Nerve-sparing techniques in open and laparoscopic prostatectomy

Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.     

Technique for nerve dissection

Nerve-sparing radical retropubic prostatectomy is a reasonable treatment option in localized prostate cancer with minimal morbidity. Recent techniques in neurovascular bundle preservation could lead to an overall improvement in postoperative quality of life without compromising cancer control in the appropriately selected patient. Different techniques for neurovascular bundle preservation have been described by most major centers. This brief article describes the updated technique of nerve-sparing radical retropubic prostatectomy for clinically localized prostate cancer. Our technique of nerve dissection starts at the lateral aspect of the prostate with secondary urethral dissection. We believe this technique is easy to learn and decreases dissection around the striated sphincter.     

Minimally invasive approaches to localized prostate carcinoma

Prostate cancer is an increasing medical problem. Radical prostatectomy and radiation therapy are effective treatments, but have the risk of significant morbidity. Clinicians have strived to develop new modalities of treatment that can maintain the excellent treatment outcomes of radical prostatectomy, but diminish the morbidity. Improved instrumentation, optics, and robotic technology have allowed the application of laparoscopic techniques to radical prostatectomy. Patients can have less blood loss and expect more rapid recovery. Intermediate oncologic outcomes appear similar to radical prostatectomy with good functional results. Cryotherapy and HIFU are tissue ablative approaches rather than extirpative approaches to prostate cancer treatment. They attempt to use nonsurgical methods to treat prostate cancer with the hope of providing oncologic control comparable to surgery and radiation while minimizing morbidity.     

Function-preserving surgery for urologic cancer

Radical surgery that is intended to cure cancer disease tends to cause some damage to the operated organ and the quality of life of the patient. It is now a worldwide trend to preserve the function and minimize the operative damage to the patient, without compromising the oncological outcome. In urologic cancers, nephron-sparing surgery for kidney tumors, and nerve-sparing procedures in radical cystectomy and radical prostatectomy for retaining potency are now more frequently used for providing better quality of life after surgery. New constructive surgeries such as neobladder formation and nerve graft techniques after complete removal of the cavernous nerve have been developed for recovering the lost function.     

保留盆腔神经丛腹腔镜宫颈癌根治术的临床疗效观察

目的探讨腹腔镜下保留盆腔自主神经的根治性子宫切除术治疗宫颈癌的临床效果。方法选取重庆市万州区人民医院2015年1月至2017年10月收治的50例子宫颈癌患者,采用数字表法随机分为腹腔镜下保留盆腔神经丛的根治性子宫切除术治疗组（LNSRH组）和腹腔镜广泛子宫切除术治疗组（LRH组）,每组各25例,比较两组患者的手术效果。结果50例患者手术全部成功,两组患者术中及术后均未出现严重并发症,LNSRH组患者的术中出血量、留置尿管时间、术后排气时间以及术后排便时间均少于LRH组患者,差异均有统计学意义（均P＜0.05）。结论腹腔镜下保留盆腔自主神经根治性子宫切除术治疗早期宫颈癌安全可行,相对腹腔镜广泛子宫切除术能明显提高术后生活质量。     

Robotic-assisted laparoscopic prostatectomy: do minimally invasive approaches offer significant advantages?

Radical prostatectomy has maintained a cardinal role in the treatment of localized prostate cancer. Robotic-assisted laparoscopic prostatectomy (RALP) has been introduced as a less invasive surgical approach. Available data on RALP versus open approaches were reviewed for surgical and cancer related outcomes. RALP is consistently associated with decreased blood loss and limited postoperative pain and hospital stay. Surgical margins seem similar between most reported series of RALP or open radical prostatectomy. Most intrainstitutional comparisons demonstrate better postoperative continence and potency with RALP, but there is still debate about whether results are superior to radical retropubic prostatectomy in the hands of a highly experienced surgeon. RALP provides outcomes at least comparable, and, in some measures, superior to open surgery. Refinements of instrumentation may provide even better results in the future.     

Post-nerve-sparing prostatectomy,dose-escalated intensity-modulated radiotherapy: effect on erectile function

PURPOSE: The advent of widespread prostate-specific antigen screening has resulted in more younger, potent men being diagnosed with early-stage, organ-confined prostate cancer amenable to definitive surgery. Nerve-sparing prostatectomy is a relatively new surgical advance in the treatment of prostate cancer. Very few data exist on the effect of postoperative radiotherapy (RT) on erectile function after nerve-sparing prostatectomy. They are based on conventional techniques using moderate doses of radiation, 45-54 Gy. Intensity-modulated RT (IMRT) is becoming more widespread because it allows dose escalation with increased sparing of the surrounding normal tissue. We investigated the effect of postprostatectomy, high-dose IMRT on patients' erectile function. METHODS AND MATERIALS: A review of patient records found 51 patients treated between April 1998 and December 2000 with IMRT after unilateral or bilateral nerve-sparing prostatectomy. The pathologic disease stage in these patients was T2 in 47.4% and T3 in 52.6%. Postoperatively, 4 patients received hormonal ablation consisting of one injection of Lupron Depot (30 mg) 2 months before RT. The median age was 65 years (range 46-77) at the time of RT. The prescribed dose was 64 Gy (range 60-66). The mean dose was 69.6 Gy (range 64.0-72.3). Erectile function was assessed before and after RT by questionnaires. Sexual potency was defined as erectile rigidity adequate for vaginal penetration. RESULTS: Of the 51 patients, 18 (35.3%) maintained their potency and 33 (64.7%) became impotent after nerve-sparing prostatectomy. Patients who underwent bilateral nerve-sparing prostatectomy had higher rates of postoperative potency than did those who underwent unilateral nerve-sparing surgery (72.2% vs. 27.8%; p = 0.025). The follow-up for the entire group was 19.5 months. All 18 patients (100%) who were potent postoperatively remained potent after RT. The median follow-up for the 18 potent patients was 27.2 months, significantly longer than that of the impotent group, 13.0 months (p <0.001). CONCLUSION: This is the first report on the effects of dose-escalated IMRT on men who have undergone nerve-sparing prostatectomy. Despite the high dose (mean dose 69.6 Gy) to the prostate bed and nerves, postoperative IMRT had no negative effect on erectile function for the patients who remained potent after nerve-sparing prostatectomy. Longer term follow-up and a larger cohort of patients are warranted to confirm these findings.     

The effect of meeting physical activity guidelines for cancer survivors on quality of life following radical prostatectomy for prostate cancer

Purpose

Recent literature has shown that preoperative physical activity (PA) can positively influence surgical outcomes. It is unknown whether the effect of meeting PA guidelines for cancer survivors can impact quality of life following radical prostatectomy for prostate cancer.

Methods

We reviewed our institutional database of prostate cancer outcomes and included patients that underwent radical prostatectomy and completed the Godin–Shephard Leisure Time Exercise Questionnaire (GLTEQ), the Patient-Oriented Prostate Utility Scale (PORPUS), the International Prostate Symptom Score (IPSS), and the five-item International Index of Erectile Function (IIEF). Participants were categorized as meeting or not meeting the American College of Sports Medicine physical activity guidelines for cancer survivors (150 min of moderate intensity or 75 min of vigorous intensity PA per week). Radical prostatectomy outcomes were measured preoperatively and at 6 and 26-weeks postoperatively.

Results

From June 2008 to August 2012, 509 men underwent curative, nerve-sparing radical prostatectomy for prostate cancer and completed the GLTEQ, of whom 46 % met the PA guidelines. Prior to surgery, men that met the PA guidelines reported higher quality of life (p?<?0.001) and erectile function (p?=?0.049) than men that did not meet the guidelines. Quality of life at all postoperative timepoints was higher for men that met the PA guidelines after adjusting for age, preoperative body mass index, and surgical approach (p?=?0.02). Men that met the PA guidelines were 19 % less likely to be incontinent at 6 weeks postoperatively (p?=?0.028).

Conclusion

PA volume may be a useful marker at predicting postoperative recovery of quality of life and urinary incontinence following radical prostatectomy.

Implications for Cancer Survivors

Cancer survivors should be encouraged to meet PA guidelines prior to surgery in an effort to attenuate the decline in HRQOL and facilitate recovery.     

Pure laparoscopic and robotic-assisted laparoscopic radical prostatectomy in the management of prostate cancer.

BACKGROUND: Until recently, open radical prostatectomy was the only approach for the surgical management of prostate cancer. Laparoscopy is now increasingly used as an alternative approach. The procedure can be performed directly or with robot assistance. METHODS: We review the relevant literature regarding oncologic and functional outcomes with laparoscopic surgery in the management of localized prostate cancer. RESULTS: Oncologic and functional outcomes are similar between open and laparoscopic radical prostatectomy. Pure laparoscopic prostatectomy and robotic assisted laparoscopic prostatectomy result in less blood loss and shorter convalescence. Costs associated with the initial investment, disposables, and maintenance of the robot system are higher than for pure laparoscopic prostatectomy. CONCLUSIONS: Laparoscopic radical prostatectomy, either pure or robotic, is becoming the preferred approach for the surgical management of localized prostate cancer. Oncologic and functional outcomes are similar to the open approach.     

Early-stage cervical cancer: is surgery better than radiotherapy?

Patients with early-stage cervical cancer may be treated appropriately with either radical surgery or radiation therapy. As most patients will be cured of their disease, side-effects of therapy and quality of life become of great importance. Individualization of treatment to reduce therapy-associated morbidity should be the main goal in cervical cancer management. Recent developments in surgical techniques, such as laparoscopy, nerve-sparing radical hysterectomy, sentinel lymph node biopsy, trachelectomy and ‘less radical’ hysterectomy, have contributed to reduce the morbidity of the surgical treatment. The use of postoperative radiotherapy or chemoradiation leads to more pronounced side effects than after either surgery or irradiation alone. Therefore, prognostic factors should be used to select patients for either surgery or radiotherapy alone to minimize the increased toxicities associated with the combination. The objectives of this review are to discuss the evidence supporting radical surgery, ‘less radical’ surgery and radiotherapy with regard to complication rate and quality of life.     

Laparoscopic surgery in urologic oncology.

BACKGROUND: Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy. METHODS: We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies. RESULTS: All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States. CONCLUSIONS: When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.     

机器人辅助在前列腺癌外科治疗的研究进展

前列腺癌发病率和死亡率逐年升高,开放性根治性前列腺切除术仍是局部晚期前列腺癌的治疗金标准。近年来,腹腔镜和机器人辅助前列腺切除术等微创技术已广泛应用,与传统开放性手术比较,其在肿瘤切缘控制、尿控能力和性功能等方面取得巨大进步。另外机器人辅助前列腺切除术在改善患者功能学方面更具优势。本综述就根治性前列腺切除术的发展、不同手术入路的选择、围手术期并发症、肿瘤学、功能学及学习曲线等方面阐述机器人运用在前列腺癌根治术中的进展。     

Laparoscopic and robotic radical prostatectomy

Radical retropubic prostatectomy is the current gold standard for surgical removal of the prostate gland. Recently, laparoscopic radical prostatectomy has been developed in an attempt to decrease surgical morbidity, and the technical difficulty of laparoscopy has been countered with the development of the da Vinci robotic interface. Studies that have compared the minimally invasive approaches with the traditional open approach have reported comparable perioperative outcomes. While long-term oncological data are available for open prostatectomy, there are only short-term studies available for laparoscopic prostatectomy. Functional outcomes, including urinary continence and sexual function, appear to be similar between the surgical approaches in the short term. However, currently, costs appear to favor open surgery, with the da Vinci-assisted prostatectomy having the highest expenses. Longer-term data are required to confidently determine the optimal balance between morbidity, oncological efficacy, functional outcomes and cost among the differing surgical approaches.     

Hand-assisted laparoscopic surgery for cancer

Minimally invasive surgical approaches were designed to enhance quality of care and improve patient outcome by minimizing postoperative pain, shortening hospital stay, reducing costs, and facilitating early return to work and presurgical lifestyle. The hand-assisted laparoscopic approach for resection of cancer is still in its formative stage, and this review places it in proper perspective within the context of minimally invasive surgery currently being performed for both benign and malignant disease. The review also outlines the potential advantages and disadvantages, techniques, and site-specific procedures of hand-assisted laparoscopic surgery for cancer.     

Laparoscopic and robotic radical prostatectomy

Radical retropubic prostatectomy is the current gold standard for surgical removal of the prostate gland. Recently, laparoscopic radical prostatectomy has been developed in an attempt to decrease surgical morbidity, and the technical difficulty of laparoscopy has been countered with the development of the da Vinci^® robotic interface. Studies that have compared the minimally invasive approaches with the traditional open approach have reported comparable perioperative outcomes. While long-term oncological data are available for open prostatectomy, there are only short-term studies available for laparoscopic prostatectomy. Functional outcomes, including urinary continence and sexual function, appear to be similar between the surgical approaches in the short term. However, currently, costs appear to favor open surgery, with the da Vinci-assisted prostatectomy having the highest expenses. Longer-term data are required to confidently determine the optimal balance between morbidity, oncological efficacy, functional outcomes and cost among the differing surgical approaches.     

胃癌微创治疗之路

外科手术是目前唯一可能治愈胃癌的手段,但传统的开腹手术通常伴随较高的并发症率和死亡率,还会对患者术后的生活质量产生较大影响。而微创外科技术由于可有效减少手术创伤,加快术后恢复,因此对于医生和患者均具有很大的吸引力,今后或将替代传统的开腹手术。目前,胃癌微创外科技术主要向着两个不同的方向发展,即内镜下肿瘤切除和腹腔镜手术。不久的将来,前哨淋巴结导航技术和机器人手术也将为胃癌治疗提供更多选择。随着各种微创技术的不断发展,胃癌患者术后的生活质量将显著改善。目前,许多有关各种微创技术的高水平临床研究正在进行当中,胃癌微创外科必将在世界范围内广为接受,并快速发展。      

Open, laparoscopic and robotic radical prostatectomy: Optimizing the surgical approach

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery.     

Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer

BACKGROUND: The primary treatments for clinically localized prostate cancer confer equivalent cancer control for most patients but disparate side effects. In the current study, the authors sought to compare health-related quality of life (HRQOL) outcomes after the most commonly used treatments. METHODS: A total of 580 men completed the Medical Outcomes Study Short Form-36, the University of California-Los Angeles (UCLA) Prostate Cancer Index, and the American Urological Association Symptom Index before and through 24 months after treatment with radical prostatectomy (RP), external beam radiation therapy (EBRT), or brachytherapy (BT). RESULTS: General HRQOL did not appear to be affected by treatment. Obstructive and irritative urinary symptoms were more common after BT (P<.001). Urinary control and sexual function were better after EBRT than BT (P<.001 and P=.02, respectively) and better after BT than RP (P<.001 and P=.01, respectively). Among potent men, recovery of sexual function was best after EBRT and was equivalent after bilateral nerve-sparing surgery or BT. Sexual bother was more common than urinary or bowel bother after all 3 treatments. Bowel dysfunction was more common after EBRT or BT than RP (P<.001). CONCLUSIONS: In the current study, treatment for localized prostate cancer was found to differentially affect HRQOL outcomes. Urinary control and sexual function were better after EBRT, although bilateral nerve-sparing surgery diminished these differences among potent men undergoing RP. BT caused more obstructive and irritative symptoms, while both forms of radiation caused more bowel dysfunction. These results may inform medical decision-making in men with localized prostate cancer.     

History of prostate cancer treatment

The last two decades have seen great advancements in our understanding of the prostate anatomy and approach including laparoscopic and robotic techniques. One should not however, forget that the techniques evolved with time. The history of developments in prostate cancer surgery, radiotherapy and hormonal therapy is fascinating and urologists through the ages had the quest to find an ideal treatment for prostate cancer in spite of their limitations of resources and understanding. Surgeons have now practiced radical prostatectomy for prostate cancer for over 100 years. Initially feared because of its complications and difficulty, the operation can now be carried out safely owing principally to advances in our knowledge of the surgical anatomy. Refinements in surgical technique based on anatomical understanding have enabled morbidity to be progressively reduced to a widely acceptable level. Within the past 10 years, the same principles have been applied successfully in laparoscopic and robotic techniques of prostatectomy. There are constant improvements in the field of radiotherapy, evolution of cryotherapy and changes in the role of hormones. To the future, the matching of patients to the treatment modality most appropriate to their tumour, and quality of life outcomes are likely to become increasingly important in determining future practice. It is worth while to look at the evolution to plan for the future.     

Robotic-assisted laparoscopic radical prostatectomy: a report of the current state

Cancer of the prostate is the most common malignancy diagnosed in the male genitourinary tract. Although a number of treatment options are available for early prostate cancer, the gold standard of treatment remains retropubic radical prostatectomy. However, robotic-assisted laparoscopic radical prostatectomy (RALP) has become a forerunner in treatment options, yielding comparable medium-term perioperative and functional outcomes. For this our team utilized MEDLINE, searching for publications on perioperative and functional outcomes related to robotic prostatectomy. Robotic-assisted prostatectomy has allowed urologists to enter the realm of minimally invasive surgery by incorporating open surgery maneuvers into a laparoscopic environment. To date, RALP perioperative and functional outcomes are comparable to the gold standard; the collection of long-term data is needed in order to establish its true efficacy.