A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer （PCa） underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1.2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients （age 65 years） and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates I year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.

Current status of laparoscopic and robotassisted nerve-sparing radical cystectomy in male patients

During radical cystectomy(RC),the neurovascular bundles are easily removed or damaged,leading to varying rates of incontinence and erectile dysfunction.The nervesparing technique was developed to preserve urinary and erectile function.The adoption of laparoscopic and robot-assisted technology has improved visualization and dexterity of pelvic surgeries,thus facilitate the nerve-sparing technique.Although nerve-sparing RC is technically similar with nerve-sparing radical prostatectomy,there are still some anatomical differences.There are mainly three different types of nerve-sparing techniques.Pelvic lymph node dissection(PLND)is another important factor to influence erectile function and urinary continence.Nerve-sparing laparoscopic radical cystectomy(LRC)and robot-assisted radical cystectomy(RARC)may be an optimal treatment choice in well-selected younger patients with lowvolume,organ-confined disease.We should attempt to do,whenever possible,a nerve-sparing cystectomy at least on oneside.However,due to the need of a well-refined surgical technique,nerve-sparing LRC and RARC is now being performed only by experienced urological surgeons.

Nerve-sparing robot-assisted radical prostatectomy:Current perspectives

Robotic-assisted radical prostatectomy(RARP)is the current standard of care with long term cure in organ-confined disease.The introduction of nerve-sparing(NS)to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes.This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes,the neurovascular bundle(NVB),various NS techniques and postoperative functional outcomes.A non-systematic review was done using PubMed,Embase and Medline databases to retrieve and analyse articles in English,with following keywords“prostate cancer”,“robotic radical prostatectomy”,“nerve-sparing”.The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies.The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other.Variables such as preoperative risk assessments,baseline potency,surgical anatomy of individual patients and surgeons’expertise play a major role in the outcomes.A tailored approach for each patient is required for applying the NS approach during RARP.

Impact of penile rehabilitation with low-dose vardenafil on recovery of erectile function in Japanese men following nerve-sparing radical prostatectomy

Erectile dysfunction （ED） is a major complication after radical prostatectomy （RP）; however, debatecontinues regarding the efficacy of penile rehabilitation in the recovery of the postoperative erectile function （EF）. This study includeda total of 103 consecutive sexually active Japanese men with localized prostate cancer undergoing nerve-sparing RP, and analyzed the postoperative EF, focusing on the significance of penile rehabilitation. In this series, 24 and 79 patients underwent bilateral and unilateral nerve-sparing RPs, respectively, and 10 or 20 mg of vardenafil was administered to 35 patients at least once weekly, who agreed to undergo penile rehabilitation. Twelve months after RP, 48 （46.6%） of the 103 patients were judged to have recovered EF sufficient for sexual intercourse without any assistance. The proportion of patients who recovered EF in those undergoing penile rehabilitation （60.0%） was significantly greater than that in those without penile rehabilitation （38.2%）. Of several parameters examined, the preoperative International Index of Erectile Function-5 （IIEF-5） score and nerve-sparing procedure were significantly associated with the postoperative EF recovery rates in patients with and without management by penile rehabilitation, respectively. Furthermore, univariate analysis identified the preoperative IIEF-5 score, nerve-sparing procedure and penile rehabilitation as significant predictors of EF recovery, among which the preoperative IIEF-5 score and nerve-sparing procedure appeared to be independently associated with EF recovery. Considering these findings, despite the lack of independent significance, penile rehabilitation with low-dose vardenafil could exert a beneficial effect on EF recovery in Japanese men following nerve-sparing RP.

The Outpatient Burch-Sling Procedure: A Nerve-Sparing Method for Correcting Female Urinary Incontinence

Conventional methods to treat urinary stress incontinence, including the Sling, Burch, and Pereyra modification methods, are limited by several shortcomings due to disrupted nerve and vaginal wall integrity. The nerve-sparing Burch-Sling method represents a surgical advancement through the use of a nerve-sparing sling to treat genuine stress urinary incontinence. The procedure involves retropubic urethropexy using the FDA-approved Burch-Sling device. In this technique, the vagina is elevated bilaterally at the urethrovesical junction to the mid-urethra toward Cooper’s ligament above the base of the bladder. Then, the anterior vaginal wall and fascia are used as an endogenous suburethral sling without dissection. Two hundred twenty cases were included in this study;two hundred patients underwent the outpatient nerve-sparing sling method, and the other twenty underwent the novel abdominal Burch method. There were no major complications. The follow-up duration ranged from 6 months to eight years. All procedures were performed at the U.S. Women’s Institute at a 400-bed hospital in Fountain Valley, CA.

Evaluation of pelvic visceral functions after modified nerve-sparing radical hysterectomy

Background Nerve-sparing radical hysterectomy （NSRH） was developed in an attempt to minimize complications after radical hysterectomy.Since 2008,a modified NSRH-nerve plane-sparing radical hysterectomy （NPSRH） has been developed at the Cancer Hospital,Chinese Academy of Medical Sciences.The aim of this study was to investigate the role of NPSRH in improving postoperative pelvic visceral dysfunctions.Methods Eighty-three patients with International Federation of Gynecology and Obstetrics （FIGO） stage IB1-IIA2 cervical cancer received NPSRH （the study group） from January 2008 to October 2012.One hundred and sixty-six patients who underwent conventional radical hysterectomy （CRH） were randomly selected as the control group.Age,pathological type and stage were matched between the two groups.The safety of surgery was assessed by duration of operation and blood transfusion rate.Postoperative short-term bladder function was analyzed by duration of catheterization.Long-term bladder,anorectal and sexual function were evaluated with questionnaires.Results Seventy-eight patients （94.0%） in the NPSRH group and one hundred and sixty patients （96.4%） in the CRH group completed the study.Median follow-up time was 31.9 months and 31.0 months respectively （P=0.708）.There was no significant difference between the two groups in terms of age,body mass index,FIGO stage,pathologic type,preoperative and postoperative therapy （P 〉0.05）.The blood transfusion rate shared no difference between two groups （P=0.364）.The operation time in the NPSRH group was significantly longer than CRH group （P 〈0.01）.But the duration of catheterization and hospitalization in the NPSRH group was significantly reduced compared with CRH group （P 〈0.01）.In addition,the incidence of long-term urinary frequency,urinary incontinence,urinary retention,straining to void,constipation and diarrhea was significantly lower in the NPSRH group （P 〈0.05）.However,there was no significant difference regarding sexual function （P 〉0.05）.Conclusions The current evidence indicated that NPSRH improved long-term bladder function compared to CRH.Moreover,it may improve long-term anorectal function as well.

Intermediate-term oncological and functional outcomes in prostate cancer patients treated with perineal robot-assisted radical prostatectomy:A single center analysis

Objective:In the last 10 years,robotic platforms allowed to resume of some alternative surgical approaches,including perineal robot-assisted radical prostatectomy(p-RARP).Herein,we present in detail the oncological and functional outcomes of patients who underwent p-RARP with a median follow-up of 30 months.Methods:Patients presenting low-or intermediate-risk prostate cancer and prostate volume up to 60 mL who underwent p-RARP between November 2018 and November 2022 were selected.Baseline,intraoperative,pathological,and postoperative data were collected and then analyzed.Results:Thirty-seven p-RARP cases were included.Such patients presented mean age of 62 years and a mean Charlson comorbidity index of 4.Body mass index of≥25 kg/m^(2)was reported by 24(64.9%)patients,as well as 7(18.9%)patients reported a past surgical history.Mean prostate volume and median prostate-specific antigen were 41 mL and 6.2 ng/mL,respectively.The median operative time was 242 min.The positive surgical margin rate was 45.9%.In terms of postoperative complications,10 patients reported complications with any grade;however,a single case(2.7%)of major(Clavien-Dindo grade≥3)complication was observed.No patient with biochemical recurrence or distant metastasis was reported at 2 years of follow-up.Recovery of continence rates were 67.6%,75.7%,and 92.9%,at 6 months,12 months,and 24 months after surgery,respectively.

Quality of life in rectal cancer surgery:What do the patient ask?

Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision(TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques(pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.

Influence of bladder neck suspension stitches on early continence after radical prostatectomy： a prospective randomized study of 180 patients

Several techniques have been introduced to improve early postoperative continence. In this study, we evaluated the impact of bladder neck （vesicourethral anastomosis） suspension on the outcome of extraperitoneal endoscopic radical prostatectomy （EERPE）. In this research, a total of 180 patients underwent EERPE. Group 1 included patients who underwent nerve-sparing EERPE （nsEERPE） （n=45）, and Group 2 included patients who underwent nsEERPE with bladder neck suspension （BNS, n=45）. Groups 3 （n=45） and 4 （n=45） included patients who received EERPE and EERPE with BNS, respectively. Patients were randomly assigned to receive BNS with their nsEERPE or EERPE procedure. Perioperative parameters were recorded, and continence was evaluated by determining the number and weight of absorbent pads （pad weighing test） on the second day after catheter removal and by a questionnaire 3 months postoperatively. Two days after catheter removal, 11.1% of Group 1, 11.1% of Group 2, 4.4% of Group 3 and 8.9% of Group 4 were conti nent. The average urine loss was 80.4, 70.1, 325.0 and 291.3 g for the each of these groups, respectively. At 3 months, 76.5% of Group I and 81.3% of Group 2 were continent. The continence figures for Group 3 and 4 were 48.5% and 43.8%, respectively. Similar overall rates were observed in all groups. In conclusion, although there are controversial reports in the literature, early continence was never observed to be significantly higher in the BNS groups when compared with the non-BNS groups, regardless of the EERPE technique performed.

A prospective randomized controlled study on scheduled PDE5i and vacuum erectile devices in the treatment of erectile dysfunction after nerve sparing prostatectomy

Cavernous nerve injury is an important cause of erectile dysfunction(ED).Although protective nerve technology has been widely used in nerve-sparing radical prostatectomy(nsRP),the incidence of ED is still very high after surgery.The purpose of our study was to evaluate erectile function(EF)and penile length in the non-erectile state(PLNES)following scheduled phosphodiesterase 5 inhibitor(PDE5i),vacuum erectile device(VED)treatment,and combination therapy after nsRP.One hundred patients with localized prostate cancer and normal EF were randomized to scheduled PDE5i group,VED treatment group,a combined treatment group,and the control group without any intervention.The International Index of Erectile Function-5(IIEF-5)scores and PLNES were evaluated after 6 months and 12 months of treatment.Sexual Encounter Profile(SEP-Question 2 and SEP-Question 3)were evaluated after 12 months of treatment.Ninety-one of the 100 randomized patients completed the study.We found that the 5 mg tadalafil once a day(OaD)combined with VED can help improve IIEF-5 scores in nsRP patients after both 6 months and 12 months.VED alone or combined with tadalafil OaD can help patients maintain PLNES.VED combined with tadalafil OaD can improve the rate of successful penetration(SEP-Question 2)after 12 months.There were no significant differences in the return to target EF after 12 months among the groups.No significant correlation was noted between the variables and return to target EF(IIEF≥17),and between the variables and effective shortening of the patient’s penis(shortening≥1 cm)after 12 months of intervention.