V476 NERVE-SPARING RETROPUBIC RADICAL PROSTATECTOMY WITH EXTRACAPSULAR DISSECTION: QUALITY OF SURGICAL EXCISION

Abstract

You have accessJournal of UrologyProstate Oncology1 Apr 2010V476 NERVE-SPARING RETROPUBIC RADICAL PROSTATECTOMY WITH EXTRACAPSULAR DISSECTION: QUALITY OF SURGICAL EXCISION Christian Barré, Geneviève Aillet, and Matthieu Thoulouzan Christian BarréChristian Barré Nantes, France More articles by this author , Geneviève AilletGeneviève Aillet Nantes, France More articles by this author , and Matthieu ThoulouzanMatthieu Thoulouzan Toulouse, France More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.550AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Potency recovery after radical prostatectomy (RP) has to be weighed against the risks of nerve-sparing surgery in relation to long-term cancer control. To prevent the risk of iatrogenic positive margins, dissection had to be beyond the boundaries of the gland, i.e. beyond the histological zones defined by McNeal. Incisions of the inner or outer layers of the capsule are technical errors as they cross the boundaries of the prostate. This is especially important as prostate cancer is multifocal, may occur within any zone, and the distance of the tumour from the boundary is highly variable and may be less than one millimetre. We describe here the extracapsular dissection of the neurovascular bundles in retropubic radical prostatectomy. METHODS After transection of the urethra and Denonvilliers' fascia, the plane between the anterior wall of the rectum and the prostate was developed. The levator fascia was freed from the neurovascular bundle and incised. A hook was used to gently lift the free edge of the neurovascular bundle, thus exposing the dissection plane between the neurovascular bundle and prostate fascia. Each pedicle of the neurovascular bundle was dissected and released from the prostate fascia. All pedicles penetrating the prostate were sectioned before their attachment point, however superficial, to the prostate fascia. Overlooking any of these pedicles carries the risk of intrafascial dissection and capsule incision. Haemostasis was achieved with 3.8 mm haemoclips. At the prostate base, the neurovascular bundle travels towards the pelvic floor and could be eased away from the prostate with less risk of injury to the cavernous nerves. The thick pedicles of the prostate base covering the lateral face of the seminal vesicle were then divided, leaving some connective tissue on the prostate. The last step was the development of the plane between the anterior wall of seminal vesicles and posterior wall of the bladder-neck. RESULTS The operative time was 120mn, the estimated blood loss was 150cc. Pathology was: pT2a, Gleason score: 3+3, negative margins, the two layers of the capsule were intact and the distance cancer-margin was 0.25 mm. Pre-operative IIEF-5 score was 23, and at 18 months follow-up it was 18 with oral pharmacological assistance. CONCLUSIONS The real challenge of nerve-sparing surgery in RP is to be able to dissect away from the prostate capsule without injury to the nerves and this case highlights the fact that extracapsular dissection is the way to prevent the iatrogenic positive margins. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e188 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Barré Nantes, France More articles by this author Geneviève Aillet Nantes, France More articles by this author Matthieu Thoulouzan Toulouse, France More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...