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HYDRODISSECTION OF PELVIC FASCIA DURING NERVE-SEMINAL SPARING RADICAL PROSTATECTOMY: HYSTOLOGICAL AND FUNCTIONAL RESULTS
707
708
RESULTS OF A RANDOMISED PLACEBO-CONTROLLED PHASE-III MULTICENTRE TRIAL IN NON-NEUROGENIC CHILDREN SUFFERING FROM OVERACTIVE BLADDER AND URINARY INCONTINENCE
THERAPY FAILURE AFTER BOTULINUM NEUROTOXIN TYPE A (BONT/A) DETRUSOR INJECTIONS IN CHILDREN/ ADOLESCENTS: PRELIMINARY RESULTS OF THE FIRST BONT/A- ANTIBODY STUDY
Marschall-Kehrel D.1, Persson De Geeter C.2, Stehr M., Vseticka J.4, Ionescu S.5, Sillen U.6, Radmayr C.7, Feustel C.8
Schulte-Baukloh H.1, Herholz J.1, Bigalke H.2, Miller K., Knispel H.H.1 6W +HGZLJ +RVSLWDO &KDULW« 0HGLFDO 6FKRRO +XPEROGW 8QLYHUVLW\ %HUOLQ 'HSW RI Urology, Berlin, Germany, 2Medical School of Hanover, Institute of Toxikology, Hanover, Germany, 8QLYHUVLW\ +RVSLWDO &KDULW« &DPSXV %HQMDPLQ )UDQNOLQ 'HSW RI 8URORJ\ Berlin, Germany
1 1 Praxis, Dept. of Urology, Frankfurt, Germany, 2Klinikum Kassel GmbH, Dept. of Urology, Essen, Germany, Dr. von Haunersches Kinderhospital, Kinderchirurgische Klinik und Poliklinik, Munich, Germany, 46RXNURP£ 8URORJLFN£ $PEXODQFH 3ROLNOLQLND , 'HSW RI 8URORJ\ -DEORQHF QDG 1LVRX Czech Republic, 5Clinical Emergency Children Hospital “M.S.Curie”, Surgery - Orthopedics, Bucharest, Romania, 6Queen Silvia Children’s Hospital, Paediatric Urology Section, Gothenburg, Sweden, 7 Universitätskliniken LKH Innsbruck, Paediatric Urology, Innsbruck, Austria, 8APOGEPHA Arzneimittel GmbH, Clinical Research, Dresden, Germany
Introduction & Objectives: Antimuscarinics are well established in the medical therapy of children VXᚎHULQJ IURP RYHUDFWLYH EODGGHU DQG XULQDU\ LQFRQWLQHQFH 7KH IROORZLQJ VWXG\ ZDV FRQGXFWHG WR FRQᚏUPWKHVXSHULRULW\DVZHOODVWKHWROHUDELOLW\DQGVDIHW\SURᚏOHRISURSLYHULQHFRPSDUHGWRSODFHER in these patients. Material & Methods: For this phase-III randomized, double-blind placebo-controlled multicentre trial a parallel-group design was selected in order to compare propiverine to placebo in children between DQG\HDUVVXᚎHULQJIURPLQFRQWLQHQFHDQGRYHUDFWLYHEODGGHU$IWHUFRPSOHWHXURORJLFDOEDVHOLQH diagnostics (patients history, physical examination, bladder diary, sonography, measurement of residual XULQHDQGXURᚐRZLISRVVLEOHZLWK(0* DZHHNSHULRGRIXURWKHUDS\ZDVLQWURGXFHG GHWDLOHGOLIHVW\OH advice, a diary appropriate for children). After re-evaluation of in- and exclusion criteria and central HYDOXDWLRQRIWKHXURᚐRZRQO\FKLOGUHQIXOᚏOOLQJWKHUHTXHVWHGLQDQGH[FOXVLRQFULWHULDUHFHLYHGDERG\ weight-adjusted medical therapy (10 or 15 mg b.i.d. propiverine or placebo) for 8 weeks. Results: 171 children were randomised to therapy after re-evaluation. Overall 87 children were treated ZLWKSURSLYHULQH ER\VJLUOV DQGZLWKSODFHER ER\VJLUOV 7KHPHDQ DJH ZDV \HDUV WKH PHDQ %0, NJPt %RWK VH[ JURXSV GLG EHQHᚏW IURP WKH WUHDWPHQW ZLWK SURSLYHULQH7KHPLFWXULWLRQIUHTXHQF\ZLWKLQKRXUV SULPDU\REMHFWLYH ZDVLPSURYHGVLJQLᚏFDQWO\ZLWK -2.0 episodes for propiverine compared to – 1.2 episodes for placebo (p=0.0007). Incontinence episodes within 7 days were reduced -2.8 times with propiverine versus -1.17 times with placebo (p=0.0002). A strong increase in the mean voided volume (p=0.0001) was recorded for children treated with propiverine PO YHUVXVSODFHER PO 7KHLQYHVWLJDWRUVHYDOXDWHGWKHVXFFHVVUDWHIRUSURSLYHULQHYHUVXV SODFHER YHU\ JRRG DQG JRRG DIWHU ZHHNV RI WKHUDS\ ZLWK FRPSDUHG WR RQO\ 7KH SRVLWLYH HᚎHFW IRU DOO HᚑFDF\ SDUDPHWHUV ZDV VHHQ LQ ERWK GRVH JURXSV DV ZHOO DV LQ ERWK JHQGHUV Propiverine was very well tolerated in the applied doses of 10 or 15 mg twice daily, whereas the total QXPEHURIVLGHHᚎHFWVZDVFRPSDUDEOHWRSODFHER YHUVXV Conclusions: 7KLV LV WKH ᚏUVW *&3FRQIRUP WULDO LQ QRQQHXURJHQLF FKLOGUHQ VXᚎHULQJ IURP 2$% DQG urinary incontinence which could show superiority of an antimuscarinic over placebo. The positive RXWFRPH IRU DOO HᚑFDF\ SDUDPHWHUV ZDV VXSSRUWHG WKURXJK D WKRURXJK WULDO GHVLJQ DQG SUHYLRXV XURWKHUDS\ IRU DOO FKLOGUHQ SULRU WR UDQGRPLVDWLRQ 2QO\ FKLOGUHQ VXᚎHULQJ IURP 2$% DQG XULQDU\ incontinence without suspicion of other underlying LUT symptoms (e.g. dysfunctional voiding) received a body-weight-adjusted medical therapy with propiverine or corresponding placebo.
P43 RADICAL PROSTATECTOMY: TECHNICAL AND PATHOLOGICAL ISSUES Friday, 28 March, 12.15-13.45, Black Hall
Introduction & Objectives: Botulinum toxin type A (BoNT/A) has been demonstrated to be an alternative therapy for detrusor overactivity of neurogenic origin. In our clinic, the indication for detrusor BoNT/A injection is made when anticholinergic treatment has failed to suppress detrusor overactivity in children/adolescents with neurogenic bladders that are otherwise threatened by surgical procedures. Unfortunately, BoNT/A therapy may not always be successful. To better understand detrusor response to BoNT/A, we investigated the presence of BoNT/A antibodies (BoNT/A-AB) and correlated the SUHVHQFHRIDQWLERGLHVZLWKFOLQLFDOᚏQGLQJV Material & Methods: :HHYDOXDWHGSDWLHQWV DJH \HDUV DYHUDJH\HDUV for the presence of BoNT/A-AB who previously underwent BoNT/A detrusor injections for detrusor overactivity. BoNT/A-AB were detected using a mouse diaphragm assay (the most sensitive assay for detection of BoNT/A-AB) before and within 4 months after the last injection. Clinical outcomes regarding urinary continence, urodynamic studies and VXEMHFWLYHRSLQLRQRIWKH%R17$LQMHFWLRQVHVVLRQZHUHGHWHUPLQHGXVLQJDQHᚑFDF\ VFDOH YHU\JRRG JRRG PRGHUDWHDQG QRHᚑFDF\ Results: The patients received up to 8 BoNT/A detrusor injection sessions (median &OLQLFDOO\RXWRISWVGHPRQVWUDWHGIDLOXUHWR%R17$WKHUDS\ VFRUHGRU RQHᚑFDF\VFDOH SWVKDGORZFRPSOLDQWDQGVWLᚎEODGGHUVUHTXLULQJDXJPHQWDWLRQ F\VWRSODVWLHV SWVGHYHORSHGWHWKHUHGFRUGV SWVKDGQRFOLQLFDOUHDVRQVIRUWKHUDS\ failure after 7 and 8 BoNT/A injections. In the 2 pts without any clinical reason for treatment failure, BoNT/A-AB titers were detected while the BoNT/A-AB titers in all other patients were negative. Conclusions: BoNT/A-AB may develop after repeated BoNT/A detrusor injections, and these antibodies may lead to therapy failure. In patients that fail to respond to BoNT/A detrusor injections and have no obvious other causes (e.g. a tethered cord syndrome or a low compliance bladder), our preliminary studies suggest that the presence of BoNT/ A-AB should be investigated.
709
710
TRANSRECTAL ULTRASOUND ASSESSMENT OF THE STRIATED URETHRAL SPHINCTER BEFORE AND AFTER RADICAL RETRO PUBIC PROSTATECTOMY
HYDRODISSECTION OF PELVIC FASCIA DURING NERVE-SEMINAL SPARING RADICAL PROSTATECTOMY: HYSTOLOGICAL AND FUNCTIONAL RESULTS
Ferruti M., Carmignani L., Acquati P., Gadda F., Dell’Orto P.G., Casellato S., Galasso G., Paparella S., Zanetti G., Rocco F.
Mari M., Ambu A., Guercio S., Mangione F., Bellina M.
Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena - IRCCS, Dept. of Urology, Milan, Italy Introduction & Objectives: The possibility of clearly visualizing the striated sphincter of the urethra with a repeatable procedure could prove particularly useful in improving the diagnostic GHᚏQLWLRQ RI LQFRQWLQHQFH IROORZLQJ UDGLFDO SURVWDWHFWRP\ $LP RI WKLV VWXG\ ZDV WR YHULI\ the possibility of assessing the striated sphincter using transrectal ultrasound, providing a description of objective landmarks that allow for repeatability. Material & Methods: 7ZHQW\WKUHH FRQVHFXWLYH SDWLHQWV VXᚎHULQJ IURP SURVWDWH FDQFHU DQG scheduled to undergo radical prostatectomy were enrolled in the study. Average age was 66.5 yrs., mean PSA was 9.09 ng/ml, mean prostate volume was 60.4 g. All patients underwent a pre-operative transrectal ultrasound and a post-operative ultrasound seven days after surgery, ZKHQ WKH FDWKHWHU ZDV UHPRYHG IXUWKHUPRUH DQ LQWUDRSHUDWLYH WUDQVUHFWDO XOWUDVRXQG VWXG\ ZDVSHUIRUPHGLQWKHᚏUVWFDVHV$Q(VDRWH$8rXOWUDVRXQGGHYLFHZLWKD750K] HQGᚏUHHQGRFDYLW\SUREHZDVXVHGURWDWLQJDQGWLOWLQJWKHSUREHWRJHWD[LDODQGORQJLWXGLQDO scans. Results: ,WZDVSRVVLEOHWRPHDVXUHWKHVWULDWHGVSKLQFWHU WKHORQJLWXGLQDOVHFWLRQVKRZHGD mean length of 14.4 mm (range 11.5-18.5 mm), whereas the axial scans yielded an average PHDVXUHPHQWRIPP UDQJHPP $QLQWUDRSHUDWLYHUHGXFWLRQLQWKHOHQJWKRIWKH striated sphincter was observed, resulting in an average intra-operative length of 7.92 mm (range 7.1-9.4 mm). At the end of the operation, after reconstruction of the sphincter using Rocco’s technique, the striated sphincter presented a triangular shape similar to the native VSKLQFWHUZLWKDQLQFUHDVHGHFKRJHQLFLW\DVLIGXHWRWKHSUHVHQFHRIKHPRUUKDJLFHᚎXVLRQ the suture stitches were particularly hyperechoic and represented an additional landmark. Seven days after surgery, the sphincter could be easily measured and the suture stitches HDVLO\ LGHQWLᚏHG DV SUR[LPDO ODQGPDUN 0HDQ SRVWRSHUDWLYH OHQJWK RI WKH VWULDWHG VSKLQFWHU was 12.8 mm. Conclusions: Description of the striated sphincter using transrectal ultrasound proved possible in all the cases we examined, both prior to and after surgery. Certain ultrasound characteristics were present in all patients, making the procedure and description easy and repeatable by GLᚎHUHQWRSHUDWRUV7KHXVHRI'SUREHVPLJKWEHDEOHWRSURYLGHDQDQDWRPLFDOGHᚏQLWLRQ of the entire structure. Our study showed that the striated sphincter can be visualized by ultrasound both when the prostate is present and after it has been removed, and that it is possible to measure it and assess its characteristics.
Eur Urol Suppl 2008;7(3):248
Ospedale degli Infermi, Dept. of Urology, Rivoli (Turin), Italy Introduction & Objectives: 3UHVHUYDWLRQ RI WKH ᚏEHUV RI OHYDWRU DQL DQG RI WKH pelvic fascia, together with nerve sparing technique, is known to be of importance for urinary continence and sexual function recovery after radical prostatectomy. We present hystologic and functional results of seminal- and nerve sparing radical prostatectomy (SNSRP) with water dissection of the pelvic fascia in order to obtain anatomical preservation of neurovascular bundles. Material & Methods: )URP-DQXDU\WR0DUFKVHOHFWHGSDWLHQWVZLWK FOLQLFDOO\ ORFDOL]HG SURVWDWH FDQFHU *6 36$ QJPO SRVLWLYH FRUH biopsies, age < 72 years, IIEF-5 score > 21) underwent SNSRP. Pelvic fascia was prepared through following steps: a small incision of endopelvic and prostatic fascia on WKHDQWHULRUVXUIDFHRIWKHSURVWDWHLVPDGHELODWHUDOO\RQD3DUDPHGLDQOLQH WKURXJK WKLVLQFLVLRQVVDOLQHLVLQMHFWHGE\DKDQGKHOGV\ULQJHZLWKEOXQWQHHGOH WKHIDVFLDLV then further incised on the Para median line bilaterally, and carefully separated from the prostate by blunt dissection, with neurovascular bundles preservation (intrafascial SURVWDWHFWRP\ &RQWLQHQFHUHVXOWVZHUHHYDOXDWHGPRQWKVSRVWRSHUDWLYHO\ ZHUH considered as continent patients with no need for pads). Sexual function results were evaluated by IIEF-5 questionnaire in patients who reached 12 months follow-up. Results: 3DWLHQWVPHGLDQDJHZDV\HDUV UDQJH 0HGLDQIROORZXSWLPH ZDV PRQWKV UDQJH SDWLHQWV KDG D SRVLWLYH PDUJLQ RQ ᚏQDO KLVWRORJ\ QRELRFKHPLFDOIDLOXUHZDVUHFRUGHGGXULQJIROORZXSWLPH$WPRQWKV SDWLHQWV ZHUHFRQWLQHQW SDWLHQWV ZHUHFRQWLQHQWULJKWIURP FDWKHWHU UHPRYDO SDWLHQWV UHDFKHG PRQWKV IROORZXS SDWLHQWV ZHUH QRW evaluable 11/18 evaluable patients (61%) had valid erections with or without PDE5 inhibitors therapy. Conclusions: Hydrodissection of both pelvic and prostatic fascia during SNSRP allowed in our experience an anatomical preparation of prostatic fascia and an easier preservation of neurovascular bundles, without increasing of positive margin rate.
708
RESULTS OF A RANDOMISED PLACEBO-CONTROLLED PHASE-III MULTICENTRE TRIAL IN NON-NEUROGENIC CHILDREN SUFFERING FROM OVERACTIVE BLADDER AND URINARY INCONTINENCE
THERAPY FAILURE AFTER BOTULINUM NEUROTOXIN TYPE A (BONT/A) DETRUSOR INJECTIONS IN CHILDREN/ ADOLESCENTS: PRELIMINARY RESULTS OF THE FIRST BONT/A- ANTIBODY STUDY
Marschall-Kehrel D.1, Persson De Geeter C.2, Stehr M., Vseticka J.4, Ionescu S.5, Sillen U.6, Radmayr C.7, Feustel C.8
Schulte-Baukloh H.1, Herholz J.1, Bigalke H.2, Miller K., Knispel H.H.1 6W +HGZLJ +RVSLWDO &KDULW« 0HGLFDO 6FKRRO +XPEROGW 8QLYHUVLW\ %HUOLQ 'HSW RI Urology, Berlin, Germany, 2Medical School of Hanover, Institute of Toxikology, Hanover, Germany, 8QLYHUVLW\ +RVSLWDO &KDULW« &DPSXV %HQMDPLQ )UDQNOLQ 'HSW RI 8URORJ\ Berlin, Germany
1 1 Praxis, Dept. of Urology, Frankfurt, Germany, 2Klinikum Kassel GmbH, Dept. of Urology, Essen, Germany, Dr. von Haunersches Kinderhospital, Kinderchirurgische Klinik und Poliklinik, Munich, Germany, 46RXNURP£ 8URORJLFN£ $PEXODQFH 3ROLNOLQLND , 'HSW RI 8URORJ\ -DEORQHF QDG 1LVRX Czech Republic, 5Clinical Emergency Children Hospital “M.S.Curie”, Surgery - Orthopedics, Bucharest, Romania, 6Queen Silvia Children’s Hospital, Paediatric Urology Section, Gothenburg, Sweden, 7 Universitätskliniken LKH Innsbruck, Paediatric Urology, Innsbruck, Austria, 8APOGEPHA Arzneimittel GmbH, Clinical Research, Dresden, Germany
Introduction & Objectives: Antimuscarinics are well established in the medical therapy of children VXᚎHULQJ IURP RYHUDFWLYH EODGGHU DQG XULQDU\ LQFRQWLQHQFH 7KH IROORZLQJ VWXG\ ZDV FRQGXFWHG WR FRQᚏUPWKHVXSHULRULW\DVZHOODVWKHWROHUDELOLW\DQGVDIHW\SURᚏOHRISURSLYHULQHFRPSDUHGWRSODFHER in these patients. Material & Methods: For this phase-III randomized, double-blind placebo-controlled multicentre trial a parallel-group design was selected in order to compare propiverine to placebo in children between DQG\HDUVVXᚎHULQJIURPLQFRQWLQHQFHDQGRYHUDFWLYHEODGGHU$IWHUFRPSOHWHXURORJLFDOEDVHOLQH diagnostics (patients history, physical examination, bladder diary, sonography, measurement of residual XULQHDQGXURᚐRZLISRVVLEOHZLWK(0* DZHHNSHULRGRIXURWKHUDS\ZDVLQWURGXFHG GHWDLOHGOLIHVW\OH advice, a diary appropriate for children). After re-evaluation of in- and exclusion criteria and central HYDOXDWLRQRIWKHXURᚐRZRQO\FKLOGUHQIXOᚏOOLQJWKHUHTXHVWHGLQDQGH[FOXVLRQFULWHULDUHFHLYHGDERG\ weight-adjusted medical therapy (10 or 15 mg b.i.d. propiverine or placebo) for 8 weeks. Results: 171 children were randomised to therapy after re-evaluation. Overall 87 children were treated ZLWKSURSLYHULQH ER\VJLUOV DQGZLWKSODFHER ER\VJLUOV 7KHPHDQ DJH ZDV \HDUV WKH PHDQ %0, NJPt %RWK VH[ JURXSV GLG EHQHᚏW IURP WKH WUHDWPHQW ZLWK SURSLYHULQH7KHPLFWXULWLRQIUHTXHQF\ZLWKLQKRXUV SULPDU\REMHFWLYH ZDVLPSURYHGVLJQLᚏFDQWO\ZLWK -2.0 episodes for propiverine compared to – 1.2 episodes for placebo (p=0.0007). Incontinence episodes within 7 days were reduced -2.8 times with propiverine versus -1.17 times with placebo (p=0.0002). A strong increase in the mean voided volume (p=0.0001) was recorded for children treated with propiverine PO YHUVXVSODFHER PO 7KHLQYHVWLJDWRUVHYDOXDWHGWKHVXFFHVVUDWHIRUSURSLYHULQHYHUVXV SODFHER YHU\ JRRG DQG JRRG DIWHU ZHHNV RI WKHUDS\ ZLWK FRPSDUHG WR RQO\ 7KH SRVLWLYH HᚎHFW IRU DOO HᚑFDF\ SDUDPHWHUV ZDV VHHQ LQ ERWK GRVH JURXSV DV ZHOO DV LQ ERWK JHQGHUV Propiverine was very well tolerated in the applied doses of 10 or 15 mg twice daily, whereas the total QXPEHURIVLGHHᚎHFWVZDVFRPSDUDEOHWRSODFHER YHUVXV Conclusions: 7KLV LV WKH ᚏUVW *&3FRQIRUP WULDO LQ QRQQHXURJHQLF FKLOGUHQ VXᚎHULQJ IURP 2$% DQG urinary incontinence which could show superiority of an antimuscarinic over placebo. The positive RXWFRPH IRU DOO HᚑFDF\ SDUDPHWHUV ZDV VXSSRUWHG WKURXJK D WKRURXJK WULDO GHVLJQ DQG SUHYLRXV XURWKHUDS\ IRU DOO FKLOGUHQ SULRU WR UDQGRPLVDWLRQ 2QO\ FKLOGUHQ VXᚎHULQJ IURP 2$% DQG XULQDU\ incontinence without suspicion of other underlying LUT symptoms (e.g. dysfunctional voiding) received a body-weight-adjusted medical therapy with propiverine or corresponding placebo.
P43 RADICAL PROSTATECTOMY: TECHNICAL AND PATHOLOGICAL ISSUES Friday, 28 March, 12.15-13.45, Black Hall
Introduction & Objectives: Botulinum toxin type A (BoNT/A) has been demonstrated to be an alternative therapy for detrusor overactivity of neurogenic origin. In our clinic, the indication for detrusor BoNT/A injection is made when anticholinergic treatment has failed to suppress detrusor overactivity in children/adolescents with neurogenic bladders that are otherwise threatened by surgical procedures. Unfortunately, BoNT/A therapy may not always be successful. To better understand detrusor response to BoNT/A, we investigated the presence of BoNT/A antibodies (BoNT/A-AB) and correlated the SUHVHQFHRIDQWLERGLHVZLWKFOLQLFDOᚏQGLQJV Material & Methods: :HHYDOXDWHGSDWLHQWV DJH \HDUV DYHUDJH\HDUV for the presence of BoNT/A-AB who previously underwent BoNT/A detrusor injections for detrusor overactivity. BoNT/A-AB were detected using a mouse diaphragm assay (the most sensitive assay for detection of BoNT/A-AB) before and within 4 months after the last injection. Clinical outcomes regarding urinary continence, urodynamic studies and VXEMHFWLYHRSLQLRQRIWKH%R17$LQMHFWLRQVHVVLRQZHUHGHWHUPLQHGXVLQJDQHᚑFDF\ VFDOH YHU\JRRG JRRG PRGHUDWHDQG QRHᚑFDF\ Results: The patients received up to 8 BoNT/A detrusor injection sessions (median &OLQLFDOO\RXWRISWVGHPRQVWUDWHGIDLOXUHWR%R17$WKHUDS\ VFRUHGRU RQHᚑFDF\VFDOH SWVKDGORZFRPSOLDQWDQGVWLᚎEODGGHUVUHTXLULQJDXJPHQWDWLRQ F\VWRSODVWLHV SWVGHYHORSHGWHWKHUHGFRUGV SWVKDGQRFOLQLFDOUHDVRQVIRUWKHUDS\ failure after 7 and 8 BoNT/A injections. In the 2 pts without any clinical reason for treatment failure, BoNT/A-AB titers were detected while the BoNT/A-AB titers in all other patients were negative. Conclusions: BoNT/A-AB may develop after repeated BoNT/A detrusor injections, and these antibodies may lead to therapy failure. In patients that fail to respond to BoNT/A detrusor injections and have no obvious other causes (e.g. a tethered cord syndrome or a low compliance bladder), our preliminary studies suggest that the presence of BoNT/ A-AB should be investigated.
709
710
TRANSRECTAL ULTRASOUND ASSESSMENT OF THE STRIATED URETHRAL SPHINCTER BEFORE AND AFTER RADICAL RETRO PUBIC PROSTATECTOMY
HYDRODISSECTION OF PELVIC FASCIA DURING NERVE-SEMINAL SPARING RADICAL PROSTATECTOMY: HYSTOLOGICAL AND FUNCTIONAL RESULTS
Ferruti M., Carmignani L., Acquati P., Gadda F., Dell’Orto P.G., Casellato S., Galasso G., Paparella S., Zanetti G., Rocco F.
Mari M., Ambu A., Guercio S., Mangione F., Bellina M.
Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena - IRCCS, Dept. of Urology, Milan, Italy Introduction & Objectives: The possibility of clearly visualizing the striated sphincter of the urethra with a repeatable procedure could prove particularly useful in improving the diagnostic GHᚏQLWLRQ RI LQFRQWLQHQFH IROORZLQJ UDGLFDO SURVWDWHFWRP\ $LP RI WKLV VWXG\ ZDV WR YHULI\ the possibility of assessing the striated sphincter using transrectal ultrasound, providing a description of objective landmarks that allow for repeatability. Material & Methods: 7ZHQW\WKUHH FRQVHFXWLYH SDWLHQWV VXᚎHULQJ IURP SURVWDWH FDQFHU DQG scheduled to undergo radical prostatectomy were enrolled in the study. Average age was 66.5 yrs., mean PSA was 9.09 ng/ml, mean prostate volume was 60.4 g. All patients underwent a pre-operative transrectal ultrasound and a post-operative ultrasound seven days after surgery, ZKHQ WKH FDWKHWHU ZDV UHPRYHG IXUWKHUPRUH DQ LQWUDRSHUDWLYH WUDQVUHFWDO XOWUDVRXQG VWXG\ ZDVSHUIRUPHGLQWKHᚏUVWFDVHV$Q(VDRWH$8rXOWUDVRXQGGHYLFHZLWKD750K] HQGᚏUHHQGRFDYLW\SUREHZDVXVHGURWDWLQJDQGWLOWLQJWKHSUREHWRJHWD[LDODQGORQJLWXGLQDO scans. Results: ,WZDVSRVVLEOHWRPHDVXUHWKHVWULDWHGVSKLQFWHU WKHORQJLWXGLQDOVHFWLRQVKRZHGD mean length of 14.4 mm (range 11.5-18.5 mm), whereas the axial scans yielded an average PHDVXUHPHQWRIPP UDQJHPP $QLQWUDRSHUDWLYHUHGXFWLRQLQWKHOHQJWKRIWKH striated sphincter was observed, resulting in an average intra-operative length of 7.92 mm (range 7.1-9.4 mm). At the end of the operation, after reconstruction of the sphincter using Rocco’s technique, the striated sphincter presented a triangular shape similar to the native VSKLQFWHUZLWKDQLQFUHDVHGHFKRJHQLFLW\DVLIGXHWRWKHSUHVHQFHRIKHPRUUKDJLFHᚎXVLRQ the suture stitches were particularly hyperechoic and represented an additional landmark. Seven days after surgery, the sphincter could be easily measured and the suture stitches HDVLO\ LGHQWLᚏHG DV SUR[LPDO ODQGPDUN 0HDQ SRVWRSHUDWLYH OHQJWK RI WKH VWULDWHG VSKLQFWHU was 12.8 mm. Conclusions: Description of the striated sphincter using transrectal ultrasound proved possible in all the cases we examined, both prior to and after surgery. Certain ultrasound characteristics were present in all patients, making the procedure and description easy and repeatable by GLᚎHUHQWRSHUDWRUV7KHXVHRI'SUREHVPLJKWEHDEOHWRSURYLGHDQDQDWRPLFDOGHᚏQLWLRQ of the entire structure. Our study showed that the striated sphincter can be visualized by ultrasound both when the prostate is present and after it has been removed, and that it is possible to measure it and assess its characteristics.
Eur Urol Suppl 2008;7(3):248
Ospedale degli Infermi, Dept. of Urology, Rivoli (Turin), Italy Introduction & Objectives: 3UHVHUYDWLRQ RI WKH ᚏEHUV RI OHYDWRU DQL DQG RI WKH pelvic fascia, together with nerve sparing technique, is known to be of importance for urinary continence and sexual function recovery after radical prostatectomy. We present hystologic and functional results of seminal- and nerve sparing radical prostatectomy (SNSRP) with water dissection of the pelvic fascia in order to obtain anatomical preservation of neurovascular bundles. Material & Methods: )URP-DQXDU\WR0DUFKVHOHFWHGSDWLHQWVZLWK FOLQLFDOO\ ORFDOL]HG SURVWDWH FDQFHU *6 36$ QJPO SRVLWLYH FRUH biopsies, age < 72 years, IIEF-5 score > 21) underwent SNSRP. Pelvic fascia was prepared through following steps: a small incision of endopelvic and prostatic fascia on WKHDQWHULRUVXUIDFHRIWKHSURVWDWHLVPDGHELODWHUDOO\RQD3DUDPHGLDQOLQH WKURXJK WKLVLQFLVLRQVVDOLQHLVLQMHFWHGE\DKDQGKHOGV\ULQJHZLWKEOXQWQHHGOH WKHIDVFLDLV then further incised on the Para median line bilaterally, and carefully separated from the prostate by blunt dissection, with neurovascular bundles preservation (intrafascial SURVWDWHFWRP\ &RQWLQHQFHUHVXOWVZHUHHYDOXDWHGPRQWKVSRVWRSHUDWLYHO\ ZHUH considered as continent patients with no need for pads). Sexual function results were evaluated by IIEF-5 questionnaire in patients who reached 12 months follow-up. Results: 3DWLHQWVPHGLDQDJHZDV\HDUV UDQJH 0HGLDQIROORZXSWLPH ZDV PRQWKV UDQJH SDWLHQWV KDG D SRVLWLYH PDUJLQ RQ ᚏQDO KLVWRORJ\ QRELRFKHPLFDOIDLOXUHZDVUHFRUGHGGXULQJIROORZXSWLPH$WPRQWKV SDWLHQWV ZHUHFRQWLQHQW SDWLHQWV ZHUHFRQWLQHQWULJKWIURP FDWKHWHU UHPRYDO SDWLHQWV UHDFKHG PRQWKV IROORZXS SDWLHQWV ZHUH QRW evaluable 11/18 evaluable patients (61%) had valid erections with or without PDE5 inhibitors therapy. Conclusions: Hydrodissection of both pelvic and prostatic fascia during SNSRP allowed in our experience an anatomical preparation of prostatic fascia and an easier preservation of neurovascular bundles, without increasing of positive margin rate.