Robotic-assisted laparoscopic radical prostatectomy after aborted retropubic radical prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38 kg/m² presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160 mL and operating time was 145 min. The patient’s pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3 months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.     

Penile fibrotic changes after radical retropubic prostatectomy

OBJECTIVE: To investigate the type of penile deformity, response to treatment of and predictive factors for the formation of penile fibrotic changes after radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: Between July 1996 and September 1998, 110 men who had undergone RRP a mean (SD, range) of 35 (20, 5-145) months previously were evaluated by one physician for their erectile dysfunction. Those men affected by penile fibrotic changes were advised to initiate medical therapy for possible Peyronie's disease; their charts were reviewed and they were interviewed to determine the outcome. RESULTS: Overall, 45 of 110 patients (41%) with erectile dysfunction after RRP had penile fibrotic changes, representing 11% of all patients undergoing RRP in the specified period. The primary clinical presentation included penile curvature in 42 men (93%) and 'waistband' deformity in 11 (24%; some had both); palpable plaques were present in 31 (69%). On assessing the outcome in 40 men, 16 (40%) felt that their condition had improved, half were unchanged and 10% progressed, within a mean follow-up of 24 months after diagnosis. Of the 16 improved, 14 were regularly using a vacuum constriction device or injection therapy. No significant factors predictive of the fibrotic changes could be identified, including the use of intracavernosal injection therapy before onset, neurovascular bundle resection, operative duration, estimated blood loss and pathological tumour grade or stage. CONCLUSIONS: Penile fibrotic changes are a significant but previously undescribed problem in men after RRP. Although predisposing factors could not be identified, most men felt that their condition stabilized or improved during treatment. Corroborative confirmation of this association and its aetiology will require prospective studies.     

Bladder neck contracture after radical retropubic prostatectomy

OBJECTIVE: To examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck sparing radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: We assessed the incidence, management and outcome of anastomotic strictures in 510 consecutive patients (mean age 61 years, range 45-76) who had open RRP by one surgeon between 1994 and 2003. RESULTS: The mean (range) follow-up was 30 (2-89) months; 48 patients (9.4%) developed an anastomotic stricture. Dilatation of the stricture was an effective treatment, with few patients requiring further treatment. CONCLUSION: Stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is relatively frequent but can usually be successfully managed with one graduated dilatation under light sedation.     

Surgical margin status after radical retropubic prostatectomy

This month there are two mini-reviews on aspects of prostate cancer. The first, from the USA, presents the implications of surgical margin status after radical prostatectomy and the potential role of adjuvant radiation therapy. The second, from the USA and Belgium, discusses the use of hormonal therapy for PSA-only recurrence of prostate cancer after previous local therapy. In the third mini-review, the condition known as hypoactive sexual desire disorder is described, and that it is often ignored or erroneously treated as erectile dysfunction suggests to the authors that education of doctors and patients is required. Finally, there is a mini-review of conventional and alternative methods for providing analgesia in renal colic.     

Open radical retropubic prostatectomy

For more than two decades, open radical prostatectomy has been considered the gold standard for the surgical management of prostate cancer. More recently, however, laparoscopic and now robotic approaches to radical prostatectomy have become increasingly popular. It is unclear whether these techniques are associated with any material advantage with regard to short-term convalescence. In addition, the high positive surgical margin rates reported with robotic prostatectomy are concerning, particularly early in the learning curve. Additional experience with these methods and long-term follow-up data are necessary to determine whether the cancer control and functional outcomes meet the standards of open radical prostatectomy.     

Nerve-sparing radical retropubic prostatectomy

A newly developed technique for radical retropubic prostatectomy that allows for preservation of sexual potency in the majority of patients is described. This technique involves removal of the prostate medial to both neurovascular bundles containing the pelvic parasympathetic nervierigentes. This technique can also be adapted to the performance of radical cystectomy.     

Modified radical retropubic prostatectomy

A significant modification of the traditional radical retropubic prostatectomy is presented. A logical stepwise surgical sequence is discussed in detail. The technique described provides excellent visualization, early ligation of vascular and lymphatic channels, decreased intraoperative blood loss, and a tension-free vesicourethral anastomosis.     

Open radical retropubic prostatectomy

We describe a surgical procedure for radical retropubic prostatectomies that we have used in a prospective series of 231 patients with localised prostate cancer (mean age 63 yr; range: 46-75 yr). Nerve-sparing was performed in 148 of 231 patients. We insist on three points: (1) high-quality preservation of the sphincter, with the sphincter divided to keep its anatomic environment intact; (2) high-precision retrograde dissection of the neurovascular bundles in the mid-gland prostate zone for early recovery of erectile function (the dissection of the bundles is described for each prostate zone [apex, mid-gland, base]); and (3) the need to standardise each step of the procedure for a reproducible protocol independent of individual patient anatomy. These three measures will ensure the best cancer control with the best functional results. The rate of positive margins for patients with organ-confined (pT2) cancer was 3.7% (2.4% related to an invaded striated sphincter). The quality of the excised specimens was further checked by noting the frequency of capsular incision (2.6%) and of inked benign prostatic glands (2.6%). By 12 mo, 94% of patients were fully continent and 70.5% had recovered the ability to maintain an erection for satisfactory sexual intercourse without the need for medication.     

前列腺癌根治术中保护控尿功能的体会

目的：减少耻骨后前列腺癌根治术患者术后尿失禁发生率。方法：对16例B超前列腺癌患者行保护控尿功能的解剖性耻骨后前列腺癌根治术。结果：16例术后随访3个月-5年，平均13个月。膀胱控尿正常者13例，轻度压力性尿失禁者2例，严重尿失禁者1例。结论：在行耻骨后前列腺癌根治术时，认识尿道括约肌及其支配神经的解剖位置及结构，避免对其损伤可以减少术后尿失禁发生率。     

Open retropubic radical prostatectomy

Radical prostatectomy (RP) is a common treatment choice for localized prostate cancer. While there is increasing utilisation of robotic assisted RP in some centres, open RP (ORP) remains well established and commonly performed in many parts of the world. The goals of modern ORP are to remove the prostate en-bloc with negative surgical margins, while minimising blood loss and preserving urinary continence and erectile function. We present a technical review of ORP incorporating contemporary techniques for control of the deep venous complex, additional haemostatic measures, nerve-sparing and vesicourethral reconstruction.     

Patient-reported sexual function after nerve-sparing radical retropubic prostatectomy

OBJECTIVE: Improved selection criteria have lead to an increasing number of nerve-sparing radical retropubic prostatectomies (RRP) in patients with clinically localised prostate cancer (PCA). Patient questionnaire based outcome analysis on post-operative erectile function after uni- or bilateral nerve-sparing RRP is described. METHODS: Between January 1992 and March 1999, 366 patients (mean age 62.5 years) underwent uni- or bilateral nerve-sparing RRP at our institution. Indication for nerve-sparing procedure was based on the results of a multivariate classification and regression tree analysis (CART). For evaluation of post-operative patient-reported rates of sexual and erectile function non-validated and validated questionnaires (IIEF 5) were administered after a follow-up of 12 months. Data of five operation periods were analysed. RESULTS: The unilateral procedure resulted in rates of 13-29% of erections sufficient for unassisted intercourse. Some degree of tumescence was reported by 37-73% of the remaining patients. Bilateral nerve-sparing procedures were almost exclusively performed in periods 3-5, only four patients of period 2 received the bilateral procedure. Here, rates of erections sufficient for intercourse were 25% (period 2), 61% (period 3), 50% (period 4), and 52% (period 5), respectively. Patients with grades 4 and 5 erections had IIEF scores of 19.2 and 20.2 and patients without rigidity or tumescence had scores of 5.7 and 7.0 after uni- and bilateral nerve-sparing procedure, respectively. Patients <60 years of age had better erections than those > or =60 (unilateral: 19% versus 13%, bilateral 45% versus 38%). CONCLUSION: Compared to a unilateral nerve-sparing procedure, the bilateral nerve-sparing technique revealed much better results inasmuch as about 50% of the patients reported recovery of erections sufficient for sexual intercourse without use of sexual aids.     

Giant posterior urethral diverticulum after radical retropubic prostatectomy

Diverticula of the male posterior urethra are uncommon and usually acquired. We report a case of a large posterior urethral diverticulum that developed after radical retropubic prostatectomy. The etiological factors of male diverticula are discussed.     

Nerve-sparing open radical retropubic prostatectomy

INTRODUCTION: In recent years, the surgical technique for open radical prostatectomy has evolved and increasing attention is paid to preserving anatomic structures and the impact on outcome and quality of life. METHODS: Technical aspects of nerve-sparing open radical retropubic prostatectomy (RRP) are described. Patient selection criteria and functional results are discussed, focusing on postoperative urinary continence. RESULTS: The video demonstrates the nerve-sparing open RRP and important steps are elucidated with schematic drawings. The value of nerve sparing, not only for preserving erectile function, but also for preserving urinary continence is discussed and results from our institution are presented. In our series, urinary incontinence was present in 1 of 71 patients (1%) with attempted bilateral nerve-sparing, 11 of 322 (3%) with attempted unilateral nerve-sparing, or 19 of 139 (14%) without attempted nerve-sparing surgery. In multiple logistic regression analysis, the only statistically significant factor influencing urinary continence after open RRP was attempted nerve sparing (odds ratio, 4.77; 95% confidence interval, 2.18-10.44; p=0.0001). CONCLUSIONS: Nerve-sparing surgery has a significant impact on erectile function and urinary continence and should be performed in all patients provided radical tumour resection is not compromised. For successful nerve preservation we advocate a lateral approach to the prostate to improve visualisation and simplify separation of the neurovascular bundles from the dorsolateral prostatic capsule. Bunching, ligating, and incising Santorini's plexus over the prostate and not over the sphincter ensures a bloodless surgical field. Mucosa-to-mucosa adaptation of the reconstructed bladder neck and the urethra is another important factor to be observed.