Complete periprostatic anatomy preservation during robot-assisted laparoscopic radical prostatectomy (RALP): the new pubovesical complex-sparing technique.

Abstract

Puboprostatic ligament preservation has been proposed as a method to accelerate continence recovery after radical prostatectomy (RP). However, these ligaments present anatomic continuity with the bladder, and there must be interruption at some point to expose the prostatourethral junction.
To describe the surgical steps of pubovesical complex (PVC)-sparing robot-assisted laparoscopic RP (RALP) and present the preliminary results of our technique.
Thirty PVC-sparing RALP procedures were performed in patients <60 yr with clinically localised prostate cancer between 2007 and 2009 by the same surgeon.
The principles of bladder neck preservation, tension and energy-free dissection of the bundles as well as seminal vesicle sparing are applied. Ventrally, a plane of dissection is developed between the detrusor apron and the prostate. The soft connective tissue between Santorini's plexus and the prostate is blandly dissected, leaving the plexus intact and in place.
The rates and location of positive surgical margins (PSM) as well as functional outcomes are presented.
Three of 30 patients (10%) had a PSM (two apical margins and one on the left posterolateral side). At catheter removal, 24 of 30 patients (80%) were dry (0 pads), and 6 of 30 patients (20%) needed one security pad. After 3 mo, 22 of 30 patients (73%) presented an International Index of Erectile Function score >17 (with or without phosphodiesterase type 5 inhibitors). Thirteen of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4. Small sample size, low mean age of enrolled patients (52 yr), and the absence of diseases that could impair the continence and potency recovery are some of the limitations of the study. Moreover, it is difficult to quantify the effect of each applied continence-sparing technique.
The holistic preservation of the PVC during RALP is technically feasible. It leads towards an absolute preservation of the periprostatic anatomy that may enhance early functional outcomes. Further studies are needed to confirm our results.

Full text

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Surgery in Motion
Complete Periprostatic Anatomy Preservation During
Robot-Assisted Laparoscopic Radical Prostatectomy (RALP):
The New Pubovesical Complex-Sparing Technique
Anastasios D. Asimakopoulosa,*, Filippo Anninob, Alejandro D’Orazioc, Clovis Fraga T. Pereirad,
Camille Mugnierc, Jean-Luc Hoepffnerc, Thierry Piechaudc, Richard Gastonc
aDivision of Urology, Department of Surgery, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy
bDepartment of Urology, University of Modena and Reggio Emilia, Modena, Italy
cDepartment of Urology, Clinique Saint Augustin, Bordeaux, France
dServic ¸o de Urologia do Instituto de Medicina Integral Prof. Fernando Figueira – IMIP, Recife/PE, Brazil
E U R OP E A N U R O L O G Y 5 8 ( 2 0 1 0 ) 4 0 7 – 4 1 7
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Article info
Article history:
Accepted April 29, 2010
Published online ahead of
print on May 18, 2010
Keywords:
Pubovesical complex
Robot-assisted prostatectomy
Radical prostatectomy
Early incontinence
Prostate cancer
Detrusor apron
Dorsal vascular complex
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Abstract
Background: Puboprostatic ligament preservation has been proposed as a method to accel-
erate continence recovery after radical prostatectomy (RP). However, these ligaments
present anatomic continuity with the bladder, and there must be interruption at some point
to expose the prostatourethral junction.
Objectives: To describe the surgical steps of pubovesical complex (PVC)–sparing robot-
assisted laparoscopic RP (RALP) and present the preliminary results of our technique.
Design, setting, and participants: Thirty PVC-sparing RALP procedures were performed in
patients <60 yr with clinically localised prostate cancer between 2007 and 2009 by the same
surgeon.
Surgical procedure: The principles of bladder neck preservation, tension and energy-free
dissection of the bundles as well as seminal vesicle sparing are applied. Ventrally, a plane of
dissection is developed between the detrusor apron and the prostate. The soft connective
tissue between Santorini’s plexus and the prostate is blandly dissected, leaving the plexus
intact and in place.
Measurements: The rates and location of positive surgical margins (PSM) as well as func-
tional outcomes are presented.
Resultsandlimitations: Threeof30patients(10%)hadaPSM(twoapicalmarginsand oneon
the left posterolateral side). At catheter removal, 24 of 30 patients (80%) were dry (0 pads),
and 6 of 30 patients (20%) needed one security pad. After 3 mo, 22 of 30 patients (73%)
presented an International Index of Erectile Function score >17 (with or without phospho-
diesterasetype5inhibitors).Thirteenof22potentpatientshadanErectionHardnessScoreof
3, and 9 of 22 patients had a score of 4. Small sample size, low mean age of enrolled patients
(52 yr), and the absence of diseases that could impair the continence and potency recovery
are some of the limitations of the study. Moreover, it is difficult to quantify the effect of each
applied continence-sparing technique.
Conclusions: The holistic preservation of the PVC during RALP is technically feasible. It leads
towards an absolute preservation of the periprostatic anatomy that may enhance early
functional outcomes. Further studies are needed to confirm our results.
# 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
Tel. +39 06 20902835/+39 340 6054387; Fax: +39 06 20902975.
E-mail address: tasospao2003@yahoo.com (A.D. Asimakopoulos).
0302-2838/$ – see back matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.doi:10.1016/j.eururo.2010.04.032

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1.Introduction
Stress urinary incontinence represents one of the most
feared complications of radical prostatectomy (RP) [1].
Patients expect not only to be continent but also to have a
quick return to continence. Some robot-assisted laparosco-
pic RP (RALP) series report continence rates at catheter
removal of about 70% [2]; however, the weighted mean
continence rate immediately after catheter removal follow-
ing RALP is 25.7% [3]. Evidently, early recovery of urinary
continence remains a challenge to be overcome.
Puboprostatic ligament preservation has been proposed
to achieve accelerated return of continence after nerve-
sparing procedures. Even with this technique, the rates of
postoperative continence remain low [4]. A possible
explanation could be that because there is demonstrable
anatomic continuity with the bladder, there are no
conceivable means of preserving the pubovesical ligaments
during RALP, and there must be interruption at some point
to expose the prostatourethral junction [5,6].
The management of the dorsal vascular complex (DVC)
could also have important implications in continence
recovery [7]. It has been demonstrated that the ‘‘cut and
ligate’’ of the DVC technique offers quicker continence
recovery than a ‘‘ligate and cut’’ technique [7]. However,
both selective and standard ligation present inherent
drawbacks (see Appendix A); thus, a ‘‘no touch’’ approach
might be the ideal way to manage the DVC.
The aim of our study was to propose and describe the
steps of a new technique of surgical dissection that
maximises the preservation of the periprostatic anatomy
by keeping intact the pubovesical complex (PVC; ie,
detrusor apron with pubovesical ligaments, DVC). To our
knowledge, this is the first demonstration of the feasibility
of this technique in the field of RALP. Our preliminary
oncologic and functional results are also presented.
2.Methods and patients
2.1. Patient selection and eligibility criteria
The PVC-sparing RALP was applied in 30 men with clinically localised
prostate cancer (PCa) from October 2007 to March 2009. All the
procedures were performed by one experienced surgeon (RG; previous
experience shown in Table 1). The study was conducted in accordance
with Good Clinical Practice rules and with the ethical principles
contained in the Declaration of Helsinki as amended in Hong Kong.
Each patient gave written informed consent, and the study protocol
obtained institutional review board approval.
All patients were staged according to the surgeon’s protocol for
intrafascial dissection with a prostatic endorectal magnetic resonance
imaging (MRI) scan (to evaluate the likelihood of extracapsular
extension). Preoperative continence and erectile status were evaluated
as documented by the International Continence Society (ICS) male short
form (ICSmaleSF) questionnaire [8] and the International Index of
Erectile Function (IIEF-6) erectile function domain score questionnaire
(questions 1–5 and 15). Vascular (eg, diabetes mellitus, hypertension,
dyslipidaemia, coronary artery disease) or neurologic comorbidities
were prospectively registered in our database both in number and in
severity. The presence of such conditions did not represent exclusion
criteria, provided preoperative continence and potency were normal.
(Inclusion and exclusion criteria are reported in Table 2. Prospectively
collected data are shown in Table 3.)
Biochemical recurrence (BCR) was defined as a serum prostate-
specific antigen (PSA) level >0.2 ng/ml on two consecutive measure-
ments. Acute toxicity of adjuvant radiation therapy (RT; onset <90 d
after the start of the treatment) was scored using the Common Toxicity
Criteria version 2.0 [9]. Late toxicity was scored according to the
Radiation Therapy Oncology Group/European Organisation for Research
and Treatment of Cancer morbidity scale version 9 [10].
All medical and surgical complications occurring both in inpatient
and outpatient settings were recorded. They were classified as early
(onset <30 d), intermediate (31–90 d), and late (>90 d) and graded
according to the modified Clavien classification [11].
2.2. Surgical technique
The patient and trocar positions and the initial steps of the surgery,
including the peritoneal incision, Retzius space preparation, and the
tension and energy-free nerve-sparing dissection have been previously
described [12]. We focus here on the refinements of our technique.
2.2.1.
The catheter balloon previously filled to 5 ml is deflated, aiding in the
identification of the bladder neck. The robotic atraumatic grasper is
advanced in the operating field, and it gently retracts the bladder.
We start the dissection on the right side, in the limit between the
detrusor and the base of the prostate, lateral to the pubovesical
ligaments. We develop this plane in depth, reaching the Denonvilliers’
fascia that covers the anterior surface of the seminal vesicle. (According
to some authors [13], no Denonvilliers’ fascia is present anterior to the
seminal vesicles—only a muscular structure with longitudinal disposi-
tion of the fibres tented between the outer layer of the bladder muscle
and the prostate base. The incision exposes the vas deferens and the
seminal vesicles.) Some big arterial branches for the base of the prostate
located here are carefully clipped (Aesculap/B Braun, Melsungen,
Bladder neck dissection: right side
Table 2 – Inclusion and exclusion criteria
Inclusion criteriaExclusion criteria
Age <60 yrPreoperative incontinence or
erectile dysfunction
Prostatic volume >60 mlClinically organ-confined
disease (cT1–cT2a)
Gleason score ?6
Total serum PSA ?10 ng/ml
Neoadjuvant therapy
Any previous prostatic, urethral,
or bladder neck surgery
Positive anterior biopsyNormal preoperative continence,
IIEF-6 >17 and normal IPSS
Positive MRI of the anterior
prostate
PSA = prostate-specific antigen; IIEF-6 = International Index of Erectile
Function; IPSS = International Prostate Symptom Score; MRI = magnetic
resonance imaging.
Table 1 – Previous experience of the senior surgeon
Type of prostatectomyYearsTotal cases
Open RP (retropubic plus perineal)
Laparoscopic
RALP
1984–1997
1997–today
2001–today
1000
3500
1400
RP = radical prostatectomy; RALP = robot-assisted laparoscopic radical
prostatectomy.
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Germany). At the end of this dissection, a triangular space is created
formed by the base of the prostate, the bladder neck, and the right
neurovascular bundle (NVB), closed inferiorly by the seminal vesicle
(Fig. 1). In this way, not only is the lateral aspect of the bladder neck
exposed but also the dissection of the NVB begins.
2.2.2.
A variablebutconsistentamount ofnervescanbe foundalong theventral
circumference of the prostatic capsule [14]. To preserve a maximum
number of nerves, we perform a high incision for nerve sparing.
Theendopelvicfascia followedbythe prostatic fasciais openedatthe
2 o’clock position. The intrafascial plane between the visceral prostatic
fascia and the capsule, which is deep to the venous sinuses of Santorini’s
plexus, is developed with blunt dissection using articulated scissors;
bipolar coagulation is used only as necessary. The right NVB is carefully
rolled off the lateral surface of the midprostate. This ‘‘lateral approach’’
permits global vision of the bundle and takes into consideration the
curve it makes on the posterolateral surface of the midgland as well as
the variations in its course, which depends on prostate volume [15].
After the initial dissection of the middle part of the bundle, we
continue its dissection in two parts—first a cranial part (retrograde,
towards the base of the prostate in order to reach the base of the seminal
vesicle), and then the caudal part (antegrade, towards the apex). Major
attention should be given in the dissection of the NVB towards the apex,
because one or two small arteries leave the bundle to enter the prostate,
Nerve-sparing technique: the lateral dissection
and traction on them could cause disruption of the capsule. These small
arteries should be identified, clipped, and divided (Fig. 2).
Considering the low risk of cancer involvement in the distal part of
the seminal vesicles of the studied group, we performed a seminal
vesicle–sparing technique. The artery to the seminal vesicle is clipped
and divided (not coagulated). No traction is applied. The same procedure
is applied for the vas deferens.
We repeatthe sametypeofbladderneckdissection,NVBpreservation,
andseminalvesicle/vasdeferenstransectionontheleftsideoftheprostate.
WiththeNVB totallyreleased,the posteriorplane isdeveloped bya lateral
approach anterior to the posterior layer of the Denonvilliers’ fascia, which
remainsinplace,coveringtheperirectalfat.Thishypovascularplanecanbe
created easily using blunt dissection. The bladder neck is left intact and
preserved:Wetransectitonlyattheendoftheprostatectomy.Atthispoint,
we focus on the ventral surface of the prostate.
2.2.3.
The tissue that obscures the prostate in part constitutes an extension of
the anterior wall of the bladder beyond the bladder neck (the detrusor
apron [DA]) [5,6]. This tissue can be grasped with the robotic atraumatic
grasper (Figs. 3 and 4). Along the anterior commissure from the point at
which the DA leaves the prostate (to attach to the pubis) to the anterior
prostate-urethral junction, an avascular plane is present (Fig. 5). The
fibromuscular tissue between the DVC and the prostate is dissected at
themidline,betweenthepubicsymphysisandtheanteriorcommissureof
Detrusor apron and pubovesical complex preservation
Fig. 1 – Evidence of the triangular space formed by the base of the
prostate, the bladder neck, and the right neurovascular bundle, closed
inferiorly by the seminal vesicle.
NVB = neurovascular bundle.
Table 3 – Prospectively collected data
Preoperative data:
Age
Vascular/neurologic comorbidities
Preoperative PSA
Clinical stage
Prostate volume (by TRUS)
Total biopsy cores
Positive biopsy cores
Biopsy Gleason score
IIEF-6
IPSS
ICSmaleSF
MRI
Intraoperative data:
Surgical time
Blood loss
Transfusion rate
Intraoperative complications
Bilateral nerve-sparing procedures
Postoperative data:
Hospital stay
Drainage blood secretion
Catheterisation time
Postoperative complications (also outpatient ones), graded according to
the modified Clavien classification
Pathologic stage and Gleason score
Surgical margin status (positive or negative)
Location of PSM
Extension of PSM (focal vs extensive)
Number of foci of PSM
ICSmaleSF (baseline, 3, 6, and 12 mo)
IIEF-6 (baseline, 3, 6, and 12 mo)
EHS (baseline, 3, 6, and 12 mo)
PSA every 3 mo
Gastrointestinal/genitourinary toxicity of adjuvant RT
PSA = prostate-specific antigen; TRUS = transrectal ultrasounds; IIEF-6 =
International Index of Erectile Function-6; IPSS = International Prostate
Symptom Score; ICSmaleSF = International Continence Society male short
form; MRI = magnetic resonance imaging; PSM = positive surgical margins;
EHS = Erection Hardness Score; RT = radiation therapy.
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the prostate, usually without severing any veins, as this is a relatively
avascular plane (Figs. 6 and7) [5]. Followingthe same plane of dissection,
we separate the DA with the pubovesical ligaments from the anterior
surface of the prostate (Figs. 8 and 9). The urethra is then divided. The
bladder neck is preserved and divided by a lateral approach at the end of
the procedure. Fig. 10 shows the final aspect of the surgical field.
2.2.4.
A
DemeTECH, Miami, FL, USA) is achieved by a lateral view starting at the
5o’clockposition.BecausethePVCisspared,itisnecessarytoperformthe
anastomosis in two halves, passing the needle under the complex on two
occasions.
Urethrovesical anastomosis
runningurethrovesical anastomosis(3-0,Poliglecaprone25;
The quality of the anastomosis is tested forany leaks. Apelvicdrain is
placed via one of the robotic ports; the prostate is then removed in an
endobag (Vygon Lapbag [75 ? 150], Unimax Medical Systems, Tapei
Hsien, Taiwan) via an umbilical incision.
2.2.5.
The drain is removed when the volume is <100 ml/d or in the absence of
anysuspicious signsofaurinaryfistula.Patientsareregularlydischarged
with the Foley catheter still in place; the catheter is then electively
removed on an outpatient basis.
All the patients received therapy with phosphodiesterase type 5
inhibitors (PDE5-Is) (initially, tadalafil 20 mg, one capsule twice per
Postoperative care
Fig. 2 – The asterisk represents a clipped distal artery that leaves the
neurovascular bundle (NVB; between the dashed lines) to penetrate into
the prostate.
P = prostate; A = apex of the gland.
Fig. 5 – The curved arrow indicates the avascular plane present between
the point at which the detrusor apron (DA) leaves the prostate (to attach
to the pubis) to the anterior prostate-urethral junction. From this level, it
starts the anterior dissection of the pubovesical complex (ie, the DA and
the dorsal vascular complex, sparing both the structures).
P = prostate; A = apex; NVB = neurovascular bundle.
* Dorsal vascular complex.
Fig. 3 – Focus on the anterior prostate.
P = prostate; DA = detrusor apron, PVF = prostatic visceral fascia.
Fig. 4 – Detrusor apron (DA) grasped by the robotic atraumatic grasper.
The asterisk represents the attachment of the DA to the pubis. The
dashed line indicates the anterior commissure of the prostate and
corresponds to the dissection plane that should be followed to separate
the DA by the ventral surface of the gland.
P = prostate; B = bladder.
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week; then, tadalafil 5 mg, one capsule per day) for the first 2 mo after
surgery and thereafter as subjectively needed.
2.3.Histopathology
Details about specimen processing are reported in Table 4. Fig. 11 shows
the histologic differences between a standard and a pubovesical-sparing
technique.
2.4.Functional outcome assessment
Validated questionnaires were mailed to the patients, and their answers
were received via mail. The mailed questionnaires included ICSmaleSF,
IIEF-6, and Erection Hardness Score (EHS) at baseline, 3, 6, and 12 mo
after surgery.
Nonresponders were sent a follow-up questionnaire. A third party
notinvolved in direct patient care collected the data. The numberof pads
the patient used at catheter removal and at 3, 6, and 12 mo after surgery
was assessed. Potency was defined as an IIEF-6 score ?17 (with or
without PDE5-Is).
3.Results
Thirty patients were prospectively evaluated. Their preop-
erative characteristics are summarised in Table 5. The
perioperative, postoperative, and pathologic results are
reported in Tables 4, 6 and 7.
The PSA nadir was <0.01 ng/ml in all cases. After a
median follow-up of 21 mo (range: 12–30), no patient had
Fig. 6 – The fibromuscular tissue between the DVC and the prostate is
dissected at the midline.
A = prostate apex; DVC = dorsal vascular complex.
* Membranous urethra.
** Fibromuscular tissue between the DVC and the prostate.
Fig. 7 – Dissection of the fibromuscular tissue (**) between the dorsal
vascular complex (DVC) and the prostate in the midline. Combined
movements of sharp and mainly bland dissection, with an upward
direction, are necessary to detach the DVC from the anterior prostatic
surface.
A = apex.
* Membranous urethra.
Fig. 8 – Development of the plane of dissection (curved arrow) between
the detrusor apron and the anterior prostatic surface. The assistant pulls
the gland to the right side. The preserved bladder neck is clearly evident
(through a lateral view).
Fig. 9 – The anterior surface of the prostate has been totally freed from
both the detrusor apron and the dorsal vascular complex.
P = prostate; DA = detrusor apron; DVC = dorsal vascular complex;
NVB = neurovascular bundle.
* Bladder neck.
** Membranous urethra.
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411

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experiencedBCR.ThreepatientswithPSMsreceivedadjuvant
RT. Mean time between surgery and irradiation was 52 d
(range: 45–60). No acute or late gastrointestinal toxicity was
observed. Data on genitourinary toxicity (GUT) are reported
in Table 8. Only a late grade 3b complication (anastomotic
stricture)wasobservedand
(Table 6).
endoscopicallyresolved
3.1. Continence
At catheter removal, 80% (24 patients) were completely dry
(0pads),while20%(6patients)usedasinglelinerforsecurity
Table 4 – Pathologic data specimen processing
Fixation
Coating (to delineate surgical margins)
Specimen processing
Apex
En bloc, 10% neutral buffered formalin
India ink
Whole mount technique [16]; specimens were step-sectioned transversely at 2–4-mm intervals
An apical shaved section, 2–4-mm thick, was truncated perpendicular to the prostatic urethra and
subsequently sectioned as slices parallel to the prostatic urethra
Either by sampling portions of tissue at the junction of the prostatic capsule and bladder neck
or by sampling the most proximal portion of the submitted specimen corresponding to the
anatomical bladder neck
2002
Tumour cells in contact with ink
39 (range: 32–54)
Bladder neck section
TNM classification
PSM definition
Mean specimen weight, g
Pathologic Gleason score
5 (2 + 3 or 3 + 2)
6 (3 + 3)
7 (3 + 4)
Mean pathologic Gleason score
Site of PSM
0
16
14
6.5
2 apical (1 right, 1 left)*
1 left posterolateral
3 vs 0
2 vs 1
Single vs multiple PSM sites
Focal**versus nonfocal PSM
PSM = positive surgical margin.
*In both cases, the preoperative biopsy was positive in the apex.
**Focal was defined a PSM <1 mm.
Table 6 – Perioperative and postoperative data
Mean operative time, min (range)
Bilateral nerve-sparing procedures
Transfusion rate
Mean blood loss, ml (range)
Mean bladder catheterisation time, d (range)
Urinary retention
Stenosis of the anastomosis
Urine leak
Prolonged drain secretion of blood
Mean hospital stay, d
132 (70–180)
30/30
0/30 (0%)
96 (70–230)
8.53 (7–9)
0/30 (0%)
1/30 (3%)
0/30 (0%)
0/30 (0%)
3.8
Pathologic stage
pT2a
pT2b
pT2c
pT2 overall
pT3a
4 (13.3%)
5 (16.6%)
18 (60%)
27 (90%)
3 (10%)
Fig. 10 – The final aspect of the surgical field. The prostate has already
been shelled out from underneath the spared pubovesical complex; the
urethrovesical anastomosis has been performed under the spared
complex by a running suture with lateral approach.
DA = detrusor apron.
* Accessory pudendal artery.
Table 5 – Preoperative patient characteristics
Mean age, yr (range)
Mean PSA, ng/ml (range)
Mean prostate volume as
evaluated by TRUS, ml (range)
Gleason score of the biopsy
5 (2 + 3 or 3 + 2)
6 (3 + 3)
Mean biopsy Gleason score
52 (43–60)
7.15 (3.8–10)
35.5 (27–42)
4
26
5.9
Clinical stage
cT1c
cT2a
Median total biopsy cores, no. (range)
Median positive biopsy cores, no. (range)
Comorbidities
21
9
16 (12–19)
3 (1–5)
One case of hypertension;
one case of dyslipidaemia
PSA = prostate-specific antigen; TRUS = transrectal ultrasound.
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Fig. 11 – Final pathology: (A) standard dissection and (B) pubovesical complex preservation. In the lower part of the figure, the microscopic view of the inserts
is provided. In (A), the order of the tissues (from anterior to posterior) is ink, striated muscle (detrusor apron), fat tissue, striated muscle fibres mingled
with some smooth muscle fibres, and prostatic parenchyma with glands. When the detrusor apron (DA) is preserved (B), the striated muscular layer (DA) and
the majority of fat tissue (that represents our marker during the anterior dissection) are no longer visible. A mixed smooth and striated muscle layer
covers the glandular parenchyma. Even if no prostatic capsule is present at this level, the limit of the prostate can be still well identified by the presence
ofthesemuscularfibres(which assumeamorecircularorientationatthislevel).Inall cases,inthemicroscopicevaluation,thismuscularlayerwasrespected;
thus, no benign prostatic glandular tissue was left in place during the anterior dissection.
Table 8 – Genitourinary toxicity in patients who received adjuvant
radiation therapy
AcuteLate
One case of
grade 1 urgency
One case of grade 2 pollakisuria/nocturia
(resulting from an anastomotic stricture
and resolved endoscopically 12 mo after RALP)
– One case of grade 1
urinary incontinence
RALP = robot-assisted laparoscopic radical prostatectomy.
Table 7 – Overall rate of positive surgical margins and distribution
per pathologic stage
Pathologic stagePSM cases (%)
pT2a
pT2b
pT2c
pT3a
Overall
pT2 PSM rate
0/4 (0)
0/5 (0)
2/18 (11)
1/3 (33)
3/30 (10)
2/27 (7)
PSM = positive surgical margin.
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reasons. One month after surgery, all the patients were
completely dry. According to the ICSmaleSF questionnaire
(0max,24 min),28patientspresentedascoreof0,whiletwo
patientsscored1(lossofurinewhencoughingorsneezing)at
catheter removal. Both patients with acute GUT recovered
within 3 mo; thus, the global continence rates (at catheter
removal,1mo,and12moaftersurgery)werenotinfluenced.
3.2.Potency/penile rigidity
The first potency evaluation was performed after 3 mo of
follow-up (time to nadir in erectile function after RP [17]).
Results are reported in Table 9 and Figs. 12–15.
4.Discussion
The traditional descriptions of puboprostatic ligament–
sparing surgery do not take into consideration the
ligaments’ demonstrable anatomic continuity with the
bladder [5,6,18]. As a consequence, in all the described
techniques, there is an interruption of these ligaments
at some point to expose the prostatourethral junction.
When surgeons declare that they do not take down
Fig. 15 – International Index of Erectile Function (IIEF-6) score.
* Significance at p < 0.05.
Table 9 – Potency evaluation according to Mulhall criteria [17]
Surgeon volumeSee Table 1
Patient comorbidity profile
Collection of erectile function outcome data
Validated questionnaires used
Baseline erectile function data
Definition of adequate erectile function
Proportion of men returning to normal erectile function (12 mo)
Proportion of men returning to preoperative IIEF-6 score (12 mo)
Extent of use of erectogenic medications (3 mo)
Extent to which a rehabilitation strategy was used
One case of hypertension, one case of dyslipidaemia
Third party
IIEF-6, EHS
Mean IIEF-6 score: 23.2
IIEF-6 score >17
100%
86.7%
See Fig. 13
Tadalafil 20 mg twice per week/tadalafil 5 mg once per day for 2 mo, then as
subjectively needed
IIEF-6 = International Index of Erectile Function-6; EHS = Erection Hardness Score.
Fig. 12 – Potency evaluation at 3 months.
IIEF = International Index of Erectile Function.
Fig. 13 – Extent of utilisation of erectogenic medications.
PDE5-Is = phosphodiesterase type 5 inhibitors.
Fig. 14 – Erection Hardness Score.
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these ligaments, they mean that they do not interrupt
their continuity by disarticulation at their junction with the
pubis [5,6].
In the perineal operation, these structures are spared,
because the prostate is shelled out from underneath the
overlying DA and DVC [5,19]. With our study, we
demonstrate for first time that the PVC can be also
preserved during RALP. Our anterior dissection aims to
spare the anatomical structure that physiologically sup-
ports the external urethral sphincter and preserves the
urethra in its normal place in the pelvic floor. With this
technique, no additional manoeuvres (suspension stitches
of the periurethral complex [20,21], puboperineoplasty
[22]) are necessary for anterior stabilisation of the urethral
sphincter. Moreover, by keeping the DVC intact, we avoid
the drawbacks of both the selective and the standard
ligation techniques (see Appendix A).
Careful patient selection with low-risk PCa maximises
the oncologic outcome. The overall rate of PSM in our study
was low and conforms to the literature [23]. In our practice,
all the candidates for intrafascial dissection are submitted
to endorectal MRI, aiming to improve the staging even for
T1c disease [24].
In a small cohort of patients like ours, performing this
technique may not have hindered the final oncologic
outcome in terms of anterior PSMs, but if the technique is
routinelyperformed,theriskofanteriorPSMcouldbecome
clinically significant. In this direction, endorectal MRI
could also aid in reducing the riskofmisdiagnosed anterior
PCa, because it provides excellent imaging of the whole
gland, including the challenging anterior part [25]. In
addition, at least two biopsies per side of the anterior
prostate were obtained in the candidates of this technique,
because they could increase detection rate in patients with
negative digital rectal examination and elevated PSA [26]
levels (ie, the majority of our patient cohort).
The described technique, although feasible, is not easy to
perform. The lateral approach to the bladder neck requires
experience to be performed safely. Even if preservation of
the bladder neck is thought to compromise cancer control
by increasing the likelihood of PSM at the prostate base [27]
andthereforeadverselyaffectingcancercontrol[28],wedid
not observe PSMs at the prostate base with bladder neck
preservation.
Finding and developing the avascular plane between the
DA and the anterior prostate-urethral junction under the
DVC is demanding. Attention should be given to small
prostates, where the length of the avascular plane is shorter
and consequently the DVC, the urethral sphincter, and the
NVBs could easily be damaged. In contrast, in very large
glands, the DA appears thinner and more spread out, and
consequently its dissection from the anterior prostate is
more difficult. Performing the urethrovesical anastomosis
under the preserved PVC is another demanding step. The
use of the fourth robotic arm to pull the DA, exposing the
prostatourethral junction, is of paramount importance.
It is important to underline that in our experience, the
single steps of the described technique were progressively
matured; now, they are described in their totality as a set of
surgical manoeuvres. Table 10 reassumes the surgical
principles of our technique.
To our knowledge, the rate of urinary continence at
catheter removal is the highest reported in the literature.
The majority of our patients were dry at catheter removal,
and the remainder only required the use of one security
liner. All patients but one (97%) did not complain of any
interference of their urinary symptoms with their quality
of life.
The published weighted mean potency rate 3 mo after
RALPis38.4%[3].Inourstudy,73%ofpatientspresentedwith
an IIEF-6 score ?17 (with or without PDE5-Is) associated
with an EHS ?3 for the same follow-up period. Our highly
Table 10 – Surgical tips and suggestions
1 Even if bladder neck preservation does not seem to hinder the oncologic outcome in terms of PSM, extra attention should be paid if preoperative
biopsies of the prostate basis are positive for high-grade PCa. Proper patient selection is crucial.
Before all the traction manoeuvres of the prostate, free the NVBs, preferably with a high anterior release technique, to maximise the preservation of
the periprostatic neuronal network and obtain a tension-free dissection.
Use clips to control small vessels, and avoid use of energy near the NVBs (energy-free dissection).
Minimise the risk of treating patients with anterior (thus nonpalpable) tumours. Endorectal MRI and additional biopsy cores of the anterior
prostate could be helpful.
Preserve any accessory pudendal artery to maintain oxygenation of the erectile tissue.
Choose adequate prostate volumes. In very small prostates, the avascular plane between the PVC and the prostate-urethral junction is short
(risk of damaging of urethral sphincter, NVBs, DVC), while in very large prostates, the DA is thin and thus difficult to dissect from the anterior
surface of the prostate.
Use the fourth robotic arm with the atraumatic grasper to pull the DA and expose adequately the prostate-urethral junction.
In low-risk PCa, there is a very low risk of PCa involvement of the distal part of the seminal vesicles (<0.3%); thus, the tips of the seminal vesicles
could be left in place, probably without hindering the final oncology. This manoeuvre reduces the risk of injury of the cavernous nerves and
consequently could improve continence and potency rates.
Remember that there is no single ‘‘trick’’ for obtaining perfect functional outcomes. Bladder neck preservation, maximised preservation of the
periprostatic nerves through the high anterior release technique, tension and energy-free dissection of the NVBs, sparing the reflection of the
endopelvic fascia (associated with an intrafascial dissection), seminal vesicle sparing, preservation of any accessory pudendal artery, and
the PVC-sparing techniques as a set of surgical manoeuvres, lead to maximised preservation of the periprostatic anatomy, which is probably
the key to success for a modern prostatectomy.
2
3
4
5
6
7
8
9
PSM = positive surgical margin; PSA = prostate-specific antigen; NVB = neurovascular bundle; MRI = magnetic resonance imaging; DVC = dorsal vascular
complex; PVC = pubovesical complex; DA = detrusor apron.
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415

Page 10

selectedcohort(preoperativelyyoung,potentpatients)could
partially explain this difference in the potency rates.
Moreover, the patients were not affected by comorbidities
that could impair the continence/potency recovery.
In addition to the highly selected cohort, the study
population was small to allow any definitive conclusions.
Moreover, several techniques with a possible synergistic
effect on continence recovery (preservation of the bladder
neck, endopelvic fascia reflection, tip of seminal vesicles;
incremental nerve-sparing technique) were performed, and
it is difficult to quantify the effect of each one.
5.Conclusions
The holistic preservation of the PVC during RALP is
technically feasible. Combined with other surgical ma-
noeuvres, it leads towards the absolute preservation of the
periprostatic anatomy. Adequately designed studies should
evaluate whether it enhances early functional outcomes.
Author contributions: Anastasios D. Asimakopoulos had full access to all
the data in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Study concept and design: Asimakopoulos, Gaston.
Acquisition of data: Asimakopoulos, Annino, D’Orazio, Fraga, Gaston.
Analysis and interpretation of data: Asimakopoulos, Gaston.
Drafting of the manuscript: Asimakopoulos.
Critical revision of the manuscript for important intellectual content:
Asimakopoulos, Gaston.
Statistical analysis: Annino.
Obtaining funding: None.
Administrative, technical, or material support: Asimakopoulos, Annino.
Supervision: Asimakopoulos, Mugnier, Hoepffner, Piechaud, Gaston.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including
specificfinancialinterestsandrelationshipsandaffiliationsrelevanttothe
subjectmatterormaterialsdiscussedinthemanuscript(eg,employment/
affiliation,grants orfunding,consultancies,honoraria, stock ownershipor
options,experttestimony,royalties,orpatentsfiled,received,orpending),
are the following: None.
Funding/Support and role of the sponsor: None.
Acknowledgment statement: The authors acknowledge D. M. Burke
(Urological Surgeon, Central Manchester University Hospitals Founda-
tion Trust) for his kind help in the English review of the manuscript.
Appendix A
Diagram 1
Appendix B. Supplementary data
The Surgery in Motion video accompanying this article
can be found in the online version at doi:10.1016/
j.eururo.2010.04.032 and via www.europeanurology.com.
Subscribers to the printed journal will find the Surgery in
Motion DVD enclosed.
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