Puboprostatic Ligaments Research Articles

Clinical Anatomy of the Superficial Preprostatic Vein and Accessory Pudendal Artery in Robot-Assisted Radical Prostatectomy.

Purpose: We herein describe the superficial preprostatic vein (SPV) anatomy and determine its relationship with the accessory pudendal artery (APA). Materials and Methods: We reviewed 500 patients with localized prostate cancer who underwent conventional robot-assisted radical prostatectomy between April 2019 and March 2023 at our institution. SPV was defined as "any vein coming from the space between the puboprostatic ligaments and running within the retropubic adipose tissue anterior to the prostate toward the vesical venous plexus or pelvic side wall." While APA was defined as "any artery located in the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum." The intraoperative anatomy of each SPV and APA was described. Results: SPVs had a prevalence rate of 88%. They were preserved in 252 men (58%) and classified as I-, reversed-Y (rY)-, Y-, or H-shaped (64%, 22%, 12%, and 2%, respectively) based on their intraoperative appearance. Overall, 214 APAs were found in 142 of the 252 men with preserved SPV (56%; 165 lateral and 50 apical APAs in 111 and 41 men, respectively). SPVs were pulsatile in 39% men perhaps due to an accompanying tiny artery functioning as a median APA. Pulsations seemed to be initially absent in most SPVs but become apparent late during surgery possibly due to increased arterial and venous blood flow after prostate removal. Pulsations were common in men with ≥1 APA. Conclusions: This study, which described the anatomical variations in arteries and veins around the prostrate and their preservation techniques, revealed that preserving this vasculature may help preserve postprostatectomy erection. ClinicalTrials: The Clinical Research Registration Number is 230523D.

Pubourethral and uterosacral male analogues suggest parallel male/female pelvic anatomy and symptom pathogenesis.

The thesis that functional/dysfunctional male/female pelvic floor anatomy are parallel, originated from two studies: a successful retropubic perineal male sling for post-prostatectomy stress urinary incontinence (SUI) and discovery of a male uterosacral ligament (USL) analogue, we named "prostatosacral ligament" (PSL). In 25 out of the studied 27 males (92.6%), it starts on both sides of the median sulcus of the prostate the ligament passes lateral to the rectum being fused with the lateral margin of the mesorectum before leaving it as it thins out to be attached posteriorly similar to the USL. The ultrasound data during straining in men and women showed the same three oppositely acting muscle vectors contracting around analogous ligaments, puboprostatic ligament (PPL) (male), and pubourethral ligament (PUL) (female). Further parallels were pubovesical ligaments (PVLs) and arc of Gilvernet as part of the continence and micturition mechanisms. Impressive evidence for parallel anatomy came from the successful cure of 22 males with post-prostatectomy SUI using a perineal retropubic tissue fixation system (TFS) minisling applied to the PPL using a similar methodology to that used in the female for PUL midurethral sling repair for cure of SUI. Laparoscopic evidence confirmed the prostate as a male analogue of the cervix, and PSLs as analogues of USLs: PSL origin from the prostate attached laterally to the mesorectum and inserted into the sacrum. Histologically, PSLs had identical features with USLs: collagen, elastin, smooth muscle, blood vessels and nerves. Virtually identical symptoms for "chronic prostatitis" (CP) and "posterior fornix syndrome" (PFS), such as chronic pelvic pain, overactive bladder (OAB), abnormal emptying, gave birth to the hypothesis, of a common pathogenesis for "CP" and "PFS", USL (or PSL) laxity. If this could be proven by "simulated operations", "CP", at least in theory, may be potentially correctible by PSL repair.

Continence-Sparing Techniques in Radical Prostatectomy: A Systematic Review of Randomized Controlled Trials.

Background: Numerous continence-sparing radical prostatectomy techniques have been developed to enhance postoperative early continence (EC) recovery; however, evidence regarding the best approach remains controversial. The objectives are to provide a critical appraisal of various prostatectomy techniques, based on the evidence of quality-assessed randomized control trials (RCTs); to summarize the immediate continence and the EC reported; and to propose a new standardization for continence outcomes reporting. Methods: Data acquired from five medical registries were reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Evidence from published, English, full-text RCTs reporting postoperative urinary continence outcomes within 6 months from surgery was included. The heterogeneity of surgical techniques and continence definitions did not allow a meta-analysis. All RCTs were critically appraised, and quality assessed. Results: In total, 39 RCTs were included: 19 of 39 studies were low-quality RCTs, presenting small cohort, monocentric, or single-surgeon data. The best RCT-supported evidence is in favor of robot-assisted radical prostatectomy (RARP) compared with laparoscopic radical prostatectomy (LRP) and of the Retzius-sparing (RS) technique over the traditional prostatectomy. Other techniques such as bladder neck and puboprostatic ligament (PPL) preservation, posterior reconstruction with or without combination of anterior suspension technique, and nerve-sparing (NS) approach seem to enhance EC. Oppositely, the endopelvic fascia preservation, bladder neck mucosa eversion/plication/slings, and the selective ligature of dorsal venous complex (DVC) were not significantly associated with EC improvements. RCTs are lacking on pubovesical complex-sparing, seminal vesicle preservation, anterior reconstruction of the puboprostatic collar, musculofascial reconstruction, and DVC suspension to the periosteum of the pubic bone techniques. Conclusions: RARP and RS have high-quality evidence supporting their ability to enhance postoperative EC recovery. NS, bladder neck, and PPL preservation may contribute to better EC recovery, although the evidence level is low. Further multicenter RCTs are needed to establish the optimal combination of standard surgical techniques. A new continence outcome-reporting standardization was proposed.

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 ...

Dorsal Vascular Complex Nonligation Method and Preservation of Puboprostatic Ligaments and Endopelvic Fascia During Laparoscopic Radical Prostatectomy: Effect on Continence.

To evaluate the impact on continence rate during 1-year follow-up of a preservation technique that included nonligation of the dorsal vascular complex and sparing of the puboprostatic ligaments and the endopelvic fascia during laparoscopic radical prostatectomy. Information from 30 patients who underwent the preservation technique was prospectively collected and compared with data from 60 patients who underwent the nonpreservation traditional technique. A single surgeon performed all procedures. Demographic and preoperative characteristics were similar. The mean patient age was 59 years in both groups. All patients were stage cT1c or cT2. Operative time was significantly lower in the preservation technique group (229.6 vs. 262.7 minutes, P < .001). There were no significant differences in intraoperative bleeding, discharge hemoglobin level, blood transfusion rate, length of hospitalization, and drop in the hemoglobin level. The probability of continence recovery was significantly higher in the preservation technique group than in the traditional technique group (hazard ratio = 0.50, 95% CI = 0.31-0.81). The continence rate (0 pads/day) for the preservation technique group versus the traditional technique group at 1, 3, 6, and 12 months was, respectively, 53.3% versus 30% (P = .031), 90% versus 45% (P < .001), 90% versus 63.3% (P = .008), and 96.6% versus 78.3% (P = .024). There were no significant differences between the groups regarding potency and oncologic outcomes. Nonligation of the dorsal vascular complex and preservation of the puboprostatic ligaments and the endopelvic fascia improved urinary continence compared with the traditional nonpreservation technique, with no impact in terms of bleeding and oncologic outcomes.

A novel method of bladder neck fixation during robot-assisted radical prostatectomy

Background. Appearance of new surgical techniques are aimed to improve not only oncological, but also functional outcomes of radical prostatectomy. A good urinary continence after radical surgical treatment remains an important aspect with not only medical but also social significance, since it can significantly reduce the patient’s quality of life.Aim. To describe a new surgical technique of lateral fixation of the bladder neck using autotissue during robotic- assisted radical prostatectomy, to evaluate its effecacy and safety.Materials and methods. From February till November 2020, 20 patients with localized prostate cancer underwent radical robot-assisted prostatectomy. All operations were performed in one medical center, by one experienced robotic surgeon (more than 1000 operations). After the imposition of vesicourethral anastomosis the reconstruction of pelvis was performed by lateral fixation of the vesical cervix with auto-tissue flaps of the intrapelvic fascia. A prerequisite was the preservation of the puboprostatic ligaments, endopelvic fascia and puboperineal muscles. The duration of the operation (console time and time of reconstruction), the volume of intraoperative blood loss, perioperative complications according to Clavien–Dindo, the duration of urethral catheter and the patient’s length of hospital stay, oncological results (pT stage, presence/absence of a surgical margin), the presence of immediate continence, as well as continence 3 months postoperatively were assessed.Results. The mean operative time was 142 (115–168) minutes, mean console time – 64 (50–98) minutes. The mean duration of lateral fixation stage was 3,5 (2–5,5) minutes. Urethral catheter was removed at 7th day postoperatively. There were no Clavien–Dindo group III–V complications registered. Immediate continence rate – 75 % (15 patients), early continence rate – 25 % (5 patients).Conclusion. The use of a new technique of lateral reconstruction during robotic-assisted radical prostatectomy using endopelvic fascia flaps is safe and effective, it improves functional outcomes without affecting oncological results.

Identifying prognostic parameters related to surgical technique in patients treated by robotic radical prostatectomy

Introduction and objectiveThe most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen. Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival. Patients and MethodProspective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years. Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors. We performed univariate and matched comparisons of survival using Kaplan–Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p). ResultsCohort of 667 patients with a median follow-up of 69 months. In univariate analysis, surgeon (adjp=0.018), preservation of puboprostatic ligaments (adjp=0.02), preservation of endopelvic fascia (adjp=0.001) and performing periurethral suspension (adjp<0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp=0.04). Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance. ConclusionsThe surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

Identificación de parámetros pronósticos relativos a la técnica quirúrgica en pacientes tratados mediante prostatectomía radical robótica

Introduction and objectiveThe most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen.Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival. Patients and MethodProspective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years.Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors.We performed univariate and matched comparisons of survival using Kaplan-Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p). ResultsCohort of 667 patients with a median follow-up of 69 months.In univariate analysis, surgeon (adjp = 0.018), preservation of puboprostatic ligaments (adjp = 0.02), preservation of endopelvic fascia (adjp = 0.001) and performing periurethral suspension (adjp < 0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp = 0.04).Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance. ConclusionsThe surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

MP15-14 PRESERVATION OF ENDOPELVIC FASCIA, PUBOPROSTATIC LIGAMENTS, DORSAL VENOUS COMPLEX AND HYDRODISSECTION OF THE NEUROVASCULAR BUNDLES IMPROVE RATES AND TIME TO CONTINENCE AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY: A PROPENSITY-SCORE MATCHED ANALYSIS

You have accessJournal of UrologyCME1 May 2022MP15-14 PRESERVATION OF ENDOPELVIC FASCIA, PUBOPROSTATIC LIGAMENTS, DORSAL VENOUS COMPLEX AND HYDRODISSECTION OF THE NEUROVASCULAR BUNDLES IMPROVE RATES AND TIME TO CONTINENCE AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY: A PROPENSITY-SCORE MATCHED ANALYSIS Ahmed S. Elsayed, Yousuf Ramahi, Ayat A. Shah, Hannah B. Ely, Zhe Jing, Holly Houenstein, Julian Joseph, Sharifeh Almasaid, Gaybrielle James, James O. Peabody, Ahmed A. Hussein, and Khurshid A. Guru Ahmed S. ElsayedAhmed S. Elsayed More articles by this author , Yousuf RamahiYousuf Ramahi More articles by this author , Ayat A. ShahAyat A. Shah More articles by this author , Hannah B. ElyHannah B. Ely More articles by this author , Zhe JingZhe Jing More articles by this author , Holly HouensteinHolly Houenstein More articles by this author , Julian JosephJulian Joseph More articles by this author , Sharifeh AlmasaidSharifeh Almasaid More articles by this author , Gaybrielle JamesGaybrielle James More articles by this author , James O. PeabodyJames O. Peabody 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.0000000000002544.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We sought to report the oncologic and functional outcomes of endopelvic fascia (EPF), puboprostatic ligament (PPL), and dorsal venous complex (DVC) preservation with hydrodissection of the neurovascular bundles (NVB) during robot-assisted radical prostatectomy (RARP). METHODS: A retrospective review of our prostate cancer database was performed. Patients who underwent either bilateral or unilateral nerve sparing-RARP were identified. Propensity score matching was performed between new surgical technique (Group 1) and a historical group (Group 2). Data was reviewed for perioperative, oncologic and functional outcomes. Kaplan Meier curves were used to depict biochemical recurrence-free survival (BRFS). Cumulative incidence curves were used to depict perfect continence (0 pads), social continence (0-1 pad) and potency (SHIM ≥17). Multivariate analyses (MVA) were used to depict variables associated with continence and potency. RESULTS: 202 patients were included in the study (76 in Group 1 and 126 in Group 2) with a median follow up of 17 months. Kaplan Meier curves showed similar BRFS (p=0.98). Group 1 showed higher perfect continence rates at 1 months (9% vs 3%), 3 months (24% vs 19%), and 6 months (54% vs 34%) compared to Group 2. Group 1 showed higher social continence rates at 1 month (15% vs 3%), 3 months (67% vs 32%), and 6 months (87% vs 53%) compared to Group 2 (Figure 1a-c). MVA showed that Group 1 was associated with perfect (HR 1.82, 95%CI 1.29–2.58, p<0.01) and social continence (HR 2.54, 95%CI 1.83 – 3.52, p<0.01), but not potency (Table 1). CONCLUSIONS: EPF, PPL, and DVC preservation with hydrodissection of the NVB offered similar oncological outcomes, but earlier and improved urinary continence rates compared to standard dissection. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e247 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed S. Elsayed More articles by this author Yousuf Ramahi More articles by this author Ayat A. Shah More articles by this author Hannah B. Ely More articles by this author Zhe Jing More articles by this author Holly Houenstein More articles by this author Julian Joseph More articles by this author Sharifeh Almasaid More articles by this author Gaybrielle James More articles by this author James O. Peabody 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 ...

Fascial space priority approach for laparoscopic total pelvic exenteration in patients with locally advanced rectal cancer.

Total pelvic exenteration (TPE) with intent to achieve a pathological R0 resection is now considered as the only chance of a long-term survival for locally advanced rectal cancer (LARC) invading into adjacent organs. Lately, laparoscopic total pelvic exenteration (LTPE) is performed and achieved in several specialized centers and showed a promising application prospect. Although this is universally realized by surgeons, there are only few specialized centers to perform this complex surgery, due to concerns about the high morbidity and mortality. The techniques associated need to be disclosed and facilitated. The aim of this article is to introduce a fascial space priority approach for laparoscopic TPE step by step (with video). We describe here a fascial space priority approach for LTPE in highly selected patients with locally advanced rectal cancer. The main principle of this approach is that all of the pelvic organs are considered as a whole, the non-vascular spaces surrounding it are separated in the first place, the vascular pedicle and nerve pedicle of pelvic organs can be isolated and then transected precisely. Meanwhile, the associated key landmarks of this approach are disclosed (see the video). The ureterohypogastric nerve fascia (UHGNF) and the vesicohypogastric fascia (VHGF) are two vital embryological planes on the lateral compartment of pelvis. The spaces on either side of them together with the retrorectal space, the space of Retzius, are all non-vascular spaces, and dissection of these spaces in LTPE surgery can be achieved simply and practicably. The ureter, the umbilical artery, the arcus tendinous fasciae pelvis (ATFP), piriformis and the puboprostatic ligament (PPL) are all important landmarks during surgery. Step-by-step illustration with precise anatomical landmarks in the present video may lead to less intraoperative blood loss and complications. LTPE with fascial space priority approach might be a standard surgical procedure for total pelvic exenteration with clear anatomy and reduced blood loss.

Retropubic TFS Minisling for Postprostatectomy Male Incontinence: First Report

Hypothesis: A structurally sound puboprostatic ligament (PPL), like the pubourethral ligament in the female, is the core structure for control of stress urinary incontinence (SUI) in males. Methods: The hypothesis was tested at several levels. Twelve transperineal ultrasound examinations were performed to confirm reflex directional closure vectors around the PPL, with digital support for the PPL rectally and cadaveric testing with a tissue fixation system (TFS) minisling, and finally, 22 cases of postprostatectomy incontinence were addressed only with retropubic insertion of a 7-mm TFS sling between the bladder neck and perineal membrane to reinforce the PPL. Results: On ultrasound testing, 3 urethral closure muscles were confirmed to act reflexively around the PPL to close the urethra distally and at the bladder neck. A finger was inserted rectally, pressed against the symphysis only on one side of the urethra at the origin of the PPL that controlled urine loss on coughing. The mean pre-op pad loss was 3.8 pads at 9 months; the mean post-op loss was 0.7 pads; 13/22 (59%) patients were 100% improved; 7/22 (31%) improved >50% but <100%; 2/22 (9.1%) improved <50%. Conclusions: The 7-mm-wide TFS minisling is the first retropubic minisling for postprostatectomy urinary incontinence. It differs significantly from transobturator male operations surgically and in modus operandi. As in the female, reconstruction of the PPL alone was sufficient to cure/improve SUI, suggesting that preservation of the PPL is of critical importance during retropubic radical prostatectomy.

PELVIC REHABILITATION FOR URINARY INCONTINENCE AFTER RADICAL PROSTATECTOMY.

Radical prostatectomy (RP) performed by open, laparoscopic, or robotic approach is considered the gold standard for localized prostate cancer (PCa). However, it carries the risk of postprostatectomy urinary incontinence (UI) and erectile dysfunction (ED) which significantly reduce patients' satisfaction with surgery and quality of life (QoL), therefore it is important to decrease the possibility or severity of these complications to a minimum. There are several preoperative prognostic factors such as urethral length and closing pressure obtained by magnetic resonance imaging and profilometry, as well as several variations in the surgical approach such as preservation of the neurovascular bundle (NVB) and puboprostatic ligaments, sparing or reconstruction of bladder neck, Retzius-sparing approach, and meticulous surgical dissection, used to predict or prevent unwanted side effects of RP. In addition, there are postoperative methods that can help reduce complications. In this review, we will present the role of pelvic rehabilitation with an emphasis on pelvic floor muscle training (PFMT) in reducing consequences of radical surgery.

Preventive intraoperative methods for restoring urine function after laparoscopic and open radical prostatectomy

Purpose of the study. To evaluate the effectiveness of preserving the anatomical structures surrounding the prostate gland for prophylactic intraoperative restoration of urinary retention functions in the postoperative period.&#x0D; Materials and methods. A study was carried out in 86 patients with prostate cancer after performing radical prostatectomy from 2013 to 2021. Men were divided into 4 groups:&#x0D; Group 1 – LRP with preservation of the puboprostatic ligaments, pubo-perineal muscle, pelvic fascia and neurovascular bundles of the penis.&#x0D; Group 2 – LRP with complete preservation of the anatomical structures of the small pelvis without preserving the neurovascular bundles of the penis.&#x0D; Group 3 – ORP with preservation of the puboprostatic ligaments, pubo-perineal muscle, pelvic fascia and neurovascular bundles of the penis.&#x0D; Group 4 – RRP with complete preservation of the anatomical structures of the small pelvis without preserving the neurovascular bundles of the penis.&#x0D; In group 1, in which LRP was performed, 58 patients with prostate cancer T1N0M0 and T2N0M0.&#x0D; In group 2 LRP 12 patients with prostate cancer T1N0M0 and T2N0M0.&#x0D; There were 12 patients with prostate cancer T1N0M0 and T2N0M0 in group 3 with RRP.&#x0D; There are 4 patients with prostate cancer T1N0M0 and T2N0M0 in group 4 with RRP.&#x0D; He diagnosis of prostate cancer in all patients was established on the basis of a histological examination of preparations obtained by performing a transrectal multifaceted biopsy of the prostate gland. The basis for performing a biopsy was an increase in the level of prostate-specific antigen (PSA) in the blood above 4 ng/ml, the presence of pathological nodes according to MRI of the pelvic organs with contrast, as well as suspicious areas of the prostate gland during digital rectal examination. A study was carried out in 86 patients with prostate cancer after performing radical prostatectomy from 2013 to 2021.&#x0D; Research results and their discussion. 12 patients of group 3 underwent open surgery-radical prostatectomy. RRP (12 people) with preservation of the pubo-prostatic ligaments, pubo-perineal muscle, pelvic fascia and neurovascular bundles of the penis.&#x0D; In 4 patients of group 4, RRP with complete preservation of the anatomical structures of the small pelvis without preservation of the neurovascular bundles of the penis.&#x0D; We do not dwell on the method of performing the operation, it is known, all 16 patients underwent lymphadenectomy.&#x0D; The average operation time in the groups LRP 1 group, LRP 2 group did not differ significantly, and amounted to 147,16. And in a comparative analysis in group 3 RR, Group 4 RR there was a difference of 89,29, open operations were performed much faster.&#x0D; In our study, the criterion for urinary retention was the absence of the patient's need to use safety pads. This definition is adhered to by many specialists involved in the surgical treatment of prostate cancer. The use of at least 1 safety pad was equivalent to urinary incontinence. And it was considered a complication after the operations performed. Inourstudy, themeantimetorestoration of the full urinary continence function was the longest where the standard surgical procedure was performed, and the shortest was in the groups where the maximum preservation of the anatomical structures of the periprostatic anatomical zone was performed.&#x0D; Conclusions. 1. The main mechanism for the rapid restoration of urinary retention in patients after radical prostatectomy with prostate cancer is the maximum preservation of the pubo-prostatic ligaments and the pubo-perineal muscle, which makes it possible to fully restore the function of urinary retention within a month. 2. Preservation, only of the neurovascular bundle of the penis, is not enough to restore the function of early urinary retention after surgery.

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 ...

Reconstruction of the ligamentous apparatus of the lower pelvis in robot-assisted radical prostatectomy as a stage of the learning curve

Objective of the study. To evaluate results of robot-assisted laparoscopic radical prostatectomy in the framework of a surgeon’s learning curve; to evaluate the effect of reconstruction of the ligamentous apparatus of the lower pelvis on early recovery of urine retention.Materials and methods. 246 patients were divided into 3 groups depending on the surgery date. The analyzed data was accumulated prospectively and retrospectively. Preoperative characteristics (TNM stage, PSA, ISUP), intraoperative characteristics (surgical time, blood loss volume, surgery type and character, type of reconstruction of the ligamentous apparatus of the lower pelvis) and postoperative characteristics (duration of bladder drainage with a urethral catheter, level and time of recovery for urine retention and erectile function) were evaluated. Reconstruction of the ligamentous apparatus of the lower pelvis was performed through reconstruction of the Denonvillier fascia (Rocco stitch), as well as through suturing fibers of the bladder neck with periurethral tissues and residual puboprostatic ligaments for stabilization of the urethrovesical complex.Results. All operations were successfully completed without conversions or transfusions. Median surgical time was 160 minutes (p = 0.0001). Median blood loss was 173.3 cm3 (p = 0.0002). Mean prostatic volume was 36 cm3 (29–47.5 cm3), and overall frequency of positive surgical margin was 12.82 %. Overall frequency of urine retention recovery was 51.6 % after 3 months, 63.7 % after 6 months (p &gt;0.05). In the patient group with reconstruction of the ligamentous apparatus of the lower pelvis, frequency of urine retention recovery was higher than in the group without reconstruction: 64.1 % vs 45.3 % (after 3 months, р = 0.041) and 74.7 % vs 62.3 % (after 6 months, р = 0.034). Conclusion. Surgical time, blood loss were significantly decreased with the number of performed operative interventions. Significant improvement of early urine retention recovery was observed in the patient group with reconstruction of the ligamentous apparatus of the lower pelvis.

Staple-transection of the dorsal venous complex and urethra in cooperative laparoscopic and transperineal endoscopic total pelvic exenteration for pelvic malignancies.

Herein, we describe our novel technique for transecting the dorsal venous complex (DVC) and urethra using a linear stapler inserted through a perineal port during endoscopic pelvic exenteration for pelvic malignancies. First, a laparoscopic approach is made using a conventional 5-trocar pneumoperitoneum technique. When the Retzius and paravesical spaces are dissected to expose the tendinous arch of the levator ani muscle, the transperineal approach is synchronously begun. After the levator ani muscle and bilateral puboprostatic ligaments are dissected, the DVC and urethra are completely exposed. A linear stapler is inserted through the transperineal port along the dorsal side of the pubic body. The DVC and urethra are carefully compressed and transected with minimal bleeding. We describe four cases of laparoscopic total pelvic exenteration using this technique. Tumor size, operation time, and estimated blood loss ranged from 30-130 mm, 535-877 minutes, and 50-1520 mL, respectively. Transperineal dissection of the DVC and urethra by linear staplers decreases both operation time and blood loss.

Role of sparing of puboprostatic ligaments on continence recovery after radical prostatectomy: a randomized controlled trial

Objective Sparing of puboprostatic ligaments (PPLs) during radical prostatectomy was introduced as a technique to improve urinary continence. This study aims to study the effect of sparing of PPLs during laparoscopic radical prostatectomy in terms of continence during the first 3 months. Methods A total of 74 patients, diagnosed with clinically localized prostate cancer, were randomly assigned to two equal groups; PPLs division and sparing during LRP. Based on the number of daily used pads, both groups completed 3 months follow-up to assess continence recovery. The effects of age, preoperative total prostate-specific antigen (PSA) and clinical tumor stage on continence recovery were also studied. The study was registered and approved by the Ethics Committee of Alexandria University-Faculty of Medicine (Protocol No. 0201074). Results Seventy-four patients were enrolled, with a mean age of 63.8 years. Baseline characteristics were comparable, except significantly higher mean PSA in the division group. Sixty patients were continent (0–1 pad/day) at 3 months follow-up. Continence was significantly better in the sparing than division group at 1 week after catheter removal (67.6% vs 40.5%, p = 0.01), at 1 month (73% vs 45.9%, p = 0.009) and 2 months (89.2% vs 51.4%, p = 0.0001). At 3 months follow-up, there was no significant difference between both groups (83.3% vs 78.4% for sparing and division groups, respectively; p = 0.28). Moreover, continence was significantly improved at 3 months compared to 1 week in both groups. Conclusion Sparing of puboprostatic ligaments during radical prostatectomy significantly improves postoperative early recovery of urinary continence.

Radical retropubic prostatectomy: Preservation of urinary continence

ObjectiveHistorical review of procedures and maneuvers described in the literature to preserve-increase urinary continence after retropubic prostatectomy. Material and methodReview of the original articles on the design of maneuvers for the preservation of urinary continence. ResultsNumerous maneuvers have been described attempting to preserve-increase urinary continence after prostatectomy. They can be grouped into preservation of puboprostatic ligaments, bladder neck, striated sphincter or trigonal innervation, construction of a neourethra, suspension of the anastomosis or the dorsal venous complex and intussusception of the bladder neck. ConclusionThere is no ideal maneuver for preserving-increasing urinary continence after retropubic prostatectomy, as there is no well-conducted work with any of these techniques that confirm their efficacy.

Effect of puboprostatic ligament preservation during robotic-assisted laparoscopic radical prostatectomy on early continence: Randomized controlled trial

ObjectiveTo prove the effectiveness of puboprostatic ligament-preserving robotic-assisted laparoscopic radical (RARP) on enhancing early continence. MethodsNinety-two patients with localized adenocarcinoma of the prostate scheduled for RARP from April 2018 to January 2019 were prospectively single-blinded and randomized into two groups, standard RARP (Group A) and puboprostatic ligament-sparing RARP (Group B). The outcomes were continent status at Foley catheter removal and 3 months after surgery using the score from the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF), pad usage, pathological margin status, blood loss, operative time, and complications. ResultsNinety-six patients were randomized (46 patients in each group), with a mean±SD age of 67.30±6.07 years. There were no differences in baseline characteristics. At 3 months after surgery, ICIQ-UI SF score (mean±SD) in Group A was significantly higher than Group B (8.74±4.28 vs. 6.93±3.96, p=0.038) but no difference at Foley catheter removal. Group A also had a significant higher score for interference with daily life (median [interquartile range, IQR]: 4 [1, 5] vs. 2 [0, 4]; p=0.041) and higher pad use (median [IQR]: 2 [0, 3] vs. 1 [1, 2]; p=0.041) at 3 months. One case in Group A had complete or severe incontinence (>5 pads/day) at 3 months. Groups A and B did not exhibit significant difference in margin status (p=0.828). There were no differences in operative time, blood loss, drain output or complications. ConclusionsUse of puboprostatic ligament-sparing RARP could be a method to accelerate early continence without affecting the final oncological outcome.

Hood Technique for Robotic Radical Prostatectomy—Preserving Periurethral Anatomical Structures in the Space of Retzius and Sparing the Pouch of Douglas, Enabling Early Return of Continence Without Compromising Surgical Margin Rates

BackgroundA common side effect following radical prostatectomy is urinary incontinence. Here, we describe a novel surgical technique to reduce postoperative urinary incontinence and facilitate early return of continence. ObjectiveTo describe the novel “hood technique” for robotic-assisted radical prostatectomy (RARP). Design, setting, and participantsThis is an institutional review board–approved prospective study of 300 patients (median age 64 yr) with localized prostate cancer treated with the RARP hood technique at a major urban hospital between April 2018 and March 2019. The exclusion criteria were as follows: patients with anterior tumor location based on biopsy or multiparametric magnetic resonance imaging. All but one patient participated in follow-up over 12 mo after the procedure. Surgical procedureThe RARP “hood technique” was performed to preserve the detrusor apron, puboprostatic ligament complex, arcus tendineus, endopelvic fascia, and pouch of Douglas. MeasurementsClinical data collected included pre- and intraoperative variables, and postoperative functional and oncological outcomes and complications. Descriptive statistical analysis was performed. Results and limitationsContinence rates at 1, 2, 4, 6 12, 24, and 48 wk after catheter removal were 21%, 36%, 83%, 88%, 91%, 94%, and 95%, respectively. Positive surgical margin rate was 6%. Thirty patients (9.7%) experienced complications after RARP: 17 (5.7%), 11 (3.6%), and one (0.4%) had Clavien-Dindo grade I, II, and III complications, respectively. This study was conducted within a single health system and may not be generalizable. The study lacked randomization and a comparative arm. ConclusionsResults indicate that the hood technique spares musculofascial structures anterior to the urethral sphincter complex with early return of continence after surgery, without compromising positive surgical margin rates. Exclusion of anterior tumor location contributed to a reduction in positive surgical margins. Patient summaryBy better preservation of anatomical structures around the urethra, we were able to achieve early return of urinary continence without a negative impact on complications and cancer outcomes.