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Hoeh B, Wenzel M, Hohenhorst L, Köllermann J, Graefen M, Haese A, Tilki D, Walz J, Kosiba M, Becker A, Banek S, Kluth LA, Mandel P, Karakiewicz PI, Chun FKH, Preisser F. Anatomical Fundamentals and Current Surgical Knowledge of Prostate Anatomy Related to Functional and Oncological Outcomes for Robotic-Assisted Radical Prostatectomy. Front Surg 2022; 8:825183. [PMID: 35273992 PMCID: PMC8901727 DOI: 10.3389/fsurg.2021.825183] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 01/23/2023] Open
Abstract
Context Meticulous knowledge about the anatomy of the prostate and surrounding tissue represents a crucial and mandatory requirement during radical prostatectomy for reliable oncological and excellent replicable, functional outcomes. Since its introduction two decades ago, robotic-assisted laparoscopic radical prostatectomy (RALP) has evolved to become the predominant surgical approach in many industrialized countries. Objective To provide and highlight currently available literature regarding prostate anatomy and to help in improving oncological and functional outcomes in RALP. Methods/Evidence Acquiring PubMed database was searched using the following keywords: “robotic-assisted radical prostatectomy,” “anatomy,” “neurovascular bundle,” “nerve,” “periprostatic fascia,” “pelvis,” “sphincter,” “urethra,” “urinary incontinence,” and “erectile dysfunction.” Relevant articles and book chapters were critically reviewed and if eligible, they were included in this review. Results New evidence in regards to prostatic anatomy and surgical approaches in RALP has been reported in recent years. Besides detailed anatomical studies investigating the meticulous structure of the fascial structures surrounding the prostate and neurovascular bundle preservation, debate about the optimal RALP approach is still ongoing, inspired by recent publications presenting promising functional outcomes following modifications in surgical approaches. Conclusions This review provides a detailed overview of the current knowledge of prostate anatomy, its surrounding tissue, and its influence on key surgical step development for RALP.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
- *Correspondence: Benedikt Hoeh
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Lukas Hohenhorst
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Köllermann
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Haese
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Marina Kosiba
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Severine Banek
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A. Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Pierre I. Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Felix K. H. Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Felix Preisser
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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Assem A, Abou Youssif T, Hamdy SM, Beltagy AM, Gozen AS. Role of sparing of puboprostatic ligaments on continence recovery after radical prostatectomy: a randomized controlled trial. Scand J Urol 2020; 55:22-26. [PMID: 33241757 DOI: 10.1080/21681805.2020.1849389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Akram Assem
- Department of Urology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tamer Abou Youssif
- Department of Urology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Seif M Hamdy
- Department of Urology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmad M Beltagy
- Department of Urology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ali Serdar Gozen
- SLK-Kliniken Urology Department, Heidelberg University, Heilbronn, Germany
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Novikov AB, Galliamov EA, Kochkin AD, Biktimirov RG, Sergeev VP, Popov SV, Orlov IN, Presnov KS, Meshankin IV, Sanzharov AE, Komarov MI, Bolgov EN, Volnykh IU, Agapov MA, Biktimirov TR, Volodin DI, Galliamov EE. ANATOMY - SPARING LAPAROSCOPIC RADICAL PROSTATECTOMY… IS IT POSSIBLE? SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-2-23-35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The fact is that nerve- and fascial-sparing robot-assisted technique improves functional results of radical prostatectomy.The aim of study: to evaluate feasibility and effectiveness of anatomy-sparing radical prostatectomy performed by conventional laparoscopy.Material and methods: A total of 4025 patients with prostate cancer who underwent conventional lap radical prostatectomy (LRP) between 2010 and 2020 were retrospectively reviewed. After that only cases of anatomy-sparing technique were enrolled. The perioperative parameters of these 714 men were analyzed. Continence was defined by “Pad-test” 1 or none.Results: There were no mortality, intra- and Clavien ≥ III postoperative complications i.q. conversions to open surgery. Average OR time & EBL – 155,3 min & 187,2 ml respectively. Mean time of bladder catheterization – 7,4 d. The frequency of positive surgical margins – 9,7%. Immediate and absolute continence has been reached in 38,2% of cases. In the other 42,3% of patients the “Pad-test” was not more than one. Thus 80,5% of our patients were satisfied with urination after surgery. Conclusions: conventional laparoscopic surgical technique described in this paper is not only feasible effective and safe but also achieve a better functional result.
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Affiliation(s)
- A. B. Novikov
- Multidisciplinary medical center of the Bank of Russia
| | | | | | | | | | | | | | - K. S. Presnov
- Multidisciplinary medical center of the Bank of Russia
| | | | | | - M. I. Komarov
- N. Blokhin`s National Medical Research Center for Oncology
| | - E. N. Bolgov
- Stavropol Regional Clinical Consultative and Diagnostic Center
| | - I. U. Volnykh
- Urological and SWL center of Russians Railways Hospital
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Schifano N, Capogrosso P, Tutolo M, Dehò F, Montorsi F, Salonia A. How to Prevent and Manage Post-Prostatectomy Incontinence: A Review. World J Mens Health 2020; 39:581-597. [PMID: 33151045 PMCID: PMC8443978 DOI: 10.5534/wjmh.200114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/25/2020] [Accepted: 08/14/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP). MATERIALS AND METHODS A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer. RESULTS Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI. CONCLUSIONS To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.
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Affiliation(s)
- Nicolò Schifano
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paolo Capogrosso
- Unit of Urology, ASST Sette Laghi - Circolo e Fondazione Macchi Hospital, Varese, Italy.
| | - Manuela Tutolo
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federico Dehò
- Unit of Urology, ASST Sette Laghi - Circolo e Fondazione Macchi Hospital, Varese, Italy.,University of Insubria, Varese, Italy
| | - Francesco Montorsi
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Salonia
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
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Xu Z, Chapuis PH, Bokey L, Zhang M. Nature and Architecture of the Puboprostatic Ligament: A Macro- and Microscopic Cadaveric Study Using Epoxy Sheet Plastination. Urology 2017; 110:263.e1-263.e8. [PMID: 28847689 DOI: 10.1016/j.urology.2017.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/21/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the nature and the architecture of the puboprostatic ligament (PPL) and its relationship with surroundings. MATERIALS AND METHODS Six adult male cadaveric pelvises (age range, 46-87 years) were prepared as serial transverse (2 sets), coronal (1 set), or sagittal (3 sets) plastinated sections, and were examined under a stereoscope and a confocal microscope. The thickness of the section was 2.5 mm, the interval between 2 adjacent sections was about 0.9 mm, and a total of about 70 serial sections per set were collected. RESULTS First, the musculotendinous sheet of the pubococcygeus contributed to the visceral endopelvic fascia, decussated in front of the detrusor apron, and fixed to the pubis. Second, anteriorly to the prostate, the detrusor apron split up into anterior, middle, and posterior layers, which contributed to the PPL, the fascial sheaths of the dorsal vascular complex, and the anterior fibromuscular stroma of the prostate, respectively. Third, the PPL originated from both the detrusor apron and the decussated and undecussated fibers of the pubococcygeus, and inserted onto the pubis. CONCLUSION This study revealed the nature and the architecture of the PPL and its relationship with surroundings. These findings provide new insights in the "suspensory system" involving the urinary continence and may incite for future surgical techniques that aim to preserve the decussated pubococcygeus and the intactness of a pubococcygeus-detrusor apron complex during radical retropubic prostatectomy.
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Affiliation(s)
- Zhaoyang Xu
- Department of Anatomy, Anhui Medical University, Hefei, China
| | - Pierre H Chapuis
- Department of Colorectal Surgery, Concord Hospital and Discipline of Surgery, Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Les Bokey
- Department of Colorectal Surgery, Liverpool Hospital and School of Medicine, University of Western Sydney, New South Wales, Australia
| | - Ming Zhang
- Department of Anatomy, University of Otago, Dunedin, New Zealand.
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Salomon L, Rozet F, Soulié M. La chirurgie du cancer de la prostate : principes techniques et complications péri-opératoires. Prog Urol 2015; 25:966-98. [DOI: 10.1016/j.purol.2015.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 08/06/2015] [Indexed: 11/25/2022]
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Sood R, Khattar N, Nayyar R, Kathuria S, Narang V, Kaushal D. Case for resurgence of radical perineal prostatecomy in Indian subcontinent. Indian J Urol 2013; 28:418-23. [PMID: 23449760 PMCID: PMC3579122 DOI: 10.4103/0970-1591.105754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Radical perineal prostatectomy was the first surgery described for prostatic carcinoma (Young, 1904) but it lost its eminent status after Walsh's description in 1982 of anatomic radical retropubic prostatectomy followed by the enthusiasm in laparoscopy and now robotics. It made resurgence after it was realized in early 1990s that the pelvic lymph node dissection is needed only in selected cases. Last decade witnessed over 80 publications addressing the results and advances in the perineal approach. Strangely, centres from the subcontinent have chosen to ignore this resurgence. We describe our early experience with the technique in 35 patients and present the case for its more widespread usage. Patients and Methods: Thirty five patients of clinically localized carcinoma prostate were operated by perineal route in our institution from December 2006 onwards. All patients had serum prostate specific antigen levels less than 10 ng/ml. Results: Operating time was 2 to 3.5 hours (mean 2.5 hours). Rectal injury occurred in three patients but was closed primarily in all and none required a colostomy. Mean duration of hospital stay was four days. The disease was organ confined in 25(71%). Positive margins were seen in 5(14%) patients. Biochemical recurrence occurred in 17% patients at one year. Seventy six percent patients had achieved continence at one year. Conclusions: As the world is taking note of radical perineal prostatectomy again, with a very small learning curve, minimal invasion and good oncological control urologists from Indian subcontinent should also embrace this procedure in view of the relative limited resources available.
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Affiliation(s)
- Rajeev Sood
- Department of Urology, PGIMER & Dr. Ram Manohar Lohia Hospital, New Delhi, India
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8
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Hinata N, Sejima T, Takenaka A. Progress in pelvic anatomy from the viewpoint of radical prostatectomy. Int J Urol 2012. [DOI: 10.1111/iju.12021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nobuyuki Hinata
- Department of Urology; Tottori University; Yonago; Tottori; Japan
| | - Takehiro Sejima
- Department of Urology; Tottori University; Yonago; Tottori; Japan
| | - Atsushi Takenaka
- Department of Urology; Tottori University; Yonago; Tottori; Japan
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Khorasani B, Arab AM, Sedighi Gilani MA, Samadi V, Assadi H. Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome. Urology 2012; 80:673-7. [PMID: 22925244 DOI: 10.1016/j.urology.2012.05.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 05/17/2012] [Accepted: 05/19/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the pelvic floor muscle motion in men with and without chronic prostatitic/chronic pelvic pain syndrome using transabdominal ultrasound. No study has directly evaluated pelvic floor muscle mobility in individuals with and without chronic pelvic pain syndrome. METHODS A convenience sample of 40 males participated in the study. Subjects were categorized into 2 groups: those with chronic pelvic pain syndrome (n = 20) and those without chronic pelvic pain syndrome (n = 20). The amount of bladder base movement on ultrasound (normalized to body mass index) was measured in all subjects and considered as an indicator of pelvic floor muscle mobility. RESULTS Statistical analysis (independent t-test) revealed significant difference in transabdominal ultrasound measurements for pelvic floor muscle function between the 2 groups (P = .03, 95% CI -0.26 to -0.01). CONCLUSION The results of this study indicate that pelvic floor muscle mobility differs in the 2 groups.
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Affiliation(s)
- Bijan Khorasani
- University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
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Asimakopoulos AD, Annino F, D'Orazio A, Pereira CFT, Mugnier C, Hoepffner JL, Piechaud T, Gaston R. Complete Periprostatic Anatomy Preservation During Robot-Assisted Laparoscopic Radical Prostatectomy (RALP): The New Pubovesical Complex-Sparing Technique. Eur Urol 2010; 58:407-17. [PMID: 20825759 DOI: 10.1016/j.eururo.2010.04.032] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 04/29/2010] [Indexed: 10/19/2022]
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Walz J, Burnett AL, Costello AJ, Eastham JA, Graefen M, Guillonneau B, Menon M, Montorsi F, Myers RP, Rocco B, Villers A. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol 2009; 57:179-92. [PMID: 19931974 DOI: 10.1016/j.eururo.2009.11.009] [Citation(s) in RCA: 304] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 11/02/2009] [Indexed: 01/20/2023]
Abstract
CONTEXT Detailed knowledge of the anatomy of the prostate and adjacent tissues is mandatory during radical prostatectomy to ensure reliable oncologic and functional outcomes. OBJECTIVE To review critically and to summarize the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control, erectile function, and urinary continence. EVIDENCE ACQUISITION A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis, and sphincter. Relevant articles and textbook chapters were reviewed, analyzed, and summarized. EVIDENCE SYNTHESIS Anatomy of the prostate and the adjacent tissues varies substantially. The fascia surrounding the prostate is multilayered, sometimes either fused with the prostate capsule or clearly separated from the capsule as a reflection of interindividual variations. The neurovascular bundle (NVB) is situated between the fascial layers covering the prostate. The NVB is composed of numerous nerve fibers superimposed on a scaffold of veins, arteries, and variable amounts of adipose tissue surrounding almost the entire lateral and posterior surfaces of the prostate. The NVB is also in close, cage-like contact to the seminal vesicles. The external urethral sphincter is a complex structure in close anatomic and functional relationship to the pelvic floor, and its fragile innervation is in close association to the prostate apex. Finally, the shape and size of the prostate can significantly modify the anatomy of the NVB, the urethral sphincter, the dorsal vascular complex, and the pubovesical/puboprostatic ligaments. CONCLUSIONS The surgical anatomy of the prostate and adjacent tissues involved in radical prostatectomy is complex. Precise knowledge of all relevant anatomic structures facilitates surgical orientation and dissection during radical prostatectomy and ideally translates into both superior rates of cancer control and improved functional outcomes postoperatively.
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Affiliation(s)
- Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Center, 232, Bd Ste. Marguerite, 13009 Marseille, France.
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Stolzenburg JU, Schwalenberg T, Horn LC, Neuhaus J, Constantinides C, Liatsikos EN. Anatomical Landmarks of Radical Prostatecomy. Eur Urol 2007; 51:629-39. [PMID: 17137708 DOI: 10.1016/j.eururo.2006.11.012] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 11/03/2006] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In the present study, we review current literature and based on our experience, we present the anatomical landmarks of open and laparoscopic/endoscopic radical prostatectomy. METHODS A thorough literature search was performed with the Medline database on the anatomy and the nomenclature of the structures surrounding the prostate gland. The correct handling of puboprostatic ligaments, external urethral sphincter, prostatic fascias and neurovascular bundle is necessary for avoiding malfunction of the urogenital system after radical prostatectomy. RESULTS When evaluating new prostatectomy techniques, we should always take into account both clinical and final oncological outcomes. The present review adds further knowledge to the existing "postprostatectomy anatomical hazard" debate. It emphasizes upon the role of the puboprostatic ligaments and the course of the external urethral sphincter for urinary continence. When performing an intrafascial nerve sparing prostatectomy most urologists tend to approach as close to the prostatic capsula as possible, even though there is no concurrence regarding the nomenclature of the surrounding fascias and the course of the actual neurovascular bundles. After completion of an intrafascial technique the specimen does not contain any periprostatic tissue and thus the detection of pT3a disease is not feasible. This especially becomes problematic if the tumour reaches the resection margin. DISCUSSION Nerve sparing open and laparoscopic radical prostatectomy should aim in maintaining sexual function, recuperating early continence after surgery, without hindering the final oncological outcome to the procedure. Despite the different approaches for radical prostatectomy the key for better results is the understanding of the anatomy of the bladder neck and the urethra.
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Stolzenburg JU, Liatsikos EN, Rabenalt R, Do M, Sakelaropoulos G, Horn LC, Truss MC. Nerve Sparing Endoscopic Extraperitoneal Radical Prostatectomy– Effect of Puboprostatic Ligament Preservation on Early Continence and Positive Margins. Eur Urol 2006; 49:103-11; discussion 111-2. [PMID: 16314031 DOI: 10.1016/j.eururo.2005.10.002] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Accepted: 10/12/2005] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A technical modification of nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with preservation of the puboprostatic ligaments is presented and compared to a previous technique. MATERIALS AND METHODS nsEERPE was performed in 100 men with clinically localized adenocarcinoma of the prostate from March 2004 through February 2005. Patients were divided into two groups: Group A included patients in whom a standard nsEERPE was performed (n=50), and group B included patients in whom a puboprostatic ligament sparing nsEERPE was performed (n=50). The postoperative follow-up was 2 weeks and 3 months evaluating preliminary effects on early continence and positive margins. RESULTS The early return to continence at 2 weeks postoperatively was achieved by 6 patients (12%) in group A, and 12 patients (24%) in group B. Three months after the procedure 24 (48%) and 38 (76%) patients were continent, in groups A and B respectively. Clinical outcome (early continence) was significantly better for Group B patients, at 2 weeks (chi-square test, p=0.0019) and at 3 months (chi-square test, p=0.0347) following surgery. No cases of complete or severe incontinence (more than 5 pads/day) were observed at 3 months after surgery, in either groups. Groups A and B did not exhibit significant differences regarding their histological status. In group A, positive margins were detected in 6.5% and 26.3% of patients with pT2 and pT3, respectively. In group B, positive margins were found in 3.2% and 15.8% of patients with pT2 and pT3, respectively CONCLUSION We propose the use of puboprostatic ligament-sparing nsEERPE as an intriguing method to ascertain recuperation of early continence after nerve sparing procedures, without hindering the final oncological outcome.
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Affiliation(s)
- Jens-Uwe Stolzenburg
- Department of Urology, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany, and Department of Urology, University Hospital of Patras, Greece.
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