Article

Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins Characteristics

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Abstract

To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) or extrafascial nerve-sparing (EF-NSP) techniques. It is believed that the IF-NSP technique used during robotic-assisted radical prostatectomy (RARP) spares more nerve fibers, while EF dissection may lower the risk for positive surgical margins (PSM). A prospective database was analyzed for RARP patients with bilateral IF- or EF-NSP technique. Collected parameters included age, body mass index, prostate-specific antigen, clinical and pathologic Gleason score and stage, estimated blood loss, operative time, and PSM characteristics. Functional outcomes were evaluated with the use of the University of California Los Angeles Prostate Cancer Index questionnaire. Men receiving postoperative hormonal or radiation therapy were excluded from sexual function analysis. A total of 110 and 703 cases with bilateral EF- and IF-NSP, respectively, were analyzed. EF-NSP patients had higher prostate-specific antigen, clinical, pathologic stage, and pathologic Gleason score. PSM rate did not achieve statistically significant difference between groups. There was a trend toward lower pT3-PSM in the EF group (51% vs 28%; P = .08). Mid- and posterolateral PSM location were lower in the EF-NSP group, 11% vs 37% and 11% vs 29%, respectively (P < .001). The IF-NSP group patients achieved statistically significant better sexual function (P = .02) and potency rates (P = .03) at 12 months after RARP. In lower risk patients, bilateral IF-NSP technique does not result in significantly higher PSM rates. EF-NSP appears to reduce posterolateral and mid-prostate PSM. Men with bilateral IF-NSP demonstrate significantly better sexual function outcomes.

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... With advances in robotic techniques and the increase in the experience using the robotic platform, RARP has shown improved functional outcomes and at least comparable oncological outcomes as compared to open and laparoscopic radical prostatectomy [7][8][9][10][11][12][13][14]. Despite these advances, the incidence of erectile dysfunction (ED) ranges widely at 1-year follow-up from 10 to 46 % after sparing RARP [15][16][17][18][19][20][21][22][23]. This wide range of ED in various reported series may be attributed to inconsistent definitions of ED, variable nerve sparing (NS) techniques, and unstandardized patients selection criteria. ...
... The extrafascial plane dissection is right through the NVBs and might enable some preservation of neural tissue or none. Thus, complete preservation of NVBs can be achieved through either intrafascial or interfascial dissection [22,23,39,40]. ...
... Table 3 summarizes the potency outcomes in various series comparing RARP with open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). These series have different inclusion criteria of patients, methods of evaluation of potency, NS techniques, surgeon's experience and follow-up [6,16,17,[19][20][21][22][23]65]. Although, there is no standardized definition of potency, but most of high-volume centres series have defined potency as ''Adequate erection sufficient for intercourse, with or without use of PDE 5 inhibitors''. ...
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Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.
... Until now, the intrafascial nerve-sparing technique has been a technique of very advanced surgeons. 9,10,[17][18][19][20][21][22][23][24] In the intrafascial nerve-sparing ELRP, the dissection of the prostate was performed between the prostatic capsule and the prostatic fascia and left virtually no periprostatic tissue overlying the prostate. Theoretically, this approach may lead to a higher incidence of PSM due to a dissection that is closer to the prostate gland. ...
... Potdevin et al. 17 found that there was a high rate of PSM in patients with pT3 disease who underwent the intrafascial nerve-sparing technique during robotassisted laparoscopic radical prostatectomy. However, Shikanov et al. 18 , Neill et al. 19 and Khoder et al. 20 reported that the bilateral interfascial nerve-sparing technique does not result in higher rates of PSM in low-risk patients. ...
... Potdevin et al. 17 found that the intrafascial technique greatly improved potency rates and shortened the time to the return of continence following robot-assisted laparoscopic radical prostatectomy. Shikanov et al. 18 reported that men with bilateral intrafascial nerve-sparing procedures demonstrated better sexual function. Neill et al. 19 found an earlier return to continence after intrafascial nervesparing laparoscopic radical prostatectomy. ...
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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 2∶1 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.Asian Journal of Andrology advance online publication, 27 May 2013; doi:10.1038/aja.2012.157.
... The extrafascial plane is defined from the external part of the NVB and is a non– nerve-sparing technique. Therefore the preservation of the NVB can be achieved by either interfascial or intrafascial dissection [35][36][37][38][39]. The Pasadena consensus panel suggested alternate terminology of dissection planes as full, partial and minimal nerve-sparing for the intrafascial, the interfascial and the subextrafascial dissections respectively (Fig. 7A) [40]. ...
... The potency rates of larger series in RARP are listed in Table 3. The potency rates changes from 54% to 97.4% in different studies [2,18,35,36,41,42,47,62,63]. These wide ranges of potency rates could be because of the inclusion criteria, the evaluation methods, different nerve-sparing techniques and approaches, the surgeons' experience and the follow-up periods. ...
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Nerve-sparing techniques in robot-assisted radical prostatectomy (RARP) have advanced with the developments defining the prostate anatomy and robotic surgery in recent years. In this review we discussed the surgical anatomy, current nerve-sparing techniques and results of these operations. It is important to define the right and key anatomic landmarks for nerve-sparing in RARP which can demonstrate individual variations. The patients’ risk assessment before the operation and intraoperative anatomic variations may affect the nerve-sparing technique, nerve-sparing degree and the approach. There is lack of randomized control trials for different nerve-sparing techniques and approaches in RARP, therefore accurate preoperative and intraoperative assessment of the patient is crucial. Current data shows that, performing the maximum possible nerve-sparing using athermal techniques have better functional outcomes.
... Another study conducted in our clinic showed a continence rate of 95,3% within the first year following RPP operations [15]. In a study through which they compared extrafascial and interfascial nerve sparing techniques in robot assisted laparoscopic prostatectomy Shikanov et al. [16] found no significant difference in terms of positive surgical margins, but potency and sexual functions were found to be statistically better for interfacial nerve sparing. Surgical margin positivity rates for robotic radical prostatectomy batches was recorded as 20,9%of which 54% was in the posterolateral region, 26% in the apex, and 20% in the basis. ...
... Surgical margin positivity rates for robotic radical prostatectomy batches was recorded as 20,9%of which 54% was in the posterolateral region, 26% in the apex, and 20% in the basis. Surgical margin positivity appears to remain an issue with intrafascial antegrade techniques [16,17]. Even though surgical margin positivity occurs less with intrafascial techniques, our study along with other literature showed that surgical margin positivity occurred less frequently in specimens dissected via the perineal approach as opposed to those dissected via the retropubic approach [18]. ...
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Aim: An anatomohistological evaluation of tissue found on specimens of radical perineal prostatectomy which could influence oncological and functional outcome. Material and Method: A certain surgeon's batch of 41 RPP (Radical perineal prostatectomy) specimens were evaluated. The RPP specimens were dissected from apex to basis. The following slices were dissected: 1 from the Apex, 2 from the center of the prostate, and 1 from the basis. Totaling 4 selected slices. Tissue surrounding these slices were anatomohistologically evaluated working from the following 7 parameters determined in light of latest anatomical and pathological insight on the prostate:"Dorsal venous complex(DVC)", "Striated muscle(Rhabdosphincter)", "Periprostatic fascial tissue (PPFT)", "Neurovascular bundle(NVB)", "Bladder neck smooth muscle", "Surgical margins" and "Capsular incision". Results: Whilst no DVC was found in the dissected Apex slices, muscle striation was found with 39 (95,1%) of the patients. PPFT within central prostate sections was found with 36 (87,8%) of the patients, predominantly within posterior quadrants. Again within central prostate sections NVB was found with 23 (56%) of the patients. All basis slices were found to have bladder neck smooth muscle. Surgical margin positivity was found with only 5 (12,1%) of the patients. Capsular incision was found with 15 (36,5%) of the patients. Discussion: Our study provides a quantitative report of the extent to which other anatomi-cal structures are extracted when removing the prostate from the perineum employing the RPP technique. That the specimen show no trace of DVC is significant in terms of pubovesical complex sparing.
... Yine aynı yazarın başka bir makalesinde ise lateral fasiyaları korunan hastalarda kontinansın daha çabuk geri döndüğü ve fasiya korumanın kontinans üzerinde etkili olduğu gösterilmiştir (11). Shikanov ve arkadaşları robot yardımlı laparoskopik prostatektomide uyguladıkları ekstrafasiyal ve interfasiyal sinir koruyucu teknikleri karşılaştırdığı çalışmada pozitif cerrahi sınır açısından istatistiki olarak anlamlı bir fark bulamamışlar, fakat interfasiyal grupta istatistiki açıdan anlamlı olarak potens ve seksüel fonksiyonlar daha iyi bulunmuştur (12). Robotik radikal prostatektomi serilerinde cerrahi sınır pozitifliği ise %20,9 olarak yayınlanmış olup bunların %54'ü posterolateralde, %26'sı apekste ve %20'si ise bazaldedir. ...
... Robotik radikal prostatektomi serilerinde cerrahi sınır pozitifliği ise %20,9 olarak yayınlanmış olup bunların %54'ü posterolateralde, %26'sı apekste ve %20'si ise bazaldedir. İntrafasiyal antegrat tekniklerde cerrahi sınır pozitifliği bir sorun olarak durmaktadır (12,13). Bu çalışmada pT3a evresinin %20 olması ve hasta çoğunluğunun pT2c ve üzeri olması tekniğin güvenilirliğini tartışmamız açısından belki daha da değerli veri sunmaktadır. ...
... [26] Additionally, comparison of interfascial and extrafascial NS technique produced 12-month potency rates of 64% and 40% (P = 0.02), respectively. [27] Additionally, men with larger prostates (>100 vs. <50 g) have decreased post-operative potency rates (61.9% vs. 72.9%, P < 0.05) at 12 months post-operatively. ...
... Additionally, although NS techniques are superior, it is evident that the degree of NS leads to different post-operative potency rates. [26] Various dissection techniques of fascial planes have been developed [27] in addition to the VIP. [23][24][25] More accurate description of the NS technique would allow for better comparison of operative techniques. ...
Article
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Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 2014 to identify studies comparing RALP with open retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy, modified RALP techniques and treatment options and management for ED following radical prostatectomy. RALP demonstrates adequate potency rates without compromising oncologic benefit, with observed benefit for potency rates compared with RRP. Additionally, specific surgical technical modifications appear to provide benefit over traditional RALP. Phosphodiesterase-5 inhibitors (PDE5I) demonstrate benefit for ED treatment compared with placebo. However, long-term benefit is often lost after use. Other therapies have been less extensively studied. Additionally, correct patient identification is important for greatest clinical benefit. RALP appears to provide beneficial potency rates compared with RRP; however, these effects are most pronounced at high-volume centers with experienced surgeons. No optimal rehabilitation program with PDE5Is has been identified based on current data. Additionally, vacuum erection devices, intracavernosal injections and other techniques have not been well validated for post RALP ED treatment.
... A PSM has been shown to be associated with higher rates of biochemical recurrence and disease progression [8][9][10]. In most studies, NVB sparing had no significant impact on PSMs [11][12][13][14][15]. Nonetheless, in several robotic prostatectomy series, increased PSM rates in pathological T3 tumors were found to be related to nerve sparing [16][17][18][19]. ...
Article
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In radical prostatectomy (RP) procedures, sparing the neurovascular bundles adjacent to the posterolateral aspect of the prostatic fascia has often been suggested as a possible risk factor for positive surgical margins. Here we aimed to quantify the probability of extracapsular extension (ECE) at the posterolateral side of the prostate to aid in nerve-sparing decision making. We evaluated 472 patients who underwent RP between July 2007 and January 2012. All patients underwent preoperative magnetic resonance imaging (MRI) with diffusion-weighted imaging and apparent diffusion coefficient mapping. We analyzed 944 side-specific prostate lobes with preoperative variables. To quantify the risk of side-specific posterolateral ECE after RP, we developed a risk-stratification scoring system through logistic regression analysis. Overall, 20.6% of 944 prostate lobes had ECE. In the multivariate analysis, prostate-specific antigen (PSA), biopsy Gleason score ≥7, percentage of side-specific cores with tumor, and posterolateral ECE on MRI were independent predictive factors of posterolateral ECE. On internal and external validation to calculate the predicted risk, the Hosmer-Lemeshow goodness-of-fit test showed good calibration (p=0.396). PSA, biopsy Gleason score, percentage of side-specific cores with tumor, and posterolateral ECE on MRI are independent predictors of posterolateral ECE. The scoring system derived from this study will provide objective parameters for use when deciding if the neurovascular bundle can be safely spared.
... 9,10 Based on the preoperative knowledge of the spatial location of biopsy-proven gross palpable nodule or high Gleason/high-volume cancer, Shikanov et al. showed a trend of a lower rate in PSM for pT3 prostate cancer in the partial NS group (28% in 110 patients compared with the complete NS group [51% in 703 patients], P = 0.08). 9 When anatomical grades of NS technique were applied according to the preoperative magnetic resonance imaging staging and intraoperative inspection to assess cancer location and moderate-to-high risk of extraprostatic disease, Tewari et al. were able to decrease the PSM rate to 7.4% (16/216). 10 Ukimura et al. reported that intraoperative TRUS navigation during laparoscopic RP can identify the risk of extraprostatic extension in biopsy-proven hypoechoic cancer, resulting in improved NSM rate (29% with TRUS navigation vs 9% without TRUS navigation, P = 0.0002) while preserving erectile function. ...
Article
Intraoperative transrectal ultrasonography during laparoscopic radical prostatectomy has been reported to lead to a reduction in surgical margin rates. However, the use of a surgeon-controlled ultrasound probe that allows for precise manipulation and direct interpretation of the image by a console surgeon has yet to be studied. The aim of the present study was to show initial feasibility using the microtransducer with 9-mm scan length controlled by the console surgeon during robot-assisted radical prostatectomy in 10 patients. The transducer is designed as a drop-in probe with a flexible cord for insertion through a laparoscopic port, and is controlled by a robotic arm with the ultrasonographic image shown as a console Tile-pro display. Intraoperative localization of the biopsy-proven cancerous hypoechoic lesion was feasible in four out of four cases. The microtransducer facilitated identification of the bladder neck as well as the appropriate level of neurovascular bundle release. Negative surgical margin was achieved in all 10 cases (100%), even though five of 10 patients (50%) had extraprostatic (pT3) disease. Recovery of erectile function and continence was encouraging. In conclusion, intraoperative ultrasound navigation using a drop-type microtransducer is a novel technique that could enhance the incremental value of the standard information.
... Intrafascial and interfascial nerve preservation has been associated with dissection into the avascular plane between the prostatic fascia and Denonvilliers' fascia, both posteriorly and anteriorly [89]. In his study, Shikanov et al. [30] found that intrafascial nerve preservation had beneficial effects on EF recovery after RARP. The authors demonstrated EF rates for the intrafascial nervesparing group and extrafascial nerve-sparing group of 42% and 22% at 3 months (P = 0.04) and 64% and 40% at 12 months (P = 0.03), respectively. ...
Article
Introduction: Erectile dysfunction (ED) is one of the most commonly affected domains of health-related quality of life after prostate cancer therapy. Functional outcomes after radical prostatectomy (RP) have continued to improve through refinement of surgical techniques and development of several procedural modifications. In this context, it has been hypothesized that robotic technologies should simplify the preservation of the neurovascular bundle, thus possibly providing improved functional outcomes. Aim: To compare the prevalence of post-RP ED and identify whether recently developed robotic technologies are able to improve erectile function (EF) recovery after RP. Methods: Literature Review. Main outcome measure: To evaluate whether post-therapy ED rates after robotic surgery have shown improvement when compared with the other forms of nerve-sparing RP. Results: Previously published series have shown EF recovery rates after robot-assisted RP (RARP) ranging between 40% and 90% of patients at 12 months, postoperatively. Some claim that the RARP procedure can also significantly shorten recovery time in return of EF when compared with open RP. On the other hand, some authors have reported that patients undergoing minimally invasive RP have experienced even more ED on comparison. Conclusions: Although it has been widely promoted by the industry and hospitals, at the moment there are not enough evidence-based data to answer the question, "Does RARP surgery provide better EF outcomes?." Because of the current market trends and patient preferences, the perfect randomized study will probably never be performed, and thus the question of which procedure's results are superior will most likely remain unanswered. Isgoren AE, Saitz TR, and Serefoglu EC. Erectile function outcomes after robot-assisted radical prostatectomy: Is it superior to open retropubic or laparoscopic approach? Sex Med Rev 2014;2:10-23.
... Although a higher rate of phosphodiesterase inhibitor prescription may have played a role, the main likely factors explaining this difference in potency rate may be related to patient selection, comorbidities, use and motivation of penile rehabilitation, and technical aspects of the nervesparing technique (interfascial vs. extrafascial plane, traction injury during dissection and thermal vs. athermal clip use during vascular pedicle control). 16,22,23 In this study, a total of 80 postoperative complications were noted including, 1.0% major and 10.1% minor according to Clavien classification. This is comparable to Pautler and colleagues' study. ...
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Introduction: While RARP (robotic-assisted radical prostatectomy) has become the predominant surgical approach to treat localized prostate cancer, there is little Canadian data on its oncological and functional outcomes. We describe the largest RARP experience in Canada. Methods: Data from 722 patients who underwent RARP performed by 7 surgeons (AEH performed 288, TH 69, JBL 23, SB 17, HW 15, QT 7, and KCZ 303 patients) were collected prospectively from October 2006 to December 2013. Preoperative characteristics, as well as postoperative surgical and pathological outcomes, were collected. Functional and oncological outcomes were also assessed up to 72 months postoperative. Results: The median follow-up (Q1-Q3) was 18 months (9-36). The D'Amico risk stratification distribution was 31% low, 58% intermediate and 11% high-risk. The median operative time was 178 minutes (142-205), blood loss was 200 mL (150-300) and the postoperative hospital stay was 1 day (1-23). The transfusion rate was only 1.0%. There were 0.7% major (Clavien III-IV) and 10.1% minor (Clavien I-II) postoperative complications, with no mortality. Pathologically, 445 men (70%) were stage pT2, of which 81 (18%) had a positive surgical margin (PSM). In addition, 189 patients (30%) were stage pT3 and 87 (46%) with PSM. Urinary continence (0-pads/day) returned at 3, 6, and 12 months for 68%, 80%, and 90% of patients, respectively. Overall, the potency rates (successful penetration) for all men at 6, 12, and 24 months were 37%, 52%, and 59%, respectively. Biochemical recurrence was observed in 28 patients (4.9%), and 14 patients (2.4%) were referred for early salvage radiotherapy. In total, 49 patients (8.4%) underwent radio-therapy and/or hormonal therapy. Conclusions: This study shows similar results compared to other high-volume RARP programs. Being the largest RARP experience in Canada, we report that RARP is safe with acceptable oncologic outcomes in a Canadian setting.
... 25 Shikanov et al. reported significantly lower (+) SM rates in the mid-and posterolateral (+) SM location in extrafascial NVB sparing group compared to interfascial NVB sparing group in their series. 26 In a series of 35 patients with pT3 PCa patients, Casey et al. reported that bilateral or unilateral NVB sparing was not associated with increased (+) SMs. 27 In a single surgeon series of 500 RARPs performed by Yee et al. for patients with palpable disease on rectal examination, the (+) SM rate was detected as 9.9% (7.7% in cT2 and 26.3% in cT3 disease) and none of the (+) SMs were detected along the NVB. ...
Article
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Around 20%-30% of patients diagnosed with prostate cancer (PCa) still have high-risk PCa disease (HRPC) that requires aggressive treatment. Treatment of HRPC is controversial, and multimodality therapy combining surgery, radiation therapy, and androgen deprivation therapy have been suggested. There has been a trend toward performing radical prostatectomy (RP) in HRPC and currently, robot-assisted laparoscopic RP (RARP) has become the most common approach. Number of publications related to robotic surgery in HRPC is limited in the literature. Tissue and Tumor characteristics might be different in HRPC patients compared to low-risk group and increased surgical experience for RARP is needed. Due to the current literature, RARP seems to have similar oncologic outcomes including surgical margin positivity, biochemical recurrence and recurrence-free survival rates, additional cancer therapy needs and lymph node (LN) yields with similar complication rates compared to open surgery in HRPC. In addition, decreased blood loss, lower rates of blood transfusion and shorter duration of hospital stay seem to be the advantages of robotic surgery in this particular patient group. RARP in HRPC patients seems to be safe and technically feasible with good intermediate-term oncologic results, acceptable morbidities, excellent short-term surgical and pathological outcomes and satisfactory functional results.
... The surgical specimens were processed according to modified Stanford protocol 14 and microscopically examined by an uro-pathologist. 15 EPE was defined as cancerous tissue found on the outside of the limit of healthy prostatic tissue and associated with the stage pT3. PSM was defined as tumour cells present at the inked margin of the specimen. ...
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Introduction: We assessed the incidence of contralateral prostate cancer (cPCa), contralateral EPE (cEPE) and contralateral positive surgical margins (cPSM) in patients diagnosed preoperatively with unilateral prostate cancer and evaluated risk factors predictive of contralateral disease extension. Methods: The occurrence of cPCa, cEPE and cPSM and the side-specific nerve-sparing technique performed were collected postoperatively from 327 men diagnosed with unilateral prostate cancer at biopsy. Parameters, such as the localization, proportion, and percentage of cancer in positive cores, were prospectively collected. Results: Overall, 50.5% of patients had bilateral disease, and were at higher risk when associated with a positive biopsy core at the apex (p = 0.016). The overall incidence of ipsilateral EPE and cEPE were 21.4% and 3.4%, respectively (p < 0.001). Compared to cPCa, ipsilateral disease was at an almost 4-fold higher risk of extending out of the prostate (p < 0.001). None of the criteria tested were identified as useful predictors for cEPE. The low incidence of cEPE in our cohort could limit our ability to detect significance. The overall incidence of ipsilateral PSM and cPSM were 15.3% and 5.8%, respectively (p < 0.001). More aggressive nerve-sparing was not associated with a higher incidence of PSM. Prostate sides selected for more aggressive nerve-sparing were associated with younger patients (p < 0.001), a smaller prostate (p = 0.006), and a lower percentage of cancer in biopsy material (p = 0.008). Conclusion: Although the risk of cPCa is high in patients diagnosed with unilateral prostate cancer at biopsy, the risk of cEPE and cPSM is low, yet not insignificant. Contralateral aggressive nerve-sparing should be used with caution and should not compromise oncological outcome.
... While some authors reported an increased risk of PSM using nervesparing procedures 4 and suggested differences between nerve-sparing techniques, 15 others suggested that nerve sparing did not compromise margin status 20 and the technique did not show significant differences. 21 Our results add to the controversy in the literature suggesting no significant association between the nerve-sparing approach and PSM at apical, peripheral, or proximal locations. Institutional surgical experience demonstrated a strong association with the rates of PSM independently of pathological and clinical characteristics. ...
... This plane of dissection is located lateral to the prostatic fascia and is associated with complete NVB removal and the worst postoperative potency recovery. However, in terms of oncologic dissection, it is the safest and most indicated in patients with extracapsular extension (ECE) due to the increased margin removal (18,19). ...
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Despite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.
... Our incidence of PSM at FSA can also be explained by our attempt to perform intrafascial nerve-sparing, which is more prone to PSM but demonstrated significantly better sexual function outcomes. [17] In the present series, RARP were performed by 8 different surgeons, of which 3 were "high-volume" surgeons (> 50 cases per year), while 5 performed less than 50 cases per year. The use of FSA, guided by mpMRI, allowed reducing PSM despite this fact. ...
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To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) in predicting upgrading, upstaging, and extraprostatic extension in patients with low-risk prostate cancer (PCa). MpMRI may reduce positive surgical margins (PSM) and improve nerve-sparing during robotic-assisted radical prostatectomy (RARP) for localized prostate cancer PCa. This was a retrospective, monocentric, observational study. We retrieved the records of patients undergoing RARP from January 2012 to December 2013 at our Institution. Inclusion criteria were: PSA <10 ng/mL; clinical stage <T3a; biopsy Gleason score <7; prostate mpMRI performed preoperatively at our Institution; intraoperative FSA of the posterolateral aspects of the specimen. All the identified lesions were scored according to the Prostate Imaging Reporting and Data System (PIRADS). We considered the lesion with the highest PIRADS score as index lesion. All the included patients underwent nerve-sparing RARP. During surgery, the specimen was sent for FSA of the posterolateral aspects. The surgeon, according to the localization scheme provided by the mpMRI, inked the region of the posterolateral aspect of the prostate that had to be submitted to FSA. We evaluated association between clinical features and PSM, upgrading, upstaging, and presence of unfavorable disease. Two hundred fifty-four patients who underwent nerve-sparing RARP were included. PSM rate was 29.13% and 15.75% at FSA and final pathology respectively. Interestingly, the use of FSA reduced PSM rate in pT3 disease (25.81%). Higher PIRADS scores demonstrated to be related to high probability of upgrading and upstaging. This significativity remains even when considering PIRADS 2–3 versus 4 versus 5 and PIRADS 2–3 versus 4–5. Also PSM at FSA were associated with higher probability of upgrading and upstaging. PIRADS score and FSA resulted to be strictly related to grading and staging, thus being able to predict upgrading and/or upstaging at final pathology.
... Shikanov et al. compared 110 cases of bilateral extrafascial NS versus 703 cases of interfascial NS. They observed significantly better sexual function in patients undergoing bilateral interfascial NS, while in lower-risk patients, bilateral interfascial NS did not result in significantly higher positive surgical margins rates [20]. Zhao et al. in a meta-analysis including 2096 patients from 7 eligible studies, compared the oncological and functional outcomes of intrafascial with non-intrafascial RP (including interfascial, extrafascial and no nerve-sparing approaches) in patients with low-risk localized prostate cancer. ...
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The purpose of this narrative review is to describe the different nerve-sparing techniques applied during radical prostatectomy and document their functional impact on postoperative outcomes. We performed a PubMed search of the literature using the keywords “nerve-sparing”, “techniques”, “prostatectomy” and “outcomes”. Other potentially eligible studies were retrieved using the reference list of the included studies. Nerve-sparing techniques can be distinguished based on the fascial planes of dissection (intrafascial, interfascial or extrafascial), the direction of dissection (retrograde or antegrade), the timing of the neurovascular bundle dissection off the prostate (early vs. late release), the use of cautery, the application of traction and the number of the neurovascular bundles which are preserved. Despite this rough categorisation, many techniques have been developed which cannot be integrated in one of the categories described above. Moreover, emerging technologies have entered the nerve-sparing field, making its future even more promising. Bilateral nerve-sparing of maximal extent, athermal dissection of the neurovascular bundles with avoidance of traction and utilization of the correct planes remain the basic principles for achieving optimum functional outcomes. Given that potency and continence outcomes after radical prostatectomy are multifactorial endpoints in addition to the difficulty in their postoperative assessment and the well-documented discrepancy existing in their definition, safe conclusions about the superiority of one technique over the other cannot be easily drawn. Further studies, comparing the different nerve-sparing techniques, are necessary.
... Following recent discoveries of the periprostatic fascial anatomy, extrafascial, interfascial, and intrafascial approaches have been developed. Comparing inter-fascial and extrafascial approaches, Shikanov et al. [15] reported a significantly improved potency rate (p=0.03) using the interfascial approach. ...
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Purpose To assess the effectiveness and safety of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer. Materials and Methods Existing systematic reviews were updated to investigate the effectiveness and safety of RARP. Electronic databases, including Ovid MEDLINE, Ovid Embase, the Cochrane Library, KoreaMed, Kmbase, and others, were searched through July 2014. The quality of the selected systematic reviews was assessed by using the revised assessment of multiple systematic reviews (R-Amstar) and the Cochrane Risk of Bias tool. Meta-analysis was performed by using Revman 5.2 (Cochrane Community) and Comprehensive Meta-Analysis 2.0 (CMA; Biostat). Cochrane Q and I2 statistics were used to assess heterogeneity. Results Two systematic reviews and 16 additional studies were selected from a search performed of existing systematic reviews. These included 2 randomized controlled clinical trials and 28 nonrandomized comparative studies. The risk of complications, such as injury to organs by the Clavien-Dindo classification, was lower with RARP than with LRP (relative risk [RR], 0.44; 95% confidence interval [CI], 1.23–0.85; p=0.01). The risk of urinary incontinence was lower (RR, 0.43; 95% CI, 0.31–0.60; p<0.000001) and the potency rate was significantly higher with RARP than with LRP (RR, 1.38; 95% CI, 1.11–1.70; I²=78%; p=0.003). Regarding positive surgical margins, no significant difference in risk between the 2 groups was observed; however, the biochemical recurrence rate was lower after RARP than after LRP (RR, 0.59; 95% CI, 0.48–0.73; I²=21%; p<0.00001). Conclusions RARP appears to be a safe and effective technique compared with LRP with a lower complication rate, better potency, a higher continence rate, and a decreased rate of biochemical recurrence.
... On the other hand, however, potency is markedly affected by the technique and few patients (<40%) are potent one year after surgery. 49 Together with the radical extirpation of the prostate gland and the seminal vesicles (Svs), an extended pelvic lymph node dissection (ePLnD) is mandatory in La-PCa 4 since as many as 25%-30% of these patients will be diagnosed with nodal metastases. 24 initially merely performed for staging purposes and according to a limited template, lymphadenectomy has recently proved possible therapeutic benefits: 50 for n+ patients treated with rP as monotherapy, the 5-and 10-years BCrFS were found to be 35% and 28%, respectively. ...
Article
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Introduction: Up to 26.5% of new dewly diagnosed prostate cancers (PCa) are locally advanced (LA). Although traditionally discouraged in this setting, radical prostatectomy (RP) lowers the risk of metastatic progression and cancer-specific death. We report a review of the available evidences and describe our surgical technique of Extrafascial robot-assisted RP. Evidence acquisition: The PubMed/Medline database was searched for "prostate cancer", "high-risk", "locally advanced", "prostatectomy". Duplicates and expert opinion papers were removed. Evidence synthesis: RP is an option in selected patients with LA-PCa and >10 years life expectancy. Five, 10 and 15 years after open RP, disease free survival rates were 85%, 73% and 67%. At the same time-points, cancer specific survival and overall survival were 95%, 90%, 79% and 90%, 76%, 53%, respectively. Post-operative potency was achieved by 25% of the patients while 79% were continent. Robotic prostatectomy provides comparable cancer control outcomes, but it is associated with a lower transfusion rate and a shorter hospitalization time. The concept of "extrafascial prostatectomy" was introduced in 2000 by Villers: this surgical approach reduces the incidence of mid- and postero-lateral positive margins (28% vs 51%, when compared to intrafascial; p = 0.08), expecially in pT3 cancers, but markedly affects potency. Conclusions: Robot-assisted RP is an option in patients with LA-PCa. Removing the prostate gland and the seminal vesicles still contained inside their aponeurotic covering, minimize the risk of positive surgical margins and clinical recurrence.
... Finally, 18 studies met the inclusion criteria [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. Sixteen studies were excluded because side specificity for PSM was lacking [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]. [44] and therefore based on DRE only. ...
Article
Context Surgical techniques aimed at preserving the neurovascular bundles during radical prostatectomy (RP) have been proposed to improve functional outcomes. However, it remains unclear if nerve-sparing (NS) surgery adversely affects oncological metrics. Objective To explore the oncological safety of NS versus non-NS (NNS) surgery and to identify factors affecting the oncological outcomes of NS surgery. Evidence acquisition Relevant databases were searched for English language articles published between January 1, 1990 and May 8, 2020. Comparative studies for patients with nonmetastatic prostate cancer (PCa) treated with primary RP were included. NS and NNS techniques were compared. The main outcomes were side-specific positive surgical margins (ssPSM) and biochemical recurrence (BCR). Risk of bias (RoB) and confounding assessments were performed. Evidence synthesis Out of 1573 articles identified, 18 studies recruiting a total of 21 654 patients were included. The overall RoB and confounding were high across all domains. The most common selection criteria for NS RP identified were characteristic of low-risk disease, including low core-biopsy involvement. Seven studies evaluated the link with ssPSM and showed an increase in ssPSM after adjustment for side-specific confounders, with the relative risk for NS RP ranging from 1.50 to 1.53. Thirteen papers assessing BCR showed no difference in outcomes with at least 12 mo of follow-up. Lack of data prevented any subgroup analysis for potentially important variables. The definitions of NS were heterogeneous and poorly described in most studies. Conclusions Current data revealed an association between NS surgery and an increase in the risk of ssPSM. This did not translate into a negative impact on BCR, although follow-up was short and many men harbored low-risk PCa. There are significant knowledge gaps in terms of how various patient, disease, and surgical factors affect outcomes. Adequately powered and well-designed prospective trials and cohort studies accounting for these issues with long-term follow-up are recommended. Patient summary Neurovascular bundles (NVBs) are structures containing nerves and blood vessels. The NVBs close to the prostate are responsible for erections. We reviewed the literature to determine if a technique to preserve the NVBs during removal of the prostate causes worse cancer outcomes. We found that NVB preservation was poorly defined but, if applied, was associated with a higher risk of cancer at the margins of the tissue removed, even in patients with low-risk prostate cancer. The long-term importance of this finding for patients is unclear. More data are needed to provide recommendations.
... Radical prostatectomy (RP) remains the standard treatment for localized PCa, reducing mortality by 10 to 15% at 10 years, through its efficacy in terms of cancer control and increased overall survival [9][10][11]. Through the study 20 cases of localized PCa in patients under 60 years treated by RP carried out in the urology department of the military teaching hospital of Rabat and a review of the different published series, we propose to analyze the particularities of this cancer in this age group. ...
... Extra-, inter-, and intra-fascial dissection planes can be planned, with those closer to the prostate and performed bilaterally associated with superior (early) functional outcomes [452][453][454][455]. Furthermore, many different techniques are propagated such as retrograde approach after anterior release (vs. ...
... Hastaların tamamı postoperatif 3. ay takibini tamamlarken; 6. ay, 12. Postoperatif Gleason skoru, n (%) NVD diseksiyonu esnasında sinirlere verilen hasar kadar diseksiyonun nereden yapıldığı da önem arz etmektedir ve interfasyal sinir koruyarak yapılan diseksiyonun ekstrafasyal sinir korunarak yapılan diseksiyona göre kısa ve uzun dönem potens oranları daha yüksek bulunmuştur. [20] Patel ve ark. ilk 500 vakalık serilerinde bilateral interfasyal NVD korudukları hastalarında 1. yıl sonunda %78 potens oranı raporlamışlardır. ...
... выявили, что у пациентов со стадией заболевания pT3 выполнение интрафасциальной нервосберегающей простатэктомии приводит к более высокому риску выявления положительного хирургического края [19]. Тем не менее, по данным S. Shikanov и соавт., билатеральное нервосбережение не сопровождается повышением риска положительного края у пациентов с РПЖ невысокого риска [20]. При этом выполнение билатерального нервосбережения сопровождается ранним восстановлением эректильной функции и функции удержания мочи [17]. ...
Article
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Introduction. Endoscopic radical prostatectomy is a highly effective treatment for localized prostate cancer. Intrafascial prostate dissection ensures early recovery of urine continence function and erectile function. This article sums up our own experience of performing intrafascial endoscopic prostatectomy.Materials and methods. 25 patients have undergone this procedure. 12 months after surgery 88.2 % of the patients were fully continent, 11.7 % had symptoms of minimal stress urinary incontinence. We encountered no cases of positive surgical margins and one case of bio-chemical recurrence of the disease.Conclusion. Oncologically, intrafascial endoscopic radical prostatectomy is as effective as other modifications of radical prostatectomy and has the benefits of early recovery of urine continence function and erectile function.
... It was concluded that the PNS technique reduced the positive surgical margin rate and preserved potency in high-risk PCa. 21 Another study reported that, among the patients with some degree of neurovascular bundle preservation for high-risk PCa, the recovery rate of EF was 47% at 24 months after a RARP. 22 In the current study, there was no significant difference in the positive surgical margin rates for any NS grade. ...
Article
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Purpose: To evaluate in Japanese patients their sexual function after robot-assisted radical prostatectomy (RARP) and to investigate the influence of the multinerve-sparing (NS) grade on their sexual function. Methods: In total, 225 patients were reviewed with localized prostate cancer who underwent RARP at the authors' institution. They underwent RARP >3 months ago, without pre- and posthormone therapy and salvage radiation. Self-administered International Index of Erectile Function (IIEF) questionnaires were used for assessment preoperatively and 1-48 months postoperatively. In all, 129 patients were evaluated with the preoperative IIEF-Question 1 and who achieved a score of ≥2 by being divided into five NS groups. The recovery rates of erection (postoperative IIEF-Question 1 score of ≥2) were calculated by using the Kaplan-Meier analysis. Results: Seventy-four percent of all the patients had not attempted sexual intercourse, but 60% had felt sexual desire at 24 months postoperatively. In those patients with a preoperative erection, the recovery rate of erection was 58% at 24 months after the RARP. Across the five NS groups, as the procedure was more nerve-sparing, the recovery rate of erection became significantly higher. The postoperative effects on erection in the bilateral and unilateral NS groups were significantly superior to those in the other NS groups. Conclusion: In Japanese patients, erection after a RARP is improved with multiNS grade procedures.
Chapter
In modern times, excision of neurovascular bundles is less common. Nomograms can help predict when to preserve nerve bundles, but often the concern is only slight, or implied on an MRI exam. When there is dominant disease on one side, an oncologically safe option is to back off a few millimeters from the capsule to increase margin clearance but preserve a reasonable amount of tissue for functional recovery. In this chapter, we consider the anatomic landmarks for partial or incremental nerve preservation, and outcomes for quality of life and cancer control.
Article
Robotic surgery is a significant technological innovation of the last 10 years. Although the advantages of robotic surgery for surgeons are obvious, robotic surgery must also demonstrate benefits for patients. We present current and future indications in oncological surgery and technological advances in medicine. Technological improvements and low cost will make this technique popular. Learning time is also shorter than for standard laparoscopy. The most obvious benefit is for the surgeon, with better ergonomics and probably a decrease of musculoskeletal diseases secondary to standard laparoscopy.
Article
L’objectif de ce travail a été d’établir par le sous-comité prostate du CCAFU des recommandations pour le diagnostic, le bilan, les traitements et la prise en charge des tumeurs de la prostate.
Article
The objective of this work was to compare the amount of residual periprostatic tissue for radical prostatectomy performed by the partial NS (PNS) technique with that performed by the nerve-sparing (NS) or wide-resection (WR) techniques. Retrospective histomorphologic evaluation of radical prostatectomy specimens (RPSs) from patients undergoing laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) was performed. The posterolateral regions corresponding to the neurovascular bundle in RPSs from 48 patients who had undergone NS, PNS, or WR during LRP (n = 30) or RARP (n = 18) were examined by two pathologists unaware of the technique used. The RPSs were evaluated at the base, mid-gland, and apex. The amount of periprostatic tissue at each site was recorded. Measurements were analyzed by use of a linear mixed model. For both LRP and RARP, each gradation of nerve-preservation was associated with periprostatic tissue, except PNS and WR did not differ for LRP at the apex and base or for RARP at the apex, mid-gland, and base. For LRP, a greater amount of tissue was on the left side of the prostate than on the right at the mid-gland level (P = 0.004) whereas for RARP the opposite was found (P = 0.024). Of 18 separate analyses, 13 were significantly associated. The study is limited by its retrospective design. The amount of periprostatic tissue in the neurovascular bundle area correlates well with the nerve-preservation approach used during LRP and RARP, providing anatomic evidence supporting the PNS approach. We also describe a novel finding of laterality bias at the mid-gland level in LRP and RARP specimens.
Article
Surgery remains a mainstay in the management of localized prostate cancer. This article addresses surgical aspects germane to the management of men with prostate cancer, including patient selection for surgery, nerve-sparing approaches, minimization of positive surgical margins, and indications for pelvic lymph node dissection. Outcomes for men with high-risk prostate cancer following surgery are reviewed, and the present role of neoadjuvant therapy before radical prostatectomy is discussed. In addition, there is a review of the published literature on surgical ablative therapies for prostate cancer.
Article
Introduction The purpose of this study was to describe the anatomy of the fascia surrounding the prostate that allows a better understanding of the nerve-sparing surgery. Methods A literature review of the last 10 years was carried out from the PubMed database using the following keywords alone or in combination: prostatic fascia, nerve-sparing surgery, prostatectomy, anatomy. Results There are three fascias surrounding the prostate: the parietal endopelvic fascia, the prostatic fascia, and the rectovesical septum. The cavernous nerves of the penis are located at the meeting of these three fascias. Discussion The intrafascial dissection allows a better nerve preservation but increases the risk of surgical margins. The extrafascial dissection allows a better control of oncological disease without nerve preservation. Interfascial dissection is a compromise. Conclusion Understanding the complexity of the anatomy of periprostatic fascias is essential during a radical prostatectomy. It allows better functional outcomes.
Article
Background The use of surgical clips for athermal dissection of the lateral prostatic pedicles and ligation during pelvic lymph node dissection (PLND) while performing robotic-assisted radical prostatectomy (RARP) has been the gold standard. Clips are used to prevent thermal injury of the unmyelinated nerve fibers and lymphceles, respectively. Objective To compare oncological and functional outcomes of a new technique of clipless, lateral pedicle control and PLND with RARP with bipolar energy (RARP-bi) versus the standard RARP technique with clips (RARP-c). Design, setting, and participants A retrospective study was conducted among 338 men who underwent RARP between July 2018 and March 2020. Surgical procedure RARP-c versus RARP-bi. Measurements We prospectively collected data and retrospectively compared demographic, clinicopathological, and functional outcome data. Urinary as well as sexual function was assessed using the Expanded Prostate Cancer Index for Clinical Practice, and complications were assessed using Clavien-Dindo grading. Multivariable regression modeling was used to examine whether the technical approach of RARP-bi versus RARP-c was associated with positive surgical margins (PSMs) or sexual and urinary function scores. Results and limitations A total of 144 (43%) and 194 (57%) men underwent RARP-bi and RARP-c, respectively. Overall, there were no differences in functional and oncological outcomes between the two approaches. On multivariable regression analysis, the RARP-bi technique was not associated with significant differences in PSMs (odds ratio [OR] = 1.04, 95% confidence interval [CI] 0.6–1.8; p = 0.9), sexual function (OR = 0.4, 95% CI 0.1–1.5; p = 0.8), or urinary function (OR = 0.5, 95% CI 0.2–1.4; p = 0.2). The overall 30-d complication rates (12% vs 16%, p = 0.5) and bladder neck contracture rates (2.1% vs 3.6%, p = 0.5) were similar between the two groups. There was no difference in lymphocele complications (1.4% vs 0.52%, p = 0.58). All complications were of Clavien-Dindo grade I–II. Conclusions Despite the concerns for an increased risk of nerve injury secondary to the use of bipolar energy for prostatic pedicle dissection, we demonstrate that this technique is oncologically and functionally similar to the standard approach with surgical clips. There was no difference in complications or lymphocele formation for techniques with versus without clips. Patient summary We describe a modified technique for prostatic pedicle dissection during robotic-assisted radical prostatectomy, which utilizes bipolar energy and is associated with shorter operative time, without compromising functional or oncological outcomes.
Article
Background: Radical prostatectomy is curative surgical treatment of choice for localized prostate cancer. The objectives are cancer control, preservation of continence and preservation of sexuality, the combination of the three constituting the Trifecta. Objective: The objective of this study was to assess, through the analysis of the literature, the sexual outcomes according to surgical approach: radical prostatectomy by laparotomy (PRL), laparoscopic radical prostatectomy (PRLa) and laparoscopic robot-assisted radical prostatectomy (PRLaRA), when nerve sparing was practiced. Methods: An exhaustive and retrospective review of literature was conducted using the Pubmed search with the following keywords: "Prostatic Neoplasms" [Mesh], "Prostatectomy" [Mesh], "Erectile Dysfunction" [Mesh], "Robotics" [Mesh], "Laparoscopy" [Mesh], Nerve sparing. Selection criteria: The selected articles were prospective or retrospective series including more than 200 patients, randomized trials and meta-analyses published between 1990 and 2014. Results: A total of 21 prospective studies (6 on PRL, 4 on PRLa and 11 on PRLaRA), 12 retrospective studies (6 on PRL, 1 on PRLa and 5 on PRLaRA), 2 randomized controlled trial and 3 meta-analyses were selected from 1992 to 2013. There was no evidence of the superiority of one surgical approach compared to others in terms of sexuality. Limits: Articles with level 1 of scientific evidence have discordant results, due to heterogeneity in the assessment criteria of postoperative sexual function. Conclusion: According to our knowledge, there is currently no difference in terms of sexual outcomes between PRL, PRLA and PRLaRA approaches.
Article
Erectile dysfunction (ED) remains a significant problem in up to 63% of men following robotic-assisted radical prostatectomy (RARP). Following the discovery of the neurovascular bundle, additional anatomic description and variation in nerve-sparing techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP nerve sparing technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP nerve sparing surgical techniques provide better outcomes compared to standard nerve-sparing RARP. The use of validated quality of life questionanires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best nerve-sparing approach. Overall, there is significant variation in RARP nerve sparing techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importane of anatomically dissecting the neurovascular bundle, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes following RARP to optimize postoperative potency.
Article
Introduction: The role of surgical approach on functional outcomes recovery in prostate cancer (PCa) patients treated with bilateral nerve-sparing radical prostatectomy (BNSRP) is still debated. In this study, we examine the association between the surgical approach and functional outcomes after BNSRP. Patients and methods: The study included 609 patients treated with robot-assisted radical prostatectomy (RARP) or open radical prostatectomy (ORP) between June 2008 and January 2011. Erectile function recovery was defined as an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score ≥22. Urinary continence recovery was defined as being completely pad-free over a 24-hour period. Patients were stratified according to their probability of postoperative erectile dysfunction and urinary incontinence, according to previously published predictive models. Multivariable logistic regression tested the association between the surgical approach and functional outcomes recovery in the overall population after stratifying patients according to their risk of erectile dysfunction and urinary incontinence. Results: Patients treated with RARP had higher 2-year erectile function (52.1% vs 67.8%; P<0.001) and urinary continence (72.0% vs 87.4%; P<0.001) recovery rates as compared to their ORP counterparts. After stratification according to the erectile dysfunction risk, RARP led to higher erectile function recovery rates in the low- and intermediate-risk erectile dysfunction groups (all P<0.001).This did not hold true, however, in patients at high risk of erectile dysfunction (P=0.5). Similarly, when patients were stratified according to their urinary incontinence risk, RARP was associated with a higher probability of urinary continence recovery in the very low, low, and intermediate risk groups only (all P<0.001). This did not hold true, however, in the group of men at high risk of postoperative urinary incontinence (P=0.8). Conclusions: RARP leads to higher urinary continence and erectile function recovery rates compared with ORP. Not all patients benefit from this approach to the same extent, however. Accurate preoperative patient selection would result in substantial savings for the health care system.
Article
The sub Comittee prostate of the CCAFU established guidelines for diagnostic, treatment, evaluation and standart of care of prostate cancer. Guidelines 2010 were updated based on systematic literature search performed by the sub-Comittee in Medline and PubMed databases to evaluate references, levels of evidence and grade of recommandation. Pathological examination of the tissue specimens was defined specifically for Gleason score according to ISP 2005 recommandations. Prostate and pelvis RMN became the reference in terms of radiological exam. Individual and early diagnosis of prostate cancer was defined and role of PSA was precised. Active surveillance became one of the standart of care of low-risk tumors, radical prostatectomy remained one of the options for all risk group tumors, length of hormonotherapy in association with radiotherapy was precised according to the risk group. Side effects of hormonotherapy treament needed specific supervision ; hormonotherapy had no indication in case of non metastatic tumors and intermittent hormonotherapy in metastatic tumors. New hormonal drugs in pre and post chemotherapy and bone target drugs opened new therapeutics pathways. From 2010 to 2013, standarts of care of prostate cancer were modified because of results of prospective studies and new therapeutics. They allowed precise treatments for each specific clinical situation. In the future, multidisciplinary treatments for high risk tumors, time of adjuvant treatment and sequencies of new hormonal treatment had to be defined.
Article
Résumé La prospective n’a pas pour objet de prédire l’avenir, de nous le dévoiler, comme s’il s’agissait d’une chose déjà faite, mais de nous aider à le construire. Si le contexte épidémiologique et thérapeutique actuel de ces tumeurs urogénitales peut évoluer en 10 ans, les méthodes diagnostiques et thérapeutiques d’aujourd’hui, ainsi que les concepts de prise en charge et l’implémentation des innovations sont déjà en pleine mutation. Plutôt que de focaliser la prospective à 10 ans uniquement sur la thérapeutique des cancers, nous chercherons à proposer une vision globale sanitaire incluant diagnostics, thérapeutiques, préventions, et l’utilisation en routine de la technomédecine, la génômique ou encore la nanomédecine. Ce voyage, dans un futur proche dans la cancérologie de demain, promet d’être plus adapté à l’évolution du mode de penser la médecine. L’exercice d’imagination de la manière dont nous traiterons les tumeurs rénales, prostatiques et urothéliales dans 10 ans, est autant une introspection au sein de notre actuel système de soins, que la manière dont nous souhaitons et pouvons le voir évoluer.
Article
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Robotic-assisted radical prostatectomy (RARP) is the current standard of care with long term cure in organ-confined disease. The introduction of nerve-sparing (NS) to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes. This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes, the neurovascular bundle (NVB), various NS techniques and postoperative functional outcomes. A non-systematic review was done using PubMed, Embase and Medline databases to retrieve and analyse articles in English,with following keywords (prostate cancer, robotic radical prostatectomy, nerve-sparing). The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies. The literature has shown NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other. Variables such as preoperative risk assessments, baseline potency, surgical anatomy of individual patients and surgeons’ expertise play a major role in the outcomes. A tailored approach for each patient is required for applying the NS approach during RARP.
Chapter
The field of urology continues to embrace new technological and procedural advancements designed to improve the morbidity, mortality, and functional outcomes for patients with urologic diseases. Robot-assisted laparoscopic surgery is one such novel development capable of improving acute and long-term perioperative outcomes compared to conventional open surgery. In the United States, robot-assisted radical prostatectomy (RARP) is the most common surgical technique for radical prostatectomy, accounting for greater than 50 % of procedures performed annually. The degree to which the availability and promotion of robot-assisted surgery (RAS) has contributed to the recognized current increases in cost and frequency of radical prostatectomy is debated (Kaye et al., Nat Rev Urol 12(1):55–60, 2015). RARP has arguably accelerated patient convalescence after radical prostatectomy, while improving ergonomics for surgeons. However, whether RAS significantly improves upon postoperative and/or oncological outcomes enough to justify its additional costs is not known. This determination requires standardized evaluation of efficacy and safety. In this review, the definition, standardization, and reporting of complications associated with RARP will be critically appraised in an effort to quantify the progress which has been made.
Article
L’assistance robotique offre à la prostatectomie totale (PT) cœlioscopique plus d’aisance technique et une plus grande précision pour la préservation des bandelettes vasculo-nerveuses (BVN). La dissection intrafasciale a ainsi été proposée afin d’assurer une meilleure conservation de ces bandelettes. Cependant, cette technique comporte un grand taux de marges positives, justifiant une autre tendance qui consiste en une approche interfasciale. Il y a encore peu d’études à ce jour comparant directement ces 2 techniques, et notre étude est la première à offrir un suivi de 2 ans.
Article
Objectives: After radical prostatectomy, surgical margin positivity is an important indicator of biochemical recurrence and progression. In our study we want to compare the surgical margin positivity rates for retropubic radical prostatectomy (RRP) and robotic assisted radical prostatectomy (RALP) and investigate the factors affecting surgical margin positivity in RALP. Materials and methods: Data from 78 RRP and 62 RALP patients operated from 2011 May to 2016 March were retrospectively screened. Patients in both groups were compared in terms of age, postop hematocrit reduction, hospital stay, duration of follow-up, surgical margin positivity, biochemical recurrence and oncologic parameters. In RALP group it was searched the relationship between the surgical margin positivity and prostate specific antigen (PSA), positive biopsy core, biopsy Gleason scoring, pathologic stage and Gleason scoring, lymph node positivity, lymphovascular and perineural invasion, extracapsular extension, seminal vesicle invasion, prostate weight. Results: Patients in the RALP group had lower postop hematocrit reduction and shorter hospital stay (p < 0.001). There was no difference in surgical margin positivity between RALP and RRP groups (37.1% vs. 29.5%, p = 0.341). In RALP group there was a correlation between surgical margin positivity and positive biopsy core number (p = 0.011), pathologic stage (p < 0.001) and Gleason score (p < 0.001), EAU risk classification (p = 0.001), seminal vesicle invasion (p = 0.045), extraprostatic extension (p < 0.001). There was no correlation between prostate weight (p = 0.896), PSA (p = 0.220), biopsy Gleason score (p = 0.266), lymph node positivity (p = 0.140), perineural (p = 0.103) and lymphovascular invasion (p = 0.92) with surgical margin positivity. Conclusions: Positive biopsy core number, pathological stage and Gleason score, EAU risk classification, seminal vesicle invasion and extraprostatic extension are correlated with surgical margin positivity in RALP.
Article
Introduction: During robot-assisted radical prostatectomy (RARP), the quality of nerve sparing (NS) was usually classified by laterality of NS (none, unilateral, and bilateral) or degree of NS (none, partial, and full). Recently, side-specific NS have been more frequently performed, but previous NS grading system might not reflect the differential NS in each side. Aim: Herein, we assessed whether a subjective NS score (NSS) incorporating both degree of NS and NS laterality can predict the time to potency recovery following RARP. Methods: Data were analyzed from 1,898 patients who had left and right neurovascular bundle sparing quality scores and at least one year of follow-up after RARP was performed between January 2008 and October 2011. Main outcome measures: Cox proportional hazard method analyses were used to determine predictive factors for early recovery. Multivariate linear regression models were used to assess subjective NSS in an effort to predict time to potency recovery. Subjective NSSs were compared to a model based on the three grades according to laterality and degree. Results: Time to potency recovery showed a statistically significant difference in favor of higher NSS by the Cox proportional hazard regression analysis (NSS 0 vs. NSS 5-6, 7-8, and 9-10; P < 0.01). The regression model indicated that the statistical significance of the subjective NSS covering the differential NS is not different from that of the conventional three-grade scales, while it has a higher R(2). The regression equation with subjective NSS was as follows: Log (Time) = 5.163 - (0.035 × SHIM Score) + 0.028 Age - (0.101 × Subjective NSS). Conclusion: The subjective NSS can reflect NS degree for each side based on the visual cues. Regression model can be used to help inform the patient about the time to postoperative potency regain, which is an important patient concern following RARP.
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With the recent increase in the elderly population, and the Westernization of the diet and increased consumption of meat products, a significant rise in the incidence of prostate cancer has been noted in the Republic of Korea. In cases with localized prostate cancer and sufficiently long life expectancy, the standard treatment is surgical resection of the prostate. Such surgical treatment is so far the only modality demonstrated through randomized prospective studies to be beneficial in terms of disease-specific survival; this procedure involves not only surgical removal of the prostate but also pelvic lymphadenectomy for accurate staging and neurovascular bundle preservation to aid in postoperative functional recovery. Prostatectomy can be carried out either with an open technique, laparoscopically, or under robot assistance. Reviews of the literature and meta-analyses have shown that laparoscopic and robot-assisted procedures offer significant reductions in blood loss and transfusion rates and advantages in terms of recovery from postoperative complications such as incontinence and impotence over open prostatectomy. However, no long-term oncologic outcomes are available for laparoscopic or robot-assisted procedures, and the long-term prevalence of incontinence and impotence for these two methods doesnot differ significantly from those for open prostatectomy, despite the laparoscopic and robot-assisted procedures being far more costly. Therefore, surgical treatment of prostate cancer should be carefully decided on following ample deliberation of various factors including the stage, age, comorbidities, and economic status of the patient and provision of sufficient information to the patient.
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Introduction We examined a novel method of grading nerve sparing in robotic-assisted laparoscopic radical prostatectomy to better predict the potency outcomes of patients at 1-year after surgery. This grading (scale) was based on the surgeon's criteria of intraoperative findings during completion of nerve sparing. This grading was then analyzed statistically to validate its association with potency outcomes. Methods We devised a study module based on measurable visual cues intraoperatively where the surgeon risk stratified the surgery into four grades depending on the completeness of nerve sparing, keeping in mind the known parameters influencing potency outcomes. A novel grading scale was then proposed and used in this study for the same. We prospectively collected data and retrospectively analyzed 425 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) at a high-volume center by a single surgeon. Results At 1 year of follow-up, it was found that age, laterality of nerve preservation, weight of prostate, and the surgeon-assigned grading were all statistically significant independent predictors of return of potency in terms of satisfactory penetrative intercourse >50% of times and Sexual Health Inventory for Men ≥17. However, prostate-specific antigen was found not to be a predictor of the same. Conclusions Intraoperative physician-assigned grading was found to be the single most significant predictor of the return of potency at 1-year post-RALP.
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Background Postoperative erectile dysfunction (ED) remains a prevalent consequence of radical prostatectomy (RP) that significantly impacts patient quality of life. Water-jet technology is widely used for dissection in neurosurgical procedures but novel to urologic surgery. Aim To establish the impact of hydro-jet dissection (HJD) of the cavernous nerves (CN) on postoperative erectile function in an animal model of RP-induced ED. Methods 32 male Sprague-Dawley rats were randomized to 4 groups: Sham surgery (n = 8), bilateral HJD of CN (n = 8), blunt CN injury (n = 8), or stretch CN injury (n = 8). After 4 weeks, erectile function was assessed by measuring intracavernous pressure (ICP), and penile tissues were harvested for immunohistologic studies. Main Outcome Measure The peak ICP and the area under the curve were calculated for each group. Immunohistologic studies were performed for α-smooth muscle actin and neuronal nitric oxide synthase on cross-sections of penile tissue. Results Rats in the HJD group demonstrate a significantly higher mean peak ICP and area under the curve compared with both CN injury groups (P = .001). Postoperative erectile function in the HJD group returned to baseline function. Preservation of α-smooth muscle actin and neuronal nitric oxide synthase was observed in the HJD group compared with the other surgical trauma groups. Clinical Implications Hydro-jet dissection used in an RP animal model maintains erectile function and offers a potential benefit that warrants further human studies. Strengths & Limitations This is a novel animal study comparing a new technology to established CN dissection techniques. This study uses an animal model, which may not completely translate to post-RP ED in humans. Conclusion Hydro-jet dissection of the CN during RP in an animal model is associated with significantly better postoperative erectile function when compared with other CN injury. Clinical studies are needed to further investigate the putative benefit of HJD on erectile function in patients undergoing RP. Campbell JD, Alenezi H, DeYoung LX, et al. Hydrojet Dissection of the Cavernous Nerves Preserves Erection Function in a Radical Prostatectomy Animal Model. Sex Med 2019;7:104–110.
Chapter
Preservation of erectile function is a major challenge in any technique of radical prostatectomy. Early reports of robotic technique centered on benefits in this area, although overall acceptance of a benefit is difficult to dissect from surgeon volume/experience. Proper technique should avoid use of diathermy close to the neurovascular bundles, and tension to the nerve should be minimized. Depending upon extent of cancer, more or less fascial tissue covering can be left on the specimen for greater margin clearance versus on the nerve bundles for more protection. This chapter focuses on a novel technique for nerve bundle release that works in a retrograde manner to minimize injury to nerve fibers that run close to the prostate base. A novel nerve protection graft is presented as an example.
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Introduction. Endoscopic radical prostatectomy is a highly effective treatment for localized prostate cancer. Intrafascial prostate dissection ensures early recovery of urine continence function and erectile function. This article sums up our own experience of performing intrafascial endoscopic prostatectomy.Materials and methods. 68 patients have undergone this procedure.Results. 12 months after surgery 88.2 % of the patients were fully continent, 11.7 % had symptoms of minimal stress urinary incontinence. We encountered no cases of positive surgical margins and two case of biochemical recurrence of the disease.Conclusion. Oncologically intrafascial endoscopic radical prostatectomy is as effective as other modifications of radical prostatectomy and has the benefits of early recovery of urine continence function and erectile function.
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Background: The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP). Methods: We used the Surveillance, Epidemiology and End RESULTS-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003-2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery. Results: ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76-1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20-1.43) and ED (HR 1.43, 95% CI 1.31-1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75-0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time. Conclusions: MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.
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The need for accurate measures of health-related quality of life (HRQOL) in men treated for prostate cancer is of paramount importance because patients may survive for many years after their diagnosis. Hence, interest has increased in choosing treatments that optimize both the quality and quantity of life in patients with this disease. This study sought to develop and evaluate a self-administered, multiitem, disease-specific instrument to capture the health concerns central to the quality of life of men treated for early stage prostate cancer. After focus group analysis and pilot testing, the instrument was tested with a large retrospective, cross-sectional survey. Exploratory factor analysis and multitrait scaling analysis were used to facilitate the formation of six scales containing 20 disease-targeted items that address impairment in the urinary, bowel, and sexual domains. The psychometric properties of the new scales were assessed by measuring test-retest reliability, internal consistency reliability, and construct validity. Performance on the new scales was compared with scores on other established cancer-related health-related quality of life instruments. Two hundred fifty-five long-term survivors of prostate cancer treatment and 273 age-matched and ZIP code-matched comparison subjects without prostate cancer from a large managed care population in California were studied. Mean age was 72.7 years. In addition to the new scales, the RAND 36-Item Health Survey (SF-36) was used as a generic core measure, and a cancer-related health-related quality of life instrument (the Cancer Rehabilitation System-Short Form) was used to provide construct validity. For the new scales, test-retest reliability ranged from 0.66 to 0.93, and internal consistency ranged from 0.65 to 0.93. Disease-targeted measures of function and bother in the three domains correlated substantially with one another. Scale scores correlated well with related, established scales. Men undergoing prostatectomy or pelvic irradiation demonstrated the expected differences in performance on the disease-specific health-related quality of life scales when compared with each other or with comparison subjects. Age was inversely related to sexual and bowel function. The UCLA Prostate Cancer Index performed well in this population of older men with and without prostate cancer. It demonstrated good psychometric properties and appeared to be well understood and easily completed. The high response among patients suggests that these men especially are interested in addressing both the general and disease-specific concerns that impact their daily quality of life.
Article
Variations in the proportion of surface occupied by tumor (percentage carcinoma), carcinoma volume, histologic grade, capsular penetration, and margin positivity were assessed in a completely sampled cancerous prostate gland. All prostatic tissue was embedded and each block serially sectioned, for a total of 2,678 histologic sections examined. Although variations in percentage carcinoma and carcinoma volume were noted in some blocks, the differences were small when compared with the initial set of 19 slides. Histologic Gleason's grade also showed little variation in the serial sections. Focal capsular penetration in one block and an increase in the number of blocks with a positive anterior margin from two to four were identified in serial sections, but this did not alter the pathologic stage because of seminal vesicle involvement by tumor. In this example, the morphologic prognosticators of tumor volume, histologic grade, margin positivity, and pathologic stage were not altered by complete serial sectioning.
Article
To examine the extent and location of positive surgical margins and their influence on progression. Two hundred fifteen consecutive radical prostatectomy specimens, using 2 to 3-mm step-sections, were reviewed. Particular attention was paid to the location and extent of positive margins. Seventy-three patients (34%) with one or more positive margins were subjected to further detailed analysis. Progression was defined as a serum prostate-specific antigen level greater than 0.1 ng/mL and rising. The mean follow-up period was 23.2 months; median 24 months (range 3 to 40). Margin-positive patients had a significantly higher biopsy tumor grape (P = 0.05) than did margin-negative patients. Capsular preforation was present in 75%, seminal vesicle invasion in 33%, and nodal metastases in 10% of margin-positive patients; in contrast, these tumor characteristics were present in 47%, 8%, and 1% of margin-negative patients, respectively. The extent of involvement of linked margins was focal in 22% and extensive in 66%. An equivocal margin identified as surgical incision into the specimen (due to hemostatic staples, surgical dissection, or retraction) was present in 12%. Seventy-one percent of patients had a positive margin at only one location. Of all 99 positive-margin locations, 40% were apical, 10% anterior, 8% bladder neck, 16% posterolateral, and 25% posterior. Thirty-four percent of margin-positive and 7% of the margin-negative patients demonstrated biochemical progression. Of the 36 patients with a positive margin as their only major risk factor for progression (seminal vesicle and lymph node negative, Gleason score less than 8), 25% have progressed. Progression occurred in 2 of 9 patients with an equivocal positive margin, and 5 of 16 with a single focal-positive margin. A multivariate analysis of margin-positive patients identified tumor volume and grade as the most significant predictors, with the location and extent of the positive margin not significant. Although more frequent at the prostatic apex, tumor at the inked margin at any location is a risk factor for postoperative biochemical progression.
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In an effort to decrease the frequency of postoperative positive surgical margins (+SM), a modified extrafascial radical prostatectomy technique was developed and evaluated. 402 consecutive radical prostatectomy specimens removed for clinical stage T2 cancers from 1987 to 1994 were histologically examined prospectively for tumor volume, extraprostatic extension and +SM. Surgical technique modification was introduced in 1990. We compared the histologic status and biological outcome of the prostatectomy cases in 1987-1989 (n = 166) to those treated from 1990 to 1994 (n = 236). The two series were comparable in (1) clinical stage and preoperative (PSA, (2) tumor volume, grade and location, and (3) capsular penetration, seminal vesicle and lymph node status. +SM fell from 32 to 25% overall, but for 146 (36%) prostates with a tumor volume <2 cm(3), +SM fell from 21 to 6% which was statistically significant. Outcome measured by biological progression showed a decrease from 33% for +SM to 13% for -SM for cases with a tumor volume <2 cm(3). For cancer volumes >2 cm(3), the incidence of +SM did not vary significantly. We describe the anatomic details necessary for exposure of periprostatic fascias and extrafascial dissection at (1) the prostatourethral junction which ensures wide excision of the anterior and apical aspect of the prostate, (2) the posterior and apical area (development of the prerectal space), lateral and posterior areas at the base of the prostate which ensures wide excision of the rectoprostatic fascia (Denonvilliers's fascia) and lateral prostatic fascia. Differences in surgical technique probably accounted for the significant decrease in +SM for those T2 cancers with volumes < or =2 cm(3) which represents 36% of the T2 cancers in our series. Recent screening with PSA (T1c cancers) increases the incidence of these cancers < or =2cm(3). This modified uni- or bilateral anatomic extrafascial prostatectomy with improved +SM and biological progression rates for T2 cases should be evaluated for T1c cases.
Article
To describe a technique using the da Vinci robotic system that enhances one's ability to visualize and dissect the apex and reduce surgical margins. An important outcome of radical prostatectomy is the reduction of iatrogenic positive margins in organ-confined prostate cancer. The clinical data of our first 140 consecutive robot-assisted radical prostatectomies were divided into two groups: group 1, cases 1 to 50; and group 2, cases 51 to 140. After reviewing the surgical margin data and appropriate video clips of our initial 50 patients, we altered our technique. Initially, we had used two sutures to control the dorsal venous complex (DVC), one proximally and distally. The prostate was freed, and, finally, the DVC and urethra were divided. However, a bundle of fat obscured the apex, leading to positive apical margins. We developed the following method. First, we removed all of the fat overlying the DVC and prostate. Second, we divided the puboprostatic ligaments and dissected the levator fibers to expose and increase the DVC length fully. Finally, we stapled and divided the DVC using a vascular stapler. The two groups were clinically comparable. Overall, the pathologic margin rate improved from 36% in group 1 to 16.7% in group 2. In group 1, 9 (27.3%) of 33 pT2 tumors had positive margins versus 3 (4.7%) of 64 pT2 tumors in group 2 (P = 0.003). The data demonstrate that this change in technique for robotic prostatectomy resulted in a more defined apical dissection and a statistically significant reduction in positive margins in patients with organ-confined disease.
Article
Anatomical nerve sparing radical prostatectomy provides excellent cancer control, although the recovery of sexual function is variable. We recently described a technique to preserve the prostatic fascia (veil of Aphrodite) that appears to enhance the quality of nerve preservation during robotic prostatectomy. In January 2003 we initiated a prospective study comparing patients undergoing prostatic fascia preservation with those undergoing conventional nerve sparing robotic radical prostatectomy. We report results at 12 months of followup From January to August 2003, 58 potent men with a Sexual Health Inventory for Men score (SHIM) of greater than 21 without phosphodiesterase 5 inhibitors underwent Vattikuti Institute prostatectomy, including 35 with preservation of the prostatic fascia (study) and 23 with conventional nerve sparing (control). Potency was assessed with self-administered SHIM questionnaires 12 months after surgery. The primary end point was achievement of erections strong enough for penetration with or without oral medications. The secondary end point was the ability to achieve normal erections (SHIM greater than 21) with and without medications. At 12 months of followup 17 of 23 control (74%) and 34 of 35 study (97%) patients achieved erections strong enough for intercourse (p = 0.002). Four control (17%) and 18 study (51%) patients achieved normal erections (SHIM greater than 21) without medication (p <0.0001). Six control (26%) and 30 study (86%) patients achieved normal erections with or without phosphodiesterase 5 inhibitors (p <0.0001). Potency rates after radical prostatectomy vary with the measure used to define potency. Irrespective of the definition used patients undergoing prostatic fascia preserving radical prostatectomy have significantly better potency outcomes than patients undergoing conventional nerve sparing robotic prostatectomy at 12 months of followup.
Article
To describe our technique of nerve sparing laparoscopic radical prostatectomy (LRP). We present the oncological and functional results (potency and urinary continence). LRP has become standard at our institution based on experience with more than 2800 consecutive cases operated on between 1997 and 2005. From May 2003 to March 2005 a total of 677 LRP were performed, 425 consecutive patients candidates for a nerve sparing technique have been operated using the intrafascial approach. The challenge of our technique is to remove the prostate without any thermic and mechanic traumatism, avoiding dissection of outer layer. Oncological data were assessed by pathological examination and post-operative PSA level. Functional results were assessed with a self questionnaire. By pathological stage, 2 pT2a specimens (7.4%), 7 pT2b specimens (21%), 44 pT2c specimens (24%), 63 pT3a specimens (43%), 11 pT3b specimens (46%) were found to have positive surgical margins (SMs). In 86 specimen (59%) positive SMs were focal inframillimetric. Median follow-up was 11 months (range 1-22). The continence rate (no leakage/no pad) was 95% at 6 months, confirmed at 12 months among 202 patients. For 137 patients, potency rate was 58.5% at 12 months. Intrafascial LRP provides satisfactory results in regard to recovery of continence and sexual function. Long-term progression and survival outcome are necessary before this procedure should be offered as a replacement for interfascial nerve sparing technique.
Article
We have recently described a modification (Veil of Aphrodite) designed to preserve the lateral prostatic fascia (LPF) during robotic prostatectomy. Here, we histologically compare the Veil of Aphrodite technique (VT) and standard nerve-sparing technique (ST). Thirty-six consecutive prostatectomies performed by a single surgeon were processed by the whole-mount method. The right and left anterolateral (AL) zones of each prostate were independently evaluated for LPF, plane of excision, capsular incision/margin status, margin clearance, and quantitative analysis of periprostatic nerve bundles using S100 immunostain. There were 42 AL zones with ST and 30 with VT. In all 42 ST zones, the plane of excision was outside the prostate and a rim of LPF was present. The mean margin clearance was 1.4 mm (0.6-2.8 mm) and the mean nerve bundle count was 10 (3-19). Capsular incision and margin status were negative in all 42. For VT, 24 of 30 zones lacked LPF and the plane of excision ran just by the prostatic edge. The mean margin clearance was 0.3 mm (0-1.7 mm) and the mean nerve bundle count was two (0-11). Two VT AL zones revealed capsular incision; the margin was negative for tumour in all 30. Differences in the margin clearances and nerve bundle counts between ST and VT were statistically significant (p < 0.0001). The LPF contains nerve bundles that run along the surface of the AL zones. The VT is a safe procedure that effectively preserves the LPF and appears to provide enhanced nerve sparing as compared to the ST.
Article
Robotic-assisted laparoscopic radical prostatectomy (RLRP) is increasingly becoming an alternative to open and laparoscopic radical prostatectomy in the treatment of localized prostate cancer. RLRP has been associated with low morbidity, short convalescence and comparable oncologic and functional outcomes. We report our initial experience of 300 consecutive cases with selective use of interfascial nerve preservation (IFNP). Between February 2003 and September 2005, 300 consecutive men underwent RLRP at our institution. Patients were followed prospectively with validated questionnaires. Mean operative time was 282 minutes with an estimated blood loss of 273 ml. The intra-operative complication rate was 2.3% with no mortality. Return to baseline (RTB) urinary function and subjective continence at 12 months were 71% and 90.2%, respectively. RTB sexual function and subjective potency at 12 months were 53% and 80.4%, respectively. Overall, the positive surgical margin (PSM) rate was 20.9%: 15.1% for pT2 and 52.1% for pT3 disease and 93.1% had an undetectable PSA (<0.1 ng/mL) with a mean follow-up of 17.3 months. Fifty-four percent of PSMs occured in a poster-lateral (PL) location. Retrospectively, IFNP was performed in 86.5% and 62.5% of pT2 and pT3 PSMs, respectively. Pathologic-T3 PSMs were found to occur significantly more often in a PL location when ipsilateral IFNP was performed when compared to non-IFNP (73% vs 33%, p=0.05). IFNP appears to result in favorable return of potency, however, postero-lateral PSMs appear to occur more frequently with this technique. Proper patient selection for robotic surgery and nerve-preservation appears to be critical in order to reduce PSM and optimize the oncologic efficacy of this technology.
Article
Contemporary techniques of radical prostatectomy achieve excellent oncologic outcomes; erectile dysfunction is the most common adverse effect. We have modified our technique of robotic radical prostatectomy (Vattikuti Institute prostatectomy [VIP]) in an attempt to minimize decrease of erectile function while maintaining the excellent oncologic outcomes achieved by the radical retropubic prostatectomy. We present our current technique of VIP with preservation of the lateral prostatic fascia ("veil of Aphrodite"). A total of 2652 patients with localized carcinoma prostate underwent VIP. The salient features of our current technique are early transection of the bladder neck, preservation of the prostatic fascia, and control of the dorsal vein complex after dissection of the prostatic apex. Oncologic and functional outcomes were obtained through a questionnaire collected by a third party not involved in patient care. Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12-66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function. VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.
Article
Based on our recently published anatomic studies, we present the most recent refinement of the endoscopic extraperitoneal radical prostatectomy (EERPE), the intrafascial nerve-sparing EERPE (nsEERPE). As part of the intrafascial technique, the dissection plane is directly on the prostatic capsule, freeing the prostate laterally from its thin surrounding fascia that contains small vessels and nerves. The technique enables puboprostatic ligament preservation, leaving intact endopelvic fascia, periprostatic fascia, and neurovascular bundles. The operation was performed in 150 patients with indications for nerve-sparing procedure. The mean operative time was 131 min (range: 50-210 min) and the mean catheterization time was 5.9 d (range: 4-20 d). Twelve months postoperatively, 94.3% of the patients were continent (no need for pads), 4.6% had minimal stress incontinence, and one patient required >2 pads/d. At the 12-mo follow-up, the potency rates (erections sufficient for intercourse with or without the use of phosphodiesterase 5 [PDE5] inhibitors) of the patients who underwent bilateral intrafascial nsEERPE were 89.7% (age: 44-55 yr), 81.1% (age: 56-65 yr), and 61.9% (age: >65 yr). Positive surgical margins in pT2 and pT3 tumors were 4.5% and 29.4%, respectively. The intrafascial nsEERPE enables the dissection of the prostate with limited trauma to the surrounding fascias and the enclosed neurovascular bundles. We propose that the preserved neurovascular bundles with intrafascial nsEERPE are more viable. The results advocate this proposition.
Article
The main objective of radical prostatectomy (RP) is optimal oncologic resection with preservation of sexual function (SF). During our initial experience with robot-assisted laparoscopic radical prostatectomy (RLRP), we noted a high rate of posterolateral location of positive surgical margins (PSM) with nerve preservation (NP). With its magnified view of the surgical field and improved instrument precision, one potential advantage of RLRP is the ability to tailor the degree of NP. We evaluated the effect of a protocol for side-specific NP based on preoperative variables on PSM rates and SF outcomes. Between June and November 2006, 150 consecutive RLRPs were performed using a surgical protocol to select side-specific NP techniques (interfascial [IF], partial extrafascial [pEF], and wide extrafascial resection [WEFR]) based on preoperative risk factors (clinical stage, biopsy Gleason score, percentage of positive cores and maximal core cancer percentage, and preoperative PSA). Pathologic and SF outcomes in these patients were compared with those of a control group of 245 consecutive RLRPs in whom non-selective IF dissection was performed. All data were prospectively collected. Mean patient age, PSA, clinical stage, biopsy Gleason score and positive core involvement, pathologic Gleason score, and stage were comparable among the two groups. The overall PSM rate (12.6% nu 20.4%; P = 0.04) and posterolateral location of PSMs (37% nu 70%; P = 0.04) were significantly lower in the study group. At 12 months, potency was reported in 80%, 67%, and 11% of men undergoing bilateral IFNP, partial extrafascial nerve preservation (pEFNP), and WEFR, respectively (P = 0.27). Planning side-specific NP during RLRP, according to selected preoperative variables, can significantly reduce overall and posterolateral PSM rates. Furthermore, partial nerve sparing (pEFNP) also appears to confer favorable early SF outcomes.
Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer
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