Transcript Neue HELIOS- Präsentationsvorlage

HELIOS Kliniken Leipziger Land
Folie: 1
Positive margins
and
early postop potency
after
Nerve-sparing ELRP
Kai Kuhnt
ChA Dr. med. Dietmar Schulz
Abteilung für Urologie
HELIOS Klinik Borna
Leipziger Land
Germany
Incidence of positive surgical margins and early postoperative potency outcome after
nerve-sparing extraperitoneal laparoscopic radical prostatectomy
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Prostate Cancer
Folie: 2
• Most frequent malignant tumor in Urology
• 2. most frequent tumor in men
• if organ confined
 radical prostatectomy
 other (Brachytherapy, Radiotherapy, Hormonetherapy,
watchful waiting…)
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Radical Prostatectomy
Folie: 3
• Open surgery
– retropubic
– perineal
• Laparosopic
– transperitoneal / extraperitoneal
– robot assisted
– antegrade / retrograde
– not nerve sparing / nerve sparing
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Nerve sparing prostatectomy
Folie: 4
Goal:
Preservation of the
„Neurovascular Bundle“
dorsolaterally of the
Prostate …
Leading to higher
postoperative potency
rate …
Improving Quality of Life
www.prostatecancercentre.co.uk
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Nerve-Sparing ELRP
Folie: 5
Indication for Nerve-Sparing:
•
Low-risk cancer
–
–
–
–
•
•
PSA ≤ 10 ng/ml
T≤2
G≤2
Gleason sum ≤ 7
Preoperative potency
Patient‘s decision
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Why positive surgical margins ?
Folie: 6
Factors that might influence the incidence of
positive 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
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 7
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
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 8
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
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 9
Factors: why PSM ? (IV)
• Surgical technique:
– combined, ante-, retrograde
– intra-, extrafascial
– uni-, bilateral nerve-sparing
• Experience of surgical team
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Series of ELRP
Folie: 10
Patients:
n = 115 men
49 – 78 years old
Not nerve sparing: 86 patients
Nerve-sparing:
29 patients
•5
•5
• 19
HELIOS Kliniken Leipziger Land
unilaterally
left
right
bilaterally
K. Kuhnt
D. Schulz
NESA DAYS 2006
Pre-operative T-Staging
Folie: 11
Pre-operative pathologic T-Staging
in NNS vs. NS group n=115
70
60
60
50
Tx
T1
T2
T3
T4
40
n
30
24
18
20
9
10
2
0
0
1
0
0
0
NNS
NS
ELRP
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Post-operative T-Staging
Folie: 12
Post-operative pathologic T-Staging
NNS vs. NS n=115
70
62
60
50
Tx
T1
T2
T3
T4
40
n
30
25
22
20
10
0
1
1
4
0
0
0
0
NNS
NS
ELRP
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Understaging
Folie: 13
Pre- and postoperative pathologic T-Staging
in NS ELRP
25
25
18
20
n
n=29
15
Tx
T1
T2
T3
9
10
4
5
1
0
0
0
0
preoperative
postoperative
Staging
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Surgical Technique
Folie: 14
• 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
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive margins and potency outcome after
nerve-sparing laparoscopic prostatectomy
Folie: 15
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
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 16
Positive surgical margins
defined as
tumor on the inked surgical surface
of the specimen
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 17
Positive margins (R1) in
non-nerve-sparing (NNS) vs nerve-sparing (NS)
ELRP according to T-stage
100,0
100,0
75,0
%
T2
T3
50,0
n = 115
22,7
25,0
4,8
8,0
NNS
NS
0,0
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 18
•
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
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Positive surgical margins
Folie: 19
 significantly higher risk for PSM
when NS in T3-tumors
!
consider organ-confined T2 tumors
for NS only !
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Early postop. potency
Folie: 20
Evaluation: 1 month postop
modified IIEF questionnaire
Potency:
HELIOS Kliniken Leipziger Land
Erection adequate for
intercourse with or without
oral 5-PDE-Inhibitors
K. Kuhnt
D. Schulz
NESA DAYS 2006
Early postop. potency
Folie: 21
Results after NS:
– spontaneous Erections
55 % (11/20)
(with and without 5-PDE)
– Erection adequate for
Intercourse 1 month p.o.
HELIOS Kliniken Leipziger Land
25 % (5/20)
K. Kuhnt
D. Schulz
NESA DAYS 2006
Early postop. potency
Folie: 22
Unilateral vs. bilateral NS
Erection without 5-Phosphodiesterase-Inhibitors
50
50
40
30
%
20
12,5
10
0
unilateral n = 8
bilateral n = 12
Nerve-sparing
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
Conclusion
Folie: 23
cauterless NS vs. NNS
 higher rate of PSM
difference significant only for T3-Tumors
CAVE: Understaging !
 promising early potency rate
recovery can take up to 2 years!
longterm follow-up required
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006
PSM
Folie: 24
Thank you !
HELIOS Kliniken Leipziger Land
K. Kuhnt
D. Schulz
NESA DAYS 2006