Endoscopic extraperitoneal radical prostatectomy: the University of Leipzig experience of 1,300 cases

We herein review our experience with endoscopic extraperitoneal radical prostatectomy (EERPE) as a first line therapy for localized prostate cancer. A series of 1,300 patients underwent EERPE (“wide excision”, standard nervesparing technique (nsEERPE), or intrafascial nsEERPE). The mean age of the patients was 63.3 years. Preoperative PSA mean value was 10.1 ng/ml. A total of 415 patients had undergone previous surgical procedure in the lower abdomen (n = 336) and prior surgery of the prostate (n = 79), respectively. The EERPE was employed in all cases without any specific selection criteria. Mean operative time was 153 (50–320) min. including lymphadenectomy with no conversion to open surgery. Seven intraoperative, 91 early and 4 late complications occurred. The transfusion rate was 0.9%. Positive surgical margins were found in 83 patients with pT2 stage (9.8%) and in 154 patients in pT3 stage (34.3%). The mean catheterization time was 6.2 days. The 12 month follow up indicated continence rate of 91.9% and potency rates of 34% in the unilateral nerve sparing group and 69.8% in the bilateral group. In the intrafascial nsEERPE group potency rates were 33.3% (unilateral) and 79.1% (bilateral) after 12 months. Postoperative positive surgical margins rate were 6.1% for pT2 and 20% for pT3 and the complications rate 4%. The results of this large series of 1,300 patients are promising. The recently introduced intrafascial nsEERPE further ameliorates the outcome of the procedure.     

Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy

OBJECTIVES: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

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.     

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.     

Influence of bladder neck suspension stitches on early continence after radical prostatectomy: a prospective randomized study of 180 patients

Several techniques have been introduced to improve early postoperative continence. In this study, we evaluated the impact of bladder neck (vesicourethral anastomosis) suspension on the outcome of extraperitoneal endoscopic radical prostatectomy (EERPE). In this research, a total of 180 patients underwent EERPE. Group 1 included patients who underwent nerve-sparing EERPE (nsEERPE) (n=45), and Group 2 included patients who underwent nsEERPE with bladder neck suspension (BNS, n=45). Groups 3 (n=45) and 4 (n=45) included patients who received EERPE and EERPE with BNS, respectively. Patients were randomly assigned to receive BNS with their nsEERPE or EERPE procedure. Perioperative parameters were recorded, and continence was evaluated by determining the number and weight of absorbent pads (pad weighing test) on the second day after catheter removal and by a questionnaire 3 months postoperatively. Two days after catheter removal, 11.1% of Group 1, 11.1% of Group 2, 4.4% of Group 3 and 8.9% of Group 4 were continent. The average urine loss was 80.4, 70.1, 325.0 and 291.3 g for the each of these groups, respectively. At 3 months, 76.5% of Group 1 and 81.3% of Group 2 were continent. The continence figures for Group 3 and 4 were 48.5% and 43.8%, respectively. Similar overall rates were observed in all groups. In conclusion, although there are controversial reports in the literature, early continence was never observed to be significantly higher in the BNS groups when compared with the non-BNS groups, regardless of the EERPE technique performed.     

Nerve-sparing endoscopic extraperitoneal radical prostatectomy: University of Leipzig technique

PURPOSE: To describe the various operative steps as well as the functional and oncologic results of nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERP). PATIENTS AND METHODS: One hundred twenty preoperatively potent patients have been treated with bilateral nsEERPE in our department. The average age of the patients was 60.3 years (range 41-74 years), and the mean prostate weight was 48.6 g (range 24-117 g). RESULTS: The mean operative time was 136 minutes (range 75-210 minutes). No conversions to open surgery were necessary. The mean catheterization time was 5.7 days (range 4-20 days). Lymphadenectomy was performed in 26 patients. The pathologic stages were pT2 in 78 and pT3 in 42 patients. Positive margins were detected in 7.7% (N = 6) and 19% (N = 8) of the patients with pT2 and pT3 disease, respectively. Erections sufficient for intercourse were reported in interviews with 58 patients (48.3%) during the 6-month follow-up period. Follow-up of at least 1 year is deemed necessary to draw more definite conclusions about erectile function. One week postoperatively, 32 patients (26.7%) required a maximum of 1 pad, 59 patients (49.2%) 2 or 3 pads, and 29 patients (24.2%) more than 3 pads per day because of incontinence, whereas 3 and 6 months after the procedure, 98 (82%) and 106 (88%) of the patients required a maximum of 1 pad, respectively. CONCLUSION: Our results demonstrate that nsEERPE can be performed with equal efficacy and preliminary results similar to those of standard open radical prostatectomy as well as transperitoneal laparoscopic prostatectomy while completely avoiding intraperitoneal complications.     

Preservation of the puboprostatic collar and puboperineoplasty for early recovery of urinary continence after robotic prostatectomy: anatomic basis and preliminary outcomes

OBJECTIVES: The aims of the present study are to prove the hypothesis that the preservation of the puboprostatic collar and puboperineoplasty contribute to the early recovery of urinary continence after robotic radical prostatectomy. We reconfirm the anatomy of the periurethral supporting tissue and show the preliminary result on the early continence of patients undergoing this modification. METHODS: Using 10, male, fresh cadavers, we traced the endopelvic fascia, the fascia of levator ani, puboprostatic ligaments, rhabdosphincter, and puboperinealis muscle to devise strategies in preserving this complex. The modifications were then attempted by a single surgeon (A.K.T.) in 19 patients undergoing robotic prostatectomy during September 2005. RESULTS: After incision of the endopelvic fascia within the fascial tendinous arch of the pelvis, the puboprostatic collar and the levator ani could be separated laterally. The puboperinealis muscle attached to part of the pubic symphysis behind the puboprostatic ligament and terminated at the perineal body. We were able to preserve the puboprostatic collar in all attempted cases. Furthermore, puboperineoplasty took 5min to complete. The total continence rate was 63.2% at median follow-up of 38.1 d. Immediate continence rate just after catheter removal was 42.1%. The rate at 1 and 4 wk was 52.6% and 71.4%, respectively. The margins of the examined specimens were all negative for malignancy. CONCLUSIONS: This modification should preserve or allow for early recovery of urinary continence from an anatomic perspective. Further studies are necessary to elucidate the clinical impact on a patient's early continence.     

保留神经的全膀胱切除术对盲结肠代膀胱控尿功能的影响

目的　探讨保留神经全膀胱切除术对盲结肠代膀胱控尿功能的影响。　方法　膀胱全切盲结肠代膀胱术共 73例 ,其中保留神经组 4 8例 ,非保留神经组 (对照组 ) 2 5例。术后随访 3～ 2 8个月 ,通过问卷和尿垫试验对比术后控尿能力。　结果　拔除尿管后 ,保留神经组白天和夜间可控率分别为 6 5 %和 4 0 % ;对照组为 34%和 2 6 %。术后达到白天和夜间可控所用的平均时间保留神经组分别为 2个月和 4个月 ;对照组为 5个月和 10个月。术后 12个月时 ,保留神经组白天和夜间可控率分别为 96 %和 87% ;对照组为 79%和 6 4 %。两组差异有显著性意义 (P <0 .0 1)。　结论　保留神经膀胱全切盲结肠代膀胱术可以提高术后控尿功能 ,减少尿失禁发生率。     

保留耻骨前列腺韧带在耻骨后根治性前列腺切除术控尿中的作用

目的 探讨耻骨后根治性前列腺切除术中保留耻骨前列腺韧带(PL)的控尿作用.方法前列腺癌患者74例.年龄52～73岁,平均65岁.术前实验室检查PSA 2.0～23.6 ng/ml,平均16.5 ng/ml.其中64例行经直肠超声引导下前列腺系统穿刺活检,病理证实为前列腺癌;10例行TURP后病理发现前列腺癌.74例均行盆腔MRI及全身骨扫描未见前列腺外转移病灶.A期6例、B期68例.手术方法:常规行双侧盆腔淋巴结清扫,锐性切开盆内筋膜至PL侧缘,50例保留PL,在尿道前方紧贴前列腺尖部的弧形缘放置集束血管钳,控制耻骨后血管复合体(包括PL与背静脉复合体);对照组24例紧贴耻骨切断PL,在尿道前方紧贴前列腺尖部的弧形缘放置集束血管钳,控制背静脉复合体.在集束钳下方用1-0可吸收线分别贯穿缝扎集束血管钳控制的组织,沿前列腺的弧形切断该束组织达前列腺尖部与尿道连接处.离断尿道.采用"网球拍"式的膀胱颈重建.整形后的膀胱颈与尿道黏膜对黏膜于2、5、7和10点分别吻合4针,将保留在复合体上的1-0缝线于重建膀胱颈的12点、距吻合缘0.5～1.0 cm处浆肌层贯穿缝扎,将其与复合体结扎固定.术后保留尿管2周.结果 74例手术均顺利.随访3～12个月.保留PL组及切断PL组年龄分别为(61.3±2.4)和(60.8±2.1)岁,实验室检查PSA分别为(14.3±1.2)和(14.7±1.3)ng/ml,手术时间为(110.5±10.4)和(109.7±10.6)min,术中出血量为(250.5±23.4)和(253.4±22.3)ml,切缘阳性率为6%(3/50)和8%(2/24);2组比较差异均无统计学意义(P>0.05).保留PL组与切断PL组术后拔除尿管不同时间的控尿率分别为:即刻26%(13/50)和0%(0/24),1个月时为50%(25/50)和12%(3/24),3个月时为80%(40/50)和42%(10/24),6个月时为96%(48/50)和67%(16/24),12个月时为100%(50/50)和75%(18/24);2组比较差异均有统计学意义(P<0.05). 结论 PL在耻骨后根治性前列腺切除术后控尿中发挥较大作用,术中应积极保留.     

Urodynamic evaluation of a suspension technique for rapid recovery of continence after radical retropubic prostatectomy

BACKGROUND: We investigated urodynamic findings involved in the rapid recovery of urinary continence after radical retropubic prostatectomy with a suspension technique. METHODS: A total of 45 consecutive patients (mean age 67.6 years) who had undergone radical retropubic prostatectomy for localized prostate cancer were evaluated with multichannel urodynamics including the maximal urethral pressure (MUP), functional urethral length (FUL), maximal cystometric capacity (MCC) and abdominal leak point pressure (ALPP) at base line, 1 week, 1 month, and 3 months postoperatively. The suspension of vesicourethral anastomosis preserving anterior attachments of puboprostatic ligaments to pubic bone was performed in 33 patients. Twelve patients did not undergo the suspension technique. RESULTS: The continence rates at 1 week, 1 month, and 3 months after radical prostatectomy in the suspension group were significantly higher than those in the non-suspension group: 67% versus 0% at 1 week (P < 0.001), 82% versus 25% at 1 month (P < 0.001), and 91% versus 50% at 3 months (P < 0.01), respectively. Postoperative ALPP at all points of measurement was significantly higher in the suspension group than in the non-suspension group (P < 0.0002). There was no difference in MUP, FUL or MCC at each point following radical prostatectomy between the two groups. CONCLUSIONS: These observations suggest that preserving anterior attachments of puboprostatic ligaments to pubic bone and fixation of urethral hyper-mobility by the suspension of vesicourethral anastomosis promotes rapid recovery of urinary continence after radical retropubic prostatectomy.     

Anatomical landmarks of radical prostatecomy

INTRODUCTION: In the present study, we review current literature and based on our experience, we present the anatomical landmarks of open and laparoscopic/endoscopic radical prostatectomy. METHODS: A thorough literature search was performed with the Medline database on the anatomy and the nomenclature of the structures surrounding the prostate gland. The correct handling of puboprostatic ligaments, external urethral sphincter, prostatic fascias and neurovascular bundle is necessary for avoiding malfunction of the urogenital system after radical prostatectomy. RESULTS: When evaluating new prostatectomy techniques, we should always take into account both clinical and final oncological outcomes. The present review adds further knowledge to the existing "postprostatectomy anatomical hazard" debate. It emphasizes upon the role of the puboprostatic ligaments and the course of the external urethral sphincter for urinary continence. When performing an intrafascial nerve sparing prostatectomy most urologists tend to approach as close to the prostatic capsula as possible, even though there is no concurrence regarding the nomenclature of the surrounding fascias and the course of the actual neurovascular bundles. After completion of an intrafascial technique the specimen does not contain any periprostatic tissue and thus the detection of pT3a disease is not feasible. This especially becomes problematic if the tumour reaches the resection margin. DISCUSSION: Nerve sparing open and laparoscopic radical prostatectomy should aim in maintaining sexual function, recuperating early continence after surgery, without hindering the final oncological outcome to the procedure. Despite the different approaches for radical prostatectomy the key for better results is the understanding of the anatomy of the bladder neck and the urethra.     

Tension and energy-free robotic-assisted laparoscopic radical prostatectomy with interfascial dissection of the neurovascular bundles

OBJECTIVES: To assess overall safety, histopathological outcomes, and early functional results after robotic-assisted laparoscopic radical prostatectomy (RALP) with a new lateral approach for the interfascial dissection of the neurovascular bundles without tension and any use of electrocautery. METHODS: Between April and September 2006, 100 consecutive patients with organ-confined prostate cancer (age < 70 yr, PSA < or = 10 microg/dl, Gleason score < or = 7, and IIEF > or = 17) underwent RALP by the same senior surgeon. Pre-, intra-, and perioperative data were recorded. The operative technique is described step by step. Patients were assessed at the 4-mo follow-up. RESULTS: RALP was successfully completed in all patients. Neither blood transfusions nor reintervention were necessary. One week following catheter removal, complete early urinary continence was achieved in 80% of patients, and spontaneous erections or penile tumescence was reported by 46 patients. Positive surgical margins were 12.1% in the pT2 group and 29% in the pT3 group. Ninety-three patients were available for analysis at the 4-mo follow-up. Of them, 92.4% were completely continent, 5.4% used 1 pad a day, and 2.2% used 2 or more pads a day. Concerning the IIEF-EF domain score, 64.5% of the patients reported a total score > or = 17, and 17.2% of them scored > or = 26. CONCLUSIONS: The novel approach described for RALP is safe and allows excellent dissection. It maintains good margin status and provides encouraging early continence and erectile functional results in selected patients. Long-term follow-up is necessary to assess the impact of this approach on oncological outcome.     

Clinical outcomes after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy) in 44 patients

PURPOSE: We describe the functional outcome on erectile function, continence and voiding, and local and distant cancer recurrence rates in 44 patients after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy). MATERIALS AND METHODS: A total of 44 males underwent cystectomy with preservation of the prostate, seminal vesicles and vasa deferentia, after which a Studer type neobladder was anastomosed to the prostate. Oncological outcome (disease specific survival, distant and local recurrence rates) and functional results (continence, voiding, erectile function) were determined. RESULTS: At a median followup of 42 months, 13 (30%) patients died of cancer. All 13 experienced widespread disease, which was combined with a pelvic recurrence (pelvic recurrence rate 6.9%) in 3. The 3-year survival according to pathological stage was 86% for pT 2N0 or lower, 63% pT3N0 and 39% for node positive tumors (anyT Npos). Prostate cancer was diagnosed in 1 patient 5 years after treatment, and recurrent carcinoma in situ in the prostatic urethra in another patient. Complete daytime and nighttime continence was achieved in 95.3% and 74.4%, respectively. Incontinence during day and night could be managed by 1 pad per day/night in 4.7% and 20.9%, respectively, while 4.7% needed more than 1 pad per night. Erectile function could be determined in 40 patients, and potency was maintained in 77.5%, impaired in 12.5% and absent in 10%. CONCLUSIONS: Functional results with regard to erectile function and urinary continence after prostate sparing cystectomy are good. Oncological results have been promising, but need to be confirmed after longer followup and in larger trials.     

Impact of nerve sparing technique on patient self-assessed outcomes after radical perineal prostatectomy

PURPOSE: We investigated the impact of nerve sparing technique on erectile function, urinary continence and health related quality of life after radical perineal prostatectomy using a validated self-assessment questionnaire. MATERIALS AND METHODS: The Expanded Prostate Cancer Index Composite questionnaire was administered preoperatively and at defined intervals after surgery to 265 patients who underwent radical perineal prostatectomy at 2 institutions between January 2001 and December 2004. Of these patients 153 (57.7%) and 112 (42.3%) underwent nonnerve sparing and nerve sparing approaches, respectively. Kaplan-Meier analysis was used to determine time to recovery of erectile function (erections firm enough for intercourse) and urinary continence (0 pads per day). RESULTS: Median patient age was 60.6 years. Median followup was 15 months. In multivariate analysis preoperative erectile function (p = 0.005) and preservation of the neurovascular bundle (p = 0.018) were independent predictors of earlier recovery of erectile function, with hazard ratios of 2.3 (95% CI 1.2-4.6) and 4.0 (95% CI 1.5-10.3), respectively. Median time to recovery of urinary continence was 4.8 months in the nerve sparing group and 6.1 months in the nonnerve sparing group (p = 0.001). In multivariate analysis nerve sparing technique (p = 0.001, HR 1.4, 95% CI 1.1-1.9) and age (p = 0.012, HR 1.7, 95% CI 1.3-2.2) were independent predictors of recovery of continence. CONCLUSIONS: This analysis suggests that nerve sparing radical perineal prostatectomy is associated with improved recovery of urinary continence and favorable health related quality of life scores and, therefore, should be considered a viable alternative to other nerve sparing approaches.     

Oncologic outcome and continence recovery after laparoscopic radical prostatectomy: 3 years' follow-up in a "second generation center"

OBJECTIVES: Laparoscopic radical prostatectomy in major centers guarantees oncologic and functional results equal to open procedures. In our institution this operation was introduced in 2001 after an adequate training in laparoscopic surgery. We report the oncologic and functional results after 3 years of experience. METHODS: We considered our first 150 patients that had undergone transperitoneal laparoscopic radical prostatectomy. The following parameters were prospectively collected and analyzed: pathological findings, surgical margins, surgical time, blood loss, hospital stay, catheterization, complications, oncologic follow-up and continence. RESULTS: Single positive surgical margins were observed in 26 patients (17.3%) and multiple positive margins in 15 patients (10%). The rates of positive margins in organ confined tumors (pT2a/b) were 11.3%. Preoperative PSA>10 ng/ml (Chi-square p<0.01), pathological stage>pT2 (Chi-square p<0.001) and Gleason score>6 (Chi-square p<0.01) were significantly correlated with positive margins. Major complications occurred in 16 patients (10.7%). The total recurrence rate is 11.7%. The continence rate at 12 months is 91.7%.with 44.3% of patients completely continent at the moment of catheter removal. CONCLUSIONS: Laparoscopic radical prostatectomy in now a well codified operation that, after an adequate training, could be learned and reproduced safely. Actually this is our first choice surgical approach in patients with localized prostate cancer.     

Factors predicting continence recovery 1 month after radical prostatectomy: Results of a multicenter survey

Objectives: To assess the factors associated with continence recovery 1 month after radical prostatectomy (RP) and to identify the correlation between these factors. Methods: In total, 2408 men treated with RP for prostate cancer (PCa) were enrolled in the present multicenter prospective study. Clinical (age, body mass index) and urological (catheterization or transurethral resection of the prostate) records, quality of life (QOL) scores determined using various instruments (including the International Index of Erectile Function [IIEF] and University of California Los Angeles, Prostate Cancer Index [UCLA‐PCI]), PCa characteristics (clinical stage [cT], prostate‐specific antigen, biopsy Gleason score), surgical features (surgical approach, nerve and bladder neck sparing, catheterization), and pathologic outcomes (pT, pN+, Gleason score, positive surgical margins) were recorded. Continence status prior to surgery and at 1 month after RP was assessed and classified as followed: (i) full continence; (ii) 0–1 pads/day; or (iii) >1 pad/day. Only patients determined to have full continence prior to surgery were included in the analysis. Data were evaluated using Spearman's correlation analysis and multivariate logistic regression. Results: Data from 1972 patients with full continence preoperatively and complete postoperative data were analyzed. At 1 month after RP, 644 patients (32.7%) were fully continent, 810 (41.1%) were using 0–1 pads/day, and 518 (26.3%) were using >1 pad/day. Univariate analysis indicated that clinical and urological data, QOL, PCa characteristics, surgical features, and pathologic outcomes were determinants for continence recovery. Multivariate analysis indicated that preoperative sexual activity (UCLA‐PCI Sexual Function P = 0.005; IIEF P = 0.040), bladder neck sparing (P = 0.003), catheterization time (P = 0.007), and catheter diameter (P = 0.046) were associated with 1 month continence recovery. Conclusions: Age and nerve sparing are not significant predictors of continence recovery 1 month after RP. Preoperative erectile function can predict post‐prostatectomy incontinence. Bladder neck preservation has a significant effect on early continence recovery after RP.     

Vattikuti Institute Prostatectomy: a single-team experience of 100 cases

PURPOSE: To analyze the outcomes of the first 100 patients undergoing robotic radical prostatectomy by a single surgical team. PATIENTS AND METHODS: From August 2001 to May 2002, we performed robotic radical prostatectomy in 100 patients with localized prostate cancer. The mean age was 60 +/- 0.67 years (SEM), the body mass index 27.5 +/- 0.35, the preoperative prostate specific antigen concentration 7.2 +/- 0.86 ng/mL, and follow-up 5.5 +/- 0.24 months. Thirty-eight patients also underwent pelvic lymph node dissection. We used the da Vinci surgical system and a subperitoneal approach (the Vattikuti Institute Prostatectomy; VIP). This is a prospective outcomes analysis of these patients. RESULTS: The mean operating time was 195 +/- 5.0 minutes, and the mean blood loss was 149 +/- 11.8 mL. No patient required blood transfusion. The stages of the cancers were pT(2a) in 21, pT(2b) in 64, pT(3a) in 5, pT(3b) in 9, and pT(3b)N(1) in 1. The positive surgical margin rate was 15%. At 1, 3, and 6 months, the continence rates were 37%, 72%, and 92%, respectively, and the potency rates were 11%, 32%, and 59%. CONCLUSION: The VIP is a safe operation with excellent operative parameters, low morbidity, and good surgical margins. The early functional results are promising.     

Intraoperative electrophysiological confirmation of urinary continence after radical prostatectomy

PURPOSE: To determine the actual effect of nerve sparing radical retropubic prostatectomy (RP) on postoperative urinary continence we used intraoperative electrophysiological testing to confirm functional preservation of the neurovascular bundle (NVB). MATERIALS AND METHODS: A total of 85 patients undergoing RP for localized prostate cancer were studied. During RP NVB preservation was assessed macroanatomically. Electrophysiological testing was then performed to confirm NVB preservation. The NVB was electrostimulated and responses were observed by monitoring intracavernous or intraurethral pressure changes. All patients were classified into 3 groups according to the degree of nerve sparing, that is a bilateral nerve sparing group, a unilateral nerve sparing group and a nonnerve sparing group, based on macroanatomical assessment as well as on electrophysiological assessment. Postoperative continence in each group was then determined. Urinary continence at baseline, and 3 and 6 months postoperatively was studied using a self-administered questionnaire. RESULTS: With electrophysiological assessment 20.6% of macroanatomically determined NVB preservations were reclassified. Analysis of the data on groups classified accurately by electrophysiological testing showed that the bilateral nerve sparing group maintained postoperative urinary function significantly more than the unilateral nerve sparing and nonnerve sparing groups. However, when only macroanatomical assessment was considered, no significant difference among the groups was found in urinary function. CONCLUSIONS: Electrophysiological assessment revealed that bilateral NVB preservation contributes to early recovery of urinary continence after RP. Thus, intraoperative electrophysiological assessment is useful for predicting postoperative quality of life.     

Patient reported sexual function following laparoscopic radical prostatectomy

PURPOSE: We evaluated the sexual function of patients who underwent laparoscopic radical prostatectomy. We assessed the effect of unilateral or bilateral preservation of the neurovascular bundle on the ability to achieve erections and have sexual intercourse postoperatively. MATERIAL AND METHODS: Between May 1998 and September 2001, 232 men underwent laparoscopic radical prostatectomy for localized prostate cancer at our institution. Sexual function questionnaires were given to the patients preoperatively. The study included 143 patients who were potent preoperatively. After the procedure the surgeon noted whether he performed unilateral, bilateral or no nerve sparing. Sexual function questionnaires were collected at 1, 3, 6 and 12 months after surgery. RESULTS: Of the 143 patients, 100, 80, 48 and 26 responded to the questionnaire at 1, 3, 6 and 12 months respectively. Of the nonnerve sparing group 11.7%, 11.1%, 16.6% and 30%, of the unilateral nerve sparing group 20%, 35%, 41.6% and 50% and of the bilateral nerve sparing group 32.5%, 41.1%, 29.1% and 87.5% respectively reported spontaneous erections 1, 3, 6 and 12 months after surgery, respectively. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%. CONCLUSIONS: The overall rate of patients who had erections preoperatively and maintained erections after surgery (53.8%) is comparable to the results for open surgery. Patients with bilateral preservation did better than those with unilateral preservation. Our preliminary results show a promising rate of potency at 1 year after laparoscopic radical prostatectomy.     

Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Urinary incontinence is one of the major drawbacks of radical prostatectomy, regardless of the procedure used (i.e. open, laparoscopic or robotic‐assisted). Several technical modifications have been described to improve postoperative continence, highlighting the role of puboprostatic ligaments and posterior reconstruction of the rhabdomyosphincter. The results obtained are inconsistent when applied to robotic surgery. The present multicentre randomized study shows that anterior suspension combined with posterior reconstruction is a safe and easy‐to‐perform technique for improving early continence after robotic‐assisted laparoscopic prostatectomy.

OBJECTIVE

• ? To assess the impact on urinary continence of anterior retropubic suspension with posterior reconstruction during robot‐assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

• ? In total, 72 patients who were due to undergo prostatectomy between July 2009 and July 2010 were prospectively randomized into two groups: group A underwent a standard RALP procedure and group B had anterior suspension and posterior reconstruction during RALP.
• ? The primary outcome measure was urinary continence, assessed using the University of California Los Angeles Prostate Cancer Index questionnaire at 15 days, and at 1, 3 and 6 months, after surgery. Other data recorded were operation duration, blood loss, length of hospital stay, duration of bladder catheterization, complications and positive margin rate.

RESULTS

• ? The continence rates at 15 days, and at 1, 3 and 6 months, after surgery were 3.6%, 7.1%, 15.4% and 57.9%, respectively, in group A, and 5.9%, 26.5%, 45.2% and 65.4%, respectively, in group B. The continence rates differed statistically between groups at 1 and 3 months (P = 0.047 and P = 0.016, respectively).
• ? There was no significant difference between groups regarding complications (P = 0.8) or positive margin rate (P = 0.46).

CONCLUSION

• ? Anterior suspension associated with posterior reconstruction during RALP improved the early return of continence, without increasing complications.