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Interpositional Nerve Grafting of the Prostatic Plexus after Radical Prostatectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e452. [PMID: 26301141 PMCID: PMC4527626 DOI: 10.1097/gox.0000000000000422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/27/2015] [Indexed: 11/26/2022]
Abstract
Background: Injury to the prostatic plexus may occur during radical prostatectomy even with the use of minimally invasive techniques. Reconstruction of these nerves by interpositional nerve grafting can be performed to reduce morbidity. Although the feasibility of nerve reconstruction has been shown, long-term functional outcomes are mixed, and the role of nerve grafting in these patients remains unclear. Methods: A retrospective study was performed on 38 consecutive patients who underwent immediate unilateral or bilateral nerve reconstruction after open prostatectomy. Additionally, 53 control patients who underwent unilateral, bilateral, or non–nerve-sparing open prostatectomy without nerve grafting were reviewed. Outcomes included rates of urinary continence, erections sufficient for sexual intercourse, and ability to have spontaneous erections. Analysis was performed by stratifying patients by D’Amico score and laterality of nerve involvement. Results: Unilateral nerve grafting conferred no significant benefit compared with unilateral nerve-sparing prostatectomy. Bilateral nerve-sparing patients demonstrated superior functional outcomes compared with bilateral non–nerve-sparing patients, whereas bilateral nerve-grafting patients displayed a trend toward functional improvement. With increasing D’Amico score, there was a trend toward worsening urinary continence and erectile function regardless of nerve-grafting status. Conclusions: In the era of robotic prostatectomy, interpositional nerve reconstruction is not a routine practice. However, the substantial morbidity experienced in patients with bilateral nerve resections remains unacceptable, and therefore, nerve grafting may still improve functional outcomes in these patients. Further investigation is needed to improve the potential of bilateral nerve grafting after non–nerve-sparing prostatectomy.
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Weyne E, Castiglione F, Van der Aa F, Bivalacqua TJ, Albersen M. Landmarks in erectile function recovery after radical prostatectomy. Nat Rev Urol 2015; 12:289-97. [PMID: 25868558 DOI: 10.1038/nrurol.2015.72] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The description of the nerve-sparing technique of radical prostatectomy by Walsh was one of the major breakthroughs in the surgical treatment of prostate cancer in the 20(th) century. However, despite this advance and consequent technological refinements to nerve-sparing surgery, a large proportion of men still suffer from erectile dysfunction (ED) as a complication of prostatectomy. A plethora of therapeutic approaches have been proposed to optimize erectile function recovery in these patients. Several preclinical and translational studies have shown benefits of therapies including PDE5 inhibitor (PDE5I) treatment, immunomodulation, neurotrophic factor administration, and regenerative techniques, such as stem cell therapy, in animal models. However, most of these approaches have either failed to translate to clinical use or have yet to be studied in human subjects. Penile rehabilitation with PDE5Is is currently the most commonly used clinical strategy, in spite of the absence of solid clinical evidence to support its use.
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Affiliation(s)
- Emmanuel Weyne
- Laboratory for Experimental Urology, Department of Development and Regeneration, University of Leuven, Herestraat 49, Box 802, 3000 Leuven, Belgium
| | - Fabio Castiglione
- Urological Research Institute, San Raffaele Scientific Institution, via Olgettina 60, 20132 Milano, Italy
| | - Frank Van der Aa
- Laboratory for Experimental Urology, Department of Development and Regeneration, University of Leuven, Herestraat 49, Box 802, 3000 Leuven, Belgium
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Department of Urology, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Marburg 420, Baltimore, MD 21287, USA
| | - Maarten Albersen
- Laboratory for Experimental Urology, Department of Development and Regeneration, University of Leuven, Herestraat 49, Box 802, 3000 Leuven, Belgium
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Abstract
Surgery remains a mainstay in the management of localized prostate cancer. This article addresses surgical aspects germane to the management of men with prostate cancer, including patient selection for surgery, nerve-sparing approaches, minimization of positive surgical margins, and indications for pelvic lymph node dissection. Outcomes for men with high-risk prostate cancer following surgery are reviewed, and the present role of neoadjuvant therapy before radical prostatectomy is discussed. In addition, there is a review of the published literature on surgical ablative therapies for prostate cancer.
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Gomez-Amaya SM, Ruggieri MR, Arias Serrato SA, Massicotte VS, Barbe MF. Gross anatomical study of the nerve supply of genitourinary structures in female mongrel hound dogs. Anat Histol Embryol 2014; 44:118-27. [PMID: 24730986 DOI: 10.1111/ahe.12116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 03/17/2014] [Indexed: 11/30/2022]
Abstract
Anatomical variations in lumbosacral plexus or nerves to genitourinary structures in dogs are under described, despite their importance during surgery and potential contributions to neuromuscular syndromes. Gross dissection of 16 female mongrel hound dogs showed frequent variations in lumbosacral plexus classification, sympathetic ganglia, ventral rami input to nerves innervating genitourinary structures and pudendal nerve (PdN) branching. Lumbosacral plexus classification types were mixed, rather than pure, in 13 (82%) of dogs. The genitofemoral nerve (GFN) originated from ventral ramus of L4 in 67% of nerves, differing from the expected L3. Considerable variability was seen in ventral rami origins of pelvic (PN) and Pd nerves, with new findings of L7 contributions to PN, joining S1 and S2 input (23% of sides in 11 dogs) or S1-S3 input (5%), and to PdN, joining S1-S2, unilaterally, in one dog. L7 input was confirmed using retrograde dye tracing methods. The PN also received CG1 contributions, bilaterally, in one dog. The PdN branched unusually in two dogs. Lumbosacral sympathetic ganglia had variant intra-, inter- and multisegmental connectivity in 6 (38%). Thus, the anatomy of mongrel dogs had higher variability than previously described for purebred dogs. Knowledge of this variant innervation during surgery could aid in the preservation of nerves and reduce risk of urinary and sexual dysfunctions.
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Affiliation(s)
- S M Gomez-Amaya
- Department of Anatomy and Cell Biology, Temple University School of Medicine, Philadelphia, PA, 19140, USA
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Abstract
Stem cell (SC) therapy for erectile dysfunction (ED) has been investigated in 35 published studies, with one being a small-scale clinical trial. Out of these 35 studies, 19 are concerned with cavernous nerve (CN) injury-associated ED while 10 with diabetes mellitus- (DM-) associated ED. Adipose-derived SCs (ADSCs) were employed in 18 studies while bone marrow SCs (BMSCs) in 9. Transplantation of SCs was done mostly by intracavernous (IC) injection, as seen in 25 studies. Allogeneic and xenogeneic transplantations have increasingly been performed but their immune-incompatibility issues were rarely discussed. More recent studies also tend to use combinatory therapies by modifying or supplementing SCs with angiogenic or neurotrophic genes or proteins. All studies reported better erectile function with SC transplantation, and the majority also reported improved muscle, endothelium, and/or nerve in the erectile tissue. However, differentiation or engraftment of transplanted SCs has rarely been observed; thus, paracrine action is generally believed to be responsible for SC’s therapeutic effects. But still, few studies actually investigated and none proved paracrine action as a therapeutic mechanism. Thus, based exclusively on functional outcome data shown in preclinical studies, two clinical trials are currently recruiting patients for treatment with IC injection of ADSC and BMSC, respectively.
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Lin G, Albersen M, Harraz AM, Fandel TM, Garcia M, McGrath MH, Konety BR, Lue TF, Lin CS. Cavernous nerve repair with allogenic adipose matrix and autologous adipose-derived stem cells. Urology 2011; 77:1509.e1-8. [PMID: 21492917 DOI: 10.1016/j.urology.2010.12.076] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 12/15/2010] [Accepted: 12/22/2010] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To investigate whether adipose-derived matrix seeded with adipose-derived stem cells (ADSC) can facilitate the repair of injured cavernous nerves (CNs). METHODS Human and rat adipose tissues were decellularized and fabricated into various forms, including adipose tissue-derived acellular matrix thread (ADMT). ADMT seeded with ADSC were transplanted into subcutaneous space and examined for signs of inflammation. ADSC-seeded ADMTs were then used to repair CN injury in rats, followed by assessment of histology and erectile function. RESULTS Adipose tissue can be fabricated into acellular matrices of various shapes and sizes, including threads and sheets. Seeding of ADMT occurred rapidly: within 24 hours, 55% of the surface was covered with ADSC and within 1 week, 90% was covered. Transplantation of the seeded ADMT into the subcutaneous space of an allogenic host showed no signs of inflammatory reaction. At 3 months after grafting into CN injury rats, approximately twice as many cells were found on seeded ADMT as on unseeded ADMT. The seeded ADMT also had various degrees of S100 and neuronal nitric oxide synthase expression, suggesting CN axonal ingrowth. Rats grafted with seeded ADMT overall had the best erectile function recovery when compared with those grafted with unseeded ADMT and those ungrafted. However, as a result of large variations, the differences did not reach statistic significance (P = .07). CONCLUSIONS Grafting of ADSC-seeded matrix resulted in a substantial recovery of erectile function and improvement of histology. However, further refinement of the matrix architecture is needed to improve the success rate.
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Affiliation(s)
- Guiting Lin
- Knuppe Molecular Urology Laboratory, Department of Urology, University of California, San Francisco, CA 94143-0738, USA
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White WM, Kim ED. Interposition nerve grafting during radical prostatectomy: cumulative review and critical appraisal of literature. Urology 2009; 74:245-50. [PMID: 19428071 DOI: 10.1016/j.urology.2008.12.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 12/15/2008] [Accepted: 12/20/2008] [Indexed: 11/25/2022]
Abstract
In 1997, the first report of sural nerve interposition grafting during radical prostatectomy was published in Urology. The favorable findings in this initial pilot study generated numerous follow-up reports that have demonstrated conflicting and contradictory outcomes. Certainly, controversy exists regarding the true benefit of nerve grafting. This review will objectively and critically summarize the salient literature, discuss evolving techniques, and offer insight into the future of interposition grafting in the current era of clinically localized prostate cancer and robotic prostatectomy.
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Affiliation(s)
- Wesley M White
- Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio 44195, USA.
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Satkunasivam R, Appu S, Al-Azab R, Hersey K, Lockwood G, Lipa J, Fleshner NE. Recovery of erectile function after unilateral and bilateral cavernous nerve interposition grafting during radical pelvic surgery. J Urol 2009; 181:1258-63. [PMID: 19152922 DOI: 10.1016/j.juro.2008.10.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE The use of cavernous nerve interposition grafting to preserve erectile function in men who require neurovascular bundle resection for cancer control is controversial. We report outcomes and predictors of cavernous nerve interposition grafting in men undergoing unilateral grafting during radical prostatectomy or bilateral grafting during radical cystectomy and prostatectomy with autologous nerve grafts. MATERIALS AND METHODS We retrospectively reviewed the electronic records of 36 patients who underwent cavernous nerve interposition grafting between 2003 and 2006. Postoperatively erectile function was assessed with the International Index of Erectile Function 15-item questionnaire. Predictors of potency, including age at surgery, time since surgery and prostate specific antigen at surgery, were assessed by univariate analysis. RESULTS A total of 33 patients (92% response rate) were followed for a median of 32, 25 and 11 months after bilateral grafting during radical cystectomy (10), unilateral grafting during radical prostatectomy (20), and bilateral grafting during radical cystectomy and prostatectomy (3), respectively. The rate of potency, defined as the ability to attain and maintain erection sufficient for penetration at least 50% of the time with or without phosphodiesterase-5 inhibitors, was 31% (5 of 13 men) for unilateral grafts, 38% (5 of 16) for bilateral grafts and 30% (3 of 10) for bilateral grafts during radical cystectomy. Age at surgery was the only significant determinant of potency and it showed an inverse relationship in the bilateral nerve graft group (p = 0.02). CONCLUSIONS Cavernous nerve interposition grafting appears to have a role in the recovery of erectile function. To our knowledge this study represents the largest series of cavernous nerve interposition grafting during cystectomy and it suggests that this should be considered during bilateral neurovascular bundle resection.
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Affiliation(s)
- Raj Satkunasivam
- Department of Surgical Oncology (Division of Urology), University Health Network, University of Toronto, Toronto, Ontario, Canada
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Mancuso P, Rashid P. NERVE GRAFTING AT THE TIME OF RADICAL PROSTATECTOMY: SHOULD WE BE DOING IT? ANZ J Surg 2008; 78:859-63. [DOI: 10.1111/j.1445-2197.2008.04680.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- Guglielmo Breda
- Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy.
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Burnett AL. Editorial Comment. J Urol 2007. [DOI: 10.1016/j.juro.2007.03.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Arthur L. Burnett
- Department of Urology, The Johns Hopkins Hospital, Baltimore, Maryland
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Turkof E, Wulkersdorfer B, Bukaty A. Reconstruction of cavernous nerves by nerve grafts to restore potency: contemporary review of technical principles and basic anatomy. Curr Opin Urol 2006; 16:401-6. [PMID: 17053519 DOI: 10.1097/01.mou.0000250279.52613.28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The review discusses the efficacy of reconstructing the neurovascular bundle to regain sexual function if nerve-sparing prostatectomy is unfeasible. RECENT FINDINGS Eleven studies could be found describing the reconstruction of neurovascular bundles. All reconstructive procedures displayed technical inadequacies. The effectiveness of unilateral neurovascular bundle reconstruction remains statistically insignificant when compared with procedures without reconstruction. The efficacy of reconstructing both neurovascular bundles ranges between 0 and 43%. Concerning basic anatomy, the neurovascular bundle contains fibers innervating the cavernous nerves, prostate, rectum, and levator ani muscle. The terms cavernous nerve and neurovascular bundle have often been wrongly considered synonymous. The pelvic splanchnic nerves probably do not join the neurovascular bundle proximal to the bladder/prostate junction but rather at variable distances from 10 to 20 mm distal to it. Therefore, described proximal coaptation sites at the bladder/prostate junction possibly encompass only the hypogastric nerve. SUMMARY Modest clinical results are partly due to inadequate surgical techniques and are mainly due to the anatomical and topographical complexity of the cavernous nerves. Contemporary nerve grafting techniques probably do not allow for the regeneration of all cavernous nerves.
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Affiliation(s)
- Edvin Turkof
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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