Nerve-sparing radical resection of prostate cancer-easily say goodbye to urine leakage and return to a better life

Foreword With the expansion of urbanized living areas and the promotion of health check-ups, the detection rate of prostate cancer is increasing year by year [1], and it is becoming younger, and the proportion of early prostate cancer has also increased.
Patients hope that both It can cure tumors and return to normal life
.

For patients with early prostate cancer who have not yet developed distant metastasis, radical prostatectomy is usually used as the first choice in clinical treatment, but common complications such as urinary incontinence and loss of sexual function after surgery [2] can seriously affect patients Due to the daily function and quality of life, some patients resist surgery and even delay the best treatment time
.

Our hospital once treated a middle-aged patient with a harmonious family and a successful career.
After learning about the complications of radical surgery, he bluntly said: "What is the fun of being a human being?" The patient was introduced to our hospital for consultation.
After careful medical history, physical examination, and imaging data were evaluated, the case was localized prostate cancer.
Our team performed "3-D laparoscopic nerve-sparing radical prostatectomy" for him.
The urinary catheter was removed Zhou Zhou and the urine flow was smooth; the erectile function was restored one month after the operation; and the normal sexual life was restored after several months of rehabilitation training
.

Nerve-sparing radical prostatectomy for prostate cancer-"new breakthrough" For the above-mentioned patients who have greater concerns about postoperative complications, our team at the Department of Urology, Zhongshan Hospital recommends a 3-D laparoscopic clinically advanced prostate with nerve-sparing prostate Radical cancer surgery, the advantage of this surgery is that it can minimize urine leakage after surgery and preserve sexual function
.

In the treatment of early prostate cancer, our team has always expected surgery to achieve three levels of goals: to control the tumor well; to achieve complete urinary control as soon as possible; and to restore the corresponding sexual function
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Therefore, for patients with early-stage prostate cancer, we have routinely carried out robotic-assisted 3-D laparoscopic nerve-sparing radical prostatectomy.
According to the actual condition of the tumor, we implement unilateral or bilateral nerve-sparing radical prostatectomy
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This operation has achieved relatively ideal results: Compared with conventional radical surgery, the recovery of urinary control has been significantly improved.
Nearly half of the patients do not need a urine pad in their daily life after a week after the catheter is removed.
The patient achieves immediate urinary control, that is, there is no need to use a urine pad after the operation
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The remaining half of the patients basically reached the state that they do not need to use changing pads in daily life within 1-3 months
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Regarding the recovery of sexual function, patients with erectile function before the operation will feel the urge to erect during 1-3 months after the operation.
Some patients have already experienced the pleasure of ejaculation, but normal sexual life requires a period of exercise to gradually recover , Or need medication assistance
.

Exploration and development of nerve-sparing radical prostatectomy for prostate cancer As early as 1982, when Walsh was performing radical prostatectomy, he discovered that the injury of the posterolateral neurovascular bundle of the prostate could cause postoperative sexual dysfunction, and the nerves and blood vessels were preserved.
Bundles can preserve the sexual function of some patients[3].
Based on this result, he designed a nerve-sparing radical prostatectomy, but some (30%) patients with vascular and nerve bundles still have sexual dysfunction after surgery.
He believes This may be related to blood vessel damage, whether the nerve bundles branch in the prostate or psychological factors
.

A questionnaire survey conducted by the Walsh team in 2009 showed that the recovery of sexual function is a gradual process: 38%, 54%, and 73 respectively at 3 months, 6 months, 12 months, and 18 months after surgery.
% And 86% of patients (with or without sildenafil citrate) had unassisted sexual intercourse
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In the two groups of patients, most of the patients retained bilateral neurovascular bundles
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The results of the questionnaire showed that among the patients who retained one neurovascular bundle, 65% of the patients recovered their sexual function
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This means that after patients undergoing surgery to preserve the neurovascular bundles, the proportion of erectile dysfunction is low whether it is short-term or long-term
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The preservation of bilateral nerves is relatively only unilateral, which can also significantly improve the recovery of sexual function of patients after surgery [4]
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Therefore, for patients who wish to preserve urinary control and sexual function after surgery, we recommend nerve-sparing radical prostatectomy
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The concept, applicable population and efficacy of nerve-sparing radical prostatectomy Q1 What is nerve-sparing radical prostatectomy? Compared with conventional radical prostatectomy, what is the difference? The sex nerve is close to the prostate capsule, buried in the posterior outer side of the prostate, which is about 5 and 7 o'clock (see Figure 1), innervating the striated urethral sphincter and cavernous body
.

Figure 1: Anatomical diagram of the sexual neurovascular bundle.
Conventional radical prostatectomy is difficult.
Postoperative complications such as positive margins, urinary incontinence, and erectile dysfunction may occur [2]
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 Nerve-sparing radical prostatectomy is carefully dissected, the surgical margin is close to the prostate capsule, and the use of energy devices in the surgical area close to the sexual nerve is avoided, which preserves the sexual nerve and has a greater effect on the recovery of postoperative urinary control.
The help of the penis also preserves the erectile function of the penis [2]
.

Q2 What kind of patients are suitable for nerve-sparing radical prostatectomy? Because the surgical margin should be close to the prostate capsule when conserving nerves, this surgical method is only suitable for early prostate cancer or localized prostate cancer, that is, the tumor cannot break through the capsule and invade the prostate capsule.
Organization
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Preoperative enhanced magnetic resonance can more accurately show the growth range of prostate cancer, such as whether it breaks through the capsule or invades the seminal vesicles
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Generally speaking, the preoperative PSA is not too high (below 20-40ng/ml), and patients whose MRI shows tumors are limited, can refer to the pathological results of prostate puncture to consider unilateral or bilateral nerve-sparing radical prostatectomy
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Of course, patients with lower age and good sexual function should give priority to reserved nerves; even elderly patients with no sexual function requirements, as long as they are localized tumors, they can also be considered reserved nerves, because reserved nerves can affect postoperatively Urinary control is of great help
.

Q3 Will reserved nerves increase the chance of residual tumors and affect the efficacy? According to the current research, in the case of localized prostate cancer, the proportion of positive resection margins is about 10-15%, and most of them are located in the apex of the prostate.
It will increase the chance of tumor residue.
In fact, our team’s experience and the research results of famous tumor centers in the world have also confirmed this point
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Keeping in mind the main points of surgery, nerve-sparing radical prostatectomy for prostate cancer patients is conducive to postoperative urinary control and preserves erectile function, but postoperative erection recovery is related to age and preoperative function
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Nerve-sparing radical prostatectomy is suitable for patients with localized prostate cancer.
Patients with younger age and good sexual function should be given priority
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For localized prostate cancer, nerve-sparing radical prostatectomy can achieve the same tumor control effect as conventional surgery, and will not increase the chance of tumor residual
.

Expert profile Zhang Jianping, deputy director of the Department of Urology, Zhongshan Hospital Affiliated to Fudan University, and the deputy chief physician, performed a number of difficult laparoscopic operations in Shanghai and Xiamen, including radical prostatectomy, partial nephrectomy, and total cystectomy
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Author: Zhang Jianping, Department of Urology, Zhongshan Hospital, Fudan University, Lai Peng References: [1] Zheng Rongshou, Sun Kexin, Zhang Siwei, et al.
Analysis of the prevalence of malignant tumors in China in 2015[J].
Chinese Journal of Oncology,2019,41(1)19 -28.
[2] Zhang Xuepei, Zhu Zhaowei, Wang Shengzheng, et al.
The Da Vinci Robotic Radical Prostate Cancer Surgery with the Vessel and Nerve Bundles Preserved by the Rolling Tube Method[J].
Modern Journal of Urology,2021,26(1)1-4.
[3] Walsh PC, Donker PJ.
Impotence Following Radical Prostatectomy: Insight Into Etiology and Prevention[J].
The Journal of Urology, 1982, 128(3):492-497.
[4] Wang Wenfu, Lu Shujian, Wang Shuo, etc.
.
Discussion on nerve preservation related problems in radical prostatectomy[J].
Journal of Urology,2019,11(1)6-12.