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Novel anatomical apical dissection utilizing puboprostatic "open-collar" technique: Impact on apical surgical margin and early continence recovery. PLoS One 2021; 16:e0249991. [PMID: 33857230 PMCID: PMC8049266 DOI: 10.1371/journal.pone.0249991] [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: 01/21/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate the impact of modifications to anatomical apical dissection including a puboprostatic open-collar technique, which visualizes the lateral aspect of the apex and dorsal vein complex (DVC) covering the rhabdosphincter while preserving the puboprostatic collar, on positive surgical margin (PSM) and continence recovery. Methods One-hundred-and-sixty-seven patients underwent gasless single-port retroperitoneoscopic radical prostatectomy using a three-dimensional head-mounted display system. Sequentially modified surgical techniques comprised puboprostatic open-collar technique, sutureless transection of the DVC, retrograde urethral dissection, and anterior reconstruction. The associations of these modifications with PSM and continence recovery were assessed. Results The puboprostatic open-collar technique, sutureless DVC transection, and retrograde urethral dissection were significantly associated with lower apical PSM (P = 0.003, 0.003, and 0.010, respectively). The former two also showed similar associations in 84 patients with anterior apical tumor (P = 0.021 and 0.030, respectively). Among 92 patients undergoing all of these three procedures, overall and apical PSM rates were 13.0% and 3.3%, respectively. Retrograde urethral dissection (odds ratio [OR] 2.73, P = 0.004) together with nerve sparing (OR 2.77, P = 0.003) and anterior apical tumor (OR 0.45, P = 0.017) were independently associated with immediate continence recovery. A multivariable model for 3-month continence recovery included anterior apical tumor (OR 0.28, P = 0.003) and puboprostatic open-collar technique (OR 3.42, P = 0.062). Immediate and 3-month continence recovery rates were 56.3% and 85.4%, respectively, in 103 patients undergoing both the puboprostatic open-collar technique and retrograde urethral dissection. Conclusion Novel anatomical apical dissection utilizing a puboprostatic open-collar technique may favorably impact on both apical surgical margin and continence recovery.
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Fukuhara H, Yamamoto S, Karashima T, Inoue K. Photodynamic diagnosis and therapy for urothelial carcinoma and prostate cancer: new imaging technology and therapy. Int J Clin Oncol 2020; 26:18-25. [PMID: 32451769 DOI: 10.1007/s10147-020-01704-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/29/2020] [Indexed: 11/30/2022]
Abstract
Photodynamic technology using light-sensitive and fluorescent substances has an important role in an accurate diagnosis for a variety of malignancies, including bladder cancer and prostate cancer. Light-sensitive and fluorescent substances accumulate specifically in tumor cells compared to normal tissue, and by light irradiation and excitation at each specific wavelength, tumor lesion, blood flow, lymph node and so on show fluorescence. 5-Aminolevulinic acid (ALA) is converted to protoporphyrin IX (PpIX) into mitochondria. PpIX is excited by blue light, red fluorescence is emitted in the mitochondria. This phenomenon is the mechanism of ALA-mediated photodynamic diagnosis (ALA-PDD). ALA-PDD has made it possible to visualize smaller lesions and flat lesions that were previously difficult to visualize by endoscope using a white-light source. So accurate diagnosis and complete resection become possible during operation. The accumulation of PpIX in the mitochondria also induces direct mitochondrial damage and subsequent cell death by red and green light. This biological reaction is the ALA-mediate photodynamic therapy (ALA-PDT). ALA-PDT has been developed as a modality for minimum invasive cancer treatment that utilizes low-energy light and photosensitizer. Vascular-activated photosensitizer induces rapid tumor ablation by PDT involving direct tumor cell killing as well as damage to the exposed microvasculature. We summarize the clinical outcomes of PDD and PDT for urothelial carcinoma and prostate cancer.
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Affiliation(s)
- Hideo Fukuhara
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan.
| | - Shinkuro Yamamoto
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan
| | - Takashi Karashima
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan
| | - Keiji Inoue
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan
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Chen W, Zhou JC, Xu L, Hu XY, Xu ZB, Guo JM. A technique of pretightening dorsal vein complex can facilitate laparoscopic radical prostatectomy. Asian J Androl 2019; 21:628-630. [PMID: 31115362 PMCID: PMC6859656 DOI: 10.4103/aja.aja_24_19] [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] [Indexed: 11/16/2022] Open
Abstract
The ligation of dorsal venous complex (DVC) is a very important procedure during laparoscopic radical prostatectomy (LRP). Inaccurate DVC ligation may lead to severe bleeding or postoperative incontinence. We, therefore, designed the DVC pretightening technique to facilitate this procedure. The 32 involved patients with localized prostate cancer underwent LRP between July 2017 and October 2018. All of the patients received DVC pretightening technique. A laparoscopic intestinal clamp was used to narrow and strain DVC. The needle passage was limited between the bone and clamp. The ligation time, DVC-related blood loss, and continence data were recorded. The ligation of DVC in 32 patients was performed with DVC pretightening technique. Every suture was completed with one attempt. The mean ligation time was 2.7 ± 1.0 min. The DVC-related blood loss was 2.0 ± 1.3 ml. The 3-month continence rate was 81.3% (26/32). Positive margin rate was 9.4% (3/32). In conclusion, the DVC pretightening technique simplified the ligation of DVC during LRP. It is a safe and reliable technique. However, large-sample randomized controlled trials are still required to confirm the advantage of the new method in improving mean ligation time, DVC-related blood loss, continence rate, and positive margin rate.
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Affiliation(s)
- Wei Chen
- Department of Urology, Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Jin-Cai Zhou
- Department of Urology, Jianhu Hospital of Nantong University, Nantong 224700, China
| | - Lei Xu
- Department of Urology, Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Xiao-Yi Hu
- Department of Urology, Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Zhi-Bing Xu
- Department of Urology, Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Jian-Ming Guo
- Department of Urology, Zhongshan Hospital of Fudan University, Shanghai 200032, China
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Zhang C, Wang H, Ye C, Guo F, Yang B, Xu C, Sun Y. The application of a blunt-tip needle to suture the dorsal venous complex in robot-assisted laparoscopic radical prostatectomy. Int J Med Robot 2017; 13. [PMID: 28371360 DOI: 10.1002/rcs.1822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Complete haemostasis of the dorsal venous complex (DVC) is of great importance in robot-assisted radical prostatectomy. In this study, we investigated the efficacy of blunt-tip needles in the surgery. METHODS Cases of robot-assisted laparoscopic radical prostatectomy were reviewed. If a blunt-tip needle had been used to suture the DVC, the patient was recruited to the blunt-tip group. If a regular needle was used, the patient was recruited to the control group. Patient characteristics and perioperative outcomes were recorded. RESULTS One hundred and nine cases were reviewed. A blunt-tip needle was used to suture the DVC in 67 cases, and a regular needle in 42 cases. All characteristics of the two groups are comparable (p > 0.05). In 66 cases in the blunt-tip group, no sutures or coagulations were needed when suturing the DVC, Five cases of DVC-related bleeding were observed in the control group, which is higher than in the blunt-tip group (p = 0.031). At the same time, no catheter was sutured in the blunt-tip group. All patients were followed for at least six months. The continence rate in the blunt-tip group is 89.6%, significantly higher than in the control group (73.8%, p = 0.031). CONCLUSIONS Using a blunt-tip needle to suture the DVC may reduce DVC-related bleeding and provide a better surgical field. It may be helpful in improving postoperative continence. However, its effect on positive margin at the apex still needs further investigation.
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Affiliation(s)
- Chao Zhang
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Huiqing Wang
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Chen Ye
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Fei Guo
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Bo Yang
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Chuanliang Xu
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Yinghao Sun
- Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China
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Standardized procedure of robotic assisted laparoscopic radical prostatectomy from case 1 to case 1200. UROLOGICAL SCIENCE 2016. [DOI: 10.1016/j.urols.2016.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Frozen section evaluation of margins in radical prostatectomy specimens: a contemporary study and literature review. Ann Diagn Pathol 2016; 24:11-8. [DOI: 10.1016/j.anndiagpath.2016.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/04/2016] [Indexed: 11/18/2022]
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Kawczyk-Krupka A, Wawrzyniec K, Musiol SK, Potempa M, Bugaj AM, Sieroń A. Treatment of localized prostate cancer using WST-09 and WST-11 mediated vascular targeted photodynamic therapy-A review. Photodiagnosis Photodyn Ther 2015; 12:567-74. [PMID: 26467273 DOI: 10.1016/j.pdpdt.2015.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/23/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) is well known for its direct cytotoxicity of the free radical-producing photochemical reaction, indirect mechanisms of action including modulation of intrinsic anti-tumour immune activity, and occlusion of pathologically altered tumour vessels leading to tumour ischaemia. The aim of this work is to critically review the evidence base for the use of vascular targeted PDT (VTP) to treat low-risk prostate cancer, and to discuss perspectives and challenges yet to be overcome. A brief general overview of focal prostate cancer therapy was provided, followed by a discussion of both basic and clinical research pertaining to prostate cancer VTP, with a focus on the palladium-based WST-09 and WST-11 photosensitisers. MATERIALS AND METHOD Literature on VTP for prostate cancer with the fallowing medical subject headings search terms: prostate cancer, photodynamic therapy, vascular targeted photodynamic therapy, bacteriopheophorbide were reviewed. The articles were selected by their relevance to the topic. RESULTS The clinical and basic research data available to date show much promise for WST-09, and WST-11 based VTP eventually joining the standard urologist's armamentarium against prostate cancer. With good reported tolerability and efficacy VTP can be proposed as an intermediate treatment for local low risk disease, halfway between watchful waiting and radical therapy.
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Affiliation(s)
- A Kawczyk-Krupka
- School of Medicine with the Division of Dentistry in Zabrze, Department and Clinic of Internal Diseases, Angiology and Physical Medicine, Center for Laser Diagnostics and Therapy, Medical University of Silesia, Batorego Street 15, 41-902 Bytom, Poland.
| | - K Wawrzyniec
- Department of Internal Diseases, 11 Listopada 48, 28-200 Staszów, Poland
| | - S K Musiol
- School of Clinical Medicine, University of Cambridge, Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge CB2 OSP, United Kingdom
| | - M Potempa
- School of Medicine with the Division of Dentistry in Zabrze, Department and Clinic of Internal Diseases, Angiology and Physical Medicine, Center for Laser Diagnostics and Therapy, Medical University of Silesia, Batorego Street 15, 41-902 Bytom, Poland
| | - A M Bugaj
- School of Medicine with the Division of Dentistry in Zabrze, Department and Clinic of Internal Diseases, Angiology and Physical Medicine, Center for Laser Diagnostics and Therapy, Medical University of Silesia, Batorego Street 15, 41-902 Bytom, Poland; College of Health, Beauty Care and Education, Brzeźnicka 3, 60-133 Poznań, Poland
| | - A Sieroń
- School of Medicine with the Division of Dentistry in Zabrze, Department and Clinic of Internal Diseases, Angiology and Physical Medicine, Center for Laser Diagnostics and Therapy, Medical University of Silesia, Batorego Street 15, 41-902 Bytom, Poland
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Fukuhara H, Inoue K, Kurabayashi A, Furihata M, Shuin T. Performance of 5-aminolevulinic-acid-based photodynamic diagnosis for radical prostatectomy. BMC Urol 2015; 15:78. [PMID: 26232024 PMCID: PMC4521460 DOI: 10.1186/s12894-015-0073-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 07/24/2015] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to investigate whether we could detect positive surgical margins during open and laparoscopic radical prostatectomy by 5-aminolevulinic acid (ALA) photodynamic diagnosis (PDD) and mapping of red fluorescence in human prostate cancer cells. Methods All 52 patients were diagnosed with prostate cancer by biopsy. They had a positive core in the apex or highly suspicious positive margins. Open and laparoscopic radical prostatectomy was performed in 18 and 34 cases, respectively. One gram of ALA solution was given intraoperatively, orally through a stomach tube. An endoscopic PDD system, including a D-Light C, CCU Tricam SLII/3CCD CH Tricam-P PDD, and HOPKINS II Straight Forward Telescope 0°, was used. The D-Light C light source was equipped with a band-pass filter. The CCU Tricam SLII/3CCD CHTricam-P PDD video camera system was equipped with a long-pass filter. The laparoscopy optic component was equipped with a yellow long-pass filter. Results One of the 52 patients had a red-fluorescent-positive margin of the excised whole prostate and the positive surgical margin was histologically confirmed. In the section of excised prostate, we obtained 141 biopsied samples. The sensitivity and specificity were 75.0 % and 87.3 %, respectively. Conclusions Intraoperative ALA-PDD is feasible. However, heat degeneration and length of positive surgical margin have crucial influences on red fluorescence. In future, a randomized clinical trial should be carried out.
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Affiliation(s)
- Hideo Fukuhara
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan.
| | - Keiji Inoue
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan.
| | - Atsushi Kurabayashi
- Department of Pathology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan.
| | - Mutsuo Furihata
- Department of Pathology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan.
| | - Taro Shuin
- Department of Urology, Kochi Medical School, Kohasu, Oko, Nankoku, Kochi, 783-8505, Japan.
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Ito K, Kenji S, Yoshii H, Hamada S, Asakuma J, Tasaki S, Kuroda K, Sato A, Horiguchi A, Asano T. Modified posterior musculofascial plate reconstruction decreases the posterior vesicourethral angle and improves urinary continence recovery in patients undergoing laparoscopic radical prostatectomy. Mol Clin Oncol 2013; 1:970-976. [PMID: 24649279 DOI: 10.3892/mco.2013.182] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/21/2013] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the efficacy of our modified posterior musculofascial plate reconstruction (PMPR) procedure in laparoscopic radical prostatectomy (LRP). Prior to 2010, four operative procedures were used to expedite continence recovery: preserving the fascia covering the levator ani muscle, preserving the bladder neck, securing a functional urethral length by using a lateral-view dissection technique and suspending the vesicourethral anastomosis from the puboprostatic ligaments. Since February, 2010, a running suture between Denonvilliers' fascia (DF) and the median fibrous raphe (MFR, the fibrous tissue that lies immediately underneath the urethra) has also been used. In vesicourethral anastomosis, a double-armed running suture was performed. At the beginning of the anastomosis, the first stitches (at 1 and 11 o'clock positions on the bladder neck) were placed 1-2 cm dorsocephalad to the bladder neck (first through the seromuscular layer and then through the full thickness of the bladder neck). At the 5 and 7 o'clock positions of the urethra, the stitches were placed through the urethral mucosa as well as the the reconstructed musculofascial plate. The bladder shape was evaluated by postoperative cystography and the clinical results were compared between patients undergoing LRP without PMPR (group A) and those undergoing LRP with PMPR (group B). The cystograms demonstrated that the PMPR significantly shortened the vertical length of the bladder and significantly decreased the posterior vesicourethral angle. At 1, 3 and 6 months after LRP, the number of daily used pads was significantly lower in group B compared to that in group A and the time to achieve a pad-free status was significantly shorter in group B. Our modified PMPR procedure significantly improved the recovery of urinary continence following LRP and this improvement may be due in part to changes of the bladder shape.
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Affiliation(s)
- Keiichi Ito
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Seguchi Kenji
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Hidehiko Yoshii
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Shinsuke Hamada
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Junichi Asakuma
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Shinsuke Tasaki
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Kenji Kuroda
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Akinori Sato
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Akio Horiguchi
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Tomohiko Asano
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
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Yossepowitch O, Briganti A, Eastham JA, Epstein J, Graefen M, Montironi R, Touijer K. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update. Eur Urol 2013; 65:303-13. [PMID: 23932439 DOI: 10.1016/j.eururo.2013.07.039] [Citation(s) in RCA: 265] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 07/25/2013] [Indexed: 02/03/2023]
Abstract
CONTEXT The clinical significance of positive surgical margins (PSMs) in radical prostatectomy (RP) specimens and the management of affected patients remain unclear. OBJECTIVE To address pitfalls in the pathologic interpretation of margin status; provide an update on the incidence, predictors, and long-term oncologic implications of PSMs in the era of robot-assisted laparoscopic RP (RALRP); and suggest a practical evidence-based approach to patient management. EVIDENCE ACQUISITION A systematic review of the literature was performed in April 2013 using Medline/PubMed, Web of Science, and Scopus databases and the Cochrane Database of Systematic Reviews. Studies focusing on PSMs in RP pertinent to the objectives of this review were included. Particular attention was paid to publications within the last 5 yr and those concerning RALRP. EVIDENCE SYNTHESIS A total of 74 publications were retrieved. Standardized measures to overcome variability in the pathologic interpretation of surgical margins have recently been established by the International Society of Urological Pathology. The average rate of PSMs in contemporary RALRP series is 15% (range: 6.5-32%), which is higher in men with a more advanced pathologic stage and equivalent to the rate reported in prior open and laparoscopic prostatectomy series. The likelihood of PSMs is strongly influenced by the surgeon's experience irrespective of the surgical approach. Technical modifications using the robotic platform and the role of frozen-section analysis to reduce the margin positivity rate continue to evolve. Positive margins are associated with a twofold increased hazard of biochemical relapse, but their association with more robust clinical end points is controversial. Level 1 evidence suggests that adjuvant radiation therapy (RT) may favorably affect prostate-specific antigen recurrence rates, but whether the therapy also affects systemic progression, prostate cancer-specific mortality, and overall survival remains debatable. CONCLUSIONS Although positive margins in prostate cancer are considered an adverse oncologic outcome, their long-term impact on survival is highly variable and largely influenced by other risk modifiers. Adjuvant RT appears to be effective, but further study is required to determine whether early salvage RT is an equivalent alternative.
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Affiliation(s)
- Ofer Yossepowitch
- Department of Urology, Rabin Medical Center, Petach-Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Alberto Briganti
- Department of Urology, Università Vita Salute San Raffaele, Milan, Italy
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Jonathan Epstein
- Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Markus Graefen
- Martini Clinic, Prostate Cancer Center, University of Hamburg, Hamburg, Germany
| | - Rodolfo Montironi
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, Ancona, Italy
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Vickers AJ, Bennette C, Touijer K, Coleman J, Laudone V, Carver B, Eastham JA, Scardino PT. Feasibility study of a clinically-integrated randomized trial of modifications to radical prostatectomy. Trials 2012; 13:23. [PMID: 22364367 PMCID: PMC3298715 DOI: 10.1186/1745-6215-13-23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 02/24/2012] [Indexed: 02/01/2023] Open
Abstract
Abstract Trial registration ClinicalTrials.gov NCT00928850
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Affiliation(s)
- Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY 11215, USA.
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Ou YC, Hung SW, Wang J, Yang CK, Cheng CL, Tewari AK. Retro-apical transection of the urethra during robot-assisted laparoscopic radical prostatectomy in an Asian population. BJU Int 2011; 110:E57-63. [DOI: 10.1111/j.1464-410x.2011.10660.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Tewari AK, Srivastava A, Mudaliar K, Tan GY, Grover S, El Douaihy Y, Peters D, Leung R, Yadav R, John M, Wysock J, Vaughan ED, Muir S, Amin MB, Rubin M, Tu J, Akthar M, Shevchuk M. Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy. BJU Int 2010; 106:1364-73. [PMID: 20377582 DOI: 10.1111/j.1464-410x.2010.09318.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P = 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥ pT3a) documented on final specimen pathology (16% vs 10%, P = 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.
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Affiliation(s)
- Ashutosh K Tewari
- Lefrak Center of Robotic Surgery, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY 10065, USA.
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Sasaki H, Miki J, Kimura T, Yamamoto Y, Koike Y, Miki K, Egawa S. Upfront transection and subsequent ligation of the dorsal vein complex during laparoscopic radical prostatectomy. Int J Urol 2010; 17:960-1. [DOI: 10.1111/j.1442-2042.2010.02632.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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