Intraoperative frozen section analysis during nerve sparing laparoscopic radical prostatectomy: feasibility study

PURPOSE: Nerve sparing radical prostatectomy may allow preservation of potency but it can increase positive surgical margins. We used intraoperative frozen section (IFS) analysis to monitor the nerve sparing procedure in laparoscopic prostatectomy. MATERIALS AND METHODS: A total of 100 patients with localized prostatic carcinoma underwent bilateral intrafascial nerve sparing laparoscopic prostatectomy with IFS. A wedge of tissue was cut from base to apex in the region of the neurovascular bundles (NVBs) and analyzed on frozen section. If carcinoma was detected at the inked margin, the corresponding NVB was resected. Definitive margin status was evaluated after permanent section analysis of IFS prostatectomy specimens and eventually NVB specimens. RESULTS: IFS analysis was positive in 24 patients, as confirmed in all by permanent section of the wedges. Three of these patients had positive margins in the prostate specimen at another site. Of the 76 tumors with negative IFSs 1 had positive margins on permanent sections of the wedges and 8 had positive margins on the prostate specimen at another site. IFS led to a decrease in the overall positive margin status from 33% to 12% and from 26.1% to 7.9% in pT2 tumors. Tumor was found on NVB resection in 8 cases (33%). CONCLUSIONS: These results suggest that IFS analysis is a reliable method by which to monitor nerve sparing during laparoscopic prostatectomy. IFS could allow the surgeon to offer a nerve sparing procedure more frequently without compromising cancer control.     

Real-time transrectal ultrasound guidance during nerve sparing laparoscopic radical prostatectomy: pictorial essay

PURPOSE: We report that real-time TRUS can visualize prostate/periprostatic anatomy and provide intraoperative navigation during nerve sparing LRP. Real-time TRUS navigation during radical prostatectomy, whether open or laparoscopic, is a novel application about which little is known. MATERIALS AND METHODS: Transperitoneal LRP with TRUS guidance has been performed in 77 consecutive men since March 2003. Gray-scale ultrasound (7.5 MHz) and power Doppler ultrasound were used. Real-time TRUS monitoring was performed preoperatively, intraoperatively and immediately postoperatively. Emphasis was placed on identifying the neurovascular bundles, defining the prostate apex contour and evaluating the location and extent of any hypoechoic cancer nodules. RESULTS: Intraoperative TRUS navigation appeared to be helpful for certain specific technical aspects of LRP, including 1) the identification of hypoechoic prostate cancer nodules, 2) precision during lateral pedicle transection and neurovascular bundle release, 3) calibrated, wider dissection at the site of suspected extracapsular extension of cancer nodules to achieve negative margins, 4) tailored dissection according to the individual prostate apex and (5) facilitation of posterior bladder neck transection for the novice. Real-time TRUS monitoring of the location of the laparoscopic scissors tip (hyperechoic spot) in regard to the safe dissection plane at the concerned anatomical site was feasible. Blood flow in the neurovascular bundles before, during and after nerve sparing LRP was documented. CONCLUSIONS: Real-time rectum based monitoring such as TRUS navigation has the potential to enhance intraoperative surgical precision during LRP. A pictorial essay highlighting the various aspects of intraoperative TRUS is presented.     

Sural nerve grafting in robotic laparoscopic radical prostatectomy: interim report

BACKGROUND AND PURPOSE: Sural nerve grafting for patients undergoing prostatectomy has been previously reported using open and minimally invasive methods. We report our experience with sural nerve grafting during robot-assisted laparoscopic radical prostatectomy (RLRP). MATERIALS AND METHODS: Patients with preoperative potency and a minimum of 6 months follow-up were included in this prospective review. A total of 333 patients were identified between February 2003 and January 2006 who met these criteria including 22 of the 25 patients who underwent sural nerve grafting. Patients were divided into 5 groups to compare unilateral and bilateral sural nerve cohorts with non-nerve-sparing and unilateral and bilateral nerve-sparing groups. Patients were followed prospectively using health-related quality-of-life questionnaires. RESULTS: Twenty-two patients underwent sural nerve grafting that included three bilateral grafts. Mean follow-up was 14 months. There was no statistical difference in patients' ages, body mass index, preoperative prostate-specific antigen level, blood loss, complications, and positive margin rate. Operative time was statistically longer for both sural graft cohorts when compared with unilateral (without graft) and bilateral nerve sparing cohorts. No significant differences in subjective or objective sexual function, sexual bother, or urinary function were seen with 6 and 12 months follow-up, possibly related to smaller sural cohorts. Graft-related complications include leg pain in one patient. CONCLUSION: Sural nerve grafting during RLRP is technically feasible and safe and offers improved dexterity and visualization deep within the pelvis. However, a larger randomized cohort of patients will be required to validate any improved benefits afforded by the robot system.     

Re: Nerve sparing laparoscopic radical prostatectomy

Dear Sirs,In prostatic cancer, the erection potency after surgery is dependent upon patient's age, tumor stage and bilateral or unilateral nerve sparing radical prostatectomy. The patients eligible for nerve sparing radical prostatec     

Update on laparoscopic and robotic radical prostatectomy

PURPOSE OF REVIEW: Laparoscopic and robotic-assisted prostatectomy have been proposed as alternatives to traditional open retropubic prostatectomy. In this review, we update the more recent data concerning the results, technical trends and controversies regarding these novel, minimally invasive procedures. RECENT FINDINGS: As a result of improved patient selection, a better understanding of surgical anatomy, and refinements in surgical techniques, traditional retropubic prostatectomy set the standards very high, leaving little room for improvement. In this review, the results of laparoscopic prostatectomy are compared with contemporary in addition to historical series. Besides the transperitoneal laparoscopic approach, which was almost exclusively used in the initial series, the introduction and development of the extraperitoneal laparoscopic approach meant a significant change in the surgical strategy of a number of teams worldwide. The relative merits of the transperitoneal and extraperitoneal approaches are discussed. Robotic radical prostatectomy is a promising technical innovation that allows us to overcome many of the inherent limitations of laparoscopic surgery. As a result of financial constraints, the experience has been limited to a few centres worldwide. SUMMARY: Although long-term results are still lacking, novel minimally invasive techniques seem to fulfil the highest standards of radical prostatectomy in terms of early oncological cure, functional results and morbidity. A standardization of data collection and evaluation methodology will be indispensable for a better comparison of the different series.     

Nerve sparing laparoscopic radical prostatectomy: our technique

PURPOSE: To describe our technique of nerve sparing laparoscopic radical prostatectomy (LRP). We present the oncological and functional results (potency and urinary continence). MATERIAL AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Perioperative complications of laparoscopic and robotic assisted laparoscopic radical prostatectomy

PURPOSE: While it remains controversial whether LRP or da Vinci RAP offers any advantages over radical retropubic prostatectomy, LRP and RAP are being used more frequently. We reviewed our experience with these minimally invasive techniques. MATERIALS AND METHODS: We reviewed intraoperative and early postoperative complications of 358 LRPs performed from October 2000 to January 2003 with those of 322 RAPs performed from June 2003 to June 2004. The transperitoneal approach with bilateral pelvic lymph node dissection was performed using each technique. Data acquisition was done independently of the 3 surgeons. RESULTS: The LRP and RAP groups had similar clinical characteristics in terms of patient race, body mass index, prostate specific antigen, risk group, and pathological tumor grade and stage. Median operative time and estimated blood loss for LRP and RAP were 4.1 and 3.1 hours, and 200 and 250 ml, respectively. No blood transfusions were given intraoperatively, although 8 patients with LRP (2.2%) and 5 with RAP (1.6%) were transfused postoperatively. Of the LRP and RAP patients 21 (5.9%) and 3 (0.3%), respectively, experienced intraoperative complications. Postoperatively 48 patients with LRP (13.4%) and 24 with RAP (6.8%) experienced urine leakage, while 19 with LRP (5.3%) and 9 with RAP (2.8%) had ileus. There were no deaths, myocardial infarctions, pulmonary emboli or cerebrovascular accidents. CONCLUSIONS: In our series surgeon experience derived from LRP may contribute to the lower complication rate and operative time of RAP. Dissemination of surgical technique and management of complications may lead to improved perioperative LRP and RAP morbidity. However, the morbidity of these 2 approaches compares favorably with that of radical retropubic prostatectomy.     

Evaluation of operative complications related to laparoscopic radical prostatectomy

Objectives:   In this decade, there have emerged many alternatives for the therapy of localized prostate cancer, such as brachytherapy, intensity modulated radiation therapy, high intensity focused ultrasound, and retropubic radical prostatectomy. In this retrospective study, we reviewed cases of complications related to laparoscopic radical prostatectomy (LRP) from our institution only, and we evaluated whether this procedure was minimally invasive or not.
Methods:   Between August 2000 and December 2006, a total of 160 patients in our institution underwent LRP as the definitive treatment for clinically localized prostate cancer. We analyzed not only the complications but also the operative time and blood loss to clarify the indications of LRP.
Results:   Major complications were defined as those requiring surgical intervention including laparoscopic repair. A total of nine major complications (5.63%) occurred in six patients (3.75%). In a Cox regression analysis, the estimated blood loss ( P  = 0.0069) and neoadjuvant hormonal therapy ( P  = 0.0019) were significant predictors of long operative time (>6 h) of LRP.
Conclusion:   The indication of LRP in this study was localized prostate cancer at the T1 or T2 stage for which neoadjuvant hormonal therapy had not been administered. We concluded that the operative and postoperative morbidities of LRP are low and that LRP can be routinely carried out by an experienced team.     

Efficacy of unilateral nerve sparing in radical perineal prostatectomy

AIM: We determine the efficacy of unilateral nerve-sparing radical perineal prostatectomy in preserving the sexual function. PATIENTS AND METHODS: Ninety-two patients with histologically confirmed unilateral prostate cancer were scheduled for contralateral nerve preservation. The perioperative morbidity was assessed using the patients' chart reviews. Postoperative health-related quality of life, urinary continence, and potency were evaluated prospectively with questionnaires provided before surgery and then after 6, 12, and 24 months. RESULTS: Unilateral nerve preservation was performed in 88 of the 92 patients. Due to extensive scarring or prostatic size, the procedure was terminated as regular radical prostatectomy in 4 other patients. The perioperative complication rate was low and of minor significance, except in 1 patient who experienced a significant myoglobulinuria due to a prolonged procedure. Blood transfusions were necessary in 5 (5.4%) patients. Ureteral reimplantation was performed in 1 patient because of ureteral stricture. Positive surgical margins were present in 12 (18%) of 67 pT2 patients and in 8 (35%) of 23 pT3 patients. A proportion of 48% (15/31) of the patients followed for more than 24 months and who had a good erectile function prior to surgery reported unassisted sexual intercourse. However, only 4 of these patients were completely satisfied with all aspects of sexual performance, as asked in a short version of the International Index of Erectile Function questionnaire. CONCLUSIONS: Unilateral nerve-sparing radical perineal prostatectomy is technically feasible and yields excellent results in terms of potency preservation for prostates <60 ml. However, the quality of erections is decreased, even in patients with erections sufficient for intercourse. Hence, appropriate sexual counseling in conjunction with medical therapy should be offered to all patients.     

Urinary continence in patients undergoing nerve sparing radical prostatectomy

Recently, the morbidity of radical prostatectomy has been reduced by improvements in surgical techniques and greater understanding of pelvic anatomy. The nerve sparing technique has been considered to be a major contribution to this advance. In our study, urinary control was compared in 33 consecutive patients undergoing a radical retropubic prostatectomy. In 13 patients, a conventional radical prostatectomy was performed and in 20 subsequent patients, a nerve sparing operation was performed. The staff surgeons were the same throughout the study. The age of the patients and pathological stage of the tumor were not significantly different between the groups. The operative time was shorter and intraoperative blood loss was less both significantly in the nerve sparing group. In the conventional operated group, there was one patient with total incontinence and two with significant incontinence requiring absorbable pads. In the nerve sparing group, there were no patients having total incontinence and one had stress incontinence requiring absorbable pads. Urethral pressure profile was measured postoperatively in 17 in the nerve sparing group and in 7 in the conventional group. The maximum urethral pressure in the nerve sparing group was 31.5 cm H2O (SD = 5.4) and in the conventional group 23.2 cm H2O (SD = 5.7) with a significant difference between groups (p less than 0.01). The functional urethral length of the nerve sparing group was 16.7 mm (SD = 5.2) and in the conventional group 13.3 mm (SD = 3.7) with no significant difference between the groups. These results suggest that preservation of neurovascular bundles from the pelvic plexus during radical prostatectomy has no important role in postoperative urinary continence.