Research progress on urogenital function preservation in extralevator abdominoperineal resection / 中华胃肠外科杂志

Extralevator abdominoperineal excision (ELAPE) has been suggested to potentially improve oncological outcomes in advanced low rectal cancer patients. However, the urogenital function impairment as one of the main complications deteriorates the quality of life in these patients. The key point to prevent urogenital function impairment is to avoid autonomic nerve injury, including the superior and inferior hypogastric nerve plexus and neurovascular bundle. Three areas should be especially focused during surgery, including the posterolateral aspect of the prostate during the separation of the rectum from prostate, the lateral wall of ischioanal fossa and the area in front of anal canal. Previous presumption supposed that extended resection, though promoting oncologic outcomes, might lead to enlarged injury to surrounding vessels and nerves that deteriorated patients′ urogenital function. But recent studies show that postoperative urogenital function outcomes of rectal cancer patients who underwent ELAPE are not inferior to conventional APE after the induction of minimal invasive approaches including laparoscopic and robotic surgery. Their quality of life can be comparable with patients who underwent conventional APE, and are even better in some particular area. Moreover, as further improvement of ELAPE procedure has been made, the concept of individualized ELAPE addressed the importance of personalized surgical procedure based on tumor stage and location, dedicating to avoid injury to vessels and nerves through preserving more surrounding tissues. Urogenital function outcomes, as part of postoperative outcomes, get more and more attention in recent years. We review current studies on urogenital function after ELAPE from anatomy to clinical research, in order to raise surgeons′ attention of nerve preservation technique and to improve their understanding of ELAPE procedure.

Current status and controversy of nerve-sparing radical hysterectomy for cercical cancer / 中国实用妇科与产科杂志

Perineural invasion in early-stage cervical cancer,is a new risk factor for the prognosis of cervical cancer.There may be a certain potential risk in retaining nerves and this is the reason why nerve-sparing radical hysterectomy(NSRH)is an important hot topic in clinical research at present.The aim to study PNI in cervical cancer is to develop clear indications for NSRH,in order to show the advantage of this surgical technique.PNI is one of the main factors affecting NSRH indications.Therefore,it is necessary to clarify the indications for NSRH,and it is imperative.

Retrospective analysis on influencing factors of intraoperative indexes of robot-assisted laparoscopic radical prostatectomy / 第二军医大学学报

Objective To explore the influencing factors of operative time, blood loss and nerve-sparing of robotassisted laparoscopic radical prostatectomy (RALP). Methods A total of 184 patients with local or locally advanced prostate cancer were enrolled, and they underwent RALP by the single surgeon in Department of Urology of Changhai Hospital of Navy Medical University (Second Military Medical University) from January 1, 2016 to October 1, 2017. The effects of age, prostate volume, postoperative pathological Gleason score, pelvic lymph node dissection and biopsy approach on the operative time, blood loss and nerve-sparing of RALP were analyzed. The influencing factors of operative time and blood loss were analyzed by multivariate linear regression analysis. Linear correlation analysis was used to identify the correlation between operative time and prostate volume. LSD-t test was used to detect the difference of operative time among the patients with different lymph node dissections. The influencing factors of nerve-sparing during RALP were analyzed by multivariate logistic regression analysis. The difference of age was analyzed by one-way ANOVA and the differences of postoperative pathological Gleason score, lymph node dissection and biopsy approach were analyzed by Kruskal-Wallis H test between the patients with unreserved, reserved unilateral and reserved bilateral nerves. Results Multivariate linear regression analysis showed that prostate volume and lymph node dissection were independent influencing factors of RALP operative time (both P0.01). There was a significantly positive linear correlation between prostate volume and operative time (r＝0.201, P＝ 0.006). The patients with extended lymph node dissection had significantly longer operative time than those with obturator lymph node dissection, and the latter had significantly longer operative time than those without lymph node dissection (both P0.01). Age, prostate volume, postoperative pathological Gleason score, pelvic lymph node dissection, and biopsy approach had no significant effect on intraoperative blood loss (all P0.05). Multivariate logistic regression analysis showed that age, postoperative pathological Gleason score, lymph node dissection and biopsy approach were independent influencing factors of nerve-sparing during RALP (OR＝0.949, 95% CI 0.906-0.995, P＝0.027; OR＝0.742, 95% CI 0.551-0.999, P＝ 0.049; OR＝0.540, 95% CI 0.322-0.903, P＝0.019; OR＝0.457, 95% CI 0.230-0.905, P＝0.025). The cases with unreserved, reserved unilateral and reserved bilateral nerves were 108, 20 and 56, respectively; and the age, postoperative pathological Gleason score, lymph node dissection and biopsy approach were significantly different among the three groups (all P0.05). Conclusion The patients with prostate cancers, who have larger prostate volume or undergo lymph node dissection during RALP, may have longer operative time. Older age, higher postoperative pathological Gleason score, undergoing lymph node dissection or transrectal biopsy are not conductive to nerve-sparing during RALP.

Study on the preoperative clinical criteria for nerve-sparing radical prostatectomy / 肿瘤研究与临床

Objective@#To investigate the preoperative clinical criteria for nerve-sparing radical prostatectomy.@*Methods@#A retrospective analysis of 79 patients undergoing radical prostatectomy with complete clinical and pathological data in Jinhua Hospital of Zhejiang University from January 2012 to December 2016 was performed. The distance between the edge of the prostate tumor and the neurovascular bundle (NVB) was measured. When the distance between the edge of the tumor and the ipsilateral NVB was >2 mm, NVB retention surgery can be performed; when it was ≤2 mm, NVB retention surgery cannot be performed. The influencing factors of the distance between the tumor edge and NVB were analyzed by χ 2 test and logistic regression analysis.@*Results@#Univariate analysis showed that side-specific positive biopsy core ≥1/3, side-specific maximum tumor length in biopsy core ≥5 mm, side-specific tumor involvement rate in biopsy core ≥1/2 and extraprostatic cancer extension by preoperative magnetic resonance imaging (MRI) examination were associated with the distance between the tumor edge and NVB (all P < 0.01). Multivariate analysis showed that extraprostatic cancer extension by preoperative MRI examination (OR = 3.66, P = 0.006) and side-specific positive biopsy core ≥1/3 (OR = 3.39, P = 0.008) were the independent influence factors.@*Conclusion@#The clinical criteria for a nerve-sparing radical prostatectomy are side-specific positive biopsy core <1/3 and no extraprostatic extension by preoperative MRI examination.

Laparoscopic type C1 hysterectomy based on the anatomic landmark of the uterus deep vein and its branches for cervical cancer / 中华肿瘤杂志

Objective@#To introduce the laparoscopic type C1 hysterectomy based on the anatomic landmark of the uterus deep vein and its branched and to evaluate its feasibility and safety for cervical cancer and its effect to bladder function and to provide some reference to simplify the surgical procedures of laparoscopic type C1 hysterectomy.@*Methods@#The clinicopathologic data of the patients with stage ⅠA2~ⅡB cervical cancer and who underwent the laparoscopic C1 hysterectomy based on anatomic landmark of the uterus deep vein and its branches between March 2010 and December 2015 was retrospectively analysed.@*Results@#A total of 99 patients received laparoscopic type C1 hysterectomy based on the anatomic landmark of the uterus deep vein and its branches, in which 93 patients reserved unilateral or bilateral pelvic autonomic nerve successfully, the other 6 patients were transfered to receive type C2 hysterectomy due to adhesions, bleeding or the low possibility of curative resection. The failure rate of the surgery was 6.1% (6/99). The average age of these 93 patients was 44.4±8.2 years (range 25~61 years) and there was one case of stage ⅠA2, 84 stage ⅠB1, 2 stage ⅠB2, 5 stage ⅡA1 and 1 stage ⅡB. The number of patients with squamous cell carcinoma was 67, adenocarcinoma was 19, adenosquamous carcinoma was 3, small cell neuroendocrine carcinoma was 3 and mixed type was 1. The average operation time was 4.1±0.5 h, the average amount of intraoperative blood loss was 103.8±84.0 ml and the mean number of excisional pelvic lymph nodes was 29.7±8.9. There was no patient with positive parametrial margin, positive vaginal margin or intraoperative ureteral injury. The postoperative catheter extraction time was 20.3±8.4 d. The median follow-up time was 20 months (rang 5~44 months), the long-term bladder dysfunction rate was 8.6% (8/93). The numbers of locally uncontrolled and distantly metastasis case were both one and both patients died. The fatality rate were 2.2% (2/93). The two-year disease-free survival and overall survival rate were 97.6% and 96.2%, respectively.@*Conclusion@#Laparoscopic type C1 hysterectomy based on the anatomic landmark of the uterus deep vein and its branches is a safe and feasible treatment method for cervical cancer and it provides a new approach for simplifying the surgical procedures of laparoscopic type C1 hysterectomy.

The value of preoperative magnetic resonance imaging in detecting the distribution of neurovascular bundles before the nerve-sparing laproscopic radical prostatectomy / 中华泌尿外科杂志

Objective To investigate the preoperative magnetic resonance imaging (MRI)examination of the distribution of neurovascular bundles (NVB) around the prostatic capsule,and its clinical value in the nerve-sparing laparoscopic radical prostatectomy (NS-LRP).Methods The clinical data of 42 patients with clinically localized prostate cancer who were admitted from January 2008 to January 2017 were retrospectively analyzed.Age ranged from 58 to 74 years,with an average of 68 years.Preoperative serum PSA range from 0.94 to 12.28 ng/dl,with an average of 7.01 ng/dl.Preoperative Gleason score range from 6 to 8,with an average of 6.Clinical stage:T1-T2 37 cases,T3 5 cases.The average preoperative International Erectile Function Index questionnaire-5 (IIEF-5) 21,of which 23 cases had normal erectile function (IIEF-5 ＞ 22).All the 42 patients underwent MRI examination before operation.According to the distribution of NVB around the prostatic capsule,they were divided into 3 groups:17 cases in group A,and no NVB was evident in all cases.In group B,8 cases were visible but not obvious.In group C,17 cases were evident NVB.There was no significant difference in age,preoperative serum PSA and Gleason score between the three groups (P ＞ 0.05).The preoperative IIEF-5 in group A,B,and C were 19.5,22.8,and 21.5,respectively,with no statistically significant difference (P ＞ 0.05).All 42 cases received NS-LRP under general anesthesia.The differences in IIEF-5 before and after surgery were compared between the three groups.Results In this study,42 cases were successfully completed.42 patients were followed up for 12 to 36 months,with an average of 14.1 months.In group A,B,and C,postoperative IIEF-5 was 8.0,14.1,and 15.5,respectively,which was statistically significant compared with preoperative values (P ＜ 0.05).The decrease of IIEF-5 afteroperation in group A was significantly different from that of group Band C (P ＜0.05).Conclusions Compared with patients with visible NVB on MRI examination,patients have no visible NVB observed on MRI with erectile function-related nerves around the prostatic capsule may be walking on both sides of the prostatic capsule and spreading over the entire anterior ventral surface of the prostate.To maxium-preserve NVB and postoperative erectile function to the utmost,NS-LRP surgery should be more accurately dissected on both sides and ventral side of the prostatic capsule.

Predicting factors for resumption of spontaneous voiding following nerve-sparing radical hysterectomy / 부인종양

OBJECTIVE: To determine factors affecting voiding recovery on the day of Foley catheter removal (postoperative day 7, POD7) after nerve-sparing radical hysterectomy (NSRH) for early-stage cervical cancer. METHODS: Early-stage cervical cancer patients, who underwent type C1 radical hysterectomy between January 2006 and June 2016 were included. Clinical and pathological data were reviewed. Association between inability to attain adequate voiding function on POD7 and potential predicting factors were evaluated in univariate and multivariate analysis. RESULTS: Of 755 patients, 383 (50.7%) resumed adequate voiding function on POD7 while 372 (49.3%) did not. Tumor size was larger in patients whose voiding function was inadequate (2.5 vs. 2.0 cm, p=0.001). Lengths of resected parametria and adjacent vagina were more extensive in patients with inadequate voiding function (p 4 cm (p 4 cm, postoperative urinary tract infection, and primary surgeon were significantly associated with inability to attain adequate voiding function on POD7. CONCLUSION: Extent of disease represented by tumor size, urinary tract infection as well as individual surgeon's technique independently predict resumption of adequate voiding function on POD7 following NSRH.

Effect of Nerve-Sparing Radical Prostatectomy on Urinary Continence in Patients With Preoperative Erectile Dysfunction / 대한배뇨장애요실금학회지

PURPOSE: We aimed to assess whether nerve-sparing radical prostatectomy (nsRP) is associated with improved recovery of urinary continence compared to non-nerve-sparing radical prostatectomy (nnsRP) in patients with localized prostate cancer and preoperative erectile dysfunction. METHODS: A total of 360 patients with organ-confined prostate cancer and an International Index of Erectile Function score of less than 17 were treated with nsRP or nnsRP in Seoul St. Mary's Hospital. Patients who received neoadjuvant or adjuvant androgen deprivation therapy or had a history of prostate-related surgery were excluded. Recovery of urinary continence was assessed at 0, 1, 3, 6, and 12 months. Postoperative recovery of continence was defined as zero pad usage. The association between nerve-sparing status and urinary continence was assessed by using univariate and multivariate Cox regression analyses after controlling for known predictive factors. RESULTS: Urinary continence recovered in 279 patients (77.5%) within the mean follow-up period of 22.5 months (range, 6-123 months). Recovery of urinary continence was reported in 74.6% and 86.4% of patients after nnsRP and nsRP, respectively, at 12 months (P=0.022). All groups had comparable perioperative criteria and had no significant preoperative morbidities. Age, American Society of Anesthesiologists score, and nerve-sparing status were significantly associated with recovery of urinary continence on univariate analysis. On multivariate analysis, age (hazard ratio [HR], 1.254; 95% confidence interval [CI], 1.002-1.478; P=0.026) and nerve-sparing status (HR, 0.713; 95% CI, 0.548-0.929; P=0.012) were independently associated with recovery of urinary continence. CONCLUSIONS: nsRP, as compared to nnsRP, improves recovery rates of urinary incontinence and decreases surgical morbidity without compromising pathologic outcomes.

Effect of the modified nerve-sparing technique in open antegrade radical prostatectomy for 30 patients with prostate cancer / 肿瘤研究与临床

Objective To evaluate the clinical value of the modified nerve-sparing open antegrade retropubic radical prostatectomy (MNS-ORP).Methods MNS-ORPs were performed in 30 patients with clinically localized prostate cancer.The modified technique included: endopelvic fascia was not incised, the prostate capsule was freed laterally from surrounding fasciae and dorsally;using the method of separating the peripheral fascia of the prostate, the Veil technique was applied to the open operation, that is, the modified Veil perserving nerve technology;pelvic lymph node dissections (9 regions and 5 groups) were extended;bladder neck preservation was completed;deep dorsal vein complex was bunched;jumper intussusception technology was applied for bladder and urethral anastomosis.Functional outcomes of continence and sexual function (IIEF-score) were followed-up.Results Median age of patients was 62 years old, and the level of PSA was 11.9 ng/ml.Median operating time was 150 minutes (75-240 minutes), blood loss was 350 ml (100-1 600 ml), preoperative IIEF-score was 21 scores (15-25 scores).Pathologic stage included pT1 (8 cases), pT2a (15 cases), pT2b (4 cases) and pT3a (3 cases).By Gleason score, there were 2 cases of 5 scores, 7 cases of 6 scores, 20 cases of 7 scores and 1 case of 8 scores.4 cases had positive margins including 2 cases (10.5 ％) of pT2 and 2 cases (67 ％) of pT3.There were no postoperative complications.Mean follow-up was 19 months (6-48 months).At the 1st month, 27 patients (90 ％) got full continence, and at the 3rd month, all of the patients had full continence.At the 3rd month and the 6th month, median IIEF-scores were 13 and 19 scores, respectively with baseline of IIEF-score reaching by 40 ％ (at the 3rd month) and 70 ％ (at the 6th month) of preoperative level.Conclusions MNS-ORP follows rationales of radical prostatectomy and might be considered for selected patients.Preserving all periprostatic fasciae/nerves can recover early continence and maintains potency without affecting outcomes.

Various types of total laparoscopic nerve-sparing radical hysterectomies and their effects on bladder function / 부인종양

OBJECTIVE: This study was conducted to ascertain the correlation between preserved pelvic nerve networks and bladder function after laparoscopic nerve-sparing radical hysterectomy. METHODS: Between 2009 and 2011, 53 patients underwent total laparoscopic radical hysterectomies. They were categorized into groups A, B, and C based on the status of preserved pelvic nerve networks: complete preservation of the pelvic nerve plexus (group A, 27 cases); partial preservation (group B, 13 cases); and complete sacrifice (group C, 13 cases). To evaluate bladder function, urodynamic studies were conducted preoperatively and postoperatively at 1, 3, 6, and 12 months after surgery. RESULTS: No significant difference in sensory function was found between groups A and B. However, the sensory function of group C was significantly lower than that of the other groups. Group A had significantly better motor function than groups B and C. No significant difference in motor function was found between groups B and C. Results showed that the sensory nerve is distributed predominantly at the dorsal half of the pelvic nerve networks, but the motor nerve is predominantly distributed at the ventral half. CONCLUSION: Various types of total laparoscopic nerve-sparing radical hysterectomies can be tailored to patients with cervical carcinomas.

Modalities of pelvic autonomic nerve-sparing surgery in pelvis-gynecology / 中国癌症杂志

Bladder function is controlled by the hypogastric nerves (sympathetic) and pelvic splanchnic nerves (parasympathetic) , and these two nerve fibers intermingle to form the pelvic plexus. Pelvic surgery was one of the important modalities being used in pelvis-gynecology, but it was commonly found that the modality could cause bladder dysfunction because of its damage to the pelvic plexus. Pelvis-gynecologic surgeries like Pive Ⅱ-Ⅳ radical hysterectomy (RH), total vaginectomy, Hartman, Dixon, and posterior pelvic exenteration are among the most important causes of urinary dysfunction. Recently, urinary dysfunction has become the major issue for patients undergoing pelvic surgery in terms of quality-of-life. Pelvic autonomic nerve-sparing (PANS) protects postsurgical bladder function in radical RH and other pelvic surgery. The review tried to discuss different types of PANS being used in variety of pelvis-gynecologic surgery. Type Ⅰ PANS can be performed in Piver Ⅱ RH in patients with endometrioid cancer, and urinary catheter will be removed 3 days after operation. Type Ⅱ PANS is used in Piver Ⅲ RH, and the catheter can be successfully removed 7 days after surgery. Sometimes, type Ⅲ PANS is administered in one-side tumor-free cardinal ligament resection, and the patients will retain their catheter for 3 weeks postoperatively. Type Ⅱ or type Ⅲ PANS may be used in total vaginectomy, Hartman, Dixon, and posterior pelvic exenteration.

Analysis of Survival and Functional Outcome after Nerve-Sparing Surgery with Extraperitoneal Lateral Lymphadenectomy for Lower Rectal Carcinoma / 中国普外基础与临床杂志

Objective To investigate the survival rate, voiding, sexual function after nerve-sparing surgery with extended systematic extraperitoneal lateral lymphadenectomy in lower rectal cancer. Methods Three hundreds and ninety-two cases with advanced lower rectal cancer who underwent nerve-sparing surgery with radical dissection from 1996 to 2000 were reviewed. Among them,173 cases only cleared in abdominal cavity,219 cases coupled with extraperitoneal lateral lymphadenectomy. Results The metastatic rate of lateral lymph node was 17.8%(39/219),the rate of non-modal foci of metastatic disease in lateral out of the abdominal cavity was 5.9%(13/219).Local recurrence rate, the abdominal cavity group was 16.2%(28/173); the coupled group was 9.6%(21/219), P

Nerve-sparing clitoral reduction in congenital adrenal hyperplasia: Experience with 22 cases.

Clitoral hypertrophy in girls is commonly caused by excessive androgen production from congenital adrenal hyperplasia. While medical treatment of this clinical entity is well established, evolution of surgical is well established, evolution of surgical reconstruction is continuing to seek a perfect result. In the past, clitorectomy, clitoral recession/relocation and clitoral placation were undertaken with unfavourable cosmetic outcome. Cumulative experience has led us to develop an alternative procedure that preserves both the neurovascular bundle and ventral mucosal wall and creates the labia minora so that normal appearing external female genitalia are achieved. From February 1992 to May 1997, 22 cases of congenital adrenal hyperplasia afflicted from clitoromegaly underwent nerve-sparing clitoral reduction at the Division of Urology, Siriraj Hospital. Four of the cases had previously undergone recession/relocation with unacceptable outcomes. Age at operation ranged from 2 months to 18 years. The follow-up period was at least six months. Satisfactory cosmetic results were obtained in all instances except one who had clitoral atrophy at five months post-operatively.

FEMALE PSEUDOHERMAPHRODITISM DUE TO ADRENOGENITAL SYNDROME

Female pseudohermaphroditism due to adrenogenital syndrome is a condition in which individuals with a 46XX karyotype, negative H-Y antigen, normal mullerian duct derivatives, and a lack of development of w lffian duct structures differentiate partially as phenotypic males. They usually manifest masculinization of the external genitalia as a result of excess endogenous androgens. Most female pseudohermaphrodities have one of the types of congenital virilizing adrenal hyperplasia. Adrenogenital syndrome is inborn errors transmitted by autosomal recessive genes and may be due to defects in any of the enzymic steps in the biosynthesis of cortisol. Most affected individuals have a failure of 21-hydroxylation which prevents the conversion of 17 alpha-hydroxyprogesterone to 11-deoxycortisol. Such a defect in 21-hydroxylase leads to excessive production of adrenal androgens causing virilization. The treatment is early endocrinologic support and surgical reconstruction. There are some considerations in surgical repairs including normal sized clitoris with adequate erogenous sensation, sufficiently wide vaginal introitus and normal aesthetic appearance of the external genitalia for her normalized life as a female. We have experienced four cases of female pseudohermaphroditism due to adrenogenital syndrome. In two cases, we performed clitoroplasty with nerve sparing technique, vulvoplasty with mons pubis augmentation, vaginoplasty with posterior perineal flap and urethral reconstruction. In the other cases, we performed clitoroplasty with nerve sparing technique, vulvoplasty and vaginoplasty There was no specific operative complication and the result of the correction was satisfactory.