- Email: [email protected]
Urinary Continence Following Nerve Sparing Radical Prostatectomy
POTENCY FOLLOWING RADICAL PROSTATECTOMY WITH WIDE UNILATERAL EXCISION OF THE NEUROVASCULAR BUNDLE. Patrick C. Walsh, Jonathan I. Epstein*, and Franklin C. Lowe.* Baltimore, MD
(Presentation to be made by Dr. Walsh). Delineation of the neurovascular bundles (NVB) has made it possible to identify the branches of the pelvic plexus
to the corpora cavernosa intraoperatively and to decide whether the bundles can be preserved or resected widely
with the specimen. In the course of performing 312 radical retropubic prostatectomies, the NVB was widely excised unilaterally in 49 men with advanced clinical disease in whom, based on preoperative or intraoperative assessment, the NVB appeared to be involved by tumor. Because of this selec-
tion criterion, this group of patients had higher clinical
stage (52% were clinical stage B2) and pathologic stage (35% had microscopic involvement of pelvic lymph nodes) than our previously r~ported series. In 38 cases the margins of resection were negative for tumor. In 11 cases, despite attempts at wide excision of the lesion,the surgical margins of resection were positive. In all 11 men there was extensive periprostatic extension of tumor and 8 had involvement of pelvic lymph nodes. In none of the 11 patients with positive surgical margins were the margins positive at the site where the NVB was spared showing that unilateral sparing of the NVB did not compromise removal of tumor. Of the 29 men who were potent preoperatively and who have been followed for one year or longer postoperatively, 20 (69%) are potent, The return of sexual function correlated with age: 100% men 40-49 years of age were potent postoperatively compared to 80% patients 50-59 years of age, and 50% men age 60-69 years. By measuring nerves in the spared region of the NVB we found that the role of the NVB in potency is not due to large nerves, but to many nerves of varying size. In conclusion, potency can be maintained following radical prostatectomy in most patients in whom it is necessary to excise one NVB widely without compromising the removal of tumor.
POTENCY SPARING RADICAL PERINEAL PROSTATECTOMY: ANATOMY, SURGICAL TECHNIQUE AND INITIAL RESULTS. Vernon E. Weldon and Frank R. Tavel, San Rafael, CA (Presentation to be made by Dr. Weldon) This report doscrib~s the anatomy and surgical technique of preservation of the nervi erigentes during radical perineal prostatectomy, and the initial results with this technique. In perineal exposure of the prostate, the historical posterior layer of Denonvilliers' fascia is indistinguishable from the posterior continuation of the lateral pelvic fascia containing the nervi erigentes, which course over the postero-lateral third of the prostate and the lateral aspect of the membranous urethra bilaterally. The detailed operative steps achieving nerve preservation include: (1) Vertical incision and lateral reflection of this pelvic fascia from the posterior prostatic capsule (the anterior layer of Denonvilliers' fascia). (2) Posterior incision of the continuous pelvic fascia containing the laterally located nervi erigentes over the membranous urethra, and shelling out the urethra from the enveloping fascia .before dividing it. (3) Division of the neurovascular pedicles entering the base of the prostate close to the prostatic capsule. Since November, 1984 this technique has been applied to 16 patients with localized prostatic adenocarcinoma immediately following bilateral pelvic lymphadenectomy. Prostates weighing up to 180 grams have been removed. No rectal injuries occurred. All are essentially continent, using no pads. Median total operating time including perineal repositioning was 3 3/4 hours. Median number of blood units transfused was none. Median length of total hospitalization was 7 days. 9 patients were potent pre-operatively, and 5 (56%) are still potent. Radical perineal prostatectomy historically offers a potential cure of localized prostatic adenocarcinoma with a precise vesico-urethral anastomosis associated with a high continence rate, reduced blood loss and morbidity, and may now be offered with a significant chance of preserving potency.
487
488
URINARY CONTINENCE FOLLOWING NERVE SPARING RADICAL PROSTATECTOMY. Pat D. 0' Donnell and Barry Finan, Litt le
EI\RLY ADJUNCI'IVE fDRMJNAL THERAPY IN CLINICALLY IDCALIZED
Rock) AR (Presentation to be made by Dr, Finan) The nerve sparing radical prostatectomy technique is noted for functional preservation of potency following surgery. In this study, urinary continence was compared in 68 consecutive patients undergoing a radical prostatectomy. In )Li. patients; a conventional radical prostatectomy was performed and in 34 subsequent patients a nerve sparing operation was done. The patient population, the clinical environment, and staff surgeons were the same throughout the study. The age of the patients in each group) the Gleason score of the tumor, the stage of the tumor, and the operative time were not significantly different between groups. In the nerve sparing group, there was one operative death due to a postoperative pulmonary embolus and 33 patients were evaluated. In the conventional operated group, there were 4 patients with total incontinence (12%) and 6 patients (18%) with stress incontinence requiring absorbent pads. In the nerve sparing group, there were no patients having total urinary incontinence and 2 patients (6%) had stress incontinence requiring absorbent pads Functional urethral length and peak urethral pressure profile were measured postoperatively in· all patients using a dual channel microtipped Millar urethral pressure profile catheter. The postoperative functional urethral length in the conventional group was 1.9cm (SD=0.6) and in the nerve sparing group was 2.3cm (SD=0.5) showing a significant difference between the two groups (p (.05). The peak resting urethral pressure of the conventional group was 35.4cm H20 (SD=l4.2) and in
Mitchell C. Benson, Gerald Hoke*, and Ralph J. Veenema, New York City, New York (Presentation to be made by Dr. Benson) The timing of honnon.al therapy in t_he treatment of prostate cancer remains controversial. Additionally, what role, if any, honronal therapy should play in t_he treatment of regional disease has yet to be determined. We had the opportunity to review a large group of patients undergoing radical prostatectorny in an era in which adjunctive orchiectomy was routine in our institution. A retrospective study of 132 patients with clinically localized prostatic cancer treated by radical retropubic prostatectomy (RRP) and orchiectomy from O to 3 months from the time of surgery was perform9d to determine the effect on survival, Patients underwent surgery from 1952 to 1979 with a rrean follow-up of 11 years. Lyrnphadenectomy was not performed in anv case. Pathologic staging revealed 12 patients stage A-2, 34 patients stage B-1, 42 patients stage B-2 and 40 patients stage C. Patients with disease pathologically limited to the prostate (stage A-2 - B-2) experienced an 85% 10 year and 49% 15 year survival. This approxirrates the actuarial survival for men in this age group and does not substantially differ from other recently published series of RRP. Patients with stage C disease experienced an 62% 10 vear and 35% 15 vear survivaL Even when patients lost to follow-up-,,ere considered dead from prostatic cancer, there 110.s still a 52% 10 year and 25% 15 year survival. While not a controlled prospective study, the finding of an apparently inproved survival in pathologic stage C prostatic cancer suggests that the initiation of per;~perative androgen deprivation may prolong survival rn this patient population.
o
the nerve sparing group was 46.5cm H20 (SD=l2.3) showing a significant difference between the two groups (p <.01). This study indicates that preservation of the pelvic nerves during radical prostatectomy has a major role in functional preservation of urinary continence.
PROSTATE CI\OCER TREATED BY RADICAL PR05TATEJ::::"I'0MY.
225A
(Presentation to be made by Dr. Walsh). Delineation of the neurovascular bundles (NVB) has made it possible to identify the branches of the pelvic plexus
to the corpora cavernosa intraoperatively and to decide whether the bundles can be preserved or resected widely
with the specimen. In the course of performing 312 radical retropubic prostatectomies, the NVB was widely excised unilaterally in 49 men with advanced clinical disease in whom, based on preoperative or intraoperative assessment, the NVB appeared to be involved by tumor. Because of this selec-
tion criterion, this group of patients had higher clinical
stage (52% were clinical stage B2) and pathologic stage (35% had microscopic involvement of pelvic lymph nodes) than our previously r~ported series. In 38 cases the margins of resection were negative for tumor. In 11 cases, despite attempts at wide excision of the lesion,the surgical margins of resection were positive. In all 11 men there was extensive periprostatic extension of tumor and 8 had involvement of pelvic lymph nodes. In none of the 11 patients with positive surgical margins were the margins positive at the site where the NVB was spared showing that unilateral sparing of the NVB did not compromise removal of tumor. Of the 29 men who were potent preoperatively and who have been followed for one year or longer postoperatively, 20 (69%) are potent, The return of sexual function correlated with age: 100% men 40-49 years of age were potent postoperatively compared to 80% patients 50-59 years of age, and 50% men age 60-69 years. By measuring nerves in the spared region of the NVB we found that the role of the NVB in potency is not due to large nerves, but to many nerves of varying size. In conclusion, potency can be maintained following radical prostatectomy in most patients in whom it is necessary to excise one NVB widely without compromising the removal of tumor.
POTENCY SPARING RADICAL PERINEAL PROSTATECTOMY: ANATOMY, SURGICAL TECHNIQUE AND INITIAL RESULTS. Vernon E. Weldon and Frank R. Tavel, San Rafael, CA (Presentation to be made by Dr. Weldon) This report doscrib~s the anatomy and surgical technique of preservation of the nervi erigentes during radical perineal prostatectomy, and the initial results with this technique. In perineal exposure of the prostate, the historical posterior layer of Denonvilliers' fascia is indistinguishable from the posterior continuation of the lateral pelvic fascia containing the nervi erigentes, which course over the postero-lateral third of the prostate and the lateral aspect of the membranous urethra bilaterally. The detailed operative steps achieving nerve preservation include: (1) Vertical incision and lateral reflection of this pelvic fascia from the posterior prostatic capsule (the anterior layer of Denonvilliers' fascia). (2) Posterior incision of the continuous pelvic fascia containing the laterally located nervi erigentes over the membranous urethra, and shelling out the urethra from the enveloping fascia .before dividing it. (3) Division of the neurovascular pedicles entering the base of the prostate close to the prostatic capsule. Since November, 1984 this technique has been applied to 16 patients with localized prostatic adenocarcinoma immediately following bilateral pelvic lymphadenectomy. Prostates weighing up to 180 grams have been removed. No rectal injuries occurred. All are essentially continent, using no pads. Median total operating time including perineal repositioning was 3 3/4 hours. Median number of blood units transfused was none. Median length of total hospitalization was 7 days. 9 patients were potent pre-operatively, and 5 (56%) are still potent. Radical perineal prostatectomy historically offers a potential cure of localized prostatic adenocarcinoma with a precise vesico-urethral anastomosis associated with a high continence rate, reduced blood loss and morbidity, and may now be offered with a significant chance of preserving potency.
487
488
URINARY CONTINENCE FOLLOWING NERVE SPARING RADICAL PROSTATECTOMY. Pat D. 0' Donnell and Barry Finan, Litt le
EI\RLY ADJUNCI'IVE fDRMJNAL THERAPY IN CLINICALLY IDCALIZED
Rock) AR (Presentation to be made by Dr, Finan) The nerve sparing radical prostatectomy technique is noted for functional preservation of potency following surgery. In this study, urinary continence was compared in 68 consecutive patients undergoing a radical prostatectomy. In )Li. patients; a conventional radical prostatectomy was performed and in 34 subsequent patients a nerve sparing operation was done. The patient population, the clinical environment, and staff surgeons were the same throughout the study. The age of the patients in each group) the Gleason score of the tumor, the stage of the tumor, and the operative time were not significantly different between groups. In the nerve sparing group, there was one operative death due to a postoperative pulmonary embolus and 33 patients were evaluated. In the conventional operated group, there were 4 patients with total incontinence (12%) and 6 patients (18%) with stress incontinence requiring absorbent pads. In the nerve sparing group, there were no patients having total urinary incontinence and 2 patients (6%) had stress incontinence requiring absorbent pads Functional urethral length and peak urethral pressure profile were measured postoperatively in· all patients using a dual channel microtipped Millar urethral pressure profile catheter. The postoperative functional urethral length in the conventional group was 1.9cm (SD=0.6) and in the nerve sparing group was 2.3cm (SD=0.5) showing a significant difference between the two groups (p (.05). The peak resting urethral pressure of the conventional group was 35.4cm H20 (SD=l4.2) and in
Mitchell C. Benson, Gerald Hoke*, and Ralph J. Veenema, New York City, New York (Presentation to be made by Dr. Benson) The timing of honnon.al therapy in t_he treatment of prostate cancer remains controversial. Additionally, what role, if any, honronal therapy should play in t_he treatment of regional disease has yet to be determined. We had the opportunity to review a large group of patients undergoing radical prostatectorny in an era in which adjunctive orchiectomy was routine in our institution. A retrospective study of 132 patients with clinically localized prostatic cancer treated by radical retropubic prostatectomy (RRP) and orchiectomy from O to 3 months from the time of surgery was perform9d to determine the effect on survival, Patients underwent surgery from 1952 to 1979 with a rrean follow-up of 11 years. Lyrnphadenectomy was not performed in anv case. Pathologic staging revealed 12 patients stage A-2, 34 patients stage B-1, 42 patients stage B-2 and 40 patients stage C. Patients with disease pathologically limited to the prostate (stage A-2 - B-2) experienced an 85% 10 year and 49% 15 year survival. This approxirrates the actuarial survival for men in this age group and does not substantially differ from other recently published series of RRP. Patients with stage C disease experienced an 62% 10 vear and 35% 15 vear survivaL Even when patients lost to follow-up-,,ere considered dead from prostatic cancer, there 110.s still a 52% 10 year and 25% 15 year survival. While not a controlled prospective study, the finding of an apparently inproved survival in pathologic stage C prostatic cancer suggests that the initiation of per;~perative androgen deprivation may prolong survival rn this patient population.
o
the nerve sparing group was 46.5cm H20 (SD=l2.3) showing a significant difference between the two groups (p <.01). This study indicates that preservation of the pelvic nerves during radical prostatectomy has a major role in functional preservation of urinary continence.
PROSTATE CI\OCER TREATED BY RADICAL PR05TATEJ::::"I'0MY.
225A