Better nerve sparing surgery for prostate cancer

Better nerve sparing surgery for prostate cancer

New to this important for the power-conservation theme was to learn the German Urology Congress 2009: More safety in patient selection and improved surgical techniques.

The radical prostatectomy ( RPE ) while sparing the erection (stiffening member) major nerves, which abut the prostate directly, is carried out for years. Such a nerve-sparing RPE (NS-RPE) also increases the chance to hold after the operation the water, thus reducing the risk ofurinary incontinence .

Uncertainties but also cases in which a Nazi RPE is eligible. So (boy) were examined in a new study, patients who had been operated on, depending on their risk of a capsule-border growth of the tumor, either without or with a unilateral or bilateral nerve sparing. The results showed that in 1561 patients in whom the tumor had the prostate capsule actually broken, the chosen procedure had no effect on the risk of PSA rise again after surgery (32%). This calls for a correct selection, which was carried out among others on the basis of nomograms (risk tables).

Two common nomograms, one of Ohori, the other of Graefen, were in another study (Diedrich) checked. Both provide the basis of preoperative findings for a clinically localized tumor at the risk of capsule rupture. The 1275 patients after open RPE both nomograms proven to be reliable. If had been operated on the basis of nerve gently on a prostate side, however, the tumor (Ohori and Graefen) had the capsule still exceeded in 1.8% and 4.2% of cases. To reduce this residual risk further, the authors recommended a frozen section (histological examination during surgery). This is also supported by other authors (Hatzichristodoulou): They led the frozen section by in 48 patients during an open Nazi RPE. In 5 patients, the operation was extended because of a positive result, in all cases with complete tumor removal. However, the operation time was extended by 30-45 minutes.

Also to improve the surgical technique, new studies were presented. Thus, the basis, the exact course of the nerves along the prostatic capsule (Sievert): After that, most run from top front-side down the back, and the distribution can be very individual. In the NS-RPE with protection of the rear-side lying neurovascular bundle can be only just over half of the nerve fibers get. This could be improved in the future, for example through the use of imaging procedures before surgery or through greater optical magnification or dye label during surgery. That the nerve course is individually very variable, confirmed a further investigation (whole). They also found that the size of the prostate does not affect the course.

How can achieve high rates of postoperative erectile function and continence by a precise surgical technique that has been shown in a movie (Budäus). Another possibility for the protection of nerves is hypothermia (cooling) during surgery (Noldus). The hemostasis is important. That is the bipolar vessel sealing to, a study on tissue samples (Eberli). In this particular electrosurgical procedures vessels are closed by electrically generated heat and pressure simultaneously. The nerves, however, are to be protected by a safety distance of 2-3mm or by directly placed next to the instrument clamp from damaging heat.

A new technique intrafasziale NS RPE, the operation within a particular layer of tissue around the prostate, illustrated a further film (Beiersdorf), wherein the engagement of the dam (perineal) was. Was demonstrated also by film (Stolzenburg 1) the careful hemostasis with sutures and a special sponge made of collagen, in this case intrafaszialer endoscopic NS-RPE.

The results of the two studies were presented intrafascial technology: A year after open intrafaszialer RPE of 50 patients were 94% fully continent and 80% to an erection sufficient for sexual intercourse capable (Khoder). And the comparison between intrafaszialer and classical NS-RPE with 200 patients showed a duplexed nerve preservation after one year continence rate of 93% compared to 91% and erectile function at 60-92% compared to 46-79% (in each case depending on the age group, per younger, the higher; Stolzenburg 2). The potency rate was thus significantly higher in intrafaszialer technology, but without the edges of the removed tissue tumor-infested (R1 = positive) were more common.