Prostatic Fascia Research Articles

FEATURES OF DEVELOPMENT AND FORMATION TOPOGRAPHIES OF THE VESICO-UMBILICAL TRIANGLE IN THE PRENATAL PERIOD OF HUMAN ONTOGENESIS

On the front abdominal wall, there is a section of the vesico- umbilical triangle, which is bounded on the sides by the umbilical arteries, and below by the bladder. In the available sources of scientifi c literature, there is practically no information on the patterns of prenatal morphogenesis and the formation of the topography of the area of the vesico- umbilical triangle of a person. However, accurate knowledge of the topography of the constituent formations of the vesico- umbilical triangle determines the choice of incision during operations and provides a theoretical explanation for the occurrence of various pathological conditions: umbilical, postoperative ventral hernias, abdominal cavity organ eventration, and the spread of purulent- infl ammatory processes.The purpose of the study was to clarify the features of prenatal morphogenesis and topographical- anatomical relationships of the vesico- umbilical triangle of a person.The study was conducted on the preparations of 7 embryos of 4-6 weeks, 14 pre-fetuses of 7-12 weeks, and 26 human fetuses aged from 4 to 10 months using the production of a series of histological sections, microscopy, macromicroscopic preparation, and injection of vessels.In embryos of 4.5-5.5 mm parietal- coccygeal length (PCL), the allantois is located in the direction of the abdominal wall, connecting with other structures in the area of the future umbilical ring. In the mesoderm of the allantois, there is a layer of vessels that form a system of umbilical vessels. On frontal sections of 10.5-12.0 mm PCL embryos, narrowing of the allantois duct is observed: a more gradual narrowing near the umbilical ring, and a sharper one closer to the cloaca. At this stage of embryogenesis, there is a clear division of the cloaca into ventral (urogenital sinus) and dorsal (rectal lining) sections.It was established that the bladder is formed from two sources – the body and top – from the caudal part of the allantois, the bottom, and neck – from the pelvic part of the genitourinary sinus. In the 3rd month of intrauterine development, the middle and deep layers of the vesico- umbilical triangle are formed, which are represented by the sheath of the rectus abdominis muscle, rectus and pyramidal muscles, prostatic and allantoic leaves. Fascial spurs, departing from the latter, divide the prostate space into four interfascial slits. The surface layer of the vesico- umbilical triangle is still poorly diff erentiated at this stage of intrauterine development. At the end of the 4th month of intrauterine development, the surface fascia of the vesico- umbilical triangle is formed as independent formations. During macro- microscopic dissection of the area of the vesico- umbilical triangle in 6-month-old fetuses, in addition to the fascial formations of the superfi cial layer, all the structures of the deep layer can be distinguished: the transverse fascia, the vestibular and allantoic fascial sheets, as well as two fascial spurs that divide the vestibular space into four interfascial gaps. From our point of view, it is appropriate to call the prostatic fascia and prostatic fi brous space vesico- umbilical.

Functional outcomes of robot-assisted radical prostatectomy with preservation of pelvic stabilized structure and early elevated retrograde liberation of neurovascular bundle

Objectives: To examine the functional outcomes of robot-assisted radical prostatectomy (RARP) with preservation of pelvic floor stabilized structure and early elevated retrograde liberation of the neurovascular bundle (PEEL). Methods: This study was a retrospective cohort study. Between June 1, 2022, and March 20, 2023, 27 cases of RARP with PEEL and 153 cases of RARP with preservation of pelvic floor stabilized structure (PPSS) were included in this study. All patients were males, aged (62.5±5.2) years (range: 50 to 73 years). There were 18 cases of ≤T2b stage and 9 cases of T2c stage. After 1∶1 propensity score matching, the postoperative functional outcomes of 27 cases of RARP with PEEL and 27 cases of RARP with PPSS were compared. All surgeries were performed by a single surgeon and included patients were clinically staged as cT1-2N0M0 without preoperative urinary incontinence or erectile dysfunction. In RARP with PEEL, the prostate was cut near the midline at the front when dissecting the neurovascular bundle, dissection was performed between the visceral layer of the pelvic fascia and the prostatic fascia, preserving the parietal layer and the visceral layer of the pelvic fascia, and the neurovascular bundle was retrogradely released from the apex. The cumulative probability curve was plotted using the Kaplan-Meier method and the Log-rank test was used to compare the differences in functional outcomes between the two groups. Univariate and multivariate analysis with the Cox proportional hazards model was used to compare postoperative urinary continence and sexual function. Results: The recovery time of continence and potency was significantly longer in the PPSS group than in the PEEL group (all P<0.05). The continence rate of the PEEL group was significantly higher than that of the PPSS group (92.59% vs. 68.10%, P=0.026) at 3 months after surgery. The potency rate of the PEEL group was also significantly higher than that of the PPSS group (40.70% vs. 15.10%, P=0.037) at 3 months after surgery. In the univariate analysis, compared to the PPSS technique, the PEEL technique was associated with a shorter recovery time of continence (HR=1.94, 95%CI: 1.08 to 3.48, P=0.027) and a shorter recovery time of potency (HR=2.06, 95%CI: 1.03 to 4.13, P=0.042). In the multivariate analysis, the PEEL technique was an independent prognosis factor for postoperative recovery of continence (HR=2.05, 95%CI: 1.01 to 4.17, P=0.047) and potency (HR=3.57, 95%CI: 1.43 to 8.92, P=0.007). All the cases of the PPSS group and the PEEL group were performed successfully with negative surgical margins. Conclusion: Compared with PPSS, PEEL may be more conducive to the recovery of urinary continence and sexual function after RARP.

Optimizing Nerve Sparing in Robotic-Assisted Radical Prostatectomy: A Comparative Investigation of Traditional and Modified Endopelvic Fascia Preservation Techniques.

Prostate cancer (PCa) is the second most common cancer and the sixth leading cause of cancer-related mortality in men. In 2000, Abbou performed the first robot-assisted radical prostatectomy, and radical prostatectomy has developed rapidly. Robot-assisted radical prostatectomy (RARP) is a valuable therapeutic option for the management of localized Pca. To present the functional outcome of robot-assisted laparoscopic radical prostatectomy using traditional and modified endopelvic fascia preservation methods in a single center in Vietnam. We prospectively analyzed a series of 65 patients diagnosed with prostate cancer from 2020 to 2023. All of those were operated by DaVinci Si system robot-assisted laparoscopic prostatectomy. Twenties patients were applied with a modified nerve-sparing technique, intrafascial dissection, and lateral prostatic fascia preservation, leaving the lateral tissue, including the neurovascular bundle, untouched and covered. We used the traditional approach, intrafascial nerve-sparing with open endopelvic fascia and lateral prostatic fascia in 45 cases. Patients were followed up to 12 months to assess the continence and erectile function by using IIEF-5 and EPIC questionnaires. The study sample included 65 cases; the mean patient age was 64.21 ± 6.68, erection rate after surgery at six months in bilateral NS was 36.58% (15/41) in the traditional group, and 68.42% (13/19) in the modified group (p=0.028). The patient did not recover erectile ability in the group of elderly patients (>65 years old) and unilateral nerve-sparing group. The continence rate six months after surgery was 86.66 % in the conventional group and 85% in the modified group, with no significant difference between the two groups. In the potency group, the IIEF-5 score was 13 ± 4.9, and the EPIC-26 score was 62.20 ± 10.04. Erectile ability in the modified group was better than the traditional group at six months after surgery. Our results showed better potency recovery in the modified group. These results should be tested in future research with randomized studies.

V10-01 A COMPREHENSIVE REVIEW OF NEUROANATOMY, PROSTATE ANATOMY AND PERI-PROSTATIC STRUCTURES

You have accessJournal of UrologyCME1 Apr 2023V10-01 A COMPREHENSIVE REVIEW OF NEUROANATOMY, PROSTATE ANATOMY AND PERI-PROSTATIC STRUCTURES Sneha Parekh and Ashutosh Tewari Sneha ParekhSneha Parekh More articles by this author and Ashutosh TewariAshutosh Tewari More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aim to present the most revised anatomy of prostate, surrounding structures and its neuroanatomy in the form a 3D animated video. METHODS: We searched the PubMed database to identify original and review articles that addressed the anatomy of the prostate and relevant surrounding structures, with an emphasis on work published from July 2002 to January 2022. Understanding the findings in literature, we applied this knowledge and created a 3D animation video. RESULTS: Laterally the prostate is surrounded by the Endopelvic fascia, which has Parietal and medially has prostatic fascia. Ventrally prostatic capsule attached to Anterior Fibromuscular Stroma (AFMS), reaches postero-lateral prostate embracing Neurovascular bundle (NVB) medially and becomes pararectal fascia covering the rectum. The detrusor apron is an extension of anterior wall of bladder towards posterior area of pubic bone and contributes to AFMS. The urethral sphincter complex consists of external rhabdosphincter, inner lissosphincter and membranous urethra. Seminal Vesicles(SV) and Vas Deferens (VD) are extra peritoneal tubular structures, located at base of prostate, surrounded by major nerves posterolaterally, associations with Proximal neurovascular plate (PNP). Prostate with surrounding structures is supplied by autonomic and somatic branches originating from lower (T11-L2) and (S2-S4). Nerve fibers from centers coalesce to form pelvic plexus, aka PNP.The autonomic fibers from PNP are distributed into NVB and ANP (Accessory Neural Pathway) in a spray like pattern, with 60% of fibers on postero-lateral and 40% on antero-lateral prostate.DVC is composed of nerve fibers, dorsal veins and prostatic arteries. The puboprostatic ligamentous complex comprises of puboprostatic ligaments, arcus tendineus, and puboperinealis muscle. The puboprostatic ligaments are dense pyramid-shaped medial portions of distal endopelvic fascia. The puboperinealis is a paired muscle that originates from pubis, flanks prostatic-urethral junction, terminates at perineal body. CONCLUSIONS: Prostate is a dense fibromuscular gland, situated in the true pelvis surrounded by a compact multi-layered fascia with intermingling nerves and vessels.The nerves from the lumbar and sacral roots along with somatic supply form the pelvic plexus, further giving the prostatic neural hammock. This forms the basis of nerve sparing and its grades. Puboprostatic ligamentous complex along with peri-prostatic fascia and detrusor apron support the prostate and has a role in erectile and continence. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e926 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sneha Parekh More articles by this author Ashutosh Tewari More articles by this author Expand All Advertisement PDF downloadLoading ...

Hydrodissection performed safely with an injection catheter during robot-assisted radical prostatectomy

ABSTRACT To facilitate nerve preservation during robot-assisted radical prostatectomy (RP), hydrodissection (HD) using an injection catheter was performed. HD during RP is a nerve-sparing technique in which an epinephrine solution is injected into the lateral prostatic fascia to separate it from the prostatic capsule. Although the beneficial effects of HD on postoperative sexual function have been reported, HD has rarely been used in robot-assisted RP. The primary reason may be the potential benefits of robotic surgery, such as less bleeding, magnified surgical view, and fine movement of instruments; another possible reason is the difficulty of handling sharp needles in a narrow intra-abdominal surgical space of robot-assisted RP. For safe fluid injection, we performed HD using an injection catheter – commonly used for endoscopic upper gastrointestinal hemostasis – during robot-assisted RP. The required time to accomplish HD and the safety of the procedure were examined in 15 HD of 11 patients. Approximately 2 minutes (median, 118 seconds; interquartile range, 106–174 seconds) were needed for HD using the injection catheter. All patients had no complications, such as injuries to the intestine, vessels, or other organs. Postoperative bleeding did not occur in any patients. HD with an injection catheter enables surgeons to perform simple and safe nerve preservation during robot-assisted RP.

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 ...

V12-08 MODIFIED APICAL DISSECTION AND LATERAL PROSTATIC FASCIA PRESERVATION: PRELIMINARY ANALYSIS OF THE REPRODUCIBILITY OF THE NOVEL TECHNIQUE

You have accessJournal of UrologyProstate Oncology I (Prostatectomy) (V12)1 Sep 2021V12-08 MODIFIED APICAL DISSECTION AND LATERAL PROSTATIC FASCIA PRESERVATION: PRELIMINARY ANALYSIS OF THE REPRODUCIBILITY OF THE NOVEL TECHNIQUE Bernardo Rocco, Luca Sarchi, Simone Assumma, Alessandra Cassani, Elena Morini, Filippo Turri, Cosimo De Carne, Carlo Bellorofonte, Paolo Marcangeli, Claudio Cesana, Giorgio Bozzini, Salvatore Micali, and Maria Chiara Sighinolfi Bernardo RoccoBernardo Rocco More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Simone AssummaSimone Assumma More articles by this author , Alessandra CassaniAlessandra Cassani More articles by this author , Elena MoriniElena Morini More articles by this author , Filippo TurriFilippo Turri More articles by this author , Cosimo De CarneCosimo De Carne More articles by this author , Carlo BellorofonteCarlo Bellorofonte More articles by this author , Paolo MarcangeliPaolo Marcangeli More articles by this author , Claudio CesanaClaudio Cesana More articles by this author , Giorgio BozziniGiorgio Bozzini More articles by this author , Salvatore MicaliSalvatore Micali More articles by this author , and Maria Chiara SighinolfiMaria Chiara Sighinolfi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002093.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Novel modified technique (mod-RALP) seems to improve functional outcomes in terms of continence and potency. Whereas these clear advantages, the issue of reproducibility of the technique has not been investigated. Moscovas et al reported their series of 104 patients (first 18 cases as a part of LC process); we aim to analyze the mod-RALP reproducibility with insights on safety and efficacy compared to standard approach. METHODS: A prospective study performed since October 2020, 20 patients with cT2 PCa undergo a mod-RALP (low-intermediate D’Amico risk group). PND was performed according to MSK nomogram, NS strategy according to PRECE tool. A single surgeon performed all procedures (BR). First transperitoneal anterior trocar placement (6 port). After bladder detachment and periprostatic fat excision, anterior bladder neck is opened followed by posterior bladder neck dissection. After seminal vesicle excision, the dissection goes caudally, in the posterior plane. The 0° camera allows blunt dissection toward the apex and lateral aspects of the prostate, avoiding energy use and sharp traumatic incisions. When a NS is planned, after posterior release, a plane medial to the lateral prostatic fascia is developed, leaving the NVBs unseen lateral to the fascial opening at the base. The anterior dissection continues underneath the puboprostatic ligament, preserving apical anatomy. Santorini plexus is controlled by a running barbed suture after the apical dissection and before the urethral division. Endpoints are time from bladder neck incision to urethral section; PSM rate stratified by pT, continence and potency at 30 days. RESULTS: Mod-RALP had no complication. Median time from bladder neck to urethral section was 42 min (DS 9). 16 patients had organ confined disease pT2 with no PSM, (25% had an apical localization of PCa), 1 pT3a, 1 pT3b and 1 pT4. As far as early continence and potency recovery all patients were continent at 30 days (safety pad in 2). All pre-op potent patients (IIEF 5>21) restored an erection sufficient for intercourse with the use of PDE-5i. CONCLUSIONS: From our preliminary experience, mod-RALP is reproducible without compromising oncological safety and operatory time. To our knowledge, this is the first case series testing the transferability of mod-RALP to an independent center. The careful dissection with maximal preservation of the apex enables a recovery of continence in all patients. Despite the single and high-volume surgeon characteristic of our series, the use of the mod-RALP should be furtherly encouraged. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1026-e1026 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bernardo Rocco More articles by this author Luca Sarchi More articles by this author Simone Assumma More articles by this author Alessandra Cassani More articles by this author Elena Morini More articles by this author Filippo Turri More articles by this author Cosimo De Carne More articles by this author Carlo Bellorofonte More articles by this author Paolo Marcangeli More articles by this author Claudio Cesana More articles by this author Giorgio Bozzini More articles by this author Salvatore Micali More articles by this author Maria Chiara Sighinolfi More articles by this author Expand All Advertisement Loading ...

V01 - Modified apical dissection and lateral prostatic fascia preservation: Preliminary analysis of the reproducibility of the novel technique

V01 - Modified apical dissection and lateral prostatic fascia preservation: Preliminary analysis of the reproducibility of the novel technique

PT037 - Technical innovations of modified apical dissection and lateral prostatic fascia preservation improves early postoperative functional recovery in robotic assisted laparoscopic radical prostatectomy

PT037 - Technical innovations of modified apical dissection and lateral prostatic fascia preservation improves early postoperative functional recovery in robotic assisted laparoscopic radical prostatectomy

Modified Apical Dissection and Lateral Prostatic Fascia Preservation Improves Early Postoperative Functional Recovery in Robotic-assisted Laparoscopic Radical Prostatectomy: Results from a Propensity Score–matched Analysis

BackgroundEarly recovery of continence and potency after robotic-assisted laparoscopic prostatectomy (RALP) still remains a challenge. ObjectiveTo assess the effect of our modified apical dissection and lateral prostatic fascia preservation (mod-RALP) technique on early functional outcomes. Design, setting, and participantsAmong 2168 patients who underwent RALP between 2017 and 2019, 104 received a mod-RALP, and for the purposes of this study they were propensity score (PS) matched with a control group of conventional RALP cases based on preoperative and histological characteristics. Surgical procedureIn the mod-RALP technique, significant dissection of the apical complex was avoided with maximized preservation of periurethral tissue around the urethral stump. Nerve sparing was also modified with intrafascial dissection inside of the lateral fascia, leaving the lateral tissue including the neurovascular bundle (NVB) untouched and covered. MeasurementsThe mod-RALP and conventional RALP groups were compared for continence and potency recovery at 1 and 6 wk postoperatively, as well as at 3, 6, and 12 mo. Kaplan-Meier curves and multivariate Cox regression models were used to identify survival estimations and their predictors. Results and limitationsThe mod-RALP technique resulted in faster continence (mean 46 vs 70 d) and potency (mean 74 vs 118 d, p < 0.05 for both) recovery. Functional recovery rates at postoperative follow-up were significantly higher in the mod-RALP group at all time points within the first 6 mo following surgery. Multivariate analyses revealed age, baseline functional status, surgical technique, and lymph node dissection as independent predictors of early functional recovery. This study is limited by its retrospective design and small size of the study groups. ConclusionsOur results with a modified technique intended to better preserve the apical complex and NVBs suggest earlier recovery of urinary continence and sexual function. These results should be tested with future randomized studies. Patient summaryWe report a modified approach to apical dissection and lateral prostatic fascia preservation in robotic-assisted laparoscopic prostatectomy that resulted in earlier continence and potency recovery as compared with our conventional technique.

V02-01 ADOPTION OF A NEW ROBOTIC PLATFORM. KEY TECHNICAL MODIFICATIONS

INTRODUCTION AND OBJECTIVE: The adoption of new robotic surgical technology requires appreciation and adaptation to the mechanical nuances. We adopted the usage of the DaVinci SP (single port) system. We described the many technical and procedural modifications necessary for safe adoption of the technology while maintaining good surgical outcomes. METHODS: In this video compilation we illustrated our step-by step technique and key points during a radical prostatectomy using the da Vinci SP robot. The surgery was performed with a transperitoneal technique by the same surgeon and tableside assistant. One robotic trocar was placed above the umbilicus and one additional trocar was placed in the right lower quadrant (single port plus one). RESULTS: (1) Patient positioning and trocar placement. (2) Instrument configuration: Cadiere-Bipolar-Scissors. (3) Bladder dropping and Retzius space access illustrating the relocation pedal and scope angulation. (4) Bladder neck and seminal vesicles approach describing the instruments use and scope working angle. (5) Denonvilliers dissection technique during the posterior access and nerve sparing. (6) Endopelvic fascia opening and lateral prostatic fascia preservation. (7) Apical anatomy preservation during the minimal apical dissection. (8) Needle-drive configuration to apply the hemostatic running suture at the DVC complex. (9) Urethral transection technique. (10) Posterior reconstruction with barbed suture and anastomosis with bidirectional running suture. CONCLUSIONS: Robotic-assisted radical prostatectomy with da Vinci SP console is feasible and safe. Therefore, we believe that with the steps described in this video compilation, we were able to safely adopt the SP robot, maintaining a technique similar to the one we have developed with the Xi console. Also, these steps are crucial to a complication-free procedure with quality outcomes. Source of Funding: No source of Funding

Lessons learned from 12,000 robotic radical prostatectomies: Is the journey as important as the outcome?

Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).

VE05 - Robotic-Assisted Radical Prostatectomy with minimal apical dissection and lateral prostatic fascia preservation: An evolution of our conventional technique

VE05 - Robotic-Assisted Radical Prostatectomy with minimal apical dissection and lateral prostatic fascia preservation: An evolution of our conventional technique

An updated approach to incremental nerve sparing for robot-assisted radical prostatectomy.

To update the algorithm for performing incremental nerve sparing (NS) using our multiparametric magnetic resonance imaging (mpMRI)-based nomogram. We applied the coefficients of the nomogram to the observations extracted from our population of patients who underwent robot-assisted radical prostatectomy between February 2014 and October 2015 and who received preoperative mpMRI. The information considered were PSA level, highest side-specific biopsy Gleason grade group, highest ipsilateral percentage core involvement with the highest Gleason grade group, and extracapsular extension (ECE) on mpMRI. The nomogram-derived probability [P (%)], after internal validation, was used as the independent variable on a classification tree to identify the most significant thresholds for ECE prediction. Incremental NS was performed as follows: Grade 1 NS: intrafascial dissection between the peri-prostatic veins and the pseudocapsule of the prostate; Grade 2 NS: inter-fascial dissection along the peri-venous plane; Grade 3 NS: inter-fascial dissection through the outer compartment of the lateral prostatic fascia; Grade 4 NS: extrafascial dissection. Data from 561 patients were considered, and 829 prostatic lobes with biopsy-documented tumour were analysed. Overall, 142 lobes presented ECE that was focal in 27 (19%) cases. The classification tree identified four risk categories. In the low- [P (%) ≤10], intermediate- [P (%) 10-21], high [P (%) 21-73] and very-high-risk [P(%) >73] groups, the ECE rates were 3.3%, 16%, 61.6% and 90%, respectively. Amongst those, ECE was focal in 41.7%, 31.7%, 7.9% and 0%, respectively. We suggest that Grade 1 NS (intrafascial) should be performed in the low-risk group. The inter-fascial approach, namely grades 2 and 3 NS, should be performed in the intermediate- and high-risk categories, respectively. Grade 4 NS (extrafascial) should be performed in the very-high-risk group. The current algorithm yields a better accuracy than the previous one; however, prospective validation is warranted.

The anatomy of the male inferior hypogastric plexus: What should we know for nerve sparing surgery.

The aim of this study was to investigate the nerve supply to the structures in the male lesser pelvis and review its clinical relevance, especially during nerve sparing surgery. Three formalin-embalmed and 16 Thiel-embalmed male hemipelves were used. They were microdissected after repeated treatments with nitric acid diluted 1:10 with milliQ-water. The inferior hypogastric plexus (IHP) is a fan-like structure lateral from the rectum on the fascia of the levator ani. Nerves emerging from the proximal, solid part of the plexus follow the internal iliacal vessels and reach the prostate from dorsolateral. The innervation of the urethra and the corpora cavernosa derives from two origins: one follows the ejaculatory duct and the seminal vesicle, reaching the proximal urethra and the prostate from dorsal; the other follows the inferior vesical artery to reach the prostate from lateral, and then forms the neurovascular bundle on both sides of the prostatic fascia, spreading to the pelvic floor muscles and the corpora cavernosa along with the distal urethra. A connection between the two parts was demonstrated in approximately one third of the samples investigated. The nerve supply to the urinary bladder, the urethra, and the corpora cavernosa emerges mainly from the IHP. The innervation of the proximal urethra and its autonomic muscular structures has a dorsal (ejaculatory duct) and lateral (inferior vesical artery) origin. To maintain good erectile and continence function it is important to save both the dorsal and lateral neurovascular roots. Clin. Anat. 31:788-796, 2018. © 2018 Wiley Periodicals, Inc.

Invited Article: Label-free nerve imaging with a coherent anti-Stokes Raman scattering rigid endoscope using two optical fibers for laser delivery

A coherent anti-Stokes Raman scattering (CARS) rigid endoscope using two optical fibers to deliver excitation beams individually is developed. The use of two optical fibers allows the correction of longitudinal chromatic aberration and enhances the CARS signal by a factor of 2.59. The endoscope is used to image rat sciatic nerves with an imaging time of 10 s. Imaging of the rabbit prostatic fascia without sample slicing is also demonstrated, which reveals the potential for the application of the CARS endoscope to robot-assisted surgery.

Prostatic Neurovascular Anatomical Variation May Explain Radical Prostatectomy Outcomes

Radical prostatectomy is a common surgical option to excise primary tumors of the prostate. However, one common complication is erectile dysfunction thought to be caused by traction or severing of the cavernous nerves that course near the prostate and have erectile functionality. Specialized surgical approaches, such as laparoscopic robot‐assisted nerve‐sparing techniques, attempt to minimize nerve damage. Yet, the majority of studies show postsurgical potency rates among the prostatectomy approaches are highly variable and 2‐month potency recovery is no better for specialized approaches than traditional ones. We hypothesize that the variability in outcomes may be explained by variability in the course and anatomical relationships of the cavernous nerves. To test this hypothesis, we conducted detailed prostatic dissections using an 8 diopter, 4x LED magnifying lamp in human male cadavers (n=5). For these dissections, the urinary bladder, prostate, and proximal penis were dissected along with accompanying neurovasculature in the lateral prostatic fascia. The neurovascular bundle (NVB) containing the cavernous nerves was isolated and its branches were followed along the prostate. Although our study was limited to five prostatic dissections, we found the course of the NVB and its branches differed in each individual, sometimes being enveloped by prostatic tissue, other times coursing along the prostatic surface with only minor adherence. The results of our preliminary investigation suggest variation in prostatic neurovascular anatomy may help explain variation in radical prostatectomy outcomes observed across multiple surgical approaches.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder: surgical technique

Objective To investigate the surgical skills of pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder. Methods From October 2014 to September 2016, 37 patients with locally advanced bladder cancer(cT2-3N0-2M0)were diagnosed, including 29 males and 8 females, Their age ranged from 52 to 71 years old. According to preoperative cystoscopy, pathological diagnosis and bladder enhanced CT and other examination, 25 patients were staged as cT2, 12 cases were staged as cT3. 25 cases of them were primary tumors, who underwent pure robotic-assisted radical cystectomy and Endo-GIA assisted orthotopic U-shape ileal neobladder reconstruction. First, bilateral lymph nodes were dissected. And the ureter was explored and dissected to the outer wall of the bladder. Then, we ligated the superior artery of bladder and expose the seminal vesicle, vas deferent duct. The DV fascia was opened to expose the posterior wall of prostate. Incise was performed along the both sides of the bladder and prostate fascia to maintain the vascular nerve bundle until the tip of prostate. The urethra was cut off and then the bladder was remove. We used Endo-GIA to cut 30-35 cm ileum and construct U-shaped bladder. The anastomosis between ureter and neo-bladder and the anastomosis between urethra and neo-bladder were performed. Perioperative and follow-up data were collected. Results The surgeries were successful in all 37 cases. The operation time ranged from 245 to 335 min , mean (285±37)min. The mean intraoperative blood loss was(187±56) ml(ranging 90-300 ml). The average postoperative hospital stay was (17±2)days (ranging 15-20 days). Postoperative intestinal function recovery time ranged from 1.3 to 2.2 days, mean (1.7±0.4)days. Surgical margins were all negative. Lymph node positive rate was 21.6% (8/37). After 1 month, 22 cases achieved complete continence. After 3 months, 35 cases get fully self-control urination, 8 cases have noctual incontinence. Postoperative follow-up ranged from 6 to 24 months, no recurrence or distant metastasis was found in this study. After 6 months, cystoscopy showed no obvious formation of bladder stones. Neo-bladder capacity ranged from 270 to 350 ml. The urodynamic examination showed bladder pressure was maintained between 19 and 25cm H2O. Conclusions Pure robotic-assisted radical cystectomy can achieve better bladder resection, better remaining of urethral and neurovascular bundles and good control of urinary continence after operation. Endo-GIA assisted orthotopic U-shaped ileal bladder need shorter intestinal tract and cause less influence to the intestinal function. The neo-bladder shape is more regular, simple doing, earn shorter operation duration, less bleeding, quick recovery, which is a safe and effective surgical approach. Key words: Urinary bladder cancer; Pure robotic-assisted; Radical cystectomy; Orthotopic U-shape ileal neobladder

PD18-01 RANDOMIZED STUDY EVALUATING SHORT-TERM FUNCTIONAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN LOW-RISK PROSTATE CANCER PATIENTS

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III1 Apr 2017PD18-01 RANDOMIZED STUDY EVALUATING SHORT-TERM FUNCTIONAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN LOW-RISK PROSTATE CANCER PATIENTS Alexander Govorov, Dmitry Pushkar, Konstantin Kolontarev, Pavel Rasner, and Vladimir Dyakov Alexander GovorovAlexander Govorov More articles by this author , Dmitry PushkarDmitry Pushkar More articles by this author , Konstantin KolontarevKonstantin Kolontarev More articles by this author , Pavel RasnerPavel Rasner More articles by this author , and Vladimir DyakovVladimir Dyakov More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.861AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many techniques have been described to optimize functional outcomes of robot-assisted radical prostatectomy (RARP). Our objective was to test the impact of surgical technique on post-operative urinary continence recovery (UCR), urinary bother symptoms and erectile function (EF) recovery in a randomized study in high-volume center. METHODS From July to December 2015 89 low-risk PCa patients signed the IC and were randomized in Group 1 (n=45, RARP with full bilateral nerve sparing (NS) and lateral prostatic fascia preservation with amniotic membrane allograft nerve wrap) and Group 2 (n=44, conventional RARP with bilateral NS). Posterior rhabdosphincter reconstruction (PRR) was performed in all cases. Patients started tadalafil 5 mg OAD from Day of catheter removal. Groups were comparable for clinical and pathological variables. We evaluated: 1) UCR rate, defined as the use of 0 pad/day; 2) post-op urinary bother symptoms measured using the QoL question in the IPSS questionnaire (no bother, score 0-2; bother, score 3 and more); 3) EF recovery rate, defined as IIEF-5>17. RESULTS Patients with full NS, preservation of lateral prostatic fascia and amniotic membrane use had significantly higher rates of UCR at 1 week, 1 and 3 months and EF recovery rates at 3 and 6 months. Urinary bother scores were lower in these men at 1, 3 and 6 months post-RARP (table 1). There was no difference in positive surgical margins and intra- /post-RARP complication rate. Results were confirmed on multivariable analyses (odds ratio for Group 1 vs. Group 2 - 2.2 for UCR [p=0.006], 1.8 for EF recovery [p=0.004] and 3.6 for urinary bother [p=0.01]). CONCLUSIONS Lateral prostatic fascia preservation with amniotic membrane allograft nerve wrap significantly improved the rate of post-RARP urinary continence, urinary bother and EF recovery in a group of low-risk PCa patients with bilateral NS and PRR in a randomized study. This in turn can translate into a higher post-operative QoL and/or patient satisfaction. The definition of surgical Pentafecta describing intraoperative technical manoeuvers optimizing functional outcomes may include 1) bilateral nerve sparing, 2) preservation of lateral prostatic fascia, 3) PRR, 4) amniotic membrane allograft use and 5) watertight anastomosis. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e359 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alexander Govorov More articles by this author Dmitry Pushkar More articles by this author Konstantin Kolontarev More articles by this author Pavel Rasner More articles by this author Vladimir Dyakov More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Whole mount microscopic sections reveal that Denonvilliers' fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision?

BackgroundExcellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (TME). Denonviliers' fascia (DVF) has been frequently studied, though the optimal anterior plane in TME is still disputed. The relationship of the lateral edges of DVF to the autonomic nerves and mesorectal fascia is unclear. We studied whole mout microscopic sections of en-bloc cadaveric pelvic exenteration and describe implications for TME. MethodsFour donated human adult cadaveric specimens (two males, two females) were obtained from the Leeds GIFT Research Tissue Programme. Paraffin-embedded mega blocks were produced and serially sectioned at 50 and 250 μm intervals. Sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, a series of eleven human fetal specimens (embryonic age of 9–20 weeks) were studied. ResultsDVF consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the prostatic fascia or posterior vaginal wall. The lateral edges of DVF appeared fan-shaped and the most posterior part was continuous with the mesorectal fascia. Fasciae were not identified in fetal specimens. ConclusionDVF is adherent to and continuous with the mesorectal fascia. Optimal surgical dissection during TME should be carried out anterior to DVF to ensure radical removal, particularly for anterior tumours. Autonomic nerves are at risk, but can be preserved by closely following the mesorectal fascia along the anterolateral mesorectum. The lack of evident fasciae in fetal specimens suggested that these might be formed in later developmental stages.