Novel technique to enhance bladder neck dissection with traction of Foley catheter during extraperitoneal laparoscopic radical prostatectomy

BackgroundLaparoscopic radical prostatectomy (LRP) is a challenging technique that is associated with a steep learning curve. We describe a novel technique to develop bladder neck traction using a Foley catheter during extraperitoneal LRP to enhance bladder neck dissection, thereby improving patient and procedural outcomes.Materials and methodsThe novel technique employed a four-trocar approach to prostatectomy, which involved the introduction of a 1-0 Vicryl suture into the extraperitoneal space using an Endo Close needle to pull up the Foley catheter tip and make the bladder neck prominent. From June 2006 to November 2012, clinicopathological data of 71 patients who underwent four-port extraperitoneal LRP (modified extraperitoneal LRP, Group 1) were assessed and compared with those from 22 patients who underwent transperitoneal LRP (Group 2) retrospectively.ResultsThe two groups were comparable in terms of pathological staging and Gleason score. The operative time was significantly shorter (p < 0.05) and the total blood loss was less in Group 1 patients (p < 0.05). No patient in either group underwent early reintervention for bleeding or blood transfusion. Bilateral or unilateral nerve sparing surgery was performed in 80.3% and 45.5% of Group 1 and Group 2 patients, respectively. The immediate, 1 month, 3 month, 6 month, and 1 year continence rates were, respectively, 19.7%, 38%, 69%, 91.5%, and 100% in Group 1 and 18.2%, 50.0%, 77.3%, 86.4%, and 95.5% in Group 2. In Group 1, 100% of patients were continent 12 months postprocedure. The potency rate was 71.4% in both groups.ConclusionImproved bladder neck enhancement provides a clearer vision during bladder neck dissection. Similar functional results and cancer control rates were also encountered during modified extraperitoneal radical prostatectomy. This novel technique is a feasible method for performing endoscopic radical prostatectomy using four ports instead of five.     

Peroperative transrectal ultrasonography-guided bladder neck dissection eases the learning of robot-assisted laparoscopic prostatectomy

OBJECTIVE

To study the role of peroperative transrectal ultrasonography (peTRUS) for the dissection of the bladder neck during robot‐assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

Integrated peTRUS in the da Vinci S system (Intuitive Surgical, Sunnyvale, CA, USA) was used for bladder neck identification and dissection in the initial 80 patients with clinically localized prostate cancer operated by two urologists. The clinical and pathological results were compared with the initial 80 patients who had RALP with no peTRUS. The location of positive margins was recorded.

RESULTS

The operative duration, blood loss, hospital stay, catheter dependency, clinical and pathological T‐stage and Gleason sum score were no different between the groups. The prostate‐specific antigen level at time of diagnosis was slightly higher for patients in the peTRUS group. Basal surgical margins (bladder neck and basal areas of both prostate lobes) were positive for tumour in 9.1% and 2.3% of patients treated without and with peTRUS, respectively (P = 0.001). Although the use of peTRUS improved the basal margin rate in the initial 30 patients in each group, it did not in the last 30 in each group, when the urologist’s experience apparently improved. In a multivariate analysis the use of peTRUS and pathological T‐stage were the best predictors of basal margin status. Pad use at 6 months after surgery was similar for both groups.

CONCLUSION

peTRUS during RALP decreased the positive surgical margin rate at the base of the prostate during the initial experience of RALP.     

Positive surgical margins in laparoscopic radical prostatectomy: the impact of apical dissection,bladder neck remodeling and nerve preservation

PURPOSE: We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between May 1998 and September 2001, 235 men underwent laparoscopic radical prostatectomy at our institution. During this period modifications were made in the technique. We stopped preserving the puboprostatic ligaments during 1999 and stopped preserving the bladder neck during 2000. We compared the incidence of apical and bladder neck margins before and after these changes in surgical technique. Nerve sparing status was documented by the surgeon at the end of the operation and its effect on the incidence of lateral positive margins was evaluated. To concentrate on the surgically induced margins this study focused on pT2 cases. RESULTS: There were 169 pT2 cases and 32 (18.9%) positive margin locations. A constant decrease was noted in the overall incidence of positive margins but, while apical margins were the most abundant in 1998, posterolateral margins were most abundant in 2001. Avoiding bladder neck preservation eliminated positive bladder neck margins in 2001. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%. CONCLUSIONS: The experience gained in this procedure led to a decrease in the incidence of positive margins. Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. Nerve preservation did not increase the incidence of positive margins. These technical modifications may improve the outcome of laparoscopic radical prostatectomy.     

机器人辅助腹腔镜根治性前列腺切除术中不同膀胱颈分离技术的临床应用

目的:探讨机器人辅助腹腔镜根治性前列腺切除术(RARP)中不同膀胱颈分离方式的临床效果。方法:回顾性分析四川省人民医院2014年10月至2018年10月收治的750例局限性前列腺癌并接受RARP患者的病例资料。根据术中膀胱颈分离方式将患者分为4组。A组500例,年龄63(62.5~67.0)岁,PSA 13(9.0~22.0)ng/ml,穿刺Gleason评分6.9(5~9)分,前列腺体积66(42~78)ml,体质指数≤25 kg/m 2300例(60%),>25 kg/m 2200例(40%);T 1c期75例(15.0%),T 2a^2b期255例(51.0%),T 2c^3a期170例(34.0%);术中采用顺向剥离方式,在膀胱颈前部12点部位行1 cm切口,切断逼尿肌并切开膀胱颈。B组133例,年龄65(61~68)岁,PSA7.4(6.4~26.0)ng/ml,穿刺Gleason评分7(6~12)分,前列腺体积70(50~89)ml,体质指数≤25 kg/m 285例(63.9%),>25 kg/m 248例(36.1%);T 1c期43例(32.3%),T 2a^2b期56例(42.1%),T 2c^3a期34例(25.6%);术中采用T形切开膀胱颈方式,正确识别膀胱与前列腺交界,T形切开膀胱颈前壁。C组81例,年龄66(64.5~70.5)岁,PSA 6.2(5.3~27.0)ng/ml,穿刺Gleason评分9(8~16)分,前列腺体积53(43~72)ml,体质指数≤25 kg/m 252例(39.1%),>25 kg/m 229例(60.9%);T 1c期39例(48.1%),T 2a^2b期27例(33.3%),T 2c^3a期15例(18.6%);术中采用顺向剥离方式联合T形切开膀胱颈方式。D组36例,年龄62(59.5~66.5)岁,PSA 14(8.4~21.0)ng/ml,穿刺Gleason评分10(6~18)分,前列腺体积80(68~92)ml,体质指数≤25 kg/m 215例(42.0%),>25 kg/m 221例(58.0%);T 1c期6例(16.6%),T 2a^2b期17例(47.2%),T 2c^3a期13例(36.2%);术中采用侧方会师方式,沿一侧的膀胱颈外侧及前列腺侧后韧带内侧进行分离,与事先建立的狄氏间隙汇合。4组患者的年龄、PSA、Gleason评分、前列腺体积、体质指数及临床分期差异均无统计学意义(P>0.05)。所有手术均由同一名术者完成。比较4组的手术时间、出血量、吻合时间、术后住院时间、术后并发症、近端切缘阳性率、尿管留置时间、术后6个月尿控率。结果:本研究750例手术均顺利完成,无中转开放病例。A、B、C、D组手术时间分别为100(70~120)min、89(70~95)min、105(80~127)min、110(90~130)min,差异无统计学意义(P>0.05);术中出血量分别为40.5(30.0~55.6)ml、52.8(41.5~53.6)ml、50.5(35.6~72.0)ml、55.3(42.0~60.5)ml,差异无统计学意义(P>0.05);吻合时间分别为20.5(18.0~25.0)min、16.1(10.7~17.3)min、25.4(18.9~27.0)min、28.5(21.0~32.0)min,B组吻合时间明显短于其他组(P<0.05);术后住院时间分别为9.3(8.0~13.0)d、8.4(6.0~16.0)d、10.8(8.0~16.0)d、7.8(7.0~14.0)d,差异无统计学意义(P>0.05)。A组出现吻合口瘘和输尿管损伤各3例,其余3组中均无严重并发症。近端切缘阳性例数分别为A组40例(8.0%)、B组0例、C组6例(7.3%)、D组3例(8.3%),B组切缘阳性率低于其他组(P<0.05)。A、B、C、D组术后尿管留置时间分别为7(6~8)d、6(4~8)d、12(6~18)d、10(6~13)d,差异无统计学意义(P>0.05);术后6个月尿控例数分别为381例(75.2%)、102例(76.9%)、61例(75.4%)、27例(73.8%),差异无统计学意义(P>0.05)。结论:本研究RARP术中各膀胱颈分离方式均安全、可行,均能有效避免输尿管损伤,术后6个月均能获得较好的尿控率,且T形切开膀胱颈方式的术后近端切缘阳性率低于其他手术方式。     

The impact of bladder neck mucosal eversion during open radical prostatectomy on bladder neck stricture and urinary extravasation

Purpose

To determine whether the bladder neck mucosal eversion (BNM-eversion) during radical retropubic prostatectomy (RRP) reduces the risk of bladder neck stricture (BNS) and of peri-anastomotic extravasation (PAE) in postoperative cystography.

Methods

Two hundred and eleven patients with clinically localized prostate cancer underwent RRP and were prospectively randomized into patients with BNM-eversion (group I) and without BNM-eversion (group II). All patients underwent an evaluation of PAE by retrograde cystography on postoperative day?8. We assessed BNS after 6?months.

Results

Ninety-two patients with and 113 patients without BNM-eversion were included. There was no significant difference in baseline characteristics, including age, TNM-classification, Gleason score, PSA, prostate volume, and blood loss in both groups. A complete follow-up of 6?months for BNS was available for 188 patients (89.1?%). Sixteen BNS out of 188 patients were recorded, 4.7?% (n?=?4) in group I and 11.7?% (n?=?12) in group II (p?=?0.09). Data from 205 out of 211 patients were available for the evaluation of the extravasation by cystography. Peri-anastomotic extravasation was detectable in 11.96?%, (11/205) in group I and in 21.24?% (24/205) in group II (p?=?0.08).

Conclusion

BNM-eversion does not have a positive influence on the prevention of bladder neck strictures. Peri-anastomotic extravasation detected by cystography does not correlate with a formation of bladder neck stricture.     

Incidence of bladder neck contracture after robot‐assisted laparoscopic and open radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To evaluate the incidence and risk factors for bladder neck contracture (BNC) in men treated with robot‐assisted laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (ORP), as BNC is a well‐described complication of ORP and may be partially attributable to technique.

PATIENTS AND METHODS

The University of California San Francisco Urologic Oncology Database was queried for patients undergoing RALP or ORP from 2002 to 2008. Patient demographics, prostate cancer‐specific information, surgical data, and follow‐up were collected. For each surgical approach, multivariate Cox proportional hazards regression was performed to evaluate associations of demographics and clinical characteristics with BNC. Time to BNC after RP was evaluated using life table and Kaplan–Meier methods.

RESULTS

From 2002 to 2008, 988 patients underwent RP as primary treatment and had at least 12 months of follow‐up. Of these men, 695 underwent ORP and 293 underwent RALP. The mean (sd ) age was 59.3 (6.80) years and 91% of men were Caucasian. D’Amico risk groups at diagnosis were low (38%), intermediate (38%), and high (24%). The BNC incidence was 2.2% (22 cases) overall, 1.4% (four) for RALP, and 2.6% (18) for ORP (P= 0.12). Patients with BNC were diagnosed a median (range) of 4.7 (1–15) months after surgery. At 18 months after surgery, the BNC‐free rate was 97% for ORP and 99% for RALP (log‐rank P= 0.13). The most common presenting complaint was slow stream, followed by urinary retention. In Cox proportional hazards regression analysis, earlier year of surgery, older age at diagnosis and higher PSA level at diagnosis were significantly associated with BNC among ORP patients. In the RALP group, none of the covariates were associated with BNC.

CONCLUSIONS

The overall incidence of BNC was low in both RALP and ORP groups. Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group.     

经精囊面吊带悬吊膀胱颈技术在腹腔镜前列腺根治切除术中的应用

目的:探讨经精囊面吊带悬吊膀胱颈技术在腹腔镜前列腺癌根治术中的应用,评价其效果。方法:2013年10月~2014年6月,在12例前列腺癌根治手术中采用经精囊面吊带悬吊膀胱颈技术行膀胱颈离断。记录手术时间、术中出血量、膀胱颈切缘阳性率、术后短期尿控情况及术后并发症的发生。结果:12例患者,平均手术时间(98±21.5)min,平均术中出血量(134±26.4)ml。术后病理报告示膀胱颈切缘均为阴性。术后3个月仅1例发生轻度尿失禁。无尿漏、肾积水等并发症发生。结论:经精囊面吊带悬吊膀胱颈技术用于腹腔镜前列腺癌根治术中膀胱颈的离断安全性好,更好地保留了膀胱颈口,易于其与尿道的吻合,减少了术后并发症的发生。     

Morphologic changes after bladder neck intussusception in laparoscopic radical prostatectomy contribute to early postoperative continence

International Urology and Nephrology - To explore the mechanism and efficacy of the modified bladder neck intussusception in laparoscopic radical prostatectomy (LSRP) on postoperative early...     

Randomized clinical trial of a bladder neck plication stitch during robot-assisted radical prostatectomy

Urinary incontinence after robot-assisted radical prostatectomy (RARP) is one of the most bothersome complications affecting patients’ daily lives. The efficacy of the bladder neck plication stitch technique in promoting an earlier return of continence was prospectively evaluated in 158 patients who underwent RARP for clinically localized prostate cancer by a single surgeon at our institute from March 2012 to January 2013. Patients were randomized 1:1 to undergo surgery with (n = 79) or without (n = 79) the bladder neck plication stitch, and their time to recovery from incontinence, defined as being pad free, was compared. Recovery from incontinence at 1, 3, and 6 months were observed in 22 (27.8%), 42 (53.2%), and 57 (72.2%) patients, respectively, treated with, and 23 (29.1%), 47 (59.5%), and 59 (74.7%) patients, respectively, treated without the bladder neck plication stitch, with no significant difference in time to recovery from incontinence between the two groups. Multivariate analysis showed that age, membranous urethral length and shape of the prostatic apex on magnetic resonance imaging were independent predictors of early recovery from urinary incontinence after RARP. The bladder neck plication stitch had no effect on time to recovery from postoperative urinary incontinence following RARP.     

Identification and preservation of accessory pudendal vessels during robot-assisted laparoscopic radical retropubic prostatectomy

The introduction of minimally invasive surgery for radical retropubic prostatectomy has increased the incidence of recognition of accessory pudendal arteries. Early identification and preservation of these vessels is paramount for optimal functional outcomes. In this article, we describe our robotic surgical technique for identification and preservation of both lateral and apical accessory pudendal arteries. The illuminated, magnified surgical field, the pneumoperitoneum which minimizes venous bleeding, and the ability to acutely angle the robotic instruments assists in the preservation of these arteries. Although anatomy precludes the preservation of all accessory pudendal arteries, adopting a strategic approach to robotic dissection allows accessory pudendal arteries to be successfully spared in most cases.     

Real-time transrectal ultrasonography during laparoscopic radical prostatectomy

PURPOSE: We describe the technical aspects of real-time transrectal ultrasound (TRUS) monitoring and guidance during laparoscopic radical prostatectomy (LRP). Furthermore, we describe the TRUS visualized anatomy of periprostatic structures during LRP. MATERIALS AND METHODS: In 25 consecutive patients undergoing transperitoneal LRP, baseline preoperative, real-time intraoperative and immediate postoperative TRUS evaluations were performed. To define periprostatic anatomy precisely TRUS measurements were obtained with specific reference to the neurovascular bundle (NVB), prostate apex, membranous urethra, bladder neck, rectal wall and any cancer nodule. Conventional gray scale, power Doppler, harmonic imaging and 3-dimensional ultrasound functions were used. RESULTS: Real-time TRUS navigation facilitated 3 technical aspects of LRP. 1) It identified the correct plane between the posterior bladder neck and prostate base, allowing quick laparoscopic identification of the vasa and seminal vesicles. 2) It identified the occasional, difficult to see distal protrusion of the prostate apex posterior to the membranous urethra, thus enhancing apical dissection with negative margins. 3) It provided visualization of any hypoechoic nodule abutting the prostate capsule, alerting the laparoscopic surgeon to perform wide dissection at that location. TRUS measured various anatomical parameters including i) the mean distance +/-SD between the NVB and the lateral edge of the prostate a) at apex (1.9 +/- 0.9 mm), b) base (2.5 +/- 0.8 mm) and c) tip of seminal vesicle (4.0 +/- 1.6 mm), ii) the dimensions of the NVB a) before (4.5 x 3.9 mm), b) after (4.2 x 3.6 mm) nerve sparing LRP and c) after nonnerve sparing LRP (0.9 x 0.9 mm), iii) arterial blood flow resistive index within NVB a) before (0.83 +/- 0.04), b) after (0.84 +/- 0.03) nerve sparing LRP and c) after nonnerve sparing LRP (0), iv) and the length of membranous urethra a) before (12.2 +/- 1.1 mm) and b) after (11.7 +/- 1.0 mm) surgery. Focal distortion of the prostate surface by an exophytic nodule was visualized on TRUS in 3 patients, necessitating ipsilateral nerve resection at LRP and contributing to negative surgical margins. CONCLUSIONS: This initial experience suggests that real-time intraoperative TRUS guidance may enhance anatomical performance of LRP. This improved understanding of periprostatic anatomy has the potential to improve functional and oncological outcomes. Such corroboration is awaited.     

Apical dissection during radical retropubic prostatectomy without ligature

During radical retropubic prostatectomy, hemostasis of the venous vascular plexus is of the utmost importance for avoiding excessive blood loss and ensuring optimal preservation of urethral length, complete extirpation of all apical prostatic notches and careful preservation of the parasympathetic nerves ('neurovascular bundles'). We have developed a careful bipolar coagulation of the venous plexus that results in a significant reduction of intra-operative blood loss, and the consequent need for transfusion, compared to the standard approach. Furthermore, this coagulation approach results in improved visibility, allowing maximum preservation of urethral length, complete extirpation of all apical prostatic notches and improved application of the nerve sparing technique compared to the standard approach. Follow-up after a mean of 14 months suggests that postoperative continence and potency is at least comparable to the standard approach. However, long-term follow-up and multicenter studies will show if this modification results in equally effective cancer control and equivalent functional results compared to the standard approach.