Neurovascular Bundle Preservation Research Articles

Early recovery of urinary continence after robot-assisted radical prostatectomy is associated with membranous urethra and neurovascular bundle preservation.

We investigated the correlation between surgical outcomes and postoperative urinary continence recovery in robot-assisted radical prostatectomy (RARP). Patients who underwent RARP in our institution (n = 195) were included in this study. Preserved urethral length (PUL) was assessed during the procedure. Other outcomes of the surgical procedure were collected from operative records. Kaplan-Meier analysis with log-rank test was used to compare urinary continence recovery rate with the PUL, sparing of the neurovascular bundle (NVB), and other surgical procedures. Univariate and multivariate analyses were performed using Cox proportional hazards model, and p-values of <0.05 were considered significant. Patients with a PUL ≥26 mm had 10.0%, 24.7%, 36.6%, and 89.0% continence recovery rates at 30, 60, 90, and 365 days after surgery, respectively, while patients with a PUL <26 mm had 0%, 17.8%, 26.1%, and 80.9% recovery rates, respectively. Kaplan-Meier curves showed significantly better postoperative urinary continence recovery at 30 days after RARP in patients with a PUL ≥26 mm than those with a PUL <26 mm (p = 0.0028) and in patients with NVB preservation than those with no NVB preservation (p = 0.014). Urinary continence recovery within 30, 60, and 90 days after surgery was 90.6% for patients with a PUL of ≥26 mm and NVB preservation, while only 82.3% for patients with a PUL of <26 mm or no NVB preservation. Our results suggest that a PUL ≥26 mm and NVB preservation after RARP correlate with a significantly higher postoperative rate of recovery of urinary continence.

Functional Impact of Neuro-Vascular Bundle Preservation in High Risk Prostate Cancer without Compromising Oncological Outcomes: A Propensity-Modelled Analysis.

Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n = 158) underwent non-NSRP and 39% (n = 516) and 50% (n = 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p = 0.09), and there was no difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39-1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29-1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.

Comparative analysis of 10-year functional outcomes of robot-assisted radical prostatectomy and radical retropubic prostatectomy. Experience of the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry

Background. Prostate cancer is the 3rd most common diagnosis among malignant tumors. The first robot-assisted radical prostatectomy (RARP) was performed in 2001. Studies comparing RARP and radical retropubic prostatectomy (RRP) are limited. In Russia, the Da Vinci robot was first installed in 2007. At the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry the program of robot-assisted surgery started in November of 2008.Aim. To perform first in Russia evaluation of 10-year functional treatment outcomes for patients with localized prostate cancer after RARP. To perform comparative analysis with RRP outcomes.Materials and methods. Medical histories of 211 patients from the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry were analyzed. Among them, 62 patients did not satisfy the inclusion criteria. Therefore, the study included 149 patients who underwent surgical treatment for localized prostate cancer between January of 2009 and December of 2011. Depending on the technique of surgical intervention, patients were divided into 2 groups: 1st – RARP (n = 82), 2nd – RRP (n = 67). All RARP were performed by a single surgeon, RRP by 2 experienced surgeons (experience &gt;1000 RRP).Results. Median follow-up was 120 months in both groups. Overall survival in the 1st and 2nd groups was 85.4 and 86.6 %, respectively (p &gt;0.05). For accuracy of functional outcomes analysis, patients who died during follow-up were excluded from the study. Frequency of neurovascular bundle preservation in the 1st and 2nd groups was 60.9 % (50/82) and 40.2 % (27/67), respectively (p = 0.01). Erectile function was preserved in 60.0 and 44.4 % males of the 1st and 2nd groups, respectively (p = 0.01). Age below 60 years (р = 0.009) and disease stage рТ2 (p = 0.026) were predictors of erectile function preservation after RARP. Continence frequency was 92.7 and 82.1 % in the 1st and 2nd groups, respectively (p = 0.048).Conclusion. Ten-year comparative analysis shows that RARP allows to achieve significantly better parameters of urinary continence and erectile function preservation in men with localized prostate cancer than RRP.

MP67-12 FIRST LOOK: LASER SPECKLE IMAGING IS A NOVEL METHOD TO IDENTIFY AND PRESERVE NEUROVASCULAR BUNDLE DURING ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP67-12 FIRST LOOK: LASER SPECKLE IMAGING IS A NOVEL METHOD TO IDENTIFY AND PRESERVE NEUROVASCULAR BUNDLE DURING ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY Matt Mikula, Jay Bishoff, Louis Kavoussi, Lee Richstone, Nicholas Kavoussi, Manish Vira, Vipul Patel, and Arun Rai Matt MikulaMatt Mikula More articles by this author , Jay BishoffJay Bishoff More articles by this author , Louis KavoussiLouis Kavoussi More articles by this author , Lee RichstoneLee Richstone More articles by this author , Nicholas KavoussiNicholas Kavoussi More articles by this author , Manish ViraManish Vira More articles by this author , Vipul PatelVipul Patel More articles by this author , and Arun RaiArun Rai More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003330.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Preserving neurovascular bundle (NVB) is been previously identified as an important factor in maintaining erectile function and urinary continence after prostatectomy. Current approaches for visualizing blood flow/perfusion in real-time are: suboptimal (lack objectivity), cumbersome (need for dye preparation and injection), and lack cost-effective utility (need for large capital equipment). Laser-Speckle-Contrast-Imaging (LSCI) LSCI displays tissue blood flow via coherent laser light scatter from red blood cells without intravenous dye. Herein, we present our initial multi-center experience and feasibility with utilizing this novel technology to identify NVB during robotic assisted laparoscopic radical prostatectomy (RALP). METHODS: RALP was performed in surgeon’s respective institutions (Global Robotics Institute, FL and Northwell Health, NY) with either multiport (Da Vinci Xi) or single port (Da Vinci SP) robotic equipment. ActivSight is an FDA cleared LSCI-based endoscopic imaging module positioned between any endoscope and camera to visualize real-time perfusion. During RALP, a 10mm laparoscope with the ActivSight module was introduced on-demand through an accessory port at key points throughout the case via assistant. RESULTS: In both antegrade and retrograde nerve dissection, ActivSightTM was able to visualize NVB and demonstrate perfusion through dissection (n =15/15). Surgeons did not express any significant workflow alterations or difficulty with using ActivSight during dissection. CONCLUSIONS: To our knowledge, this is the first clinical experience describing laser speckle imaging in real-time visualization of the critical structures during RALP. LSCI provided in all cases the ability to identify and additional confidence in preserving the NVB even to highly experienced surgeons. While information presented here demonstrates some early potential promise, further research and development will be required to validate utility in the NVB preservation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e947 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matt Mikula More articles by this author Jay Bishoff More articles by this author Louis Kavoussi More articles by this author Lee Richstone More articles by this author Nicholas Kavoussi More articles by this author Manish Vira More articles by this author Vipul Patel More articles by this author Arun Rai More articles by this author Expand All Advertisement PDF downloadLoading ...

V06-01 NERVE-SPARING ROBOT-ASSISTED RADICAL CYSTOPROSTATECTOMY WITH HYDRODISSECTION AND VASCULAR STAPLER: ADHERING TO SURGICAL PRINCIPLES

You have accessJournal of UrologyCME1 Apr 2023V06-01 NERVE-SPARING ROBOT-ASSISTED RADICAL CYSTOPROSTATECTOMY WITH HYDRODISSECTION AND VASCULAR STAPLER: ADHERING TO SURGICAL PRINCIPLES Nassib Abou Haidar, Hannah B. Ely, Jorge Daza, Ian J. Cooke, Muammer Altok, Ahmed A. Hussein, and Khurshid A. Guru Nassib Abou HaidarNassib Abou Haidar More articles by this author , Hannah B. ElyHannah B. Ely More articles by this author , Jorge DazaJorge Daza More articles by this author , Ian J. CookeIan J. Cooke More articles by this author , Muammer AltokMuammer Altok More articles by this author , Ahmed A. HusseinAhmed A. Hussein More articles by this author , and Khurshid A. GuruKhurshid A. Guru More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy remains the gold-standard treatment of muscle-invasive bladder cancer. Nerve sparing approaches have been performed and described over the past decades. The advent of robotic approaches with superior vision and magnification, has allowed enhanced techniques of nerve sparing during radical cystectomy. We hereby illustrate the main anatomical landmarks and the use of hydrodissection for neurovascular bundle preservation during robotic assisted radical cystectomy. METHODS: In this video, we highlight the operative steps during radical cystectomy, to achieve neurovascular bundle preservation. We describe the technique of using Endo GIA to release the bladder pedicle as well as the use of saline needle hydrodissection to facilitate the dissection of the neurovascular bundle away from the prostate pedicle. We also describe the use of the Endo GIA stapler to divide the prostate pedicle, while minimizing the traction on the cavernosal nerves. RESULTS: We compiled the important operative steps as well as the essential anatomical landmarks that have been previously described to perform neurovascular bundle sparing during radical cystectomy. We further attempt to refine the technique of nerve sparing utilizing the advantage of magnification and superior functionality of robotic surgery. CONCLUSIONS: Robotic surgery has allowed improved vision and understanding of complex pelvic anatomy. This has made way for enhanced surgical technique for neurovascular preservation during radical cystectomy. Source of Funding: Roswell Park Alliance Foundation © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e509 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nassib Abou Haidar More articles by this author Hannah B. Ely More articles by this author Jorge Daza More articles by this author Ian J. Cooke More articles by this author Muammer Altok More articles by this author Ahmed A. Hussein More articles by this author Khurshid A. Guru More articles by this author Expand All Advertisement PDF downloadLoading ...

Эффективность трехмерной системы визуализации при выполнении лапароскопической радикальной простатэктомии.

Introduction. The three-dimensional (3D) imaging during laparoscopic procedures can improve the quality of that surgeries. There is a shortage of publications about the potential benefits of 3D navigation in laparoscopic surgery with urological diseases. Radical prostatectomy (RPE) is known as the gold standard of treatment of localized prostate cancer (PC), and investigation of imaging technologies in laparoscopic surgery in PC patients is a hot topic. Aim. To compare the perioperative outcomes of laparoscopic RPE performed with 3D and two-dimensional (2D) imaging. Materials and methods. We performed retrospective analysis of perioperative outcomes in 146 patients who had undergone radical surgery with localized PC. All the patients were divided into 4 groups by the surgery features: 1) 2D imaging with the technique for neurovascular bundles preservation (TNVBP) (n=52); 2) 2D without TNVBP (n=46); 3) 3D with TNVBP (n=23); 4) 3D without TNVBP (n=25). We assessed operative time, intraoperative blood loss volume (IBLV), duration of the bladder drainage, positive surgical margin (PSM) detection rate, duration of the postoperative inpatient period, urinary continence recovery rate, erectile function recovery (EFR) rate. Results and discussion. In groups 1, 2, 3, 4 the operative time was 171,4±21,1, 168,3±23,2, 98,7±17,3, 92,2±22,2 min, and the IBLV was 294,2±62,1, 281,2±53,2, 144,2±31,7, 148,5±33,0 mL, respectively. PSM detection rate was 1,92±0,11%, 2,17±0,04% in groups 1, 2, while PSM had not been detected in groups 3, 4. In all the participants, duration of the bladder drainage was 5–7 days, and the full recovery of urinary continence was detected at both 6 and 12 months after the surgery. The postoperative inpatient period was 8–10 days in groups 1, 2, and 8–9 days in groups 3, 4. The EFR at 3 months after the surgery was detected in 38,4%, 28,3%, 34.8%, 28.0% of patients, while at 12 months it was detected in 59,6%, 41,3%, 82,6%, 56,0% of patients in groups 1, 2, 3, 4, respectively. Conclusion. We revealed the following features of perioperative period of laparoscopic RPE performed with 3D imaging compared to 2D: 1) the operative time was reduced by 42–45% (р&lt;0,05); 2) the IBLV was reduced by 47–51% (р&lt;0,05); 3) the PSM had not been detected; 4) there was the tendency to the shorter postoperative inpatient period; 5) the EFR rate was increased by 1,3–1,4 times (р&lt;0,05), and the best EFR outcomes were obtained via 3D imaging together with TNVBP. Thus, our study demonstrates the advisability of usage of both 3D imaging and TNVBP during the laparoscopic RPE.

Surgical approach affecting long-term urinary continence status after robot-assisted laparoscopic prostatectomy prospectively evaluated using self-reported functional status (Expanded Prostate Cancer Index Composite, EPIC-26).

The aim of the study was to examine the influence of the surgical approach for robot-assisted laparoscopic prostatectomy (RALP) on long-term urinary continence status in the era of self-reported functional status measures using the Expanded Prostate Cancer Index Composite 26. This is a prospective evaluation of 232 patients undergoing RALP between September, 2019 and September, 2020. Urinary continence status and postoperative incontinence (pad usage) were evaluated 12 months after RALP using Expanded Prostate Cancer Index Composite 26 questionnaires. Patients were categorized according to their surgical approach and outcome into the following groups: successful nerve sparing (NS), primarily without nerve sparing (prim. NNS), and no nerve sparing by secondary resection (NNS by SR). The median levels of their questionnaire outcomes were evaluated and compared using the Wilcoxon rank sum test with continuity correction. Urinary continence status 12 months after RALP differed significantly between the NS and prim. NNS (p = 0.0071) and the NS and NNS by SR (p = 0.0076) groups. There was no significant difference between the prim. NNS and NNS by SR (p = 0.53) groups. Pad usage 12 months after RALP had no significant difference with regard to SR of the neurovascular bundle (p = 0.14). Patient-reported outcomes of long-term urinary continence status seem to show no difference in postoperative continence, regardless of whether a non-nerve-sparing result was planned or reached through SR. Instead, preservation of neurovascular bundle seems to lead to better long-term continence rates.

Prediction of recovery time of urinary incontinence following robot-assisted laparoscopic prostatectomy.

Postoperative urinary incontinence recovery following robot-assisted laparoscopic prostatectomy is an important outcome. We investigated whether factors that affect urinary incontinence can predict the duration of postoperative incontinence recovery. A total of 310 patients underwent robot-assisted laparoscopic prostatectomy. Continence recovery was defined as either pad-free or a safety pad only status. Univariate and multivariate analyses were performed on clinical variables to identify those that were associated with continence recovery. A scoring system to predict recovered continence was constructed using statistically significant variables. The validity of this tool was tested in a new cohort of 273 patients. Factors associated with recovery of urinary incontinence were membranous urethral length, preservation of bilateral neurovascular bundles, and a preoperative Prostate Imaging Reporting and Data System score of ≥3 in the apex. Age was related only to incontinence recovery at 1 month. To prepare the score, weighting was performed using the estimated values. Using the developed scoring system, participants in the verification set were divided into three groups. The early recovery group had a median incontinence recovery of 4 (4-12) weeks, the medium recovery group, 12 (4-24) weeks, and the late recovery group, 24 (24-48) weeks, which was a significant difference (p < 0.001). The applied scoring system based on preoperative factors related to incontinence and derived from patient groups was significantly associated with continence recovery time. In patients undergoing robot-assisted laparoscopic prostatectomy, our unit-weighted regression model of clinical variables can predict the duration of continence recovery.

Association of nerve-sparing grading in robotic radical prostatectomy and trifecta outcome.

To evaluate the neurovascular bundle preservation grades during robotic-assisted radical prostatectomy and compared to the trifecta combined outcome (oncologic control, continence, and sexual function) twelve months after the surgery. Cohort of patients who underwent nerve-sparing robotic-assisted radical prostatectomy had the neurovascular bundle preservation retrospectively graded from 0 to 8 according to the Hopkins subjective visual classification. Patients then were divided into two groups, according to the median of nerve-sparing grading: those with score six or high and those with score less than six. Main outcome was the trifecta combined outcome and secondary outcomes was the individual trifecta criteria (prospective analysis). A secondary analysis with groups divided according to pre-operatory SHIM score was made. One hundred robotic-assisted nerve-sparing radical prostatectomy were performed, of which 83 were included. There were 53 patients with grading greater than or equal to six (group 1) and 30 patients less than six (group 2). 66.6% patients (35/53) in group 1 had a trifecta combined outcome of compared to 33.3% (10/30) in group 2 (p = 0.017). Individually, the erectile function was higher in group 1 (73.6%) compared to group 2 (46.7%) (p = 0.014). Both the results of the combined endpoint trifecta and erection were also maintained in the group with preoperative SHIM ≥ 17. The grading of preservation of the neurovascular bundle in radical prostatectomy is related to a better combined trifecta outcome one year after surgery.

Bladder neck size and its association with urinary continence after robot-assisted radical prostatectomy.

This study aims to determine whether bladder neck size (BNS) measured during surgery is associated with urinary continence after robot-assisted radical prostatectomy. Between June 2015 and March 2019, 365 consecutive eligible patients undergoing robot-assisted radical prostatectomy were enrolled into a prospective observational cohort study. The primary outcome was patient-reported urinary continence status at 1, 3, 6, 12 and 24 months postoperatively, with continence defined as 0 pad/day. The primary exposure was BNS (largest diameter) measured intraoperatively just before performance of vesicourethral anastomosis. Other covariates included age, body mass index, NCCN risk category, nerve-sparing, membranous urethral length measured intraoperatively and weight of the resected specimen. Well-preserved neurovascular bundle (bilateral/unilateral/none) was highly correlated with urinary continence status at every point after surgery. No difference could be seen between the group with BNS ≤17 mm and the >17-mm group at 1, 3 and 6 months after surgery, but there was better urinary rate of continence in narrow BNS group (≤17 mm) at 12 and 24 months after surgery. Multivariate analysis showed both nerve sparing and bladder neck diameter to be independent factors affecting urinary continence at 12 and 24 months after surgery. Preservation of neurovascular bundles was associated with better urinary continence after surgery. Smaller BNS was associated with better urinary continence in late stages after surgery (12-24 months after surgery).

PD49-07 SEXUAL FUNCTION RECOVERY FOLLOWING OPEN AND ROBOTIC RADICAL PROSTATECTOMY: RESULTS OF AN ACADEMIC PENILE REHABILITATION PROGRAM

You have accessJournal of UrologyCME1 May 2022PD49-07 SEXUAL FUNCTION RECOVERY FOLLOWING OPEN AND ROBOTIC RADICAL PROSTATECTOMY: RESULTS OF AN ACADEMIC PENILE REHABILITATION PROGRAM Ugo Falagario, Michele Di Nauta, Andrea Checchia, Marco Recchia, Anna Ricapito, Nicola D'Altilia, Pasquale Annese, Gian Maria Busetto, Luigi Cormio, Giuseppe Carrieri, and Carlo Bettocchi Ugo FalagarioUgo Falagario More articles by this author , Michele Di NautaMichele Di Nauta More articles by this author , Andrea ChecchiaAndrea Checchia More articles by this author , Marco RecchiaMarco Recchia More articles by this author , Anna RicapitoAnna Ricapito More articles by this author , Nicola D'AltiliaNicola D'Altilia More articles by this author , Pasquale AnnesePasquale Annese More articles by this author , Gian Maria BusettoGian Maria Busetto More articles by this author , Luigi CormioLuigi Cormio More articles by this author , Giuseppe CarrieriGiuseppe Carrieri More articles by this author , and Carlo BettocchiCarlo Bettocchi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002620.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical prostatectomy (RP) is the gold standard treatment for clinically localized prostate cancer (PCa) in patients with a life expectancy 10 yr. Notwithstanding improvements in surgical techniques, erectile dysfunction (ED) is a common sequela of RP.The aim of the present study was to evaluate the effect of early penile rehabilitation in a dedicated Penile Rehabilitation Program on both assisted and unassisted erectile function (EF) in men who developed ED after open and robotic RP. METHODS: All patients undergoing open or robotic RP and early penile rehabilitation were included in the present study. All patients were treated and followed up at a single academic institution in a dedicated Penile Rehabilitation Program. Treatment included phosphodiesterase type 5 inhibitors (PDE5Is), intracavernous injections and vacuum erection devices (VEDs). EF recovery was defined as IIEF>20. Both assisted and unassisted EF was evaluated. Data were prospectively collected and retrospectively reviewed. Kaplan Mayer curves were used to evaluate EF recovery. Ethical Committee approval has been obtained. RESULTS: a total of 397 patients were eligible. 168 (42.3%) underwent robotic RP. Unilateral and bilateral nerve sparing was performed in 38 (9.6%) and 116 (29.2%) patients respectively.A combination of PDE5I and intracavernous injections was the most frequently used first line treatment (233, 59%). VEDs were used in 52 patients in addition to PDE5I and intracavernous injections (39, 10%) or intracavernous injections (23, 6%). In patients with a preoperative IIEF>21, assisted and unassisted EF recovery rates were 78% and 36% respectively.In patients with a preoperative IIEF<16, assisted and unassisted EF recovery rates were 46% and 18% respectively. Sub analysis showed a moderate benefit of penile rehabilitation also in patients with a preoperative IIEF<16 undergoing bilateral nerve sparing RP.Intensive penile rehabilitation with PDE5I, intracavernous injections and VEDs led to the best patient perceived results. CONCLUSIONS: Intensive penile rehabilitation programs improves EF recovery in patients undergoing radical prostatectomy. Preservation of Neurovascular bundles should be attempted also in patients with preoperative ED. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e832 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ugo Falagario More articles by this author Michele Di Nauta More articles by this author Andrea Checchia More articles by this author Marco Recchia More articles by this author Anna Ricapito More articles by this author Nicola D'Altilia More articles by this author Pasquale Annese More articles by this author Gian Maria Busetto More articles by this author Luigi Cormio More articles by this author Giuseppe Carrieri More articles by this author Carlo Bettocchi More articles by this author Expand All Advertisement PDF DownloadLoading ...

Short-term stretched penile length analysis for subsequent erectile dysfunction after robotic-assisted radical prostatectomy with bilateral neurovascular bundle preservation

ABSTRACT Introduction Stretched Penile Length (SPL) is observed to shrink after radical prostatectomy (RP) and has chances resuming the length as long as 12 months. Objective To assess the short-term SPL change from patients after robotic-assisted radical prostatectomy (RARP) with bilateral neurovascular bundle (NVB) preservation and experiencing subsequent erectile dysfunction (ED). Effects from tadalafil, post-operative androgen deprivation therapy (ADT), and no medication or intervention are compared. Methods From April to December 2018, patients developing ED (IIEF-5&amp;lt;22) after RARP with bilateral NVB preservation were included. SPL was measured as length from pubic symphysis to external urethral opening. Tadalafil 5 mg once daily (Group 1), postoperative ADT (Group 2) and control group (Group 3) were classified. Postoperative ADT was prescribed during the whole periods of 6 months for surgical adverse effects in group 2. Follow-ups were arranged 2 weeks after operation in the first time, and then every month up to 6 months. Student t test, chi-square test and SAS 9.4 were utilized to see if significant difference when p&amp;lt;0.05. Results With 64 men, 1 was excluded for preoperative ADT use. SPL-related comparisons were listed at Table 1. Preoperative SPL was measured without differences. Generally, in 6-month span, more men were with increased SPL in group 1 than in group 3, and also more with deterioration compared to group 3 (p=0.048). Same trend was observed in group 2 compared to group 3 (p=0.036). Men in group 1 (at the time deciding to take tadalafil) experienced a worse shortening SPL than group 3 (the 30–day change after operation) (p&amp;lt; 0.0001). Significantly improvement on SPL between before (7.93±1.89 (median: 7.5) cm) and after (8.59±2.17 (median:9) cm) tadalafil in group 1 (p=0.037) and also significantly improved against the SPL change from post-operative 30-day to 5-month of group 3 (p=0.004). Conclusions In our analysis, 63.7% of subsequent ED after RARP with bilateral NVB preservation would experience SPL shortening around 3 cm (around 30% of preoperative SPL) if only observation in 6 months after operation. Postoperative ADT for 6 months would contribute to approximately additional 15% shortening rates with the same degree. Significant improvement around 1 cm (around 10% of the preoperative SPL) on SPL was observed after tadalafil 5 mg once daily with median 4-month prescription. Disclosure Work supported by industry: no.

Does the risk of obstructive sleep apnea (OSA) affect erectile function recovery (EFR) after radical prostatectomy (RP)?

ABSTRACT Introduction Obstructive sleep apnea (OSA) affects as many as 7% of adult men in the general population, higher in men with obesity and large neck sizes. OSA is associated with ED. No data to date has assessed EFR after RP in men with OSA. Objective The objective of this study was to define EFR rates 2 years post-RP. Methods Records of men who underwent RP with 24-month post-RP follow-up were reviewed. ADT and radiation therapy were exclusions. Men completed the OSA screening questionnaire, STOP-BANG (SB) pre-RP. Men were divided into OSA risk groups: high, intermediate, and low. EFR was recorded using IIEF-EFD score, with a score of at least 24 indicating recovery. Univariable and multivariable logistic regression analyses assessed predictors of EFR. Results 454 men were analyzed. Mean age 62 ± 7 years. Of the studied population,12% had a history of OSA,10% had diabetes,12% were current smokers, and 37% were former smokers. The median STOP-BANG (SB) score was 2. High, intermediate, and low risk of OSA scores were 8%, 41% and 51% respectively. Mean baseline testosterone (T) was 495 ng/dL, PSA 7.4 ng/mL, and EFD score 22. Most men had a Gleason sum of 7 (87%). 73% of patients had bilateral or unilateral neurovascular bundle preservation. At the 2-year follow up, median EFD score in high, intermediate and low OSA risk groups: were 9, 16, and 18 respectively. The low OSA risk group was significantly more likely to recover (OR = 1.6, 1.1 – 2.4) than the moderate/high group. Younger age (OR = 0.92, 0.89 – 0.95), absence of diabetes (OR = 0.31, 0.14 – 0.72), higher baseline T (OR per 100 units = 1.40, 1.04 – 1.89), higher baseline EFD score (OR = 1.16, 1.11 – 1.22), and lower Gleason score (OR = 0.53, 0.34 – 0.82) were also associated with recovery at 2 years. Conclusions In our cohort, at 2 years post-RP, increasing OSA risk is associated with poorer EFR in men post-RP. Disclosure Work supported by industry: no.

V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION

You have accessJournal of UrologyCME1 May 2022V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION Marcio Covas Moschovas, Travis Rogers, Jonathan Noel, Jaber Abdel, Seetharam Bhat, and Vipul Patel Marcio Covas MoschovasMarcio Covas Moschovas More articles by this author , Travis RogersTravis Rogers More articles by this author , Jonathan NoelJonathan Noel More articles by this author , Jaber AbdelJaber Abdel More articles by this author , Seetharam BhatSeetharam Bhat More articles by this author , and Vipul PatelVipul Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors. However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients. In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection. In this video compilation, we have illustrated the details of different grades of NVB preservation. METHODS: Our video describes the details of different degrees of nerve-sparing using anatomical landmarks. We have illustrated the key aspects of a full nerve sparing, partial nerve sparing and intrafascial dissection preserving the lateral prostatic fascia. RESULTS: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o’clock positions on the right and left sides, respectively. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. CONCLUSIONS: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection). Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marcio Covas Moschovas More articles by this author Travis Rogers More articles by this author Jonathan Noel More articles by this author Jaber Abdel More articles by this author Seetharam Bhat More articles by this author Vipul Patel More articles by this author Expand All Advertisement PDF downloadLoading ...

Full functional-length urethral sphincter- and neurovascular bundle preservation improves long-term continence rates after robotic-assisted radical prostatectomy

The objective of the study was to test the impact of implementing standard full functional-length urethral sphincter (FFLU) and neurovascular bundle preservation (NVBP) with intraoperative frozen section technique (IFT) on long-term urinary continence in patients undergoing robotic-assisted radical prostatectomy (RARP). We relied on an institutional tertiary-care database to identify patients who underwent RARP between 01/2014 and 09/2019. Until 10/2017, FFLU was not performed and decision for NVBP was taken without IFT. From 11/2017, FFLU and IFT-guided NVBP was routinely performed in all patients undergoing RARP. Long-term continence (≥ 12 months) was defined as the usage of no or one safety- pad. Uni- and multivariable logistic regression models tested the correlation between surgical approach (standard vs FFLU + NVBP) and long-term continence. Covariates consisted of age, body mass index, prostate volume and extraprostatic extension of tumor. The study cohort consisted of 142 patients, with equally sized groups for standard vs FFLU + NVBP RARP (68 vs 74 patients). Routine FFLU + NVBP implementation resulted in a long-term continence rate of 91%, compared to 63% in standard RARP (p < 0.001). Following FFLU + NVBP RARP, 5% needed 1–2, 4% 3–5 pads/24 h and no patient (0%) suffered severe long-term incontinence (> 5 pads/24 h). No significant differences in patient or tumor characteristics were recorded between both groups. In multivariable logistic regression models, FFLU + NVBP was a robust predictor for continence (Odds ratio [OR]: 7.62; 95% CI 2.51–27.36; p < 0.001). Implementation of FFLU and NVBP in patients undergoing RARP results in improved long-term continence rates of 91%.

Intraoperative Neurovascular Bundle Preservation with Hyaluronic Acid during Radical Brachytherapy for Localized Prostate Cancer: Technique and MicroMosfet In Vivo Dosimetry.

Purpose: To evaluate the reduction in the absorbed dose delivered to the neurovascular bundle (NB) in patients with localized prostate cancer treated with only HDR brachytherapy and NB protection with hyaluronic acid (HA) on the side of the prostate to increase the distance from NB to the radioactive sources. Methods: This is the first published report in the medical literature that studies a new approach to decrease neurovascular bundle toxicity and improve quality of life for patients with prostate cancer treated with radical brachytherapy as monotherapy. Transperineal HA injection on the side of the prostate into the lateral aspect of the prostate fat was used to consistently displace several autonomic fibers and vessels on the lateral wall of the prostate away from radiation sources. Results: When a protection in the form of an HA layer is placed, the reduction effect at the maximum dose is between 46% and 54% (calculated values), which means that the method for protection is highly recommended. The values of the absorbed dose calculated in this project have been compared with the ones given by the treatment planning system. Conclusions: This newly created space decreases absorbed dose in the NB, calculated with the TPS and measured by microMOSFET due to the thickness of HA.

Neurovascular bundle preservation in robotic-assisted radical prostatectomy: How I do it after 15.000 cases.

ABSTRACTDespite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.

Does the Risk of Obstructive Sleep Apnea (OSA) Affect Erectile Function Recovery (EFR) After Radical Prostatectomy (RP)?

ABSTRACT Introduction Obstructive sleep apnea (OSA) affects as many as 7% of adult men in the general population, higher in men with obesity and large neck sizes. OSA is associated with ED. No data to date has assessed EFR after RP in men with OSA. Objective The objective of this study was to define EFR rates 2 years post-RP. Methods Records of men who underwent RP with 24-month post-RP follow-up were reviewed. ADT and radiation therapy were exclusions. Men completed the OSA screening questionnaire, STOP-BANG (SB) pre-RP. Men were divided into OSA risk groups: high, intermediate, and low. EFR was recorded using IIEF-EFD score, with a score of at least 24 indicating recovery. Univariable and multivariable logistic regression analyses assessed predictors of EFR. Results 454 men were analyzed. Mean age 62 ± 7 years. Of the studied population,12% had a history of OSA,10% had diabetes,12% were current smokers, and 37% were former smokers. The median STOP-BANG (SB) score was 2. High, intermediate, and low risk of OSA scores were 8%, 41% and 51% respectively. Mean baseline testosterone (T) was 495 ng/dL, PSA 7.4 ng/mL, and EFD score 22. Most men had a Gleason sum of 7 (87%). 73% of patients had bilateral or unilateral neurovascular bundle preservation. At the 2-year follow up, median EFD score in high, intermediate and low OSA risk groups: were 9, 16, and 18 respectively. The low OSA risk group was significantly more likely to recover (OR = 1.6, 1.1 – 2.4) than the moderate/high group. Younger age (OR = 0.92, 0.89 – 0.95), absence of diabetes (OR = 0.31, 0.14 – 0.72), higher baseline T (OR per 100 units = 1.40, 1.04 – 1.89), higher baseline EFD score (OR = 1.16, 1.11 – 1.22), and lower Gleason score (OR = 0.53, 0.34 – 0.82) were also associated with recovery at 2 years. Conclusions In our cohort, at 2 years post-RP, increasing OSA risk is associated with poorer EFR in men post-RP. Disclosure No

Anatomical Fundamentals and Current Surgical Knowledge of Prostate Anatomy Related to Functional and Oncological Outcomes for Robotic-Assisted Radical Prostatectomy.

ContextMeticulous knowledge about the anatomy of the prostate and surrounding tissue represents a crucial and mandatory requirement during radical prostatectomy for reliable oncological and excellent replicable, functional outcomes. Since its introduction two decades ago, robotic-assisted laparoscopic radical prostatectomy (RALP) has evolved to become the predominant surgical approach in many industrialized countries.ObjectiveTo provide and highlight currently available literature regarding prostate anatomy and to help in improving oncological and functional outcomes in RALP.Methods/Evidence AcquiringPubMed database was searched using the following keywords: “robotic-assisted radical prostatectomy,” “anatomy,” “neurovascular bundle,” “nerve,” “periprostatic fascia,” “pelvis,” “sphincter,” “urethra,” “urinary incontinence,” and “erectile dysfunction.” Relevant articles and book chapters were critically reviewed and if eligible, they were included in this review.ResultsNew evidence in regards to prostatic anatomy and surgical approaches in RALP has been reported in recent years. Besides detailed anatomical studies investigating the meticulous structure of the fascial structures surrounding the prostate and neurovascular bundle preservation, debate about the optimal RALP approach is still ongoing, inspired by recent publications presenting promising functional outcomes following modifications in surgical approaches.ConclusionsThis review provides a detailed overview of the current knowledge of prostate anatomy, its surrounding tissue, and its influence on key surgical step development for RALP.

A pilot study to investigate the effect of topical microporous polysaccharide haemospheres on outcomes following robot-assisted radical prostatectomy.

Controlling bleeding without disturbing the anatomy and function of the structures in the prostate bed remains a significant challenge during radical prostatectomy (RP). Five grams of powdered microporous polysaccharide haemospheres (MPH) was applied to the prostate bed at the end of robot-assisted RP in 422 consecutive patients. Continence was defined as no pads and potency as the ability to have penetrative sex with or without PDE5 inhibitors in previously potent, non-diabetic men aged <70 years following bilateral intra- or inter-fascial neurovascular bundle (NVB) preservation. In total, 95.3% of patients had nerve preservation and the mean operating time and blood loss were 142 minutes and 200ml, respectively. There were no intraoperative complications, and the postoperative transfusion rate was 0.2%. The mean hospital stay was 1.7 nights, and duration of catheterisation was 12 days. Final pathology demonstrated a mean prostate weight of 40.0g and 14.5% replacement by cancer, most commonly Gleason 7. The positive surgical margin rate for pT2 tumours was 10.0%. Biochemical recurrence was 2.1% at a mean follow-up of 18.0 months. Continence and potency rates at 4 weeks and 1 year after surgery were 76.4% and 97.7% and 27.8% and 78.1%, respectively. The trifecta and pentafecta rates 1 year after surgery were 53.1% and 45.8%. Powdered MPH applied to the prostate bed at the end of robot-assisted RP appears to be a safe, easily applied and useful adjunct to conventional haemostasis. The suggestion that it might also improve the functional outcomes of RP merits further investigation in the context of a randomised trial.