Elsevier

European Urology

Volume 53, Issue 5, May 2008, Pages 931-940
European Urology

Surgery in Motion
Intrafascial Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy

https://doi.org/10.1016/j.eururo.2007.11.047Get rights and content

Abstract

Objectives

Based on our recently published anatomic studies, we present the most recent refinement of the endoscopic extraperitoneal radical prostatectomy (EERPE), the intrafascial nerve-sparing EERPE (nsEERPE).

Methods

As part of the intrafascial technique, the dissection plane is directly on the prostatic capsule, freeing the prostate laterally from its thin surrounding fascia that contains small vessels and nerves. The technique enables puboprostatic ligament preservation, leaving intact endopelvic fascia, periprostatic fascia, and neurovascular bundles. The operation was performed in 150 patients with indications for nerve-sparing procedure.

Results

The mean operative time was 131 min (range: 50–210 min) and the mean catheterization time was 5.9 d (range: 4–20 d). Twelve months postoperatively, 94.3% of the patients were continent (no need for pads), 4.6% had minimal stress incontinence, and one patient required >2 pads/d. At the 12-mo follow-up, the potency rates (erections sufficient for intercourse with or without the use of phosphodiesterase 5 [PDE5] inhibitors) of the patients who underwent bilateral intrafascial nsEERPE were 89.7% (age: 44–55 yr), 81.1% (age: 56–65 yr), and 61.9% (age: >65 yr). Positive surgical margins in pT2 and pT3 tumors were 4.5% and 29.4%, respectively.

Conclusions

The intrafascial nsEERPE enables the dissection of the prostate with limited trauma to the surrounding fascias and the enclosed neurovascular bundles. We propose that the preserved neurovascular bundles with intrafascial nsEERPE are more viable. The results advocate this proposition.

Introduction

Laparoscopic radical prostatectomy (LRP) and retropubic radical prostatectomy (RRP) are well-established procedures for the management of localized prostate cancer. The functional and oncologic results of both techniques are comparable [1], [2], [3], [4], [5], [6], [7], [8].

The initial experience (2002) with extraperitoneal endoscopic radical prostatectomy (EERPE) revealed surgical and oncologic results similar to those of transperitoneal LRP combined with the complete avoidance of the intraperitoneal complications while preserving the advantages of the minimally invasive surgery and retropubic approach [6], [7], [9]. The technique has undergone various refinements and modifications to achieve higher standards of efficacy [10].

The understanding of the anatomy of the bladder neck, urethra, and the neurovascular bundle (NVB) provided the base for the performance of the nerve-sparing EERPE (nsEERPE) and the most recent intrafascial nsEERPE, which resulted in improved potency and early continence [10], [11], [12], [13].

Section snippets

Patient positioning and trocar placement

The positioning of the patient, trocar placement, and the preparation of the preperitoneal space has been described in detail in previous reports [9], [10], [11], [12], [13]. In short, the patient is placed in a supine position with a 10° head-down tilt. The trocar placement is shown in Fig. 1. The preparation of the space of Retzius begins with an incision in the infraumbilical crease laterally to the midline and carried down to the posterior rectus sheath where a balloon trocar is inserted

Results

The intrafascial nsEERPE was performed in 150 consecutive patients by several surgeons. Cystography was performed 5 d postoperatively and if satisfactory (no paravasation), the catheter was removed. The perioperative patient data are summarized in Table 1. Patients older than 70 yr underwent surgery because of their overall good health and minimal comorbidities. Conversion and transfusion rates were 0% and 1.3%, respectively. The mean operative time was 131 min.

Continence was defined as no need

Discussion

The understanding of the anatomic structure of the NVB and the cavernosal nerves is of great interest due to the need to preserve the nerves necessary for erection and consequently to improve the potency-related functional results after RP. Efforts are being made to unify the existing terminology of the anatomic structures surrounding the prostate [11], [14], [15], [16], [17], [18].

Costello et al recently showed that most of the NVB descends posteriorly to the seminal vesicle. The nerves pass

Conclusions

Intrafascial nsEERPE is a further evolution of the current nsEERPE. The initial results are promising, with oncologic results similar to any other RP technique and favorable functional outcomes.

Conflicts of interest

The authors have nothing to disclose.

Acknowledgments

The authors gratefully acknowledge the assistance of Mr. Jens Mondry (Director Moonsoft, Germany) in preparing Fig. 1, and Mr. Gottfried Müller in preparing Fig. 2, Fig. 3, Fig. 4, Fig. 5.

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