Bilateral Neurovascular Bundle Research Articles

Radical retropubic versus laparoscopic prostatectomy: a prospective comparison of functional outcome

Objectives To evaluate and compare prospectively the functional results (urinary continence and erectile function) after retropubic and laparoscopic radical prostatectomy. Methods From 1998 to 2001, 300 patients underwent radical prostatectomy, 70 by the retropubic and 230 by the laparoscopic approach. All of them completed a confidential, self-administered questionnaire regarding urinary continence and erectile function before and 1, 3, 6, and 12 months after surgery. The results were analyzed separately for day and nighttime urinary continence and by neurovascular bundle status and age for erectile function. Results No differences were found between the two groups except for the duration of bladder catheterization (7.8 days for the retropubic and 5.8 for the laparoscopic approach, P = 0.0006). Before surgery, 296 patients (98.7%) were continent and 290 (96.6%) were potent. One year after surgery, diurnal urinary continence increased progressively to 66.7% and 71.6% ( P >0.05), nocturnal continence to 66.7% and 87.1% ( P = 0.008), and potency rates to 30% and 41% ( P >0.05) for the retropubic and the laparoscopic approaches, respectively. After preservation of one and two neurovascular bundles, the potency rate increased to 27% and 46% and 44% and 53% for the retropubic and laparoscopic approaches, respectively ( P >0.05). For patients younger than 60 years old with bilateral neurovascular bundle preservation, the potency rates were 72% and 81% ( P >0.05). Conclusions The two approaches showed similar outcomes regarding continence and erectile function 1 year after surgery. However, the recovery of nocturnal continence seemed to occur earlier after the laparoscopic approach. It is necessary to conduct additional studies to determine the potential benefits of the laparoscopic approach regarding nocturnal continence.

Intraoperative electrical stimulation of cavernous nerves with monitoring of intracorporeal pressure to confirm nerve sparing during radical prostatectomy: Early clinical results.

We performed intraoperative cavernous nerve stimulation with an intracavernous pressure (ICP) monitoring system to confirm nerve sparing during radical pelvic surgery and assessed the results. Nineteen cases of radical prostatectomy and three of radical cystoprostatectomy were examined. Electrical stimulation of the site where the neurovascular bundle (NVB) was determined to run was performed and changes in ICP were measured before and after prostate removal. Of the 22 patients, bilateral NVBs were preserved in six patients while unilateral NVB was preserved in 16. Before dissection, all NVBs examined exhibited positive responses (ICP changes of>5 mmHg) to nerve stimulation. After removal of the prostate, positive responses were observed in 22 (79%) of 28 macroanatomically preserved NVBs. Of 16 sides on which the NVB was not preserved, there were positive responses in five (31%). In these patients, some nerve fibers were macroscopically observed lateral to the original site of NVB. Finally, bilateral or unilateral nerve sparing was confirmed electrophysiologically in 20 (91%) of the 22 patients. Intraoperative stimulation of the NVB while monitoring ICP changes is a simple and reliable method of accurately evaluating the preservation of cavernous nerves. This system may provide further insight into the mechanism of postoperative erectile dysfunction.

Laparoscopic radical prostatectomy: the initial UK series.

To test the reproducibility of other series of laparoscopic radical prostatectomy (LRP) for safety, efficacy and early oncological and functional results. One hundred consenting patients with clinically localized adenocarcinoma of the prostate and a Gleason sum of < or = 8 opting for surgery underwent LRP undertaken by one surgeon. Their mean (range) age was 62.2 (52-72) years, weight 78.8 (65-100) kg, prostate specific antigen (PSA) level 8.0 (2-32) ng/mL, and Gleason sum 6.0 (4-8). A five-port antegrade transperitoneal technique was used in all cases. The mean (range) operative duration was 245 (145-600) min, blood loss 313 (50-1300) mL, parenteral morphine sulphate administration 20.2 (0-160) mg and hospital stay after LRP 4.2 (3-13) nights. Bilateral neurovascular bundle preservation was attempted in 58% of patients. The transfusion rate was 3%. The conversion and re-intervention rates were 1% and 2%, respectively. There were eight complications, six of which were in the initial 26 cases, i.e. bladder neck stenosis (two), and rectal injury, laparotomy for bleeding, premature drain removal leading to urinary peritonitis, ulnar nerve neuropraxia, port-site hernia and paralytic ileus in one each. The positive surgical margin rate was 16%. All patients had a PSA level of < or = 0.1 ng/mL at 3 months. By 1 year 90% of patients were pad-free and 62% operated on using a bilateral nerve-sparing technique had erections. There were no biochemical failures. The mean (range) follow-up was 9.8 (1-24) months. The present results are similar to those reported by other centres with greater experience and confirm that LRP is an effective, safe and precise technique. Once intial experience has been gained it offers advantages over open surgery in the form of a dry and magnified operative site, and a lower likelihood of blood transfusion, in addition to the generic advantages of laparoscopy.

Sural nerve graft during laparoscopic radical prostatectomy: Initial experience

Objective: To determine the technical feasibility of sural nerve grafting for restoration of cavernous nerve continuity after radical retropubic prostatectomy by the laparoscopic approach. Materials and methods: 15 potent men (mean age: 56±4 years) underwent laparoscopic radical prostatectomy with deliberate wide uni- or bilateral neurovascular bundle resection. After prostatectomy, but before the vesicourethral anastomosis, an autologous sural nerve graft was interposed between the divided end of the cavernous nerves using a laparoscopic approach. Results: All 15 procedures could be completed laparoscopically. Visual cooptation between the nerve graft and the cut ends of the neurovascular bundles was possible in all 15 cases. Surgical time for the entire procedure ranged between 210 to 275 min with 30 to 60 min of this time required for the nerve harvest and graft. Conclusion: This experience demonstrates that sural nerve graft replacement is technically feasible by the laparoscopic approach. The magnified optics, bloodless surgical field, and improved instrumentation create an optimal environment for sural nerve grafting to the cut ends of the neurovascular bundles. Quality of life survey data at 12 to 18 month follow-up will be needed to assess functional return.

Bilateral nerve grafting during radical retropubic prostatectomy: extended follow-up

Objectives. To confirm the benefit of using an interposition sural nerve graft at the time of radical retropubic prostatectomy in an extended series of men with at least 1 year of follow-up. We previously reported the return of erectile function after resection of both cavernous nerves. Methods. Twenty-eight potent men with clinically localized prostate cancer underwent radical retropubic prostatectomy with deliberate wide bilateral neurovascular bundle resection and the placement of bilateral nerve grafts. Erectile dysfunction questionnaires and patient interviews were completed at 6-month intervals. A minimum of 12 months of follow-up (mean 23 ± 10 months) was obtained for 23 men (mean age 58 ± 6 years). A control group of 12 men who underwent bilateral nerve resections, but declined nerve graft placement, was also followed up. Results. Of the 23 men, 6 (26%) had spontaneous, medically unassisted erections sufficient for sexual intercourse with vaginal penetration. An additional 6 men (26%) described “40% to 60%” spontaneous erections (fullness, no rigidity, not able to penetrate). Ten men (43%) had intercourse with sildenafil. No demonstrable erections occurred before 5 months postoperatively. The greatest return of function thus far was observed at 18 months after surgery. Conclusions. This surgical technique continues to show promise as an advance in prostate cancer surgery. The results of this study demonstrated recovery of erectile function in men who underwent bilateral nerve graft placement during radical retropubic prostatectomy when both cavernous nerves were deliberately resected.

Impact of a modified apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins: a comparative study in 212 patients

Objectives. To assess the impact of a modified technique of apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins (PSMs). Methods. Between 1992 and 1998, 212 nonconsecutive patients with localized prostate cancer (57 T1, 155 T2) underwent radical retropubic prostatectomy and were divided into two groups: group 1, 85 patients who underwent surgery before January 1994; and group 2, 127 patients who underwent surgery with the modification of the apical dissection after January 1994. The modified technique consisted of a wide excision of periprostatic soft tissue at the apex, including the bilateral neurovascular bundles. The clinical data (age, prostate-specific antigen, clinical staging) and pathologic findings (pathologic staging, Gleason score, PSM rate) of the two groups were compared. Results. No significant difference was found between the two groups regarding the median prostate-specific antigen level (10.8 ng/mL and 9.5 ng/mL), Gleason score, and pathologic staging. Overall, the PSM rate was 53% in group 1 and 20.5% in group 2 ( P <0.001). The number of PSMs decreased 2.6-fold in group 2. The PSM rate was significantly reduced at the apex with the new technique (group 1, 33.3%; group 2, 7.7%; P = 0.008). The PSM rate expressed with the odds ratio was 4.4-fold lower for patients in group 2 than for those in group 1. Conclusions. The modified apical dissection in radical retropubic prostatectomy significantly improves the PSM rate in patients with localized T1-T2 prostate cancer.

Bilateral nerve graft during radical retropubic prostatectomy: 1-year followup.

With the interposition of a sural nerve graft to replace resected cavernous nerves at radical retropubic prostatectomy, we have previously reported the return of effective erectile function. We determine the efficacy of this procedure in a series of men with at least 1-year followup. A total of 12 potent men (mean age plus or minus standard deviation 57 +/- 6 years) with clinically localized prostate cancer underwent radical retropubic prostatectomy, with deliberate wide bilateral neurovascular bundle resection and placement of bilateral nerve grafts. A series of patient and partner erectile dysfunction questionnaires, and patient interviews were performed at 3, 6, 12 and 18 months postoperatively. Only results for those men with a followup of 12 months or greater (mean 16 +/- 4) are presented. A control group of 12 men who had undergone bilateral nerve resection but declined nerve graft placement, was also followed. Of the 12 men 4 (33%) had spontaneous medically unassisted erections sufficient for sexual intercourse with vaginal penetration. An additional 5 (42%) men describe "40 to 60%" spontaneous erections, with fullness, no rigidity and not able to penetrate. Overall, 9 (75%) men had return of erectile activity. No demonstrable erections occurred before 5 months postoperatively. The greatest return of function was observed at 14 to 18 months after surgery. This surgical technique has minimal morbidity and represents a significant advance in prostate cancer surgery in men requiring bilateral nerve resection. Our study clearly demonstrates recovery of erectile function in men who underwent bilateral nerve graft placement during radical retropubic prostatectomy when both cavernous nerves were deliberately resected.

BILATERAL NERVE GRAFT DURING RADICAL RETROPUBIC PROSTATECTOMY: 1-YEAR FOLLOWUP

Purpose: With the interposition of a sural nerve graft to replace resected cavernous nerves at radical retropubic prostatectomy, we have previously reported the return of effective erectile function. We determine the efficacy of this procedure in a series of men with at least 1-year followup.Materials and Methods: A total of 12 potent men (mean age plus or minus standard deviation 57 ± 6 years) with clinically localized prostate cancer underwent radical retropubic prostatectomy, with deliberate wide bilateral neurovascular bundle resection and placement of bilateral nerve grafts. A series of patient and partner erectile dysfunction questionnaires, and patient interviews were performed at 3, 6, 12 and 18 months postoperatively. Only results for those men with a followup of 12 months or greater (mean 16 ± 4) are presented. A control group of 12 men who had undergone bilateral nerve resection but declined nerve graft placement, was also followed.Results: Of the 12 men 4 (33%) had spontaneous medically unassi...

FACTORS PREDICTING RECOVERY OF ERECTIONS AFTER RADICAL PROSTATECTOMY

Because preservation of functioning penile erections is a major concern for many patients considering treatment for localized prostate cancer, we analyzed various factors determined before and after radical retropubic prostatectomy to identify those significantly associated with recovery of erectile function. Our prospective database of patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy was used to determine factors predictive of erection recovery after radical prostatectomy. The study included 314 consecutive men with prostate cancer treated with radical retropubic prostatectomy between November 1993 and December 1996. Preoperative potency satisfactory for intercourse and degree of neurovascular bundle preservation during the operation were documented. Patient age, preoperative potency status and extent of neurovascular bundle preservation but not pathological stage were predictive of potency recovery after radical prostatectomy. At 3 years after the operation 76% of men younger than age 60 years with full erections preoperatively who had bilateral neurovascular bundle preservation would be expected to regain erections sufficient for intercourse. Compared to the younger men, those 60 to 65 years old were only 56% (95% confidence interval [CI] 37 to 84) and those older than 65 years were 47% (95% CI 30 to 73) as likely to recover potency. Patients with recently diminished erections were only 63% (95% CI 38 to 100) as likely to recover potency as men with full erections preoperatively, and those with partial erections were only 47% (95% CI 23 to 96) as likely to recover potency. Resection of 1 neurovascular bundle reduced the chance of recovery to 25% (95% CI 10 to 61) compared to preserving both nerves. Knowledge of preoperative erectile function and patient age before the operation and the degree of neurovascular bundle preservation afterward may aid in patient counseling regarding potency recovery after radical prostatectomy.

Brachytherapy radiation doses to the neurovascular bundles

Purpose: To investigate the role of radiation dose to the neurovascular bundles (NVB) in brachytherapy-related impotence. Methods and Materials: Fourteen Pd-103 or I-125 implant patients were studied. For patients treated with implant alone, the prostate and margin (clinical target volume [CTV]) received a prescription dose of 144 Gy for I-125 or 115 Gy for Pd-103. Two patients received Pd-103 (90 Gy) with 46 Gy supplemental external beam radiation (EBRT). Axial CT images were acquired 2 to 4 hours postoperatively for postimplant dosimetry. Because the NVBs cannot be visualized on CT, NVB calculation points were determined according to previously published anatomic descriptions. Bilateral NVB points were considered to lie posterior-laterally, approximately 2 mm from the prostatic capsule. NVB doses were recorded bilaterally, at 0.5-cm intervals from the prostatic base. Results: For Pd-103, the average NVB doses ranged from 150 Gy to 260 Gy, or 130% to 226% of the prescription dose. For I-125, the average NVB dose ranged from 200 Gy to 325 Gy, or 140% to 225% of the prescription dose. These was no consistent relationship between the NVB dose and the distance from the prostatic base. To examine the possible effect of minor deviations of our calculation points from the true NVB location, we performed NVB calculations at points 2 mm medial or lateral from the NVB calculation point in 8 patients. Doses at these alternate calculation points were comparable, although there was greater variability with small changes in the calculation point if sources were located outside the capsule, near the NVB calculation point. Three patients who developed early postimplant impotence had maximal NVB doses that far exceeded the average values. Conclusions: In the next few years, we hope to clarify the role of high NVB radiation doses on potency, by correlating NVB dose calculations with a large number of patients enrolled in an ongoing I-125 versus Pd-103 trial for early-stage patients, for whom detailed dosimetric and potency data are being collected prospectively. In the future, we anticipate that NVB doses may be incorporated into dosimetry guidelines to maximize tumor control and minimize treatment-related morbidity.

Treatment of erectile dysfunction after radical prostatectomy with sildenafil citrate (Viagra)

Objectives. To determine whether the response to the new oral medication, sildenafil citrate (Viagra), was influenced by the presence or absence of the neurovascular bundles, as recent reports on its success did not specify the efficacy of the drug in patients with erectile dysfunction after radical prostatectomy. Methods. Baseline and follow-up data from 28 healthy patients presenting with erectile dysfunction after radical prostatectomy were obtained. Patients receiving any neoadjuvant/adjuvant hormones or adjuvant radiation therapy were excluded. Patients reported what their erectile status was before surgery, before sildenafil therapy, and after using a minimum of four doses of sildenafil. Both the patients and their spouses were interviewed using the Cleveland Clinic post-prostatectomy questionnaire, which includes questions about response to therapy, duration of intercourse, spousal satisfaction, side effects, and related topics. The patients were compared on the basis of the type of surgical procedure they had undergone—nerve sparing or non-nerve sparing. A positive response to sildenafil was defined as erection sufficient for vaginal penetration. Results. Of the 15 patients who had bilateral nerve-sparing procedures, 12 (80%) had a positive response to sildenafil, with a mean duration of 6.92 minutes of vaginal intercourse. These 12 patients also reported a spousal satisfaction rate of 80%. All 12 of the responders had a positive response within the first three doses, and 10 of the 12 responded with the first or second dose. None of the 3 patients who had undergone a unilateral nerve-sparing procedure responded, nor did any of the 10 patients who had undergone a non-nerve-sparing procedure. The two most common side effects of the drug were transient headaches (39%) and abnormal color vision (11%). No patients discontinued the medication because of side effects. Conclusions. Successful treatment of erectile dysfunction in a patient after prostatectomy with sildenafil citrate may depend on the presence of bilateral neurovascular bundles. No patient who had undergone a non-nerve-sparing procedure responded. Whether patients who undergo unilateral nerve-sparing procedures will respond to sildenafil is still unclear because of the small number of patients in our study. These findings should encourage urologists to continue to perform and perfect the nerve-sparing approach. The ability to restore potency with an oral medication after radical prostatectomy will impact our discussion with the patient on the surgical morbidity of radical prostatectomy.

Consecutive evaluation of vesico-urethral function in patients undergoing radical retropubic prostatectomy

We evaluated vesico-urethral function after radical retropubic prostatectomy in 18 male patients by consecutive urodynamic studies. At the time of the operation average age was 68 years with a range between 56 to 78 years old. The follow-up period after the operation was over 12 months in all patients. Pathological stage was T1 in 2, T2 in 6, T3 in 8 and T4 in 2 patients. Urodynamic evaluation including uroflowmetry, cystometry, urethral pressure profilometry (UPP) and external anal or urethral sphincter electromyography was performed before and 1, 3, 6 and 12 months after the operation. The status of postoperative urinary incontinence was reported by the patients. Sixty-five per cent of the patients revealed the low compliance bladder less than 10 ml/cm water at one month after the operation, however, most patients had normal vesical compliance and normal cystometrogram at 12 months. Both functional profile length (FPL) and maximum urethral closure pressure (UCPmax) in UPP were markedly lowered immediately after the operation and both indexes were significantly lower even at one year after the operation than preoperative ones. Both the incidence and the degree of incontinence improved during postoperative 12 months; complete urinary control was achieved in 11 patients (61%), stress urinary incontinence was present in 6 patients (33%) and one patient (6%) was still totally incontinent. Shortening FPL was considered to be the risk factor on postoperative urinary incontinence. Resection of bilateral neurovascular bundles and lower UCPmax seemed to have the possibility of the influence on it. Low compliance bladder is also likely to be one of the factors to cause early postoperative incontinence.