Denonvilliers’ fascia acts as the fulcrum and hammock for continence after radical prostatectomy

Application of Denonvilliers' Fascia Arch as an Anatomical Landmark in Laparoscopic Radical Prostatectomy: A Retrospective Cohort Study

BACKGROUND

This study aims to evaluate the clinical application of Denonvilliers' fascia arch (DFA) as a novel anatomical landmark in laparoscopic radical prostatectomy (LRP), comparing with the conventional extraperitoneal LRP approach.

PATIENTS AND METHODS

This retrospective cohort study analyzed 304 patients who underwent LRP between January 2019 and January 2024. Patients were divided into two groups: the experimental group (n = 152), who underwent extraperitoneal LRP using DFA as a landmark, and the control group (n = 152), who underwent conventional LRP. Perioperative outcomes, including surgical time, blood loss, complications, and functional recovery (urinary continence and erectile function), were evaluated. Logistic regression analysis assessed the risk factors for postoperative urinary incontinence and erectile dysfunction.

RESULTS

The experimental group showed significantly improved outcomes. The median surgical time was 134 minutes, compared with 171 minutes in the control group (P < 0.001). Intraoperative blood loss was lower in the experimental group (58 mL vs. 103 mL, P < 0.001). The incidence of rectal injury was lower (1 vs. 9 cases, P = 0.010), and the Clavien-Dindo grade ≥ II complication rate was significantly reduced (3.3% vs. 10.4%, P = 0.013). The experimental group also showed better recovery in urinary continence (30.9% vs. 17.8%, P = 0.008) and erectile function (median IIEF score of 8 vs. 6, P < 0.001).

CONCLUSIONS

The use of DFA as a landmark in LRP improves surgical efficiency, reduces complications, and enhances functional recovery compared to the conventional approach. DFA provides an effective method for precise DF identification, offering substantial clinical value in LRP.

Improved early continence following laparoscopic radical prostatectomy: the urethral hammock technique

PURPOSE

To introduce and illustrate a novel urethral reconstruction technique-the 'urethral hammock-technique'-and to assess its impact on early postoperative continence following laparoscopic radical prostatectomy (LRP).

METHODS

119 patients who underwent LRP between January 2020 and May 2022 (hammock group: n = 43, control group: n = 76) were included in the study. The primary outcome was continence (zero pads or max. one security pad) at 1, 3, and 6 months following surgery. Secondary outcomes were operative time, complications, and histological findings. Univariate and multivariate regression analyses were performed to reveal predictors for continence. p values < 0.05 with a two-sided 95%-confidence interval were considered statistically significant.

RESULTS

Baseline characteristics were comparable among both groups. The number of patients achieving complete continence in both the hammock and control groups at various time intervals was: 4 weeks 37.2% (16/43) vs. 19.2% (14/73) (p = 0.047); 3 months 60.5% (26/43) vs. 37.3% (28/75) (p = 0.021) and 6 months 72.1% (31/43) vs. 60.3% (44/73) (p = 0.23), respectively. Adjusting for bladder neck preservation status and age, the hammock technique was a significant predictor for continence for the 4-week (OR 0.33, 95% CI 0.13-0.83, p = 0.019) and 3-month (OR 0.28, 95% CI 0.12-0.66, p = 0.004) interval but not for the 6-month interval (OR 0.64, 95% CI 0.27-1.5, p = 0.31). Operative time, complication rates, time till catheter extraction and histological findings were comparable between both groups (all p > 0.05).

CONCLUSIONS

The hammock technique is a simple and reproducible technique to improve early postoperative continence for at least 3 months following surgery. However, these promising results warrant confirmation through a randomized controlled trial.

Surgical techniques to preserve continence after robot-assisted radical prostatectomy

Radical prostatectomy significantly impacts the inherent anatomy of the male pelvis and the functional mechanisms of urinary continence. Incontinence has a considerable negative influence on the quality of life of patients, as well as their social and psychological wellbeing. Numerous surgical techniques have been demonstrated to support the preservation of continence during robot-assisted radical prostatectomy (RARP). In this in-depth analysis, we give a general summary of the surgical techniques used in RARP and their impact on incontinence rates.

Efficacy and safety evaluation of complete intrafascial prostatectomy in suspected prostate cancer patients with dysuria: a retrospective cohort study

Background

Suspected localized prostate cancer (PCa) patients with dysuria Complete intrafascial prostatectomy (CIP) can remove the whole prostate gland with the maximal retain of adjacent normal tissues around the prostate, and can be applied in some suspected localized prostate cancer (PCa) patients with dysuria. However, precious few studies have assessed the efficacy and safety of CIP in these patients without preoperative needle biopsies.

Methods

In this retrospective single-arm cohort study, all 22 suspected PCa patients with dysuria who underwent CIP at our hospital were enrolled. The clinical data including age, prostate-specific antigen (PSA), free-serum PSA, prostate volume, perioperative and postoperative complications were collected. The PSA level at 6 weeks after CIP and recoveries of urinary continence and erectile function were acquired in the follow-up procedures, and were used as the main measurements of efficacy and safety for CIP respectively.

Results

The patients had an average age of 71.91±8.29 years and an average preoperative PSA level of 10.75±4.25 ng/mL. The operations for all 22 patients were successfully completed. The average operation time was 135.20±41.44 min (range, 40.0-215.0 min), and the average blood loss volume was 128.64±145.09 mL. In total, 17 patients (77.27%) had PCa confirmed by postoperative pathology, and 5 patients (22.73%) had benign prostatic hyperplasia. The PSA level dropped to 0.010±0.004 ng/mL at 6 weeks after surgery. According to the loose criteria to assess urinary incontinence, the patients achieved continence rates of 63.6% immediately after the operation, 95.5% at 1 month, and 100% at 3 months. According to the strict criteria, the continence rates immediately, and at 1, 3, 6, and 9 months after surgery were 27.3%, 63.6%, 90.9%, 95.5%, and 100%, respectively. None of the patients complained of urinary obstruction symptoms after surgery. Before CIP, all the patients had erectile dysfunction and an International Index of Erectile Function 5 (IIEF-5) score of 9.64±5.91. After surgery, the patients had IIEF-5 scores at 3, 6, and 12 months of 5.45±4.43, 6.95±5.30, and 7.57±5.69, respectively.

Conclusions

Although the study had some limitations, CIP may be a prudent option for patients with suspected localized PCa who also present with dysuria.

Identifying prognostic parameters related to surgical technique in patients treated by robotic radical prostatectomy

INTRODUCTION AND OBJECTIVE

The most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen. Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival.

PATIENTS AND METHOD

Prospective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years. Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors. We performed univariate and matched comparisons of survival using Kaplan-Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p).

RESULTS

Cohort of 667 patients with a median follow-up of 69 months. In univariate analysis, surgeon (adjp=0.018), preservation of puboprostatic ligaments (adjp=0.02), preservation of endopelvic fascia (adjp=0.001) and performing periurethral suspension (adjp<0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp=0.04). Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance.

CONCLUSIONS

The surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

Denonvilliers’ Fascia: The Prostate Border to the Outside World

Simple Summary

Prostate cancer is a very common neoplasm in men, with surgery being a valuable tool for its successful management. The prostate gland lies deep in the male pelvis with several sheets of fibrous membranes surrounding it along anterior, lateral, and posterior surfaces. These membranes are called fasciae. Arteries, veins, and nerve fibers that are important for erectile function and continence can be found within these fasciae. An important fascia covering the posterior surface of the prostate and separating it from the rectum is Denonvilliers’ fascia. This structure is important for the confinement of cancer within the prostate and for completing an operation without damaging the nerves responsible for erectile function and continence while also removing all neoplastic tissue. This review covers the anatomical aspects of this structure, along with providing some clinical insight on how to use this knowledge to improve clinical outcomes.

Abstract

The fascial structure around the prostate has been a controversial issue for several decades, but its role in radical prostatectomy is crucial to achieving successful nerve-sparing surgery. One of the fasciae surrounding the prostate is Denonvilliers’ fascia, forming its posterior border with the rectum and enclosing along its layers several fibers of the neurovascular bundle. This review focuses on embryological and anatomical points of Denonvilliers’ fascia, aiming to provide a summary for the operating general surgeons and urologists of this area.