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Folie: 1
HELIOS Kliniken Leipziger Land
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive margins and
early postop potency after
Nerve-sparing ELRP
Kai Kuhnt ChA Dr. med. Dietmar Schulz
Abteilung für UrologieHELIOS Klinik Borna
Leipziger Land Germany
Incidence of positive surgical margins and early postoperative potency outcome after nerve-sparing extraperitoneal laparoscopic radical prostatectomy
Folie: 2
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Prostate Cancer
• Most frequent malignant tumor in Urology
• 2. most frequent tumor in men
• if organ confined
radical prostatectomy
other (Brachytherapy, Radiotherapy, Hormonetherapy,
watchful waiting…)
Folie: 3
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Radical Prostatectomy
• Open surgery
– retropubic
– perineal
• Laparosopic
– transperitoneal / extraperitoneal
– robot assisted
– antegrade / retrograde
– not nerve sparing / nerve sparing
Folie: 4
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Nerve sparing prostatectomy
Goal:
Preservation of the „Neurovascular Bundle“ dorsolaterally of the Prostate …
Leading to higher postoperative potency rate …
Improving Quality of Life www.prostatecancercentre.co.uk
Folie: 5
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Nerve-Sparing ELRP
Indication for Nerve-Sparing:
• Low-risk cancer– PSA ≤ 10 ng/ml– T ≤ 2– G ≤ 2– Gleason sum ≤ 7
• Preoperative potency• Patient‘s decision
Folie: 6
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Why positive surgical margins ?
Factors that might influence the incidence ofpositive surgical margins in nerve-sparing prostatectomy (I)
• Staging error:
clinical vs. pathological staging and grading
• Patient selection (indication?)
• Cancer volume and topography
• Volume of specimen in relation to patient’s pelvis
Folie: 7
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
Factors: why PSM ? (II)
• Obliteration of dissection plane
due to previous core biopsies
• Prostatitis and Periprostatitis
• Previous TUR-P transurethral resection of prostate
• Neoadjuvant antiandrogen therapy
Folie: 8
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
Factors: why PSM ? (III)
• Technique of haemostasis: - Increased insufflation pressure
- Local haemostatics
- Bipolar
- Clips
- Suture-ligature
• Availability of intraoperative frozen sections (IFS)
analysis
• Location of intraoperative frozen sections
Folie: 9
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
Factors: why PSM ? (IV)
• Surgical technique: – combined, ante-, retrograde
– intra-, extrafascial
– uni-, bilateral nerve-sparing
• Experience of surgical team
Folie: 10
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Series of ELRP
Patients:n = 115 men
49 – 78 years old
Not nerve sparing: 86 patients
Nerve-sparing: 29 patients• 5 unilaterally left• 5 right• 19 bilaterally
Folie: 11
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Pre-operative T-Staging
0
60
24
2 0 1
9
18
0 0
0
10
20
30
40
50
60
70
n
NNS NS
ELRP
Pre-operative pathologic T-Staging in NNS vs. NS group n=115
Tx
T1
T2
T3
T4
Folie: 12
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Post-operative T-Staging
0 1
62
22
1 0 0
25
40
0
10
20
30
40
50
60
70
n
NNS NS
ELRP
Post-operative pathologic T-StagingNNS vs. NS n=115
Tx
T1
T2
T3
T4
Folie: 13
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Understaging
1
9
18
0 0 0
25
4
0
5
10
15
20
25
n n=29
preoperative postoperative
Staging
Pre- and postoperative pathologic T-Staging in NS ELRP
Tx
T1
T2
T3
Folie: 14
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Surgical Technique
• Laparoscopic extraperitoneal radical prostatectomy in an
antegrade cauterless technique
• Five port technique
• Pelvic lymphadenectomy if
– PSA ≥10 ng/ml or
– Gleason score ≥7
• Cauterless Intrafascial preparation (Veil of Aphrodite)
• Vesicourethral anastomosis with 8 2x0 vicryl sutures UR6
Folie: 15
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive margins and potency outcome after nerve-sparing laparoscopic prostatectomy
Keypoints of the cauterless technique
• No cautery and ultrasonic shears after bladder neck
exposure
• Exposure of seminal vesicles and prostatic pedicles first
• Preservation of tissue ventral to the rectum
• Prostatic vessels are clipped tangentially
at capsule level
• Suture ligatures (5x0) for arterial bleedings
Folie: 16
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
Positive surgical margins
defined as
tumor on the inked surgical surface
of the specimen
Folie: 17
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
4,8
22,7
8,0
100,0
0,0
25,0
50,0
75,0
100,0
%n = 115
NNS NS
Positive margins (R1) in non-nerve-sparing (NNS) vs nerve-sparing (NS)
ELRP according to T-stage
T2
T3
Folie: 18
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
• Other recent series: – PSM in lap. prostatectomy: 4.4% - 35%
• Our series:– T2 tumors:
• 4.8% in NNS• 8.0% in NS
– T3 Tumors:• 22,7 % (5/22) in NNS• 100 % (4/4) in NS prostatectomy
Folie: 19
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Positive surgical margins
significantly higher risk for PSM when NS in T3-tumors
! consider organ-confined T2 tumors for NS only !
Folie: 20
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Early postop. potency
Evaluation: 1 month postop
modified IIEF questionnaire
Potency: Erection adequate for intercourse with or without oral 5-PDE-Inhibitors
Folie: 21
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Early postop. potency
Results after NS:
– spontaneous Erections 55 % (11/20)
(with and without 5-PDE)
– Erection adequate for
Intercourse 1 month p.o. 25 %(5/20)
Folie: 22
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Early postop. potency
12,5
50
0
10
20
30
40
50
%
unilateral n = 8 bilateral n = 12
Nerve-sparing
Erection without 5-Phosphodiesterase-Inhibitors
Unilateral vs. bilateral NS
Folie: 23
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
Conclusion
cauterless NS vs. NNS
higher rate of PSM difference significant only for T3-Tumors
CAVE: Understaging !
promising early potency raterecovery can take up to 2 years! longterm follow-up required
Folie: 24
K. Kuhnt D. Schulz NESA DAYS 2006HELIOS Kliniken Leipziger Land
PSM
Thank you !
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