Laparoscopic vs open retropubic intrafascial nerve-sparing radical prostatectomy: surgical and functional outcomes in 300 patients

Incidence of Rectal Injury After Radical Prostatectomy: A Systematic Review and Meta-analysis

Context

Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe infection/sepsis, and late sequelae, such as a rectourethral fistula (RUF). Considering its traditionally low incidence, uncertainty remains as to predisposing risk factors and management.

Objective

To examine the incidence of RI after RP in contemporary series and to propose a pragmatic algorithm for its management.

Evidence acquisition

A systematic literature search was performed using the Medline and Scopus databases. Studies reporting data on RI incidence were selected. Subgroup analyses were conducted to assess the differential incidence by age, surgical approach, salvage RP after radiation therapy, and previous benign prostatic hyperplasia (BPH)-related surgery.

Evidence synthesis

Eighty-eight, mostly retrospective noncomparative, studies were selected. The meta-analysis obtained a pooled RI incidence of 0.58% (95% confidence interval [CI] 0.46-0.73) in contemporary series with significant across-study heterogeneity (I² = 100%, p < 0.00001). The highest RI incidence was found in patients undergoing open RP (1.25%; 95% CI 0.66-2.38) and laparoscopic RP (1.25%; 95% CI 0.75-2.08) followed by perineal RP (0.19%; 95% CI 0-276.95) and robotic RP (0.08%; 95% CI 0.02-0.31). Age ≥60 yr (0.56%; 95% CI 0.37-06) and salvage RP after radiation therapy (6.01%; 95% CI 3.99-9.05), but not previous BPH-related surgery (4.08%, 95% CI 0.92-18.20), were also associated with an increased RI incidence. Intraoperative versus postoperative RI detection was associated with a significantly decreased risk of severe postoperative complications (such as sepsis and bleeding) and subsequent formation of a RUF.

Conclusions

RI is a rare, but potentially devastating, complication following RP. RI incidence was higher in patients ≥60 yr of age, and in those who underwent open/laparoscopic approach or salvage RP after radiation therapy. Intraoperative RI detection and repair apparently constitute the single most critical step to significantly decrease the risk of major postoperative complications and subsequent RUF formation. Conversely, intraoperatively undetected RI can lead more often to severe infective complications and RUF, the management of which remains poorly standardised and requires complex procedures.

Patient summary

Accidental rectum tear is a rare, but potentially devastating, complication in men undergoing prostate removal for cancer. It occurs more often in patients aged 60 yr or older as well as in those who underwent prostate removal via an open/laparoscopic approach and/or prostate removal after radiation therapy for recurrent disease. Prompt identification and repair of this condition during the initial operation are the key to reduce further complications such as the formation of an abnormal opening between the rectum and the urinary tract.

A comparison of perioperative outcome between robot-assisted and laparoscopic radical prostatectomy: experience of a single institution

PURPOSE

To compare perioperative and pathological results in different approaches of robotic or laparoscopic radical prostatectomy.

MATERIALS AND METHODS

We retrospectively reviewed 206 patients diagnosed with pros¬tate cancer (PC) from June 2016 to October 2017 in the First Affiliated Hospital of Nan¬jing Medical University. A total of 132 cases underwent robot-assisted laparoscopic radical prostatectomy (RLRP) including 54 patients on transperitoneal robot-assisted laparoscopic radical prostatectomy (Tp-RLRP) and 78 on extraperitoneal robot-assisted laparoscopic radical prostatectomy (Ep-RLRP). Meanwhile, 74 patients performed with extraperitoneal laparoscopic radical prostatectomy (Ep-LPR) were also included. Peri¬operative and pathological data were compared among these groups.

RESULTS

All operations were completed without conversion. There was no signifi¬cant difference in basic and pathological characteristics of patients between each two groups. In Tp-RLRP vs. Ep-RLRP: Significant differences were found in the comparison in to¬tal operation time [235.98 ± 59.16 vs. 180.45 ± 50.27 min, P = 0.00], estimated blood loss (EBL) [399.07 ± 519.57 vs. 254.49 ± 308.05 mL, P = 0.0473], postoperative pelvic drainage time [5.37 ± 2.33 vs. 4.24 ± 3.08 d, P = 0.0237] and postoperative length of stay [8.15 ± 3.30 vs. 6.49 ± 3.49 d, P = 0.0068] while no significant differences were detected in other variables. In Ep-RLRP vs. Ep-LPR: Longer total operation time was observed in Ep-RLRP when compared to Ep-LPR [180.45 ± 50.27 vs. 143.80 ± 33.13 min, P = 0.000]. No significant differences were observed in other variables.

CONCLUSION

In RLRP, Ep-RLRP was proved a safe and effective approach based on the perioperative results compared to Tp-RLRP. Ep-RLRP and Ep-LPR provides equivalent perioperative and pathological outcomes.

Oncological safety of intrafascial nerve-sparing radical prostatectomy compared with conventional process: a pooled review and meta-regression analysis based on available studies

Background

Intrafascial prostatectomy was a modified technique from the conventional nerve-sparing surgery in order to improve patients’ post-surgical continence and erectile function; however, ongoing controversy exists regarding the oncological safety of this technique. In this study we aimed to provide a critical and pooled analysis based on published literatures regarding the oncological outcomes after intrafascial nerve-sparing prostatectomy.

Methods

Database searches were performed for published articles till June 2018 on PubMed. Three reviewers screened fulfilled papers and extracted data independently. Main outcome was the positive surgical margins (PSMs) rates stratified by pathological stages. We performed both one-arm and comparative meta-analysis to evaluate the oncological safety of intrafascial technique. Moreover, we built meta-regression models to assess the confounding factors.

Results

We retrieved a total of 117 records after electronic search, of which 21 studies were finally included in this review. There were 15 controlled studies and 6 surgical series. Our one-arm meta-analysis demonstrated that the total PSM rates after intrafascial techniques ranging from 2.2 to 35%, with a pooled rate of 14.5% on average (480 of 3151 patients, 95% confidence interval[CI]: 11.2–17.5%). Meta-regression model showed that patients’ age, pT2 cancer percentage and Selection Score of Oncological Safety (SSOS) were significantly associated with total PSM rate; moreover, each 1 point of SSOS could decrease the total PSM rate by 1.3% on average. Comparative meta-analysis demonstrated that there was no significant difference between intra- and inter-fascial group regarding PSM rates.

Conclusions

With stringent case selection and when performed by experienced surgeons, intrafascial prostatectomy could offer an acceptable or, at least, equivalent PSM rate compared with the conventional interfascial approach. Preoperative SSOS more than 7 points could be considered as an indication of intrafascial radical prostatectomy.

Electronic supplementary material

The online version of this article (10.1186/s12894-019-0476-2) contains supplementary material, which is available to authorized users.

Intrafascial nerve-sparing radical prostatectomy improves patients' postoperative continence recovery and erectile function: A pooled analysis based on available literatures

BACKGROUND

Intrafascial nerve-sparing prostatectomy has been currently applied based on the updated anatomic understanding of periprostatic cavernous nerves, in order to provide patients better postoperative recovery of continence and potency. The aim of our study is to perform a pooled analysis of available literatures regarding the functional outcomes following intrafascial nerve-sparing technique.

METHODS

The authors performed database searches of articles published till October 2017 on PubMed using following keywords across the "title" and "abstract" field of the records: intrafascial, veil, curtain dissection, high anterior release, incremental nerve sparing, and radical prostatectomy. Fulfilled papers were screened and data were extracted independently by 3 reviewers. Main outcome was the postoperative continence and potency rate stratified by follow-up durations. Both 1-arm and comparative meta-analyses were performed and meta-regression models were conducted to evaluate the confounding factors.

RESULTS

Using the electronic search strategy, a total of 71 records were retrieved and 20 studies were finally included, of which 6 were surgical series and 14 were controlled studies. Our 1-arm meta-analysis summarized the pooled continence rates after intrafascial prostatectomy were 59.4%, 76.2%, 89.9%, and 92.2% at postoperative follow-up of 1, 3, 6, and 12 months, respectively. Regardless of the variance in potency definition, the pooled potency rates after intrafascial prostatectomy were 42.2%, 54.2%, and 72.2% at 3, 6, and 12 months, respectively. Comparative analysis showed that the intrafascial group offered better continence rates at 1, 3, and 6 months with an odds ratio (OR) of 2.38 (95% confidence interval [CI]: 1.73-3.26), 1.82 (95% CI: 1.18-2.82), and 2.19 (95% CI: 1.43-3.34) as compared with the interfascial group. Moreover, potency rate in the intrafascial group was higher at 12 months than in the interfascial group, with an OR of 2.44 (95% CI: 1.35-4.42).

CONCLUSION

Based on the limited evidence, our study demonstrated that intrafascial nerve-sparing prostatectomy could provide patients with earlier recovery of continence and better erectile function compared with conventional interfascial approach, but physiological mechanisms about this technique still need further study.

Unexpected hemorrhage of a rare vessel, a pubic branch of the external iliac artery, after laparoscopic radical prostatectomy: Case report

RATIONALE

Postoperative hemorrhage is a rare complication after laparoscopic radical prostatectomy (LRP), with no case reports of bleeding from the external iliac artery in the literature.

PATIENT CONCERNS

A 73-year-old man diagnosed with clinical stage 2c prostate cancer underwent LRP successfully with only approximately 200 mL of intraoperative blood loss. However, his blood pressure dropped from 135/74 to 80/49 mm Hg and his hemoglobin decreased by 66 g/L compared with the preoperative level within 5 hours.

DIAGNOSES

Active hemorrhage from a pubic branch of the external iliac artery was found by digital subtraction angiography (DSA).

INTERVENTIONS

The patient was treated with superselective intraarterial embolization.

OUTCOMES

The bleeding stopped and the patient recovered uneventfully with no further hemorrhage or other complications.

LESSONS

Although postoperative hemorrhage after LRP is exceptionally rare, it can occur not only in the internal iliac artery but also in the external iliac artery. In addition, contracted pelvis cases should be addressed with more caution by the laparoscope holder in case external iliac artery is injured.

[Functional results and treatment of functional dysfunctions after radical prostatectomy]

OBJECTIVE

To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer.

MATERIAL AND METHOD

Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta.

RESULTS

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach.

CONCLUSION

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.

Prevention and management of post prostatectomy erectile dysfunction

Sexual dysfunction is common in patients with prostate cancer (PC) following radical prostatectomy (RP). Review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics, intra and postoperative factors that may influence EF recovery, and postoperative treatments for erectile dysfunction (ED). A literature search was performed using Google and PubMed database for English-language original and review articles, either published or e-published up to July 2013. The literature still demonstrates a great inconsistency in the definition of what is considered normal EF both before and after RP. Thus, using validated psychometric instruments with recognized cut-offs for normalcy and severity during the pre- and post-operative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative ED, the concept of spontaneous or pharmacologically-assisted erections, and the difference between “back to baseline” EF and “erections adequate enough to have successful intercourse” clearly emerge as key issues in the eventual understanding of post-RP ED prevention and promotion of satisfactory EF recovery. Patient factors (including age, baseline EF, comorbid conditions status), cancer selection (non- vs. uni- vs. bilateral nerve-sparing), type of surgery (i.e., intra vs. inter vs. extrafascial surgeries), surgical techniques (i.e., open, laparoscopic and robotically-assisted RP), and surgeon factors (i.e., surgical volume and surgical skill) represent the key significant contributors to EF recovery. A number of preclinical and clinical data show that rehabilitation and treatment in due time are undoubtedly better than leaving the erectile tissue to its unassisted postoperative fate. The role of postoperative ED treatment for those patients who received a non-nerve-sparing RP was also extensively discussed. Optimal outcomes are achieved mainly by the careful choice of the correct patient for the correct type of surgery. Despite a plethora of potential rehabilitative approaches, they should be only considered as “strategies”, since incontrovertible evidence of their effectiveness for improving natural EF recovery is limited. Conversely, numerous effective therapeutic options are available for treating post-RP ED.

Transarterial embolization for pelvic hematoma following laparoscopic radical prostatectomy: A case report and review of the literature

The present study reports a case of hemorrhage from branches of the right obturator artery following laparoscopic radical prostatectomy. On post-operative day 9, the patient complained of lower abdominal pain, and the hemoglobin and hematocrit levels had decreased. Emergency computed tomography angiography showed a large pelvic hematoma suggesting active bleeding. Transarterial embolization (TAE) was performed using microcoils. There were no post-procedure complications. At 3 months post-surgery, using computed tomography, the pelvic hematoma was shown to have been absorbed. To the best of our knowledge, TAE for a hemorrhage from the obturator artery following laparoscopic prostatectomy has not previously been described. TAE is a safe and minimally invasive treatment compared with surgical intervention, and should be considered as a treatment for post-operative arterial hemorrhage.

Comparison of functional outcomes after retropubic, laparoscopic and robot-assisted radical prostatectomy: A meta-analysis

AIM: To assess the 6-mo and 12-mo functional outcomes after retropubic, laparoscopic and robot-assisted laparoscopic radical prostatectomy retropubic radical prostatectomy (RRP) laparoscopic radical prostatectomy (LRP); robot-assisted laparoscopic prostatectomy (RARP).

METHODS: A literature search was conducted using the PubMed, EMBASE, The Cochrane Library and the Web of Knowledge databases updated to March, 2014 for relevant published studies. After data extraction and quality assessment via the Newcastle-Ottawa Scale or the Cochrane collaboration’s tool for assessing risk of bias, meta-analysis was performed using RevMan 5.1. Either a random-effects model or a fixed-effects model was used. Potential publication bias was assessed using visual inspection of the funnel plots, and verified by the Egger linear regression test.

RESULTS: Thirty-seven studies were identified in total: 14 articles comparing LRP with RRP, 12 articles comparing RARP with RRP, and 11 articles comparing RARP with LRP. For urinary continence, a statistically significant advantage was observed in RARP compared with LRP or RRP both at 6 mo [odds ratio (OR) = 1.93; P < 0.01, OR = 2.23; P < 0.05, respectively] and 12 mo (OR = 1.47; P < 0.01, OR = 2.93; P < 0.01, respectively) postoperatively. The continence recovery rates after LRP and RRP, with obvious heterogeneity (6-mo: I² = 74%; 12-mo: I² = 75%), were equivalent (6-mo: P = 0.52; 12-mo: P = 0.75). In terms of potency recovery, for the first time, we ranked the three surgical approaches into a superiority level: RARP > LRP > RRP, with a statistically significant difference at 12 mo [RARP vs LRP (OR = 1.99; P < 0.01); RARP vs RRP (OR = 2.66; P < 0.01); LRP vs RRP (OR = 1.34; P < 0.05)], respectively. Meta-regression and subgroup analyses according to adjustment of the age, body mass index, prostate volume, Gleason score or prostate-specific antigen did not vary significantly.

CONCLUSION: Current evidence suggests that minimally invasive approaches (RARP or LRP) are effective procedures for functional recovery. However, more high-quality randomized control trials investigating the long-term functional outcomes are needed.

Are HIV-infected men vulnerable to prostate cancer treatment disparities?

BACKGROUND

HIV-infected (HIV(+)) men face cancer treatment disparities that impact outcome. Prostate cancer treatment and treatment appropriateness in HIV(+) men are unknown.

METHODS

We used electronic chart review to conduct a retrospective cohort study of 43 HIV(+) cases with prostate cancer and 86 age- and race-matched HIV-uninfected (HIV(-)) controls with prostate cancer, ages 40 to 79 years, from 2001 to 2012. We defined treatment appropriateness using National Comprehensive Cancer Network guidelines and the Charlson comorbidity index (CCI) to estimate life expectancy.

RESULTS

Median age was 59.5 years at prostate cancer diagnosis. Median CD4(+) T-cell count was 459.5 cells/mm(3), 95.3% received antiretroviral therapy, and 87.1% were virally suppressed. Radical prostatectomy was the primary treatment for 39.5% of HIV(+) and 71.0% of HIV(-) men (P = 0.004). Only 16.3% of HIV(+) versus 57.0% of HIV(-) men received open radical prostatectomy (P < 0.001). HIV(+) men received more radiotherapy (25.6% vs. 16.3%, P = 0.13). HIV was negatively associated with open radical prostatectomy (OR = 0.03, P = 0.007), adjusting for insurance and CCI. No men were undertreated. Fewer HIV(+) men received appropriate treatment (89.2% vs. 100%, P = 0.003), due to four overtreated HIV(+) men. Excluding AIDS from the CCI still resulted in fewer HIV(+) men receiving appropriate treatment (94.6% vs. 100%, P = 0.03).

CONCLUSION

Prostate cancer in HIV(+) men is largely appropriately treated. Under- or overtreatment may occur from difficulties in life expectancy estimation. HIV(+) men may receive more radiotherapy and fewer radical prostatectomies, specifically open radical prostatectomies.

IMPACT

Research on HIV/AIDS survival indices and etiologies and outcomes of this prostate cancer treatment disparity in HIV(+) men are needed.

Prospective comparison of one year follow-up outcomes for the open complete intrafascial retropubic versus interfascial nerve-sparing radical prostatectomy

Current work provides a prospective direct comparison between Open complete intrafascial-radical-prostatectomy (OIF-RP) and interfascial-RP in all outcomes in single centre series. Both techniques were done prospectively in 430 patients. Inclusion criteria for OIF-RP (n=241 patients) were biopsy Gleason-score ≤6 and PSA ≤10 ng/ml while for interfascial-RP (n=189) were Gleason-score ≤7 and PSA ≤15. The perioperative parameters (e.g. operative time, complications etc.), pathologic results, surgical margins and revisions were reviewed. Pre- and postoperative (3 and 12 months) evaluation of continence and potency was performed. All patients have preoperative IIEF-score of ≥15. Continence was classified as complete (no pads), mild (1-2 pads/day) and incontinence (>2 pads/day). Median patients’ age was 63.7 vs. 64.5 years for OIF-RP vs. Interfascial-RP, respectively. Preoperative PSA-level was significantly lower in OIF-RP (5.8 vs. 7.1), otherwise, similar perioperative data in both groups except for more frequent pT3-tumors in interfascial-RP group (18%). No statistical significance regarding continence was observed between OIF-RP vs. Interfascial-RP groups at 3 (82% vs. 85%) and 12 months (98% vs. 96%) postoperatively. Potency rates (IIEF ≥15) after OIF-RP were 96% (≤55 years), 72% (55-65), and 75% (>65 years) at 12 months. The respective rates for interfascial-group were 58%, 61% and 51%. There was an advantage for OIF-RP potency-outcomes without significance over Interfascial-RP in weak potency patients (IIEF=15-18). We conclude that OIF-RP is associated with better functional results without compromising early oncological results compared to interfascial-RP. Complete preservation of periprostatic fasciae provides significantly better postoperative recovery of sexual function even for weak potency patients. Longer follow-up is mandatory to further evaluate the outcome results of this technique.

A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1:2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤ 65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.

Laparoscopic versus open bilateral intrafascial nerve-sparing radical prostatectomy after TUR-P for incidental prostate cancer: surgical outcomes and effect on postoperative urinary continence and sexual potency

OBJECTIVE

To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRPT) and nerve-sparing retropubic radical prostatectomy (nsRRPT) after TUR-P for incidental prostate cancer.

MATERIALS AND METHODS

Between January 2003 and August 2011, 125 nsLRPT and 128 nsRRPT for incidental prostate cancer diagnosed after TUR-P were performed at our clinic. Demographic data, peri- and postoperative measurements and functional outcomes were compared.

RESULTS

The mean operative time was 153.1 ± 35.4 min for nsLRPT and 122.5 ± 67.5 min for nsRRPT (p = 0.03). The mean catheterization time was 8 ± 1 days in the laparoscopic group and 11 ± 2 days in the open group (p = 0.02). Also, the length of hospitalization presents statistical significant difference in the two groups. Positive margins were detected in 2.4 and 4.7% of patients with pT2c tumours in the laparoscopic and open groups, respectively (p = 0.09). At a mean follow-up of 26.9 ± 9.3 months for the nsLRPT group and of 27.8 ± 9.7 months for the nsRRPT group, all patients were alive with no evidence of tumour recurrence. Twelve months postoperatively, complete continence was reported in 96.8% of patients who underwent an nsLRPT and in 89.4% of patients in the nsRRPT group (p = 0.02). At that time, 74.4% of patients in the nsLRPT group and 53.1% in the nsRRPT group reported the ability to engage in sexual intercourse (p = 0.0004).

CONCLUSION

nsLRPT after TUR-P, performed by expert surgeons, results to be a safe procedure with excellent functional outcomes with regard to the urinary continence and sexual potency.

Dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy

Objectives

To describe a novel dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and to evaluate its postoperative outcomes.

Methods

A total of 109 patients who underwent laparoscopic radical prostatectomy by a single surgeon were evaluated, including 44 patients with dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy, 20 patients with conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and 45 patients with non-nerve-sparing laparoscopic radical prostatectomy. Functional outcomes were evaluated using a self-administered questionnaire (Expanded Prostate Cancer Index Composite). Continence was defined as zero to one security pad per day. Oncological outcomes were evaluated based on positive surgical margin.

Results

In the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group, the continence rate was 57%, 77% and 95% at 1, 3 and 12 months, respectively. The continence rate in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy group was 37%, 63% and 90%, and in the non-nerve-sparing laparoscopic radical prostatectomy group it was 23%, 57% and 82% at 1, 3, and 12 months, respectively. The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group showed a significantly earlier recovery from incontinence compared with that in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and non-nerve-sparing laparoscopic radical prostatectomy groups (log–rank test, P = 0.044 and P < 0.001). Similarly, the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group tended to show a more early recovery in relation to urinary function of the Expanded Prostate Cancer Index Composite. Regarding sexual function, there were no significant differences between the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and conventional intrafascial nerve-sparing laparoscopic radical prostatectomy groups. In pT2 patients, the positive surgical margin rate of the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group (11%) was similar to that of the other two groups (conventional intrafascial nerve-sparing laparoscopic radical prostatectomy 7%; non-nerve-sparing laparoscopic radical prostatectomy 11%).

Conclusions

The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome.

Intrafascial dissection significantly increases positive surgical margin and biochemical recurrence rates after robotic-assisted radical prostatectomy

INTRODUCTION

Improved visualization and magnification in robot-assisted laparoscopic radical prostatectomy (RALRP) has tempted many urologists to dissect the neurovascular bundle closer to the prostate following the layers of the pseudo-capsule of the prostate. This might bear a higher risk of decreased tumor control.

MATERIALS AND METHODS

An analysis of a consecutive series of 186 patients who underwent RALRP at our institution was performed. The outcome of patients with intrafascial nerve-sparing (INS) was compared with the outcome of patients who underwent interfascial, extrafascial or no nerve-sparing (non-INS).

RESULTS

A total of 80 patients (43.0%) received INS. The overall R1 rate was 27.9%. For pT2 tumors the rate of R1 was 33.8% in INS versus 14.8% in non-INS (odds ratio 2.936, 95% confidence interval 1.338-6.443, p = 0.007). Recurrence-free survival was significantly shorter in INS (p = 0.05; hazard ratio 3.791).

CONCLUSION

The intrafascial dissection technique for RALRP bears a high risk of incomplete resection in localized prostate cancer resulting in unfavorable outcome.

Prevention and management of postprostatectomy sexual dysfunctions. Part 1: choosing the right patient at the right time for the right surgery

CONTEXT

Sexual dysfunction is common in patients following radical prostatectomy (RP) for prostate cancer (PCa).

OBJECTIVE

To review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics and intra- and postoperative factors that may influence EF recovery.

EVIDENCE ACQUISITION

A literature search was performed using Google and PubMed database for English-language original and review articles either published or e-published up to November 2011.

EVIDENCE SYNTHESIS

The literature demonstrates great inconsistency in what constitutes normal EF before surgery and what a man may consider a normal erection after RP. The use of validated psychometric instruments with recognised cut-offs for normalcy and severity during the pre- and postoperative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative erectile dysfunction (ED), the concept of spontaneous or pharmacologically assisted erections, and the difference between "back to baseline" EF and "erections adequate enough to have successful intercourse" clearly emerge as key issues in the eventual understanding of the prevention of ED and promotion of satisfactory EF recovery post-RP. Patient factors (including age, baseline EF, and status of comorbid conditions), cancer selection (unilateral vs bilateral nerve sparing), type of surgery (ie, intra- vs inter- vs extrafascial surgeries), surgical techniques (ie, open, laparoscopic, and robot-assisted RP), and surgeon factors (ie, surgical volume and surgical skill) represent the key significant contributors to EF recovery.

CONCLUSIONS

The complexity of the issues discussed throughout this review culminates in the simple concept that optimal outcomes are achieved by the careful choice of the correct patient for the correct type of surgery.

Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients

Study Type - Therapy (case series).

LEVEL OF EVIDENCE

 4. What's known on the subject? and What does the study add? Bilateral nerve-sparing radical prostatectomy still represents an issue for urologists as the indications to perform it depend oft from the personal clinical experience. Moreover, until now data concerning bilateral and unilateral laparoscopic nerve-sparing radical prostatectomy have been limited. This study states that bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes when compared with unilateral nsLRP and it suggests to prefer a bilateral nerve-sparing technique in younger patients with low-risk, organ-confined prostate cancer.

OBJECTIVE

To evaluate the surgical and functional outcomes in bilateral and unilateral nerve-sparing laparoscopic radical prostatectomy (nsLRP).

PATIENTS AND METHODS

Between January 2005 and May 2009, 457 nsLRP were performed at our clinic. In all, 250 patients underwent a bilateral nsLRP and 207 patients underwent an unilateral nsLRP. One surgeon performed all the operations. All patients presented at biopsy a localized prostate cancer. Demographic data and perioperative and postoperative measurements and outcomes were compared.

RESULTS

The operative times for bilateral nsLRP and unilateral nsLRP were 165 ± 45 min and 130 ± 25 min, respectively. The mean intra-operative blood loss was 450 ± 300 mL and 270 ± 160 mL in the bilateral and unilateral nsLRP groups with a transfusion rate of 3% and 1%, respectively (P = 0.013). Conversion to open surgery was never deemed necessary. Postoperatively, the mean Gleason Score after nsLRP and distribution of tumour stages was similar in the two groups, and the frequency of positive margins in both groups did not present any statistically significant difference. At 12 months, a complete continence was reported in 97% of patients who underwent a bilateral nsLRP and in 88% of patients of the unilateral nsLRP group. At that time, 69% in the bilateral nsLRP and 43% in the unilateral nsLRP groups reported the ability to engage in sexual intercourse.

CONCLUSION

The bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes with regard to urinary continence and sexual potency, when compared with unilateral nsLRP, reporting similar oncological outcomes.