Intrafascial Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy

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1 european urology 53 (2008) available at journal homepage: Surgery in Motion Intrafascial Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy Jens-Uwe Stolzenburg a, *, Robert Rabenalt a, Minh Do a, Thilo Schwalenberg a, Mathias Winkler b, Anja Dietel a, Evangelos Liatsikos c a Department of Urology, University of Leipzig, Leipzig, Germany b Department of Urology, Charing Cross Hospital, London, United Kingdom c Department of Urology, University of Patras, Patras, Greece Article info Article history: Accepted November 16, 2007 Published online ahead of print on December 3, 2007 Keywords: Intrafascial Laparoscopy Nerve-sparing Prostatectomy 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: 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: yr), 81.1% (age: 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. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, University of Leipzig, Liebigstraße 20, Leipzig, Germany. Tel ; Fax: address: stolj@medizin.uni-leipzig.de (J.-U. Stolzenburg) /$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 932 european urology 53 (2008) 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 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 nervesparing EERPE (nseerpe) and the most recent intrafascial nseerpe, which resulted in improved potency and early continence [10 13]. 2. Methods 2.1. The technique 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 13]. In short, the patient is placed in a supine position with a 108 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 and the preperitoneal space is developed. Finally, the camera trocar is placed and further trocars inserted with attention to the course of epigastric vessels (sequence of placement is shown in Fig. 1) Anatomic landmarks The anatomic landmarks that should be recognized are the spermatic cord, the external iliac vessels, the pubic arch with Cooper s ligament, the symphysis, and caudally the bladder and prostate. The anterior surfaces of both bladder and prostate as well as the endopelvic fascia are visible to the surgeon. To expose these structures, the removal of the fatty tissue surrounding them is necessary Bladder-neck dissection The first step of the intrafascial technique is different from the original EERPE and the standard nseerpe. The endopelvic fascia is not incised and the Santorini plexus is not ligated at the beginning of the intrafascial procedure as in the other EERPE techniques. The bladder neck can be identified in the shape of a triangle over the prostate. The dissection of the bladder neck starts at the 12 o clock position and progresses along the margin between the prostate and the bladder in an effort to depict the longitudinal musculature of the bladder neck. The incision of the bladder neck is enlarged from 10 o clock to the 2 o clock position. The texture of the tissue is a useful guide for the dissection. Fig. 1 Trocar placement for intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy (1 4 = sequence of placement of trocars). Notice the course of the epigastric vessels on both sides. Trocar no. 2 should be inserted medially, and trocar no. 3 should be inserted laterally to the epigastric vasculature.

3 european urology 53 (2008) Incision of the periprostatic fascia and bladder-neck incision With the bladder neck as the starting point, a bilateral incision of the periprostatic fascia is made and directed distally toward the apex while remaining medial to the puboprostatic ligaments (Fig. 2A). The right plane of dissection of the periprostatic fascias is recognized when the surface of the prostate is completely smooth and reflecting. As a result, the development of a plane between the prostate and its overlaying fascia is possible. The main purpose for these maneuvers is the development of the correct plane and the detachment of the prostate from its envelopment. All lateral periprostatic fascias (including the endopelvic fascia) as well as the puboprostatic ligaments remain intact. The bladder neck is now fully incised (Fig. 2B). The assistant pulls up the balloon catheter toward the retropubic space keeping the catheter and its surrounding structures under continuous tension (Fig. 2C and D). Sharp dissection is performed in the lateral direction developing the plane between the bladder neck and the prostate while avoiding the involvement of the lateral tissue attachments of the prostate and bladder. At this point, it is mandatory to mobilize the periprostatic fascia including the branches of the NVBs before the dissection of the dorsal bladder neck posteriorly between the 5 o clock and 7 o clock positions Preparation of the seminal vesicles As dissection posteriorly behind the bladder neck continues, the ampullae and seminal vesicles are mobilized with sharp and blunt dissection (Fig. 3A). Care is taken to avoid any injury to the pelvic plexus and the NVB, which run in close proximity to the tips of the seminal vesicles. Titanium clips are used to achieve hemostasis Stripping down Denonvilliers fascia Denonvilliers fascia is then visualized. The appropriate plane of intrafascial dissection can be found by stripping down the Denonvilliers fascia from the prostatic capsule (Fig. 3B and C). In contrast to the incision of the fascia in the first described nseepre, only blunt dissection of the fascia from the prostate is performed. The dissection is gradually directed toward the apex of the prostate while remaining strictly in the midline to avoid injury of the neurovascular bundles (Fig. 3D). The presence of gas in the retroperitoneal space and the laparoscopic magnification are factors facilitating the dissection. When there is doubt for tumor infiltration, frozen section analysis should be performed Dissection of the prostatic pedicles The prostate is now mobilized from its surrounding fascias and is still attached by the pedicles and the apex. During the initial fascial incision ventrolaterally as well as during the blunt dissection of Denonvilliers fascia two planes are created to facilitate prostatic pedicle dissection. The shining surface of the prostatic capsule is clearly seen medially and laterally. The assistant elevates the seminal vesicles ventrally to allow clear exposure of the prostatic pedicle (Fig. 4A). The prostatic pedicles are then clipped and cut step by step (Fig. 4B). Care Fig. 2 Incision of the superficial fascia overlaying the prostate ventrally (A). Anterior bladder-neck dissection (B and C) and lateral bladder-neck dissection (C). pb = pubic bone; pl = puboprostatic ligaments; p = prostate; ef = endopelvic fascia; bl = bladder; bn = bladder neck; c = catheter.

4 934 european urology 53 (2008) Fig. 3 Posterior bladder-neck dissection and dissection of the vas deferentia (A), stripping Denonvilliers fascia from the prostatic capsule (B and C), and dissection of the posterior part of the prostate toward the apex (D). p = prostate; bl = bladder; Dv = Denonvilliers fascia; ef = endopelvic fascia. must be taken to avoid inadvertent injury to the NVB and the pedicles are divided by clipping and cutting in small steps directly on the surface of prostatic capsule (Fig. 4C). When the prostatic pedicles are detached, the prostate is mobilized from the remainder of the periprostatic fascia toward the apex. Blunt dissection is preferred; the assistant retracts the partially mobilized prostate to the opposite side. Finally, the prostate is completely detached from the surrounding fascias, the bladder, prostatic pedicles, and NVBs Ligation of the dorsal venous plexus (Santorini plexus) The next step of the procedure is the ligation of the dorsal venous complex. A 2-0 Vicryl suture on a GS-22 needle (slightly straightened to facilitate needle handling) is guided from left to right between the dorsal venous complex and the anterior urethral wall. Thus, ligation of the Santorini plexus is achieved (Fig. 4D) Dissection of the urethra Sharp dissection of the prostate from the external sphincter and the urethra at the site of apex is then performed [9 13]. The apical dissection is a three-step procedure. It starts with the division of the Santorini plexus (step 1). This is performed from laterally to medially (Fig. 5A), until full division is completed. After the Santorini plexus is divided, the border between the apex of the prostate and the urethra (external sphincter) becomes apparent. The second step is the dissection and division of the junction between the striated part of the urethral sphincter and the apex of the prostate. The dissection is made carefully and converges medially from both sides. The urethra with the external sphincter is dissected from the apex in small carefully performed steps. Finally, the inner smooth (anterior) muscular layer of the urethra is separated (step 3). Dissection of this layer is performed proximally very close to the prostate to preserve the urethral length (Fig. 5B). The urethral catheter is now visible. The assistant pulls the catheter up to expose the lateral and posterior apical limit. Vertical dissection is performed to allow the complete division of the prostate from the posterior urethra. The gland is placed in an endoscopic retrieval bag. The bag is partly retracted through the left iliac fossa trocar site and clamped. The trocar is reinserted adjacent to the bag Vesicourethral anastomosis The vesicourethral anastomosis is carried out with seven to nine interrupted sutures [9 13]. The number of sutures varies based on the size of the opening of the bladder neck. All sutures are placed outside-in at the bladder and insideout at the urethra. Thus, all sutures are tied extra-luminally. The first suture is placed at the 8 o clock position and the next four sutures at the 7, 6, 5, and 4 o clock positions. When the dorsal anastomosis is completed, the catheter is inserted to serve as a guide for the rest of the sutures. Systematic placement of sutures at the 3, 9, 11, and 1 o clock positions is performed (Fig. 5C). The suture used is a 2-0 Vicryl with UR-6 needle. Finally, a 16F Robinson drain is placed through the

5 european urology 53 (2008) Fig. 4 Prostatic pedicle dissection and sparing of the neurovascular bundles (A C), ligation of Santorini plexus (D). p = prostate; pp = prostatic pedicle; ef = endopelvic fascia; nbv = neurovascular bundle; Sp = Santorini plexus; pl = puboprostatic ligaments; r = rectum. 5-mm right iliac fossa port site (Fig. 5D), and the endoscopic bag is retracted through the 12-mm trocar port site Patient selection criteria and evaluation methods Preoperative potency, maximal Gleason score 3+4 (not 4+3), stages T1/T2, and prostate-specific antigen (PSA) level <10 ng/ml were criteria for intrafascial nseerpe. When a palpable tumor was present, frozen section was performed. A small group of patients wishing to definitely undergo nseerpe despite higher Gleason score or PSA level were treated with intrafascial nseerpe. In the latter group, frozen sections were always obtained, even if frozen sections could not show the condition of the entire NVB. Pelvic lymph node dissection as a staging procedure was performed when indicated (PSA >10 ng/ ml and Gleason score >7). Preoperative and postoperative evaluation of continence and erectile function were performed with the use of International Continence Society questionnaire and the International Index of Erectile Function, respectively. A preoperative interview also was conducted. The postoperative follow-up was defined at 3, 6, and 12 mo. Fourteen core prostate biopsies were performed, with 12 core biopsies by referring urologists. 3. 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 for pads. Occasional urine leakage (1 2 pads) during the day with normal activity including walking was classified as minimal stress incontinence. Continence results are shown in Table 2. Of note, the early continence rates (3 mo postoperatively) indicated that 72.7% of the patients were continent, 20% had minimal stress incontinence, and 7.3% required >2 pads/d. Twelve months postoperatively, 94.3% were continent, 4.6% had minimal stress incontinence, and one patient required >2 pads/d. Erections sufficient for intercourse with or without the help of PDE5 inhibitors were reported by 61.2% of the patients who underwent bilateral nseerpe at 6 mo postoperatively (data available for 129 patients) and 79.3% (n = 87 patients) at 12 mo. Potency results are stratified for age in Table 3.

6 936 european urology 53 (2008) Fig. 5 Apical dissection. Dissection of the anterior urethra is performed from laterally to medially (A) and in three steps (B): step 1: dissection of Santorini plexus; step 2: dissection of the apex of the prostate and the urethra with the external sphincter (star), step 3: dissection of the inner smooth muscular layer of the urethra (dot). Urethrovesical anastomosis (interrupted sutures): sequence of stitches (external numbers). (C) The internal numbers show the site of each stitch clockwise. (D) Placement of drainage. p = prostate; u = urethra; nvb = neurovascular bundle; Sp = Santorini plexus; pl = puboprostatic ligaments; bl = bladder. Table 1 Perioperative data Mean age, yr (range) 60.2 (44 75) Preoperative PSA, ng/ml (range) 7.02 ( ) Mean operation time, min (range) 131 (50 210) Transfusion rate 1.3% Conversion rate 0% Mean catheterization time, d (range) 5.9 (4 20) Mean prostate weight, g (range) 42.9 (17 92) gr PSA = prostate-specific antigen. The histologic results are presented in Table 4. Positive surgical margins in pt2 and pt3 tumors were 4.5% and 29.4%, respectively. A total number of four early complications were encountered. Two cases of anastomotic leakage were treated with prolonged catheterization of 1 wk. Two patients with postoperative hematoma causing discomfort underwent endoscopic and open revision. 4. 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 potencyrelated functional results after RP. Efforts are being made to unify the existing terminology of the anatomic structures surrounding the prostate [11,14 18]. Table 2 Continence after intrafascial technique Completely continent 1 2 pads/d >2 pads/d 3 mo postoperatively (n = 150) 72.7% (109 patients) 20% (30 patients) 7.3% (11 patients) 6 mo postoperatively (n = 129) 85.3% (110 patients) 12.4% (16 patients) 2.3% (3 patients) 12 mo postoperatively (n = 87) 94.3% (82 patients) 4.6% (4 patients) 1.1% (1 patient)

7 european urology 53 (2008) Table 3 Functional results (potency) Potency (intercourse) 6 mo postoperatively 12 mo postoperatively Intrafascial nseerpe n = 129 Intrafascial nseerpe n =87 Bilateral nerve-sparing <55 yr 18/23 (78.3%) 26/29 (89.7%) yr 38/69 (55.1%) 30/37 (81.1%) >65 yr 13/37 (35.1%) 13/21 (61.9%) Overall 79/129 (61.2%) 69/87 (79.3%) nseerpe = nerve-sparing endoscopic extraperitoneal radical prostatectomy. Table 4 Histologic results Staging Total no. Gleason score (sum) Positive surgical margin (rate) R1 pt2a n = 20 (13.3%) x PSMs in pt2 6/133 = 4.5% 4+3 pt2b n = 5 (3.3%) pt2c n = 108 (72%) x (5.6%) 4+3 3x pt3a n = 13 (8.6%) x (38.5%) PSMs in pt3 5/17 = 29.4% 4+3 2x pt3b n = 4 (2.6%) x pt4 n = 0 (0%) PSM = positive surgical margin. Costello et al recently showed that most of the NVB descends posteriorly to the seminal vesicle. The nerves pass anteriorly and converge at the midprostatic level and when they approach the apex, diverge again. The anterior and posterior nerves of the NVB are separated by 3 cm at the level of the base of the prostate. At this anatomic site, the cavernosal nerves are not easily distinguished from the surrounding tissues and care should be taken during graft anastomosis for the connection of all nerve endings [16]. Walsh et al proposed that the NVB is enclosed within the two layers of a lateral pelvic fascia composed of the lateral layer of the levator fascia and a medial one of the prostatic fascia. Moreover, the same group advocated the preservation of the prostatic fascia on the prostate during the performance of a nerve-sparing procedure [14]. According to the experience gained with robotic prostatectomy, Menon et al stated that the NVBs are located between the layers of the periprostatic fascia and the anterior layers of Denonvilliers fascia forming a triangular-shaped tunnel. The authors propose that the periprostatic fascia must be incised anterior and parallel to Table 5 Comparison of potency results of standard nseerpe and intrafascial nseerpe Potency (intercourse) 12 mo postoperatively Standard nseerpe n = 186 [30] Intrafascial nseerpe n =87 Bilateral nerve-sparing <55 yr 27/34 (79.4%) 26/29 (89.7%) yr 80/109 (72.5%) 30/37 (81.1%) >65 yr 19/43 (44.2%) 13/21 (61.9%) Overall 126/186 (67.7%) 69/87 (79.3%) nseerpe = nerve-sparing endoscopic extraperitoneal radical prostatectomy.

8 938 european urology 53 (2008) the NVBs to perform a nerve-sparing procedure [15]. Kiyoshima et al proved that the NVB is located on the posterolateral region of the prostate in 48% of the patients. In the rest of the patients (52%) the NVB is widely distributed on the entire lateral aspect of the prostate without any specific localization. Thus, the authors proposed the wide dissection of the lateral aspect of the prostate during radical prostatectomy to preserve the NVB. In addition, the authors described the lateral pelvic fascia as a multilayer fascia connected to the prostate capsule with collagen fibers. The site and the localization of the NVB are considered by this group to be related to the degree of fusion between prostate capsule and lateral pelvic fascia [18]. We favor the hypothesis of one pelvic fascia (endopelvic fascia) covering the prostate and bladder. The fascia is attached to the pubic bone and forms the puboprostatic ligaments. The incision of the endopelvic fascia during the intrafascial nseerpe takes place only ventrally and medially to the puboprostatic ligaments. Careful dissection of the prostate laterally from its thin surrounding fascia (periprostatic fascia) probably results in preservation of the small nerves and vessels contained in the fascias. There is a tendency by the groups performing intrafascial nerve-sparing technique to attempt a dissection as close to the prostatic capsule as possible. Even though the definition of fascial layers is not yet clear, there is certainly a plane of dissection between the prostate and the surrounding tissues. The role of the lateral nerves in continence or erectile function is also unclear. The presence of nerves is well proven and an attempt to maintain as many nerves as possible without compromising the oncologic outcome seems of value [11,15,18]. The intrafascial nseerpe provides results (early complication rate) that are at least similar to those published in the literature. Lein et al in a series of 1000 patients and median follow-up of 28.8 mo reported an intraoperative and early complication rate of 11.8% [19]. Remzi et al in a prospective study comparing laparoscopic extraperitoneal, transperitoneal RP, and open RRP showed that full continence during the 12-mo follow-up was achieved in 88%, 85%, and 81% of patients, respectively ( p = 0.2) [8]. Others have reported 6-mo postoperative complete continence rates of 76% and 86%, respectively, with laparoscopic techniques [20,21]. Mattei et al in a recent report of their robotic tension-free experience showed that 1 wk after catheter removal, complete early urinary continence was achieved in 80% of patients. In addition, at the 4-mo follow-up, 92.4% of them were completely continent, 5.4% used 1 pad/d, and 2.2% used 2 pads/d [22]. Potency results of unilateral and bilateral nervesparing open RRP are reported to be variable among different centers and reach up to 86% at 12 mo postoperatively in younger patients, with bilateral nerve-sparing and the use of PDE5 inhibitors [3,23 26]. Anastasiadis et al reported potency rates at 12 mo after LRP (n = 230) and open retropubic prostatectomy (n = 70) of 30% and 41%, respectively. After preservation of one or both NVBs, the potency rates increased from 37% to 44% for the retropubic approach and from 46% to 53% for the LRP, respectively. Patients younger than 60 yr who underwent bilateral NVB preservation were reported to be potent in 72% and 81% of the cases, respectively [2]. Graefen et al [26] reported rates of erections at 12 mo after bilateral RRP in men <55 yr, yr, and >65 yr of 96.5%, 90.7%, and 84.3%, and rates of intercourse of 69.0%, 52.8%, and 37.3%, respectively. Savera et al [27] revealed that 96% of 154 patients who had veil of Aphrodite nerve-sparing roboticassisted radical prostatectomy (VA RARP) reported having intercourse at 1 yr, whereas 71% recovered to normal erectile function. An interesting comparison of the previously described nseerpe and the intrafascial nseerpe is shown in Table 5. After RRP, the overall rate of positive surgical margin rate reported by Barrè was 7.8% (pt2 = 3.7%, pt3 = 17.4%) [3]. The oncologic data of 1000 LRPs at the Montsouris Institute revealed positive surgical margin rates of 6.9% for pt2a and 34% for pt3b tumors [4]. Touijer et al tried to evaluate the effect of a continuous quality improvement program on the positive surgical margin rate after LRP. They showed that the predicted probability for a positive surgical margin falls from 17.3% for the first patient to 7.5% for the 301st [28]. Atug et al reported a decreaseintherateofpositivesurgicalmargins from 45.4% in the first 33 cases to 11.7% in the last 34 cases (total 100 cases of RARP) [29]. All anterolateral zones, which represent the planes of periprostatic fascias, were negative for tumor and a 6.6% capsular incision rate was observed by Savera et al (VA RALP) [27]. 5. 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.

9 european urology 53 (2008) 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 Figs Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi: / j.eururo and via com. Subscribers to the printed version will find the supplementary data attached (DVD). References [1] Rassweiler J, Schulze M, Teber D, Seemann O, Frede T. Laparoscopic radical prostatectomy: functional and oncological outcomes. Curr Opin Urol 2004;14: [2] Anastasiadis AG, Salomon L, Katz R, Hoznek A, Chopin D, Abbou C. Radical retropubic versus laparoscopic prostatectomy: a prospective comparison of functional outcome. Urology 2003;62: [3] Barré C. Open radical retropubic prostatectomy. Eur Urol 2007;52: [4] Guillonneau B, el-fettouh H, Baumert H, et al. 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