1Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032, China; 2Department of Oncology, Shanghai Medical College, Fudan University
Abstract：Objective: Nerve-sparing is one of the three goals in radical prostatectomy (RP). For low-risk prostate cancer, effective nerve-sparing is central to anatomically RP. The study is to optimize the surgical techniques of intrafascially laparoscopic RP through learning surgical video and pathological section. Methods: Twenty patients with low risk prostate cancer (PSA<10 μg/L, Gleason Score 3+3, T2a-b) and normal erectile function were given intrafascial laparoscopic RP in 2014. Anatomical structures in surgery were analyzed via comparing the anatomical level between surgical video and pathological section. Three months after operation, erectile function was assessed according to the International Index of Erectile Function (IIEF). Results: By comparing and analyzing surgical video and pathological section, the operative skills were summarized as follows: 1. Pulling prostate and then exposing and cutting the collateral ligament fixing prostate at the place of 5:00 and 7:00. 2. Drawing prostate and neurovascular bundle (NVB) to form "prostate-NVB" angle, then separating prostate and NVB along with prostate. 3. Stripping prostate fascia in the inside of NVB vein with pull technique and cutting it at the place of 3:00 and 9:00. 4. Expanding "prostate-NVB" angle and operational space with rotating prostate to identify and loose NVB. 5. Dissociating and exposing urethra to the side of prostate to avoid the damage of distal NVB after cutting off DVC. 6. Cutting the anterior wall of urethra and rotating prostate, and then taking care of prostate contour to avoid positive incisal margin. All of PSA value decreased to <0.2 μg/L with the median value of 0.015 μg/L. Fourteen patients still have reserved erectile function, and 18 patients only used less than one nappy everyday after 3 months. Conclusions: The surgical techniques in intrafascial laparoscopic RP were constantly optimized by means of comparing the anatomical level between surgical video and pathological section and analyzing the postoperative erectile function.
[1]Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin, 2015,65(1):5-29. [2]Cao DL, Ye DW, Zhang HL, et al. A multiplex model of combining gene-based, protein-based, and metabolite-based with positive and negative markers in urine for the early diagnosis of prostate cancer. Prostate, 2011,71(7):700-710. [3]Zhu Y, Wang HK, Qu YY, et al. Prostate cancer in East Asia: evolving trend over the last decade. Asian J Androl, 2015,17(1):48-57. [4]叶定伟,朱耀.中国前列腺癌的流行病学概述和启示.中华外科杂志,2015(4):249-252. [5]Zhu Y, Han CT, Chen HT, et al. Influence of age on predictiveness of genetic risk score for prostate cancer in a Chinese hospital-based biopsy cohort. Oncotarget, 2015,6(26):22978-22984. [6]Walsh PC. Radical prostatectomy for the treatment of localized prostatic carcinoma. Urol Clin North Am, 1980,7(3):583-591. [7]Walsh PC, Jewett HJ. Radical surgery for prostatic cancer. Cancer, 1980,45(7 Suppl):1906-1911. [8]Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol, 1982,128(3):492-497. [9]Greco F, Wagner S, Hoda MR, et al. Laparoscopic vs open retropubic intrafascial nerve-sparing radical prostatectomy: surgical and functional outcomes in 300 patients. BJU Int, 2010,106(4):543-547. [10]Galfano A, Ascione A, Grimaldi S, et al. A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery. Eur Urol, 2010,58(3):457-461. [11]Stolzenburg JU, Kallidonis P, Do M, et al. A comparison of outcomes for interfascial and intrafascial nerve-sparing radical prostatectomy. Urology, 2010,76(3):743-748. [12]Stewart GD, El-Mokadem I, Mclornan ME, et al. Functional and oncological outcomes of men under 60 years of age having endoscopic surgery for prostate cancer are optimal following intrafascial endoscopic extraperitoneal radical prostatectomy. Surgeon, 2011,9(2):65-71. [13]Greco F, Hoda MR, Wagner S, et al. Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients. BJU Int, 2011,108(4):583-587. [14]Neill MG, Louie-Johnsun M, Chabert C, et al. Does intrafascial dissection during nerve-sparing laparoscopic radical prostatectomy compromise cancer control? BJU Int, 2009,104(11):1730-1733. [15]Khoder WY, Buchner A, Siegert S, et al. Oncological and functional results of open intrafascial radical prostatectomy. Urologe A, 2011,50(9):1106-1109.
