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 !