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Long term erectile function results of radical perineal prostatectomy. Rev Int Androl 2022; 20:152-157. [PMID: 35331662 DOI: 10.1016/j.androl.2020.12.007] [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: 05/16/2020] [Revised: 10/18/2020] [Accepted: 12/06/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Although many patients are being treated by radical prostatectomy (RP), there is still insufficient information about the changes in long-term erectile function after RP. Our aim is to examine long term, up to 5 year erectile function status of patients after Radical Perineal Prostatectomy (RPP). MATERIALS AND METHODS One hundred and thirty-two patients, who underwent bilateral nerve-sparing Radical Perineal Prostatectomy (RPP) in between January 2012 and January 2017, with preoperative age≤70, prostate volume<80g, transrectal ultrasound (TRUS) guided biopsy Gleason score (GS)<7, prostate specific antigen (PSA) value<10ng/mL, and cT stage≤2 (N0, M0) were included into this study. Exclusion criteria were previous cardiovascular diseases, serious chronic renal and/or hepatic insufficiency, neurological diseases, uncontrolled diabetes mellitus, and severe lung diseases. Patients who received additional treatment (hormonal and/or radiotherapy) after RPP were also excluded from the study group. Erectile function was evaluated before surgery and at postoperative 3rd, 12th, and 60th months. Patients with an "International Index of Erectile Function (IIEF) - 5" score of ≥21 and patients whose IIEF-5 scores were between 16 and 20 but responded as "yes" to the "Sexual Encounter Profile (SEP) - 2" and "SEP-3" questions were accepted as having normal erectile function. RESULTS Out of the 132 patients, 96 (72.7%) of the patients were found to be potent in the first postoperative year. A total of 118 patients were evaluated at the end of 5 years. Eighty seven (73.7%) patients had normal erectile function according to our criteria. DISCUSSION According to the results of our study, short term and long term erectile function outcomes of patients undergoing RPP were favorable and there was no statistically significant difference between short and long term results.
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Shim JS, Tae JH, Noh TI, Kang SH, Cheon J, Lee JG, Patel VR, Kang SG. Toggling Technique Allows Retrograde Early Release to Facilitate Neurovascular Bundle Sparing During Robot-Assisted Radical Prostatectomy: A Propensity Score-Matching Study. J Korean Med Sci 2022; 37:e6. [PMID: 34981681 PMCID: PMC8723890 DOI: 10.3346/jkms.2022.37.e6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study aimed to present the surgical facilitation of neurovascular bundle (NVB) sparing using the toggling technique (30° lens down/up switching) and to evaluate erectile dysfunction (ED) recovery after robot-assisted radical prostatectomy (RARP). METHODS We assessed 144 patients (group with toggling, n = 72; group without toggling, n = 72) who underwent RARP with bilateral NVB sparing using propensity score matching. Inclusion criteria were ≥ 1 year follow-up and preoperative potency as per the Sexual Health Inventory for Men (SHIM) questionnaire (≥ 17 points). Recovery of ED after RARP was defined as return to baseline sexual function or self-assessment regarding successful intercourse. The subjective surgeon's nerve sparing (SNS) score and tunneling success rates were used to evaluate surgical facilitation. The recovery rate of ED between the groups was analyzed using Kaplan-Meier analysis. RESULTS A better ED recovery trend was confirmed according to the SNS score (R² = 0.142, P = 0.004). In the analysis of NVB sparing ease, the toggling group showed higher SNS scores (on right/left side: P = 0.011 and < 0.001, respectively) and overall tunneling success rates (87% vs. 74%, P = 0.001) than the group without toggling. Overall, ED recovery rates were 82% (59/72) and 75% (54/72) in the groups with and without toggling, respectively, at the 1-year follow-up (P = 0.047), and the toggling group showed a faster ED recovery rate at 3 months (47% vs. 35%, P = 0.013). In a specific analysis of the potent cohort (< 60 years, bilateral full NVB spared, SHIM score ≥ 22), the ED recovery rate reached 87% (14/16) in the toggling group. CONCLUSION The retrograde early release with the toggling technique improves the facilitation of NVB sparing, leading to improved ED recovery.
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Affiliation(s)
- Ji Sung Shim
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Tae
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Tae Il Noh
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seok Ho Kang
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jun Cheon
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jeong Gu Lee
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Vipul R Patel
- Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA
| | - Sung Gu Kang
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea.
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Song WH, Sun I, Jang G, Lee JH, Jeong JH, Lee JC, Kim HC, Jeong CW. Feasibility study of a novel rectal cooling system for hypothermic radical prostatectomy in a swine model. Investig Clin Urol 2022; 63:475-481. [PMID: 35796142 PMCID: PMC9262486 DOI: 10.4111/icu.20220092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022] Open
Abstract
Thermal damage and inflammatory responses of the sphincter and neurovascular bundles (NVBs) are responsible for post-prostatectomy incontinence and erectile dysfunction. Intraoperative hypothermia in the pelvic cavity may reduce the occurrence of these complications. We evaluated the feasibility of a novel rectal cooling system using an animal model. A novel rectal cooling system consisting of a cooling console and a multi-lumen rectal balloon was developed. We conducted animal tests on male pigs to evaluate the efficacy and safety of the system. The primary endpoint was to maintain the temperature of the NVBs at 25℃ (±5℃) during and after the electrocauterization of the bladder neck for 10 seconds. The safety endpoint was device-related complications or significant changes in the core body temperature of the pigs. The NVB temperature was below 30℃ within 3 minutes of activation of the rectal balloon. The temperature of the proximal NVB was consistently maintained below 25℃ in all cases. The temperature 1 cm from the bladder neck did not rise above 38°C and dropped to the initial level within 1 minute after electrocauterization. During cooling, the minimum temperature at the apex of the prostate was reduced to 10.1℃. There were no device-related complications or significant changes in core body temperature throughout the experiment. Animal tests suggest the feasibility and safety of this novel rectal cooling system. A first-in-human trial to assess the safety and efficacy of this system during radical prostatectomy is warranted.
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Affiliation(s)
- Won Hoon Song
- Department of Urology, Seoul National University Hospital, Seoul, Korea
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Inyoung Sun
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Gwan Jang
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Urology, Seoul National University Hospital, Seoul, Korea
- Department of Urology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jae Hyeon Jeong
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Jung Chan Lee
- Department of Biomedical Engineering, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Chan Kim
- Department of Biomedical Engineering, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, Seoul, Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
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Shin TY, Lee YS. Robot-assisted radical prostatectomy with clipless intrafascial neurovascular bundle-sparing approach: surgical technique and one-year functional and oncologic outcomes. Sci Rep 2020; 10:17595. [PMID: 33077779 PMCID: PMC7573617 DOI: 10.1038/s41598-020-74513-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/29/2020] [Indexed: 11/09/2022] Open
Abstract
Various neurovascular bundle-sparing techniques have been introduced to maximize recovery of erectile function after robot-assisted radical prostatectomy (RARP). The clipless intrafascial neurovascular bundle-sparing technique aims to preserve periprostatic structures and neurovascular bundles as much as possible by avoiding clipping of the vascular pedicles. This study reports 1-year functional and oncologic outcomes and postoperative complications in 105 patients with intact preoperative erectile function who underwent a modified clipless intrafascial neurovascular bundle-sparing RARP. Intact erectile function was defined as score ≥ 21 on the Sexual Health Inventory for Men questionnaire or ability to have sexual intercourse. Median follow-up was 26.5 months (IQR 15.25-48). Postoperative erectile function recovery rates were 71.4%, 81.9%, 88.6%, 92.4%, and 94.3% at 1, 3, 6, 9, and 12 months, respectively. The rate of positive surgical margins was 16.2% overall and 11.8% in patients with stage pT2 disease. The biochemical recurrence rate was 6.7% overall. The modified clipless intrafascial neurovascular bundle-sparing technique is safe and feasible and can achieve excellent recovery of erectile function after RARP. Further large-scale prospective comparative studies are warranted.
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Affiliation(s)
- Tae Young Shin
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, 14068, Republic of Korea
| | - Yong Seong Lee
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, 14068, Republic of Korea.
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Kumar A, Patel VR, Panaiyadiyan S, Seetharam Bhat KR, Moschovas MC, Nayak B. Nerve-sparing robot-assisted radical prostatectomy: Current perspectives. Asian J Urol 2020; 8:2-13. [PMID: 33569267 PMCID: PMC7859364 DOI: 10.1016/j.ajur.2020.05.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
Robotic-assisted radical prostatectomy (RARP) is the current standard of care with long term cure in organ-confined disease. The introduction of nerve-sparing (NS) to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes. This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes, the neurovascular bundle (NVB), various NS techniques and postoperative functional outcomes. A non-systematic review was done using PubMed, Embase and Medline databases to retrieve and analyse articles in English, with following keywords "prostate cancer", "robotic radical prostatectomy", "nerve-sparing". The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies. The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other. Variables such as preoperative risk assessments, baseline potency, surgical anatomy of individual patients and surgeons' expertise play a major role in the outcomes. A tailored approach for each patient is required for applying the NS approach during RARP.
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Affiliation(s)
- Anup Kumar
- Department of Urology,Robotics and Renal Transplant, Vardhman Mahaveer Medical College and Safdarjang Hospital, New Delhi, India
| | - Vipul R Patel
- Department of Robotic Surgery, AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Sridhar Panaiyadiyan
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Marcio Covas Moschovas
- Department of Robotic Surgery, AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Brusabhanu Nayak
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
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Pushkar DY, Kolontarev KB. [Robot-assisted radical prostatectomy. Functional result. Part I. (in Russian only)]. Khirurgiia (Mosk) 2019:111-120. [PMID: 30938366 DOI: 10.17116/hirurgia2019031111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Robot-assisted operations as widely used in urology, gynecology, general and cardiovascular surgery are considered by many experts as a new 'gold standard' of surgical treatment of various diseases in developed countries. Robot-assisted radical prostatectomy for prostate cancer is the most common robotic procedure. Better functional outcomes of robot-assisted radical prostatectomy are due to another (new) understanding of pelvic surgical anatomy, new approach implying dissection and preservation of external urethral sphincter and neurovascular structures. Prostate neuroanatomy, various approaches to preserve neurovascular structures and own experience of nerve-sparing robot-assisted radical prostatectomy with functional results are reviewed in the article.
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Affiliation(s)
- D Yu Pushkar
- Chair of Urology, Evdokimov Moscow State University of Medicine and Dentistry of Ministry of Health of the Russia, Moscow, Russia
| | - K B Kolontarev
- Chair of Urology, Evdokimov Moscow State University of Medicine and Dentistry of Ministry of Health of the Russia, Moscow, Russia
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Campbell JD, Alenezi H, DeYoung LX, Brock GB, Pautler SE. Hydro-Jet Dissection of the Cavernous Nerves Preserves Erection Function in a Radical Prostatectomy Animal Model. Sex Med 2019; 7:104-110. [PMID: 30674444 PMCID: PMC6377382 DOI: 10.1016/j.esxm.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/17/2018] [Accepted: 11/27/2018] [Indexed: 11/16/2022] Open
Abstract
Background Postoperative erectile dysfunction (ED) remains a prevalent consequence of radical prostatectomy (RP) that significantly impacts patient quality of life. Water-jet technology is widely used for dissection in neurosurgical procedures but novel to urologic surgery. Aim To establish the impact of hydro-jet dissection (HJD) of the cavernous nerves (CN) on postoperative erectile function in an animal model of RP-induced ED. Methods 32 male Sprague-Dawley rats were randomized to 4 groups: Sham surgery (n = 8), bilateral HJD of CN (n = 8), blunt CN injury (n = 8), or stretch CN injury (n = 8). After 4 weeks, erectile function was assessed by measuring intracavernous pressure (ICP), and penile tissues were harvested for immunohistologic studies. Main Outcome Measure The peak ICP and the area under the curve were calculated for each group. Immunohistologic studies were performed for α-smooth muscle actin and neuronal nitric oxide synthase on cross-sections of penile tissue. Results Rats in the HJD group demonstrate a significantly higher mean peak ICP and area under the curve compared with both CN injury groups (P = .001). Postoperative erectile function in the HJD group returned to baseline function. Preservation of α-smooth muscle actin and neuronal nitric oxide synthase was observed in the HJD group compared with the other surgical trauma groups. Clinical Implications Hydro-jet dissection used in an RP animal model maintains erectile function and offers a potential benefit that warrants further human studies. Strengths & Limitations This is a novel animal study comparing a new technology to established CN dissection techniques. This study uses an animal model, which may not completely translate to post-RP ED in humans. Conclusion Hydro-jet dissection of the CN during RP in an animal model is associated with significantly better postoperative erectile function when compared with other CN injury. Clinical studies are needed to further investigate the putative benefit of HJD on erectile function in patients undergoing RP. Campbell JD, Alenezi H, DeYoung LX, et al. Hydrojet Dissection of the Cavernous Nerves Preserves Erection Function in a Radical Prostatectomy Animal Model. Sex Med 2019;7:104–110.
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Affiliation(s)
- Jeffrey D Campbell
- Department of Surgery, Division of Urology, Western University, London, Ontario, Canada
| | - Husain Alenezi
- Department of Surgery, Division of Urology, Western University, London, Ontario, Canada
| | - Ling X DeYoung
- Department of Surgery, Division of Urology, Western University, London, Ontario, Canada
| | - Gerald B Brock
- Department of Surgery, Division of Urology, Western University, London, Ontario, Canada
| | - Stephen E Pautler
- Department of Surgery, Division of Urology, Western University, London, Ontario, Canada; Division of Surgical Oncology, Department of Oncology, Western University, London, Ontario, Canada.
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Huang D, Qiao XL, Liang QJ, Wei W, Kong JR, Huan Kang CSZ, Liu Y, Wang WN. Molecular characterization and function analysis of a nucleotide excision repair gene Rad23 from Litopenaeus vannamei after Vibrio alginolyticus challenge. FISH & SHELLFISH IMMUNOLOGY 2018; 83:190-204. [PMID: 30195911 DOI: 10.1016/j.fsi.2018.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 09/03/2018] [Accepted: 09/05/2018] [Indexed: 06/08/2023]
Abstract
Nucleotide excision repair (NER) removes many different types of DNA lesions, and NER related host factors are reported to aid recovery steps during viral integration. Here, we report the identification and characterization of a DNA repair gene Rad23 from Litopenaeus vannamei and explore its role in innate immunity of crustaceans. LvRad23 contains a1149 bp open reading frame (ORF) which encodes a 382 amino acids protein with predicted theoretical isoelectric point of 4.21. LvRad23 was ubiquitously expressed in the muscle, eyestalk, gill, stomach, heart, legs, intestine, and hepatopancreas in order from high to low and LvRad23 protein was showed to be located in the cytoplasm of Drosophila S2 cells. The homology analysis showed that it has a high sequence homology with Rad23 protein from Marsupenaeus japonicus. Vibrio alginolyticus challenge induced a remarkable up-regulation of LvRad23 mRNA in hepatopancreas. Knocking down LvRad23can interfere the NER pathway by down regulating the expression of replication protein A (RPA) and proliferating cell nuclear antigen (PCNA). However it didn't cause any significant difference on total hemocyte count (THC) between LvRad23-silenced and non-silenced group.LvRad23-silenced then challenge with V. alginolyticus inducing high level of reactive oxygen species (ROS) and DNA damage in hemolymph. As well as decreased THC, which seriously diminished the innate immune system of L. vannamei. Meanwhile, the NER pathway was reactived by enhancing the expression of LvRad23 and promoting the production of LvPCNA to resist apoptosis and maintain proliferation of hemolymph cells in the later stage. Our results suggest that LvRad23 plays a vital role in shrimp specific immune response to V. alginolytcus through its participation in NER pathway.
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Affiliation(s)
- Di Huang
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China
| | - Xue-Li Qiao
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China
| | - Qing-Jian Liang
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China
| | - Wei Wei
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China
| | - Jing-Rong Kong
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China
| | - Chang-Sheng Zhao Huan Kang
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China
| | - Yuan Liu
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China.
| | - Wei-Na Wang
- Guangzhou Key Laboratory of Subtropical Biodiversity and Biomonitoring, Guangdong Provincial Key Laboratory for Healthy and Safe Aquaculture, College of Life Science, South China Normal University, Guangzhou, 510631, PR China.
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Huynh LM, Skarecky D, Porter J, Wagner C, Witt J, Wilson T, Lau C, Ahlering TE. A Randomized Control Trial Of Anti-Inflammatory Regional Hypothermia On Urinary Continence During Robot-Assisted Radical Prostatectomy. Sci Rep 2018; 8:16352. [PMID: 30397236 PMCID: PMC6218497 DOI: 10.1038/s41598-018-34657-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/05/2018] [Indexed: 12/16/2022] Open
Abstract
The present study seeks to present a single-blind, randomized control trial of a hypothermic anti-inflammatory device, the endorectal cooling balloon (ECB), to assess whether regional hypothermia could improve 90-day and time to pad-free continence following robot-assisted radical prostatectomy (RARP). Five high-volume surgeons at three institutions had patients randomized (1:1) to regional hypothermia with ECB versus control. Patients were blinded to device use, as it was inserted and removed intraoperatively. Knowledge of device use was restricted to the operating room personnel only; recovery room and ward nursing staff were not informed of device use and instructed to indicate such if a patient inquired. An independent and blinded data acquisition contractor assessed outcomes via components of the EPIC and IPSS. The primary outcome was categorical pad-free continence at 90-days and the secondary outcome was a Kaplan-Meier time-to pad-free continence at 90 days. 100 hypothermia and 99 control patients were included. The primary outcome of 90-day pad-free continence was 50.0% (27.8-70.0%) in the hypothermia group versus 59.2% (33.3-78.6%) in the control (p = 0.194). The secondary outcome of Kaplan Meier analysis for time to 90-day continence was not statistically significant. At one year, there were also no statistically significant differences in continence recovery. Post-hoc analysis revealed a trend towards improvement in continence in one of three sites. Overall, the trial demonstrated no benefit to regional hypothermia either in our primary or secondary outcomes. It is suggested that surgical technique and prevention of surgical trauma may be more advantageous to improving continence recovery.
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Affiliation(s)
- Linda M Huynh
- Department of Urology, University of California, Irvine, Orange, CA, USA
| | - Douglas Skarecky
- Department of Urology, University of California, Irvine, Orange, CA, USA
| | - James Porter
- Swedish Urology Group, Swedish Medical Center Seattle and Issaquah, Seattle, WA, USA
| | - Christian Wagner
- Urology Department, St. Antonius-Hospital Gronau GmbH, Westfalen, Germany
| | - Jorn Witt
- Urology Department, St. Antonius-Hospital Gronau GmbH, Westfalen, Germany
| | - Timothy Wilson
- Department of Urology, City of Hope National Medical Center, Duarte, CA, USA
| | - Clayton Lau
- Department of Urology, City of Hope National Medical Center, Duarte, CA, USA
| | - Thomas E Ahlering
- Department of Urology, University of California, Irvine, Orange, CA, USA.
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Porpiglia F, Manfredi M, Checcucci E, Garrou D, De Cillis S, Amparore D, De Luca S, Fregnan F, Stura I, Migliaretti G, Fiori C. Use of chitosan membranes after nerve-sparing radical prostatectomy improves early recovery of sexual potency: results of a comparative study. BJU Int 2018; 123:465-473. [PMID: 30303604 DOI: 10.1111/bju.14583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the 1-year efficacy of chitosan membrane (ChiMe) application on the neurovascular bundles (NVBs) after nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) in potency recovery rate. To compare the results with those of a contemporary cohort of patients who did not benefit from chitosan use. PATIENTS AND METHODS Patients in the ChiMe group were enrolled at our institution from July 2015 to September 2016 in a preliminary phase II study. All of them underwent NS-RARP with ChiMe applied on the NVBs and were followed over time to complete a 1-year follow-up. The control group was composed of patients who underwent NS-RARP at our institution without the application of ChiMe from January 2015. The patients were further classified into two groups based on the amount of nerves spared: Group A, comprised patients who underwent a monolateral or bilateral full NS; Group B, comprised patients in which a full NS was not performed. The demographics, peri- and postoperative data, and complications were recorded and compared. Potency recovery was recorded for Group A vs Group B in both the ChiMe and the control groups. RESULTS In all, 136 patients were enrolled in the ChiMe group and 334 patients in the control group. There were no differences between groups in terms of baseline variables. Based on the amount of nerves preserved, 183 patients were included in Group A and 287 in Group B. Odds ratios at different time points showed that the only two factors influencing potency recovery were the amount of nerves preserved (Group A vs Group B) and the application or not of ChiMe on the NVBs spared. Comparing the ChiMe vs control groups at different time points, we found a statistically significant improvement in the potency recovery rate in the ChiMe group at 1 month (36.76% vs 25.88%; P = 0.02) and 2 months (52.2% vs 39.22%; P = 0.01) after surgery, showing a favourable trend at every time point of the entire follow-up period, even if not significant after the second postoperative month. In Group A, the log-rank test showed a statistically significant difference between the ChiMe vs control groups (P = 0.02), in particular at 1 and 2 months after surgery (P = 0.02 and P = 0.01, respectively). CONCLUSION The application of ChiMe on the NVBs resulted in a higher potency recovery rate at 1 and 2 months after a bilateral or monolateral full NS-RARP. A trend of a higher and shorter potency recovery rate showed it to be favourable to use ChiMe, even in the cohort of patients who did not undergo a full NS procedure.
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Affiliation(s)
- Francesco Porpiglia
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Matteo Manfredi
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Enrico Checcucci
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Diletta Garrou
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Sabrina De Cillis
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Daniele Amparore
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Stefano De Luca
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Federica Fregnan
- Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
| | - Ilaria Stura
- Department of Public Health and Pediatric Sciences, School of Medicine, University of Turin, Orbassano (Turin), Italy
| | - Giuseppe Migliaretti
- Department of Public Health and Pediatric Sciences, School of Medicine, University of Turin, Orbassano (Turin), Italy
| | - Cristian Fiori
- Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
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Neuroprotective and Nerve Regenerative Approaches for Treatment of Erectile Dysfunction after Cavernous Nerve Injury. Int J Mol Sci 2017; 18:ijms18081794. [PMID: 28820434 PMCID: PMC5578182 DOI: 10.3390/ijms18081794] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 01/02/2023] Open
Abstract
Erectile dysfunction (ED) is a significant cause of reduced quality of life in men and their partners. Cavernous nerve injury (CNI) during pelvic surgery results in ED in greater than 50% of patients, regardless of additional patient factors. ED related to CNI is difficult to treat and typically poorly responsive to first- and second-line therapeutic options. Recently, a significant amount of research has been devoted to exploring neuroprotective and neuroregenerative approaches to salvage erectile function in patients with CNI. In addition, therapeutic options such as neuregulins, immunophilin ligands, gene therapy, stem cell therapy and novel surgical strategies, have shown benefit in pre-clinical, and limited clinical studies. In the era of personalized medicine, these new therapeutic technologies will be the future of ED treatment and are described in this review.
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Abstract
Radical prostatectomy (RP) is the most common cause of stress urinary incontinence (UI) in men. Several anatomic structures affect or may affect urinary continence - urethral sphincter, levator ani muscle, puboprostatic ligaments, bladder neck, endopelvic fascia, neurovascular bundle - and understanding of the anatomy of pelvic floor and urethra is crucial for satisfactory functional outcome of the procedure. Surgical techniques implemented to improve continence rates include nerve-sparing procedure, bladder neck preservation/plication, urethral length preservation, musculofascial reconstruction, puboprostatic ligaments preservation or seminal vesicle preservation. Perioperative (preoperative and postoperative) pelvic floor muscle training (PFMT) aims to shorten the duration of postoperative UI and thus, improve early continence rates postoperatively. In the review, complex information regarding anatomical, intra- and perioperative factors affecting urinary continence after RP is provided, including description of important anatomical structures, possible implications for surgical technique and evaluation of different PFMT strategies in perioperative period.
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Affiliation(s)
- Dalibor Pacik
- Department of Urology, University Hospital Brno, Masaryk University, Brno, Czech Republic. E-mail.
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Skarecky D, Yu H, Linehan J, Morales B, Su MY, Fwu P, Ahlering T. Hypothermic Cooling Measured by Thermal Magnetic Resonance Imaging; Feasibility and Implications for Virtual Imaging in the Urogenital Pelvis. Urology 2017; 108:220-224. [PMID: 28733200 DOI: 10.1016/j.urology.2017.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/02/2017] [Accepted: 07/06/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To study the combination of thermal magnetic resonance imaging (MRI) and novel hypothermic cooling, via an endorectal cooling balloon (ECB), to assess the effective dispersion and temperature drop in pelvic tissue to potentially reduce inflammatory cascade in surgical applications. METHODS Three male subjects, before undergoing robot-assisted radical prostatectomy, were cooled via an ECB, rendered MRI compatible for patient safety before ECB hypothermia. MRI studies were performed using a 3T scanner and included T2-weighted anatomic scan for the pelvic structures, followed by a temperature mapping scan. The sequence was performed repeatedly during the cooling experiment, whereas the phase data were collected using an integrated MR-high-intensity focused ultrasound workstation in real time. Pelvic cooling was instituted with a cooling console located outside the MRI magnet room. RESULTS The feasibility of pelvic cooling measured a temperature drop of the ECB of 20-25 degrees in real time was achieved after an initial time delay of 10-15 seconds for the ECB to cool. The thermal MRI anatomic images of the prostate and neurovascular bundle demonstrate cooling at this interface to be 10-15 degrees, and also that cooling extends into the prostate itself ~5 degrees, and disperses into the pelvic region as well. CONCLUSION An MRI-compatible ECB coupled with thermal MRI is a feasible method to assess effective hypothermic diffusion and saturation to pelvic structures. By inference, hypothermia-induced rectal cooling could potentially reduce inflammation, scarring, and fistula in radical prostatectomy, as well as other urologic tissue procedures of high-intensity focused ultrasound, external beam radiation therapy, radioactive seed implants, transurethral microwave therapy, and transurethral resection of the prostate.
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Affiliation(s)
- Douglas Skarecky
- Department of Urology, University of California Irvine, Orange, CA.
| | - Hon Yu
- Department of Radiology, University of California Irvine, Orange, CA
| | - Jennifer Linehan
- Department of Urology, John Wayne Cancer Institute, Santa Monica, CA
| | - Blanca Morales
- Department of Urology, University of California Irvine, Orange, CA
| | - Min-Ying Su
- Department of Radiology, University of California Irvine, Orange, CA
| | - Peter Fwu
- Department of Radiology, University of California Irvine, Orange, CA
| | - Thomas Ahlering
- Department of Urology, University of California Irvine, Orange, CA
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Can dehydrated human amnion/chorion membrane accelerate the return to potency after a nerve-sparing robotic-assisted radical prostatectomy? Propensity score-matched analysis. J Robot Surg 2017; 12:235-243. [PMID: 28656504 DOI: 10.1007/s11701-017-0719-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/12/2017] [Indexed: 12/20/2022]
Abstract
The objective of this study is to determine if the use of dehydrated human amnion/chorion membrane (dHACM) allograft wrapped around the NVB during a robotic-assisted radical prostatectomy (RARP) accelerates the return to potency. 940 patients with preoperative SHIM >20 underwent RARP with some degree of bilateral NS. Of these, 235 patients underwent RARP, with bilateral placement of dHACM graft around the NVBs. They were matched in a 1:3 proportion with a similar group of patients (n = 705) who did not receive the allograft (control group or group 2). Minimum follow-up was 12 months. Postoperative outcomes were analyzed between propensity-matched dHACM graft (group 1) and non-graft groups (group 2). Kaplan-Meier survival curves were compared across techniques using the log-rank test. There were no significant demographic differences between the two groups. Potency was defined as the ability to achieve and maintain satisfactory erections firm enough for sexual intercourse, with or without the use of PDE-5 inhibitors. The mean time to potency was significantly lower in group 1 (2.37 months) versus group 2 (3.94 months) (p < 0.0001). The potency recovery rates were superior for group 1 at all early time points measured except at 12 months. The time to potency was significantly shorter in the dHACM group with full NS, 2.19 ± 1.84 versus 2.78 ± 2.70 mo. in the non-dHACM with full NS (p = 0.029). In the dHACM group with partial NS, the mean time to potency was 3.05 ± 2.32 versus 3.92 ± 3.42 mo. in the non-dHACM with partial NS (p = 0.021). Patients who received the dHACM wrap around the NVB after RARP accelerates the return to potency when compared to a similar control group without the use of the allograft. We also demonstrated that this faster return to potency occurs regardless of the degree of the NS preservation. Younger patients (<55 years of age) had the highest overall advantage if they received the graft. Our results indicate that dHACM placement at the site of the prostatic NVB does not increase the risk of BCR after RARP, neither in the presence of PSM, extra-prostatic disease (≥pT3) nor high Gleason score (Gleason ≥8).
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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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Current status of various neurovascular bundle-sparing techniques in robot-assisted radical prostatectomy. J Robot Surg 2016; 10:187-200. [PMID: 27251473 DOI: 10.1007/s11701-016-0607-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.
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Lin Y, Lin WC, Fwu PT, Shih TC, Yeh LR, Su MY, Chen JH. Investigation of factors affecting hypothermic pelvic tissue cooling using bio-heat simulation based on MRI-segmented anatomic models. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2015; 122:76-88. [PMID: 26198131 PMCID: PMC4549219 DOI: 10.1016/j.cmpb.2015.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/08/2015] [Accepted: 07/03/2015] [Indexed: 06/11/2023]
Abstract
This study applied a simulation method to map the temperature distribution based on magnetic resonance imaging (MRI) of individual patients, and investigated the influence of different pelvic tissue types as well as the choice of thermal property parameters on the efficiency of endorectal cooling balloon (ECB). MR images of four subjects with different prostate sizes and pelvic tissue compositions, including fatty tissue and venous plexus, were analyzed. The MR images acquired using endorectal coil provided a realistic geometry of deformed prostate that resembled the anatomy in the presence of ECB. A single slice with the largest two-dimensional (2D) cross-sectional area of the prostate gland was selected for analysis. The rectal wall, prostate gland, peri-rectal fatty tissue, peri-prostatic fatty tissue, peri-prostatic venous plexus, and urinary bladder were manually segmented. Pennes' bioheat thermal model was used to simulate the temperature distribution dynamics, by using an in-house finite element mesh based solver written in MATLAB. The results showed that prostate size and periprostatic venous plexus were two major factors affecting ECB cooling efficiency. For cases with negligible amount of venous plexus and small prostate, the average temperature in the prostate and neurovascular bundles could be cooled down to 25 °C within 30 min. For cases with abundant venous plexus and large prostate, the temperature could not reach 25 °C at the end of 3 h cooling. Large prostate made the cooling difficult to propagate through. The impact of fatty tissue on cooling effect was small. The filling of bladder with warm urine during the ECB cooling procedure did not affect the temperature in the prostate or NVB. In addition to the 2D simulation, in one case a 3D pelvic model was constructed for volumetric simulation. It was found that the 2D slice with the largest cross-sectional area of prostate had the most abundant venous plexus, and was the most difficult slice to cool, thus it may provide a conservative prediction of the cooling effect. This feasibility study demonstrated that the simulation tool could potentially be used for adjusting the setting of ECB for individual patients during hypothermic radical prostatectomy. Further studies using MR thermometry are required to validate the in silico results obtained using simulation.
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Affiliation(s)
- Yuting Lin
- Tu and Yuen Center for Functional Onco-Imaging of Department of Radiological Sciences, University of California, Irvine, CA 92697, USA
| | - Wei-Ching Lin
- Department of Radiology, China Medical University Hospital, Taichung 40402, Taiwan
| | - Peter T Fwu
- Tu and Yuen Center for Functional Onco-Imaging of Department of Radiological Sciences, University of California, Irvine, CA 92697, USA
| | - Tzu-Ching Shih
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung 40402, Taiwan
| | - Lee-Ren Yeh
- Department of Radiology, E-Da Hospital and I-Shou University, Kaohsiung 82445, Taiwan
| | - Min-Ying Su
- Tu and Yuen Center for Functional Onco-Imaging of Department of Radiological Sciences, University of California, Irvine, CA 92697, USA
| | - Jeon-Hor Chen
- Tu and Yuen Center for Functional Onco-Imaging of Department of Radiological Sciences, University of California, Irvine, CA 92697, USA; Department of Radiology, E-Da Hospital and I-Shou University, Kaohsiung 82445, Taiwan.
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Ramirez D, Zargar H, Caputo P, Kaouk JH. Robotic-assisted laparoscopic prostatectomy: An update on functional and oncologic outcomes, techniques, and advancements in technology. J Surg Oncol 2015; 112:746-52. [PMID: 26369794 DOI: 10.1002/jso.24040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 08/26/2015] [Indexed: 11/11/2022]
Abstract
The robotic platform has revolutionized the management of prostate cancer over the last 15 years. Several techniques have been developed to improve functional and oncologic outcomes, including meticulous apical and posterior dissection, nerve sparing techniques, bladder neck and urethral length sparing, and anastomotic reconstruction. Future developments involving novel single-site, robotic technology will undoubtedly further the field of minimally invasive urology. These topics are reviewed within this article.
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Affiliation(s)
- Daniel Ramirez
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Homayoun Zargar
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Peter Caputo
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
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Dev HS, Wiklund P, Patel V, Parashar D, Palmer K, Nyberg T, Skarecky D, Neal DE, Ahlering T, Sooriakumaran P. Surgical margin length and location affect recurrence rates after robotic prostatectomy. Urol Oncol 2015; 33:109.e7-13. [DOI: 10.1016/j.urolonc.2014.11.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/09/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
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Sood A, Jeong W, Peabody JO, Hemal AK, Menon M. Robot-assisted radical prostatectomy: inching toward gold standard. Urol Clin North Am 2014; 41:473-84. [PMID: 25306159 DOI: 10.1016/j.ucl.2014.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Robot-assisted radical prostatectomy (RARP) offers excellent and lasting oncologic control. Technical refinements in apical dissection, such as the retroapical approach of synchronous urethral transection, and adoption of real-time frozen section analysis of the excised prostate during RARP have substantially reduced positive surgical margin rates, particularly in high-risk disease patients. Furthermore, precision offered by the robotic platform and technical evolution of radical prostatectomy, including enhanced nerve sparing (veil), have led to improved potency and continence outcomes as well as better safety profile in patients undergoing surgical therapy for prostate cancer.
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Affiliation(s)
- Akshay Sood
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
| | - Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - James O Peabody
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, Medical Center Boulevard, NC 27157-1090, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
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Orvieto MA, Coelho RF, Chauhan S, Mathe M, Palmer K, Patel VR. Erectile dysfunction after robot-assisted radical prostatectomy. Expert Rev Anticancer Ther 2014; 10:747-54. [DOI: 10.1586/era.10.16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Preservation of postoperative urinary continence remains the primary concern of all men and their surgeons following robot-assisted radical prostatectomy (RARP). Without doubt, continence is the most important quality of life issue following radical prostatectomy. Identification of difficulties and lessons learned over time has helped focus efforts in order to improve urinary quality of life and continence. This review will examine definitions of continence and urinary quality of life evaluation, technical aspects and the impact of patient-related factors affecting time to and overall continence.
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Robotic-assisted radical prostatectomy after the first decade: surgical evolution or new paradigm. ISRN UROLOGY 2013; 2013:157379. [PMID: 23691367 PMCID: PMC3649202 DOI: 10.1155/2013/157379] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/07/2013] [Indexed: 12/16/2022]
Abstract
Early studies indicate that robotic-assisted radical prostatectomy (RARP) has promising short-term outcomes; however, RARP is beyond its infancy, and the long-term report cards are now beginning. The important paradigm shift introduced by RARP is the reevaluation of the entire open radical prostatectomy experience in surgical technique by minimizing blood loss and complications, maximizing cancer free outcomes, and a renewed assault in preserving quality of life outcomes by many novel mechanisms. RARP provides a new technical “canvas” for surgical masters to create upon, and in ten years, has reinvigorated a 100-year-old “gold standard” surgery.
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Kaiho Y, Yamashita S, Arai Y. Optimization of sexual function outcome after radical prostatectomy using phosphodiesterase type 5 inhibitors. Int J Urol 2013; 20:285-9. [DOI: 10.1111/iju.12071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 12/09/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Yasuhiro Kaiho
- Department of Urology; Tohoku University Graduate School of Medicine; Sendai; Japan
| | - Shinichi Yamashita
- Department of Urology; Tohoku University Graduate School of Medicine; Sendai; Japan
| | - Yoichi Arai
- Department of Urology; Tohoku University Graduate School of Medicine; Sendai; Japan
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Retrograde versus antegrade nerve sparing during robot-assisted radical prostatectomy: which is better for achieving early functional recovery? Eur Urol 2012; 63:169-77. [PMID: 23092543 DOI: 10.1016/j.eururo.2012.09.051] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 09/19/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated. OBJECTIVE To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes. DESIGN, SETTING, AND PARTICIPANTS Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups. SURGICAL PROCEDURE RARP with antegrade NS (n=172) or RARP with retrograde NS (n=172). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied. RESULTS AND LIMITATIONS Positive margin rates were similar (11.1% vs 6.9%; p=0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482-4.089; p=0.001) at 3, 4.024 (95% CI, 2.171-7.457; p<0.001) at 6, and 2.145 (95% CI, 1.019-4.514; p=0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study. CONCLUSIONS In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.
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Jeong SJ, Kim HJ, Kim JH, Oh JJ, Lee SC, Jeong CW, Yoon CY, Hong SK, Byun SS, Lee SE. Urinary continence after radical prostatectomy: Predictive factors of recovery after 1 year of surgery. Int J Urol 2012; 19:1091-8. [DOI: 10.1111/j.1442-2042.2012.03106.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol 2012; 62:368-81. [PMID: 22763081 DOI: 10.1016/j.eururo.2012.05.057] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/25/2012] [Indexed: 11/20/2022]
Abstract
CONTEXT Radical retropubic prostatectomy (RRP) has long been the most common surgical technique used to treat clinically localized prostate cancer (PCa). More recently, robot-assisted radical prostatectomy (RARP) has been gaining increasing acceptance among patients and urologists, and it has become the dominant technique in the United States despite a paucity of prospective studies or randomized trials supporting its superiority over RRP. OBJECTIVE A 2-d consensus conference of 17 world leaders in prostate cancer and radical prostatectomy was organized in Pasadena, California, and at the City of Hope Cancer Center, Duarte, California, under the auspices of the European Association of Urology Robotic Urology Section to systematically review the currently available data on RARP, to critically assess current surgical techniques, and to generate best practice recommendations to guide clinicians and related medical personnel. No commercial support was obtained for the conference. EVIDENCE ACQUISITION A systematic review of the literature was performed in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. EVIDENCE SYNTHESIS The results of the systematic literature review were reviewed, discussed, and refined over the 2-d conference. Key recommendations were generated using a Delphi consensus approach. RARP is associated with less blood loss and transfusion rates compared with RRP, and there appear to be minimal differences between the two approaches in terms of overall postoperative complications. Positive surgical margin rates are at least equivalent with RARP, but firm conclusions about biochemical recurrence and other oncologic end points are difficult to draw because the follow-up in existing studies is relatively short and the overall experience with RARP in locally advanced PCa is still limited. RARP may offer advantages in postoperative recovery of urinary continence and erectile function, although there are methodological limitations in most studies to date and a need for well-controlled comparative outcomes studies of radical prostatectomy surgery following best practice guidelines. Surgeon experience and institutional volume of procedures strongly predict better outcomes in all relevant domains. CONCLUSIONS Available evidence suggests that RARP is a valuable therapeutic option for clinically localized PCa. Further research is needed to clarify the actual role of RARP in patients with locally advanced disease.
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Abstract
Radical prostatectomy remains the gold-standard treatment for clinically localized prostate cancer. Although cancer control is the primary goal, secondary outcomes such as continence recovery are of great importance to patients. Thus, it is a challenge for prostate cancer surgeons to optimize continence outcomes without compromising oncologic results. Many high-volume surgeons have demonstrated excellent long-term continence rates in their patients, but early continence is variable and less than ideal even in expert hands. A plethora of individual technical maneuvers exist to optimize early recovery of continence, but as yet there is no composite technique that incorporates the relevant anatomic principles of minimizing damage to the urinary sphincters and their nerves, maximizing functional urethral length, creating a secure and watertight vesicourethral anastomosis, providing circumferential fascioligamentous support to the anastomosis and external sphincter, and ameliorating postoperative bladder descent. Our ten-step approach to collating these individual maneuvers into a unified technique could be used by surgeons to obtain the best possible early recovery of urinary control for their patients, without risking their oncologic outcomes.
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Skarecky D, Morales B, Chang A, Ahlering T. Simple method to predict return of continence after robot-assisted radical prostatectomy. J Endourol 2011; 25:1451-5. [PMID: 21815809 DOI: 10.1089/end.2011.0013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE After removal of the Foley catheter after robot-assisted radical prostatectomy (RARP), recovery of continence can take days to months. We sought to identify a simple means to predict time to recovery of postoperative continence. PATIENTS AND METHODS Preoperative characteristics on 172 men who were undergoing RARP were entered into an electronic database. All men were queried via telephone and/or returned a 7-day log of pad use. Men without need for pads were excluded (n=41). At 4 to 7 days, responses were grouped as: one pad (n=55), two pads (n=35), or three or more pads (n=41). Patients returned self-addressed postcards noting the date of 0-pad urinary status. Univariate and multivariate analysis of variables were assessed for ability to predict time to continence. RESULTS No preoperative factors, such as age, International Index of Erectile Function-5, prostate-specific antigen level, American Urological Association symptom score, body mass index, uroflowmetry, nerve-sparing status, estimated blood loss, or prostate weight, were found to predict time to continence. Pad use at 4 to 7 days, however, was highly correlated with median time to continence. The median time to continence for men using one pad was 35 days, two pads was 42 days, and for three or more pads was 73 days (P=0.0001). CONCLUSIONS As has been previously reported, we found no reliable baseline factors that predicted postoperative time to 0-pad continence. We did find that determining pad usage at 4 to 7 days after catheter removal strongly predicted time to pad-free continence. This method is simpler then pad weights, predicts high- and low-risk men for delayed continence, and can be used for counseling/intervention.
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Affiliation(s)
- Douglas Skarecky
- Department of Urology, University of California, Irvine, Orange, California 92868, USA
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Abstract
Controlled tissue cooling, or hypothermia, has been used therapeutically for decades to mitigate the negative effects of traumatic, ischemic, and surgical insults. When applied systemically, moderate hypothermia can attenuate or prevent the extent of neurologic sequelae. Localized hypothermia, on the other hand, has the capacity to reduce tissue edema, suppress inflammation, and minimize the severity of peripheral nerve injury. Therapeutic hypothermia has been used in critical care, neurosurgery, ophthalmology, otolaryngology, cardiothoracic surgery and most recently in urology. Nerve injury during radical pelvic surgery can result in urinary incontinence or retention, impotence and bowel dysfunction. Localized hypothermia during radical prostatectomy has demonstrated improved recovery of urinary continence and erectile function, and similar benefits might be observed in other types of radical pelvic surgery.
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Affiliation(s)
- David S Finley
- Institute of Urologic Oncology, David Geffen School of Medicine, University of California Los Angeles, 924 Westwood Boulevard, Suite 1050, Los Angeles, CA 90095, USA.
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Robotic-assisted laparoscopic prostatectomy: a critical analysis of its impact on urinary continence. Curr Opin Urol 2011; 21:185-94. [DOI: 10.1097/mou.0b013e3283455a21] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jeong SJ, Yi J, Chung MS, Kim DS, Lee WK, Park H, Yoon CY, Hong SK, Byun SS, Lee SE. Early recovery of urinary continence after radical prostatectomy: Correlation with vesico-urethral anastomosis location in the pelvic cavity measured by postoperative cystography. Int J Urol 2011; 18:444-51. [DOI: 10.1111/j.1442-2042.2011.02760.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Current world literature. Curr Opin Urol 2011; 21:257-64. [PMID: 21455039 DOI: 10.1097/mou.0b013e3283462c0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Finley DS, Chang A, Morales B, Osann K, Skarecky D, Ahlering T. Impact of Regional Hypothermia on Urinary Continence and Potency After Robot-Assisted Radical Prostatectomy. J Endourol 2010; 24:1111-6. [DOI: 10.1089/end.2010.0122] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David S. Finley
- Institute of Urologic Oncology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - Alexandra Chang
- Department of Urology, University of California, Irvine, Orange, California
| | - Blanca Morales
- Department of Urology, University of California, Irvine, Orange, California
| | - Kathryn Osann
- Department of Urology, University of California, Irvine, Orange, California
| | - Douglas Skarecky
- Department of Urology, University of California, Irvine, Orange, California
| | - Thomas Ahlering
- Department of Urology, University of California, Irvine, Orange, California
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Chauhan S, Coelho RF, Rocco B, Palmer KJ, Orvieto MA, Patel VR. Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy. Int Braz J Urol 2010; 36:259-72. [DOI: 10.1590/s1677-55382010000300002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2010] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Rafael F. Coelho
- University of Central Florida School of Medicine, USA; University of Sao Paulo, Brazil; European Institute of Oncology, Italy
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Stolzenburg JU, Do M, Kallidonis P, Ghulam N, Hellawell G, Haefner T, Liatsikos EN. Hemostasis During Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy. J Endourol 2010; 24:505-9. [DOI: 10.1089/end.2009.0160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
| | - Minh Do
- Department of Urology, University of Leipzig, Leipzig, Germany
| | | | - Nabi Ghulam
- Department of Urology, University of Aberdeen, Aberdeen, Scotland
| | - Giles Hellawell
- Department of Urology, Northwick Park Hospital, London, United Kingdom
| | - Tim Haefner
- Department of Urology, University of Leipzig, Leipzig, Germany
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Loughlin KR, Prasad MM. Post-Prostatectomy Urinary Incontinence: A Confluence of 3 Factors. J Urol 2010; 183:871-7. [DOI: 10.1016/j.juro.2009.11.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Kevin R. Loughlin
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michaella M. Prasad
- Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Finley DS, Osann K, Chang A, Santos R, Skarecky D, Ahlering TE. Hypothermic Robotic Radical Prostatectomy: Impact on Continence. J Endourol 2009; 23:1443-50. [DOI: 10.1089/end.2009.0411] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David S. Finley
- Institute of Urologic Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kathryn Osann
- Department of Medicine, University of California Irvine, Orange, California
| | - Alexandra Chang
- Department of Urology, University of California Irvine, Orange, California
| | - Rosanne Santos
- Department of Urology, University of California Irvine, Orange, California
| | - Douglas Skarecky
- Department of Urology, University of California Irvine, Orange, California
| | - Thomas E. Ahlering
- Department of Urology, University of California Irvine, Orange, California
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Magheli A, Burnett AL. Erectile dysfunction following prostatectomy: prevention and treatment. Nat Rev Urol 2009; 6:415-27. [PMID: 19657376 DOI: 10.1038/nrurol.2009.126] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Re: Finley et al.: Hypothermic nerve-sparing radical prostatectomy: rationale, feasibility, and effect on early continence. (Urology 2009;73:691-696). Urology 2009; 73:1426-7; author reply 1427. [PMID: 19482166 DOI: 10.1016/j.urology.2008.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 12/02/2008] [Accepted: 12/03/2008] [Indexed: 11/22/2022]
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