The incidence and anatomy of accessory pudendal arteries as depicted on multidetector-row CT angiography: clinical implications of preoperative evaluation for laparoscopic and robot-assisted radical prostatectomy

3D printed patient-specific prostate cancer models to guide nerve-sparing robot-assisted radical prostatectomy: a systematic review

Precise knowledge of each patient's index cancer and surrounding anatomy is required for nerve-sparing robot-assisted radical prostatectomy (NS-RARP). Complementary to this, 3D printing has proven its utility in improving the visualisation of complex anatomy. This is the first systematic review to critically assess the potential of 3D printed patient-specific prostate cancer models in improving visualisation and the practice of NS-RARP. A literature search of PubMed and OVID Medline databases was performed using the terms "3D Printing", "Robot Assisted Radical Prostatectomy" and related index terms as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eight articles were included; six were identified via database searches, to which a further two articles were located via a snowballing approach. Eight papers were identified for review. There were five prospective single centre studies, one case series, one technical report and one letter to the editor. Of these articles, five publications (62.5%) reported on the utility of 3D printed models for NS-RARP planning. Two publications (25%) utilised 3D printed prostate models for simulation and training, and two publications (25%) used the models for patient engagement. Despite the nascency of the field, 3D printed models are emerging in the uro-oncological literature as a useful tool in visualising complex anatomy. This has proven useful in NS-RARP for preoperative planning, simulation and patient engagement. However, best practice guidelines, the future regulatory landscape, and health economic considerations need to be addressed before this synergy of new technologies is ready for the mainstream.

Development of a Three-dimensional Surgical Navigation System with Magnetic Resonance Angiography and a Three-dimensional Printer for Robot-assisted Radical Prostatectomy

We sought to develop a surgical navigation system using magnetic resonance angiography (MRA) and a three-dimensional (3D) printer for robot-assisted radical prostatectomy (RARP). Six patients with pathologically proven localized prostate cancer were prospectively enrolled in this study. Prostate magnetic resonance imaging (MRI), consisting of T2-weighted sampling perfection with application-optimized contrasts using different flip-angle evolutions (SPACE) and true fast imaging with steady-state precession (true FISP), reconstructed by volume rendering, was followed by dynamic contrast-enhanced MRA performed with a volumetric interpolated breath-hold examination (VIBE) during intravenous bolus injection of gadobutrol. Images of arterial and venous phases were acquired over approximately 210 seconds. Selected images were sent to a workstation for generation of 3D volume-rendered images and standard triangulated language (STL) files for 3D print construction. The neurovascular bundles (NVBs) were found in sequence on non-contrast images. Accessory pudendal arteries (APAs) were found in all cases in the arterial phase of contrast enhancement but were ill-defined on non-contrast enhanced MRA. Dynamic contrast-enhanced MRA helped to detect APAs, suggesting that this 3D system using MRI will be useful in RARP.

Multiple variations in the pelvic vasculature - a case report

A thorough knowledge of possible variations of pelvic vasculature is very useful for surgeons, gynaecologists, radiologists, urologists and orthopaedic surgeons. We report multiple vascular variations in the left half of the pelvis of an adult male cadaver. Iliolumbar artery arose from the main trunk of the internal iliac artery. Posterior division of the internal iliac artery gave two lateral sacral arteries and a superior gluteal artery. The anterior division of the internal iliac artery gave origin to superior vesical, inferior vesical, inferior gluteal and internal pudendal arteries. The internal pudendal artery gave origin to a common trunk before leaving the pelvis. The common trunk divided into middle rectal artery and deep artery of the penis. The obturator artery took origin from the inferior epigastric artery and descended downward to the pelvis and left the pelvis by passing through the obturator foramen. Most of the other veins accompanying the arteries joined to form a plexus on the superior surface of the pelvic diaphragm. This plexus condensed to form anterior and posterior divisions of the internal iliac vein. Apart from this, the posterior part of the plexus drained directly into the common iliac vein through a large unnamed vein.

Pelvic magnetic resonance imaging angioanatomy of the arterial blood supply to the penis in suspected prostate cancer patients

PURPOSE

To describe the internal pudendal artery (IPA) and accessory pudendal artery (APA) detected by magnetic resonance (MR) angiography to help surgeons to find and preserve them during radical prostatectomy (RP).

MATERIALS AND METHODS

Constrast-enhanced MR 3.0 T angiography of the pelvis were performed in 111 male patients suspected diagnosis of prostate cancer (PCa), and describe the penile arterial blood supply.

RESULTS

There are three patterns of the arterial blood supply to the penis (IPA and/or APA) accounting for 51.4%, 46.8% and 1.8% of cases, respectively. About the accessory pudendal artery (APA): 54/111 (48.6%) patients had APA with five different branching patterns, they were type I (APA bilateral symmetry): 17 (31.5%); type II (APA bilateral asymmetry): 1 (1.9%); type III (APA unilateral lateral): 13 (24%); type IV (APA unilateral apical): 21 (38.9%); type V (APA unilateral mix): 2 (3.7%). APA origin were from inferior epigastric artery (IEA): 7 (9.5%); from inferior vesical artery (IVA): 32 (43.2%); from obturator artery (OA): 35 (47.3%).

CONCLUSION

A precise angioanatomic evalutation of arteries destined to the penis by MR angiography pre-operation for male pelvic organs will help surgeons to preserve them and contributes to reduce the erectile dysfunction after these procedures.

Erectile Function Following Prostate Cancer Treatment: Factors Predicting Recovery

Prostate cancer represents the most common nonskin malignancy encountered in men, and the excellent long-term survival achieved in the majority of patients has allowed more attention to be given to the side effects associated with its treatment. Erectile function is one of the main concerns of patients when considering treatment options for prostate cancer. Not surprisingly, post-treatment sexual function is closely related to outcome satisfaction and has long-lasting effects on quality of life. Radical prostatectomy is currently the most commonly employed therapy for prostate cancer. Conflicting rates of erectile dysfunction have been reported after surgery, owing not only to different surgical techniques but also because of dissimilar patient populations and definitions. Providing accurate information to individual patients in regards to their chances of recuperating the ability to have intercourse after treatment is important not only because it allows patients to make informed decisions but also because it has the potential to reduce treatment dissatisfaction. This article mainly focuses on discussing predictors of erectile function after radical prostatectomy. Patient factors, surgical aspects, including comparisons between open, laparoscopic, and robotic approaches, and postoperative management issues that impact sexual outcomes are evaluated. Prediction models combining multiple factors are described. The definition and chronology of erectile function recovery and impact of sexual function on quality of life after surgery are also discussed. Teloken PE and Mulhall JP. Erectile function following prostate cancer treatment: Factors predicting recovery. Sex Med Rev 2013;1:91-103.

Anatomy of the sinoatrial nodal branch in Korean population: imaging with MDCT

Objective

To evaluate, on a retrospective basis, the anatomic characteristics of the arterial supply to the sinoatrial node (SAN) in the Korean population using an ECG-gated multi-detector CT (MDCT).

Materials and Methods

The electrocardiographic-gated MDCTs of 500 patients (258 men and 242 women; age range, 17-83 years; mean age, 58.6 ± 12.04 years) were analyzed retrospectively. In each case, the SAN artery (arteries) was named according to a special nomenclature with regard to origin, course, and termination.

Results

A total of 516 SAN arteries were visualized in 496 patients. The SAN was supplied by a single artery in 476 (96.4%) cases and by 2 arteries in 18 (3.6%) cases. The SAN originated from the right coronary artery in 265 (53.4%) cases and from the left circumflex in 213 (43%) cases.

Conclusion

This study can provide basic data on variations of the SAN artery in the Korean population.

Preoperative detection and localization of accessory pudendal artery with contrast-enhanced MR angiography

PURPOSE

To evaluate the diagnostic performance of contrast material-enhanced magnetic resonance (MR) angiography for preoperative detection and localization of accessory pudendal arteries (APAs) in patients with prostate cancer.

MATERIALS AND METHODS

This prospective study was approved by the institutional review board, and informed consent was obtained. Between July 2007 and December 2010, 127 patients underwent contrast-enhanced MR angiography following prostate MR imaging at 3.0 T before robot-assisted laparoscopic radical prostatectomy (RALP). APAs were defined as any arteries located in the periprostatic region and anastomosed with the common penile artery or its branches; they were then subclassified into lateral and apical APAs. For detecting and localizing APAs, MR angiograms were evaluated prospectively by one reader and retrospectively by two independent blinded readers. Diagnostic performance was determined on a per-patient basis by using surgical findings as the reference standard. In addition, the origin of APAs identified at both surgery and contrast-enhanced MR angiography was determined by consensus of two retrospective readers. Interreader agreements were assessed by using k statistics.

RESULTS

At surgery, 19 APAs (seven right apical, three left apical, four right lateral, and five left lateral) were detected in 16 patients, and 16 of these APAs were localized in 13 patients at preoperative contrast-enhanced MR angiography. Prospectively, sensitivity, specificity, and accuracy of contrast-enhanced MR angiography for the localization of APAs were 81.3%, 93.7%, and 92.1%, while retrospectively they were 87.5%, 91.9%, and 91.3% for reader 2 and 75.0%, 90.1%, and 88.2% for reader 3, respectively. Overall interreader agreement was substantial (k = 0.795). Nine and seven APAs originated from the obturator artery and the inferior vesical artery, respectively.

CONCLUSION

Contrast-enhanced MR angiography can be used for the preoperative detection of APAs in patients with prostate cancer.

Fine-tuning robot-assisted radical prostatectomy planning with MRI

OBJECTIVES

Robot-assisted radical prostatectomy (RARP) has now become the most common surgical treatment option for prostate cancer (CaP). Clinicopathologic data (i.e., biopsy, digital rectal exam, prostate specific antigen level) and patient-specific factors (e.g., age, erectile function, co-morbidities) are the primary sources of information that urologists use for counseling and treatment decision making. Magnetic resonance imaging (MRI) has evolved along a similar temporal arc to RARP, with increased utilization and precision over the past decade. MRI prior to RARP provides multifaceted adjunctive information, including enhancement of locoregional staging, delineation of spatial anatomic information, and identification of aberrant anatomy, all of which aid in patient treatment counseling and operative planning. This article is designed for urologic surgeons who perform RARP, with the aim of providing a review of prostate MRI imaging and highlighting findings which may specifically alter the operation.

METHODS AND MATERIALS

A review of the literature was performed, focusing on the most recent publications.

RESULTS

MRI imaging of the prostate has become increasing accurate for the identification, localization, and characterization of CaP lesions. In addition to tumor-specific information, a number of intra- and extra-prostatic findings are consistently identified on MRI which may impact RARP.

CONCLUSIONS

MRI provides important information which may alter RARP.