of regaining both urinary continence [hazard ratio (HR) 0.59, 95% CI 0.39–0.90, p = 0.026] and EF (HR 0.28, 95% CI 0.13–0.57, p = 0.009). Age at surgery had a significant influence on both continence and EF in multivariate analysis. Major limitation of the study was that no formal preoperative assessment of continence and potency was done. Conclusion Extending the LND template beyond the eLND template may cause at least a significant delay in recovery of urinary continence and leads to less recovery of EF.
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Affiliation(s)
- Heikki Seikkula
- Department of Urology, Central Finland Hospital District, Jyväskylä, Finland.,Department of Urology, University Hospital, Turku, Finland
| | - Pieter Janssen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Manuela Tutolo
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Lorenzo Tosco
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Meerleer
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | - Wouter Everaerts
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
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Abstract
Purpose of Review Due to the increasing numbers of radical prostatectomies (RP) performed for prostate cancer, a substantial number of patients are now suffering from post-operative erectile dysfunction (ED). The aim of this study is to summarize the current literature on surgical techniques for managing post-prostatectomy erectile dysfunction. Recent Findings The PubMed database was searched for English-language articles published up to Jan 2017 using the following search terms: “prostatectomy AND erectile dysfunction”, “prostatectomy AND penile prostheses”, and “prostatectomy AND penile implants”. All of the studies that evaluated medical treatment were excluded. In the last few decades, the understanding of the anatomy of the male pelvis and prostate has improved. This has led to significant changes in the nerve-sparing radical prostatectomy techniques, with the aim of preserving post-surgical erectile function (EF). In this scenario, the prostate vascular supply and the anatomy of the neurovascular bundles have a central role. Penile prosthesis implantation is considered the third-line treatment option for RP ED patients, and they have been reported to be a very successful treatment with the highest patient satisfaction rate. Summary Considering the failure of penile rehabilitation, and the lack of evidence for accessory pudendal artery (APA) preservation and nerve graft, nerve-sparing surgery and penile prostheses represent, today, the only methods to permanently and definitively preserve or erectile function after RP.
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21
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Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Khera M. Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017; 14:285-296. [DOI: 10.1016/j.jsxm.2016.11.325] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
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22
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Zaitouna M, Alsaid B, Lebacle C, Timoh KN, Benoît G, Bessede T. Origin and nature of pelvic ureter innervation. Neurourol Urodyn 2017; 36:271-279. [PMID: 28235166 DOI: 10.1002/nau.22919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/09/2015] [Indexed: 12/15/2022]
Abstract
AIMS Innervation of the pelvic ureter traditionally comes from the pelvic plexus. This innervation is independent: adrenergic and cholinergic. The purpose of this study was to describe more precisely the origin and nature of its innervation (adrenergic, cholinergic, nitrergic, and somatic). METHODS Six specimens of normal human fetal pelvis (four male and two female) from 20 to 30 weeks gestation were studied. The sections of these fetuses, carried out every 5 µm without interval, were treated with Hematoxylin Eosin (HE), with Masson's trichrome (TriM), immunolabeling of smooth muscle cells with smooth anti-actin, of nerves with anti-S100 protein, anti-tyrosine hydroxylase, anti-VAChT, anti-nNOS, and with anti- peripheral myelin protein 22 (PMP 22). The slides were scanned and two-dimensional images reconstructed in 3D, and analyzed. RESULTS The terminal pelvic ureter travels above and inside the inferior hypogastric plexus (IHP). The nerve fibers that innervate the ureterovesical junction come mainly from the superior hypogastric plexus (SHP) which gives off the hypogastric nerves and pelvic branches of the sacral plexus that form the IHP. Most nerve fibers meet below the ureter, behind the bladder to form an ascending bundle, which innervates the pelvic ureter. Immunohistochemical analysis shows that the nerves of the pelvic ureter consist of adrenergic, cholinergic, and nitrergic fibers. CONCLUSION The innervation of the distal ureter depends mainly on the SHP. This innervation is adrenergic, cholinergic, and nitrergic. It innervates the pelvic ureter in an ascending manner. This anatomical information can change rectal resection and ureteral reimplantation techniques and drug treatments for pelvic ureter stones. Neurourol. Urodynam. 36:271-279, 2017. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Mazen Zaitouna
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France.,Laboratory of Anatomy, Faculty of Medicine, University of Damascus, Damascus, Syria.,Urology Department, G.H. Paris Sud, APHP, Paris Sud University, Le Kremlin Bicêtre, France
| | - Bayan Alsaid
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France.,Laboratory of Anatomy, Faculty of Medicine, University of Damascus, Damascus, Syria
| | - Cédric Lebacle
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Krystel Nyangoh Timoh
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Gérard Benoît
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Thomas Bessede
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France.,Urology Department, G.H. Paris Sud, APHP, Paris Sud University, Le Kremlin Bicêtre, France
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23
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Surgical Management of Localized and Locally Advanced Prostate Cancer. Urol Oncol 2017. [DOI: 10.1007/978-3-319-42603-7_73-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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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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25
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Cochetti G, Boni A, Barillaro F, Pohja S, Cirocchi R, Mearini E. Full Neurovascular Sparing Extraperitoneal Robotic Radical Prostatectomy: Our Experience with PERUSIA Technique. J Endourol 2016; 31:32-37. [PMID: 27824258 DOI: 10.1089/end.2016.0477] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Primary aim of this study was to investigate the feasibility and the safety of PERUSIA (posterior, extraperitoneal, robotic, under santorini, intrafascial, anterograde) radical prostatectomy (RP). Secondary aim was to evaluate oncologic and functional results. The main intent of PERUSIA is to reduce injury of the Neuro-Vascular Bundles (NVB) and to preserve periurethral anterior structures. This is the first reported prospective cohort study about our technique. MATERIALS AND METHODS We collected prospective data of a cohort of 210 patients who had undergone PERUSIA RP between January 2013 and May 2015. Key points of this technique included the following: posterior approach to intrafascial plane, which was developed from the median to lateral side, anterograde preservation of the Veil of Aphrodite, and development of an anterior avascular plane to preserve the santorini plexus. We included only sexually potent patients with low-risk disease. Perioperative, oncologic, and functional outcomes were collected. Postoperative full continence was defined as no pad use. Patients were defined potent when International Index of Erectile Function (IIEF-5) score was >17. Median follow-up was 22 months. RESULTS Median operative time and median estimated blood loss were 120 minutes and 150 mL, respectively. 25 patients (11.9%) experienced a total of 36 complications overall with an overall complication rate of 17.1%. We reported 3 (8.3%) grade IIIb complications and no major ones. Overall positive surgical margin rate was 20% with biochemical recurrence occurring in 3.8% of patients at a median follow-up of 22 months. Immediate urinary continence rate (1 day after catheter removal) was 66.6%. At 3 and 12 months, the continence rate was 90.4% and 96.1%, respectively, while sexual potency rate was 70.4% and 80.9%. CONCLUSION PERUSIA RP has proved to be safe and effective for low-risk prostate cancer with exciting functional outcomes in terms of early recovery of urinary continence and sexual potency.
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Affiliation(s)
- Giovanni Cochetti
- 1 Division of Urological, Andrological Surgery and Minimally-Invasive Techniques, Department of Surgical and Biochemical Sciences, University of Perugia , Perugia, Italy
| | - Andrea Boni
- 1 Division of Urological, Andrological Surgery and Minimally-Invasive Techniques, Department of Surgical and Biochemical Sciences, University of Perugia , Perugia, Italy
| | - Francesco Barillaro
- 1 Division of Urological, Andrological Surgery and Minimally-Invasive Techniques, Department of Surgical and Biochemical Sciences, University of Perugia , Perugia, Italy
| | - Solajd Pohja
- 1 Division of Urological, Andrological Surgery and Minimally-Invasive Techniques, Department of Surgical and Biochemical Sciences, University of Perugia , Perugia, Italy
| | - Roberto Cirocchi
- 2 Division of General Surgery, Department of Surgical and Biochemical Sciences, University of Perugia , Perugia, Italy
| | - Ettore Mearini
- 1 Division of Urological, Andrological Surgery and Minimally-Invasive Techniques, Department of Surgical and Biochemical Sciences, University of Perugia , Perugia, Italy
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26
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Nerve Sparing, Robot-Assisted Radical Cystectomy with Intracorporeal Bladder Substitution in the Male. J Urol 2016; 196:1549-1557. [DOI: 10.1016/j.juro.2016.04.114] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 11/17/2022]
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27
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Moszkowicz D, Rougier G, Julié C, Nyangoh Timoh K, Beauchet A, Vychnevskaia K, Malafosse R, Nordlinger B, Peschaud F. Total mesorectal excision for cancer: histological and immunohistochemical evidence of nerve removal and risk-factor analysis. Colorectal Dis 2016; 18:O367-O375. [PMID: 27591734 DOI: 10.1111/codi.13501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 06/26/2016] [Indexed: 12/14/2022]
Abstract
AIM Whether or not nerve-sparing rectal-cancer surgery can effectively prevent removal of the pelvic autonomic nerves has not been substantiated microscopically. We aimed to analyse the quality of nerve preservation in female patients by quantifying residual nerve fibres in total mesorectal excision specimens, to analyse pro-erectile function of the nerve fibres removed and to determine risk factors for pelvic denervation. METHOD Serial transverse sections from female patients, 64 ± 18 years of age, were studied after the mesorectal fascia was inked and studied histologically [using anti-S100 and anti-neuronal nitric oxide synthase (nNOS) antibodies]. Nerve fibres located within 1 mm of the inked surface were counted and analysed according to type of surgery, tumour location, pT stage, circumferential resection margin and the necessity for a posterior colpectomy. RESULTS Twelve specimens were analysed. Per specimen, the mean number of nerve-fibre sections outside the mesorectum was 5.3 ± 3.6 (range: 1-12). The mean number of fibres per specimen was 6.4 ± 4.1 in patients having a low-rectal tumour and 4.4 ± 2.9 in those with mid or higher rectal tumours (P = 0.42). The mean number of fibres was higher (9.2) for T4 tumours than for T2/T3 tumours (5.0 ± 3.5), but this difference was not statistically sigmificant (P = 0.25). Patients having abdominoperineal excision, a posterior colpectomy or a circumferential resection margin of less than 1 mm had significantly more nerve fibres in the specimen (10.6 ± 1.9 vs 4.4 ± 2.8; P = .041). Fibres localized at the anterolateral rectum corresponded to branches of the neurovascular bundle, expressing rich pro-erectile activity (positive anti-nNOS immunostaining). CONCLUSION The neurovascular bundle is a key risk zone for pelvic denervation during total mesorectal excision. Abdominoperineal excision, posterior colpectomy and an invaded circumferential resection margin are associated with perineal denervation.
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Affiliation(s)
- D Moszkowicz
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France.,UVSQ, Paris Saclay University, UFR des sciences de la santé Simone Veil, Montigny-Le-Bretonneux, France
| | - G Rougier
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France
| | - C Julié
- UVSQ, Paris Saclay University, UFR des sciences de la santé Simone Veil, Montigny-Le-Bretonneux, France.,AP-HP, Hôpital Ambroise Paré, Service d'anatomo-pathologie, Boulogne-Billancourt, France
| | - K Nyangoh Timoh
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France.,UVSQ, Paris Saclay University, UFR des sciences de la santé Simone Veil, Montigny-Le-Bretonneux, France
| | - A Beauchet
- AP-HP, Hôpital Ambroise Paré, Service de biostatistiques, Boulogne-Billancourt, France
| | - K Vychnevskaia
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France.,UVSQ, Paris Saclay University, UFR des sciences de la santé Simone Veil, Montigny-Le-Bretonneux, France
| | - R Malafosse
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France
| | - B Nordlinger
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France
| | - F Peschaud
- AP-HP, Hôpital Ambroise Paré, Service de chirurgie digestive, oncologique et métabolique, Boulogne-Billancourt, France. .,UVSQ, Paris Saclay University, UFR des sciences de la santé Simone Veil, Montigny-Le-Bretonneux, France.
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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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Capogrosso P, Salonia A, Briganti A, Montorsi F. Postprostatectomy Erectile Dysfunction: A Review. World J Mens Health 2016; 34:73-88. [PMID: 27574591 PMCID: PMC4999493 DOI: 10.5534/wjmh.2016.34.2.73] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 06/20/2016] [Indexed: 11/16/2022] Open
Abstract
In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis.
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Affiliation(s)
- Paolo Capogrosso
- Università Vita-Salute San Raffaele; Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Salonia
- Università Vita-Salute San Raffaele; Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Briganti
- Università Vita-Salute San Raffaele; Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Università Vita-Salute San Raffaele; Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
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Vessel-sparing radiation and functional anatomy-based preservation for erectile function after prostate radiotherapy. Lancet Oncol 2016; 17:e198-208. [DOI: 10.1016/s1470-2045(16)00063-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/06/2016] [Accepted: 01/21/2016] [Indexed: 12/14/2022]
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Abstract
The cavernous nerves, which course along the surface of the prostate gland, are responsible for erectile function. During radical prostatectomy, urologists are challenged in preserving these nerves and their function. Cavernous nerves are microscopic and show variable location in different patients; therefore, postoperative sexual potency rates are widely variable following radical prostatectomy. A variety of technologies, including electrical and optical nerve stimulation, dye-based optical fluorescence and microscopy, spectroscopy, ultrasound and magnetic resonance imaging have all been used to study cavernous nerve anatomy and physiology, and some of these methods are also potential intraoperative methods for identifying and preserving cavernous nerves. However, all of these technologies have inherent limitations, including slow or inconsistent nerve responses, poor image resolution, shallow image depth, slow image acquisition times and/or safety concerns. New and emerging technologies, as well as multimodal approaches combining existing methods, hold promise for improved postoperative sexual outcomes and patient quality of life following radical prostatectomy.
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Walz J, Epstein JI, Ganzer R, Graefen M, Guazzoni G, Kaouk J, Menon M, Mottrie A, Myers RP, Patel V, Tewari A, Villers A, Artibani W. A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy: An Update. Eur Urol 2016; 70:301-11. [PMID: 26850969 DOI: 10.1016/j.eururo.2016.01.026] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/18/2016] [Indexed: 11/17/2022]
Abstract
CONTEXT In 2010, we published a review summarising the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control and the functional outcome of prostatectomy. OBJECTIVE To provide an update based on new literature to help the surgeon improve oncologic and surgical outcomes of radical prostatectomy (RP). EVIDENCE ACQUISITION We searched the PubMed database using the keywords radical prostatectomy, anatomy, neurovascular bundle, nerve, fascia, pelvis, sphincter, urethra, urinary continence, and erectile function. Relevant articles and textbook chapters published since the last review were critically reviewed, analysed, and summarised. Moreover, we integrated aspects that were not addressed in the last review into this update. EVIDENCE SYNTHESIS We found new evidence for several topics. Up to 40% of the cross-sectional surface area of the urethral sphincter tissue is laterally overlapped by the dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers fascia is fused with the base of the prostate in a horizontal fashion dorsally/caudally of the seminal vesicles, requiring sharp detachment when preserved. During extended pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal iliac area. Dissection planes for nerve sparing can be graded according to the amount of tissue left on the prostate as a safety margin against positive surgical margins. Vascular structures can serve as landmarks. The urethral sphincter and its length after RP are influenced by the shape of the apex. Taking this shape into account allows preservation of additional sphincter length with improved postoperative continence. CONCLUSIONS This update provides additional, detailed information about the surgical anatomy of the prostate and adjacent tissues involved in RP. This anatomy remains complex and widely variable. These details facilitate surgical orientation and dissection during RP and ideally should translate into improved outcomes. PATIENT SUMMARY Based on recent anatomic findings regarding the prostate and its surrounding tissue, the urologist can individualise the dissection during RP according to cancer and patient characteristics to improve oncologic and functional results at the same time.
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Affiliation(s)
- Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France.
| | - Jonathan I Epstein
- Departments of Pathology, Urology, and Oncology, Johns Hopkins Medical, Baltimore, MD, USA
| | | | - Markus Graefen
- Martini Clinic, Prostate Cancer Centre, Hamburg, Germany
| | - Giorgio Guazzoni
- Department of Urology, Humanitas Research Hospital, Rozzano, Italy
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | | | - Robert P Myers
- Institute of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Vipul Patel
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA
| | - Ashutosh Tewari
- Prostate Cancer Institute, Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Arnauld Villers
- Department of Urology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
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Abstract
Radical cystectomy (RC) with pelvic lymph node dissection (PLND) followed by urinary diversion is the treatment of choice for muscle-invasive bladder cancer (BC) and non-invasive BC refractory to transurethral resection of the bladder (TUR-B) and/or intravesical instillation therapies. Since the morbidity and possible mortality of this surgery are relevant, care must be taken in the preoperative selection of patients for the various organ-sparing procedures (e.g., bladder-sparing, nerve sparing, seminal vesicle sparing) and various types of urinary diversion. The patient's performance status and comorbidities, along with individual tumor characteristics, determine possible surgical steps during RC. This individualized approach to RC in each patient can maximize oncological safety and minimize avoidable side effects, rendering 'standard' cystectomy a surgery of the past.
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Affiliation(s)
- Beat Roth
- Department of Urology, University of Bern, Bern, Switzerland
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Kiss B, Paerli M, Schöndorf D, Burkhard FC, Thalmann GN, Roth B. Pelvic Lymph Node Dissection may be Limited on the Contralateral Side in Strictly Unilateral Bladder Cancer without Compromising Oncological Radicality. Bladder Cancer 2016; 2:53-59. [PMID: 27376125 PMCID: PMC4927826 DOI: 10.3233/blc-150031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Results of a dynamic multimodality mapping study showed no lymphatic drainage of the lateral bladder wall to the contralateral internal iliac region. OBJECTIVES To validate whether pathoanatomical mapping in bladder cancer (BC) patients can confirm these results. METHODS Between 01/2000 and 07/2013, 825 BC patients preoperatively staged ≥pT1 and without clinical signs of metastases (cN0 cM0) underwent extended pelvic lymph node dissection (ePLND) and radical cystectomy at our department. Of these patients, 23% (193/825) were lymph node (LN) positive in the pathological specimen; 26% (51/193) of this subgroup had strictly unilateral BC. Pathoanatomical mapping was used to retrospectively validate the distribution of LN involvement in these 51 patients. RESULTS A median of 35 LNs were removed per patient (range: 13-80 LNs), with a median of 2 positive LNs (range: 1-14 LNs). 27% (14/51) of patients presented with LN metastases on the contralateral side. No positive LNs were found in the contralateral internal iliac region or the contralateral fossa of Marcille. 10% (5/51) of patients had LN metastases only on the contralateral side without evidence of metastases on the tumor-bearing side. CONCLUSIONS Our findings corroborate the data of a dynamic mapping study showing bilateral lymphatic drainage in almost one third of patients with strictly unilateral BC, but no lymphatic drainage from the lateral bladder wall to the contralateral internal iliac region. If prospective studies confirm these results, the contralateral internal iliac region may be omitted during ePLND in patients with strictly unilateral BC.
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Affiliation(s)
- Bernhard Kiss
- Department of Urology, University of Bern , Bern, Switzerland
| | - Michael Paerli
- Department of Urology, University of Bern , Bern, Switzerland
| | | | | | | | - Beat Roth
- Department of Urology, University of Bern , Bern, Switzerland
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Dariane C, Moszkowicz D, Peschaud F. Concepts of the rectovaginal septum: implications for function and surgery. Int Urogynecol J 2015; 27:839-48. [PMID: 26690361 DOI: 10.1007/s00192-015-2878-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/26/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers' rectoprostatic fascia or rectovesical septum (RVS). Its purpose-and, indeed, its existence-are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men. METHODS A review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested. RESULTS This manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men. CONCLUSIONS The RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery.
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Affiliation(s)
- Charles Dariane
- Service de Chirurgie Digestive, Oncologique et Métabolique, Hôpital Ambroise-Paré, AP-HP, 92104, Boulogne-Billancourt, France
- Université de Versailles St-Quentin-en-Yvelines, UFR des Sciences de la santé Simone-Veil, 78180, Montigny-Le-Bretonneux, France
| | - David Moszkowicz
- Service de Chirurgie Digestive, Oncologique et Métabolique, Hôpital Ambroise-Paré, AP-HP, 92104, Boulogne-Billancourt, France
- Université de Versailles St-Quentin-en-Yvelines, UFR des Sciences de la santé Simone-Veil, 78180, Montigny-Le-Bretonneux, France
| | - Frédérique Peschaud
- Service de Chirurgie Digestive, Oncologique et Métabolique, Hôpital Ambroise-Paré, AP-HP, 92104, Boulogne-Billancourt, France.
- Université de Versailles St-Quentin-en-Yvelines, UFR des Sciences de la santé Simone-Veil, 78180, Montigny-Le-Bretonneux, France.
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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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Asimakopoulos AD, Miano R, Galfano A, Bocciardi AM, Vespasiani G, Spera E, Gaston R. Retzius-sparing robot-assisted laparoscopic radical prostatectomy: Critical appraisal of the anatomic landmarks for a complete intrafascial approach. Clin Anat 2015. [DOI: 10.1002/ca.22576] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Anastasios D. Asimakopoulos
- Department of Experimental Medicine and Surgery; UOC of Urology, University of Rome Tor Vergata, Policlinico Casilino; Rome Italy
- Department of Urology; Clinique Saint-Augustin; Bordeaux France
| | - Roberto Miano
- Department of Experimental Medicine and Surgery; UOC of Urology, University of Rome Tor Vergata, Policlinico Tor Vergata; Rome Italy
| | - Antonio Galfano
- Department of Urology; Ospedale Niguarda Ca' Granda; Milan Italy
| | | | - Giuseppe Vespasiani
- Department of Experimental Medicine and Surgery; UOC of Urology, University of Rome Tor Vergata, Policlinico Tor Vergata; Rome Italy
| | - Enrico Spera
- Department of Experimental Medicine and Surgery; UOC of Urology, University of Rome Tor Vergata, Policlinico Casilino; Rome Italy
| | - Richard Gaston
- Department of Urology; Clinique Saint-Augustin; Bordeaux France
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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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Diallo D, Zaitouna M, Alsaid B, Quillard J, Ba N, Allodji RS, Benoit G, Bedretdinova D, Bessede T. The visceromotor and somatic afferent nerves of the penis. J Sex Med 2015; 12:1120-7. [PMID: 25689562 DOI: 10.1111/jsm.12851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Innervation of the penis supports erectile and sensory functions. AIM This article aims to study the efferent autonomic (visceromotor) and afferent somatic (sensory) nervous systems of the penis and to investigate how these systems relate to vascular pathways. METHODS Penises obtained from five adult cadavers were studied via computer-assisted anatomic dissection (CAAD). MAIN OUTCOME MEASURES The number of autonomic and somatic nerve fibers was compared using the Kruskal-Wallis test. RESULTS Proximally, penile innervation was mainly somatic in the extra-albugineal sector and mainly autonomic in the intracavernosal sector. Distally, both sectors were almost exclusively supplied by somatic nerve fibers, except the intrapenile vascular anastomoses that accompanied both somatic and autonomic (nitrergic) fibers. From this point, the neural immunolabeling within perivascular nerve fibers was mixed (somatic labeling and autonomic labeling). Accessory afferent, extra-albugineal pathways supplied the outer layers of the penis. CONCLUSIONS There is a major change in the functional type of innervation between the proximal and distal parts of the intracavernosal sector of the penis. In addition to the pelvis and the hilum of the penis, the intrapenile neurovascular routes are the third level where the efferent autonomic (visceromotor) and the afferent somatic (sensory) penile nerve fibers are close. Intrapenile neurovascular pathways define a proximal penile segment, which guarantees erectile rigidity, and a sensory distal segment.
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Affiliation(s)
- Djibril Diallo
- U1195 (Neuroprotective, neuroregenerative and remyelinating small molecules), University Paris-Sud, INSERM, Le Kremlin-Bicêtre, France.,Urology Department, University Paris-Sud Hospital of Bicetre, Le Kremlin-Bicêtre, France
| | - Mazen Zaitouna
- U1195 (Neuroprotective, neuroregenerative and remyelinating small molecules), University Paris-Sud, INSERM, Le Kremlin-Bicêtre, France.,Urology Department, University Paris-Sud Hospital of Bicetre, Le Kremlin-Bicêtre, France
| | - Bayan Alsaid
- U1195 (Neuroprotective, neuroregenerative and remyelinating small molecules), University Paris-Sud, INSERM, Le Kremlin-Bicêtre, France
| | - Jeanine Quillard
- Anatomic Pathology Department, University Paris-Sud Hospital of Bicetre, Le Kremlin-Bicêtre, France
| | - Nathalie Ba
- INSERM i2b Institute, University Paris-Sud, Le Kremlin-Bicêtre, France
| | | | - Gérard Benoit
- U1195 (Neuroprotective, neuroregenerative and remyelinating small molecules), University Paris-Sud, INSERM, Le Kremlin-Bicêtre, France
| | - Dina Bedretdinova
- INSERM CESP U1018 Institute, University Paris-Sud, Villejuif Cedex, France
| | - Thomas Bessede
- U1195 (Neuroprotective, neuroregenerative and remyelinating small molecules), University Paris-Sud, INSERM, Le Kremlin-Bicêtre, France.,Urology Department, University Paris-Sud Hospital of Bicetre, Le Kremlin-Bicêtre, France
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Ganzer R, Stolzenburg JU, Neuhaus J, Weber F, Burger M, Bründl J. Is the Striated Urethral Sphincter at Risk by Standard Suture Ligation of the Dorsal Vascular Complex in Radical Prostatectomy? An Anatomic Study. Urology 2014; 84:1453-8. [DOI: 10.1016/j.urology.2014.06.092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/14/2014] [Accepted: 06/18/2014] [Indexed: 11/28/2022]
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Terrier JE, Ferretti L, Journel NM, Ben-Naoum K, Graziana JP, Huyghe E, Marcelli F, Methorst C, Montaigne O, Savareux L, Faix A. [Should we recommend an erectile rehabilitation after radical prostatectomy? Systematic review of the literature by the Sexual Medicine Committee of the French Urology Association]. Prog Urol 2014; 24:1043-9. [PMID: 25218439 DOI: 10.1016/j.purol.2014.07.004] [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] [Received: 06/15/2014] [Revised: 07/02/2014] [Accepted: 07/17/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Radical prostatectomy has evolved considerably during the last 20 years, with one hand, a thorough knowledge of the anatomy of the prostate, and secondly, the introduction of new conservation techniques of neurovascular bundles. Despite this progress, the rate of post-prostatectomy erectile dysfunction varies between 30 and 90% depending on the series and this element impacts the quality of life after radical prostatectomy. The objective of this work was to conduct a review of the literature in order to evaluate the various protocols of post-radical prostatectomy erectile rehabilitation. PATIENTS AND METHODS A systematic review of the literature from the basic PubMed search was performed using the following keywords. Therapy erectile dysfunction, radical prostatectomy, penile rehabilitation, phosphodiesterase 5 inhibitor, intracavernous injection. RESULTS The critical analysis of selected studies highlights the lack of standard protocol that established erectile rehabilitation early after radical prostatectomy. These studies have shown that early treatment, injections or intracavernous PDE5 inhibitors improved recovery of erections as recommended by the French Association of Urology. CONCLUSION Management of disorders of post-radical prostatectomy sexuality is essential, it must be organized in a well-established protocol combining pharmacological and therapeutic education assistances delivered by practitioners or nurses. It would need to develop in a clinical trial a standard protocol.
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Affiliation(s)
- J-E Terrier
- Service d'urologie-andrologie, université Jean-Monnet, CHU de Saint-Étienne, 34, rue Francis-Baulier, 42023 Saint-Étienne cedex 2, France.
| | - L Ferretti
- Service d'urologie-andrologie, CHU de Bordeaux, 33000 Bordeaux, France
| | - N Morel Journel
- Service d'urologie-andrologie, CHU Lyon sud, hospices civiles de Lyon, 69495 Lyon, France
| | - K Ben-Naoum
- Service d'urologie-andrologie, CHU de Nîmes, 30029 Nîmes, France
| | - J-P Graziana
- Service d'urologie-andrologie, clinique mutualiste de la Porte de l'Orient, 56100 L'Orient, France
| | - E Huyghe
- Service d'urologie-andrologie, CHU de Toulouse, 31059 Toulouse, France
| | - F Marcelli
- Service d'urologie-andrologie, CHU de Lille, 59000 Lille, France
| | - C Methorst
- Service d'urologie-andrologie, hôpital Foch, 92151 Suresnes, France
| | - O Montaigne
- Service d'urologie-andrologie, CHU de Lille, 59000 Lille, France
| | - L Savareux
- Service d'urologie-andrologie, clinique de la Chataigneraie, 63110 Clermont-Ferrand, France
| | - A Faix
- Service d'urologie-andrologie, clinique Beausoleil, 34070 Montpellier, France
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Inside-out autologous vein grafts fail to restore erectile function in a rat model of cavernous nerve crush injury after nerve-sparing prostatectomy. Int J Impot Res 2014; 27:59-62. [PMID: 25078050 DOI: 10.1038/ijir.2014.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 05/01/2014] [Accepted: 07/01/2014] [Indexed: 11/08/2022]
Abstract
Some autologous tissues can restore erectile function (EF) in rats after a resection of the cavernous nerve (CN). However, a cavernous nerve crush injury (CNCI) better reproduces ED occurring after a nerve-sparing radical prostatectomy (RP). The aim was to evaluate the effect on EF of an autologous vein graft after CNCI, compared with an artificial conduit. Five groups of rats were studied: those with CN exposure, exposure+vein, crush, crush+guide and crush+vein. Four weeks after surgery, the EF of rats was assessed by electrical stimulation of the CNs. The intracavernous pressure (ICP) and mean arterial pressure (MAP) were monitored during stimulations at various frequencies. The main outcome, that is, the rigidity of the erections, was defined as the ICP/MAP ratio. At 10 Hz, the ICP/MAP ratios were 41.8%, 34.7%, 20.9%, 33.9% and 20.5%, respectively. The EF was significantly lower in rats if the CNCI was treated with a vein graft instead of an artificial guide. Contrary to cases of CN resection, autologous vein grafts did not improve EF after CNCI. In terms of clinical use, the study suggests to limit an eventual use of autologous vein grafts to non-nerve-sparing RPs.
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MRI-based 3D pelvic autonomous innervation: a first step towards image-guided pelvic surgery. Eur Radiol 2014; 24:1989-97. [DOI: 10.1007/s00330-014-3211-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 04/29/2014] [Indexed: 12/30/2022]
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Dixon L, Brown M, Challacombe B. Selection for focal therapy: is it too early to judge? Eur Urol 2014; 66:20-1. [PMID: 24405780 DOI: 10.1016/j.eururo.2013.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 12/20/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Luke Dixon
- Guy's and St. Thomas' NHS Foundation Trust, Urology, Guy's Hospital, London, UK
| | - Matthew Brown
- Guy's and St. Thomas' NHS Foundation Trust, Urology, Guy's Hospital, London, UK
| | - Benjamin Challacombe
- Guy's and St. Thomas' NHS Foundation Trust, Urology, Guy's Hospital, London, UK.
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Abstract
Focal therapy for prostate cancer is a nascent and emerging field. As such, the patient selection criteria for this new treatment paradigm are evolving in parallel to both the technology on which this approach depends and to our unfolding understanding of the natural history of prostate cancer. Until, and while, prospective trials of focal therapy are being reported, patient selection criteria will be flexible and very dependent on the therapeutic goals. We must carefully define the therapeutic intentions of focal therapy before engaging in the actual process of determining optimal patient selection. The therapeutic intent will define the most appropriate candidate for such therapy. Patient selection encompasses multiple complex issues including the type of prostate biopsy (12 core transrectal versus mapping transperineal) to the type of imaging (multiparametric magnetic resonance imaging or enhanced ultrasound) to the specific anatomical location of the disease within the prostate (apex, mid-prostate, base) and a comprehensive assessment of the patient's overall health and life expectancy. It is not as simple as saying a patient with a certain grade or a certain number of cores is or is not appropriate for focal therapy. There are many more considerations for a reasonable and thoughtful approach to this new treatment.
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Affiliation(s)
- John F Ward
- Associate Professor, Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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Bertrand MM, Alsaid B, Droupy S, Benoit G, Prudhomme M. Optimal plane for nerve sparing total mesorectal excision, immunohistological study and 3D reconstruction: an embryological study. Colorectal Dis 2013; 15:1521-8. [PMID: 24131598 DOI: 10.1111/codi.12459] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 06/09/2013] [Indexed: 02/08/2023]
Abstract
AIM Genito-urinary complications are frequent after rectal surgery and are often due to nerve damage. The relationship between the pelvic nerves and surgical planes are unclear. The aim of the study was to determine the relationship between the inferior hypogastric plexus and the fascia of the lateral pelvic wall and between Denonvilliers' fascia and the efferent branches of the inferior hypogastric plexus. METHOD Computer-assisted anatomical dissection was used. Serial histological sections were made from six human foetuses and a male adult. Sections were stained with haematoxylin and eosin, Masson's trichrome and immunostainings. The sections were then digitalized and reconstructed in three dimensions. RESULTS The inferior hypogastric plexus was situated in a virtual space between the fascia propria of the rectum and the fascia on the upper surface of the levator ani. During the lateral dissection, the optimal surgical plane is the plane of the fascia propria of the rectum. We located Denonvilliers' fascia in three dimensions. It plays the role of a protective sheet for the neurovascular bundle. The optimal plane for nerve preservation is situated behind Denonvilliers' fascia. CONCLUSION This study has enabled a clear visualization of the optimal planes to perform total mesorectal excision while ensuring nerve preservation. Three-dimensional visualization clearly helps to bridge the gap between histological examination and the findings of surgery.
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Affiliation(s)
- M M Bertrand
- Laboratory of Experimental Anatomy, Faculty of Medicine, Montpellier-Nîmes, University Montpellier I, Nîmes, France
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Galfano A, Di Trapani D, Sozzi F, Strada E, Petralia G, Bramerio M, Ascione A, Gambacorta M, Bocciardi AM. Beyond the Learning Curve of the Retzius-sparing Approach for Robot-assisted Laparoscopic Radical Prostatectomy: Oncologic and Functional Results of the First 200 Patients with ≥1 Year of Follow-up. Eur Urol 2013; 64:974-80. [DOI: 10.1016/j.eururo.2013.06.046] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 06/24/2013] [Indexed: 11/25/2022]
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Oakley SH, Mutema GK, Crisp CC, Estanol MV, Kleeman SD, Fellner AN, Pauls RN. Innervation and Histology of the Clitoral–Urethal Complex: A Cross-Sectional Cadaver Study. J Sex Med 2013; 10:2211-8. [DOI: 10.1111/jsm.12230] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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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Droupy S, Al Said B, Lechevallier É, Colson MH, Giuliano F. Sexualité et cancer de la prostate. Prog Urol 2013; 23:696-711. [DOI: 10.1016/j.purol.2013.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 03/18/2013] [Indexed: 01/09/2023]
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