1. HELIOS Kliniken Leipziger Land Folie: 1 K. Kuhnt D. Schulz NESA DAYS 2006 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

2. HELIOS Kliniken Leipziger Land Folie: 2 K. Kuhnt D. Schulz NESA DAYS 2006 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…)

3. HELIOS Kliniken Leipziger Land Folie: 3 K. Kuhnt D. Schulz NESA DAYS 2006 Radical Prostatectomy Open surgery –retropubic –perineal Laparosopic –transperitoneal / extraperitoneal –robot assisted –antegrade / retrograde –not nerve sparing / nerve sparing

4. HELIOS Kliniken Leipziger Land Folie: 4 K. Kuhnt D. Schulz NESA DAYS 2006 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

5. HELIOS Kliniken Leipziger Land Folie: 5 K. Kuhnt D. Schulz NESA DAYS 2006 Nerve-Sparing ELRP Indication for Nerve-Sparing: Low-risk cancer –PSA 10 ng/ml –T 2 –G 2 –Gleason sum 7 Preoperative potency Patients decision

6. HELIOS Kliniken Leipziger Land Folie: 6 K. Kuhnt D. Schulz NESA DAYS 2006 Why positive surgical margins ? 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 patients pelvis

7. HELIOS Kliniken Leipziger Land Folie: 7 K. Kuhnt D. Schulz NESA DAYS 2006 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

8. HELIOS Kliniken Leipziger Land Folie: 8 K. Kuhnt D. Schulz NESA DAYS 2006 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

9. HELIOS Kliniken Leipziger Land Folie: 9 K. Kuhnt D. Schulz NESA DAYS 2006 Positive surgical margins Factors: why PSM ? (IV) Surgical technique: –combined, ante-, retrograde –intra-, extrafascial –uni-, bilateral nerve-sparing Experience of surgical team

10. HELIOS Kliniken Leipziger Land Folie: 10 K. Kuhnt D. Schulz NESA DAYS 2006 Series of ELRP Patients: n = 115 men 49 – 78 years old Not nerve sparing:86 patients Nerve-sparing: 29 patients 5 unilaterallyleft 5 right 19 bilaterally

11. HELIOS Kliniken Leipziger Land Folie: 11 K. Kuhnt D. Schulz NESA DAYS 2006 Pre-operative T-Staging

12. HELIOS Kliniken Leipziger Land Folie: 12 K. Kuhnt D. Schulz NESA DAYS 2006 Post-operative T-Staging

13. HELIOS Kliniken Leipziger Land Folie: 13 K. Kuhnt D. Schulz NESA DAYS 2006 Understaging

14. HELIOS Kliniken Leipziger Land Folie: 14 K. Kuhnt D. Schulz NESA DAYS 2006 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

15. HELIOS Kliniken Leipziger Land Folie: 15 K. Kuhnt D. Schulz NESA DAYS 2006 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

16. HELIOS Kliniken Leipziger Land Folie: 16 K. Kuhnt D. Schulz NESA DAYS 2006 Positive surgical margins defined as tumor on the inked surgical surface of the specimen

17. HELIOS Kliniken Leipziger Land Folie: 17 K. Kuhnt D. Schulz NESA DAYS 2006 Positive surgical margins

18. HELIOS Kliniken Leipziger Land Folie: 18 K. Kuhnt D. Schulz NESA DAYS 2006 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

19. HELIOS Kliniken Leipziger Land Folie: 19 K. Kuhnt D. Schulz NESA DAYS 2006 Positive surgical margins significantly higher risk for PSM when NS in T3-tumors ! consider organ-confined T2 tumors for NS only !

20. HELIOS Kliniken Leipziger Land Folie: 20 K. Kuhnt D. Schulz NESA DAYS 2006 Early postop. potency Evaluation: 1 month postop modified IIEF questionnaire Potency: Erection adequate for intercourse with or without oral 5-PDE-Inhibitors

21. HELIOS Kliniken Leipziger Land Folie: 21 K. Kuhnt D. Schulz NESA DAYS 2006 Early postop. potency Results after NS: – spontaneous Erections55 % (11/20) (with and without 5-PDE) – Erection adequate for Intercourse1 month p.o.25 %(5/20)

22. HELIOS Kliniken Leipziger Land Folie: 22 K. Kuhnt D. Schulz NESA DAYS 2006 Early postop. potency Unilateral vs. bilateral NS

23. HELIOS Kliniken Leipziger Land Folie: 23 K. Kuhnt D. Schulz NESA DAYS 2006 Conclusion 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

24. HELIOS Kliniken Leipziger Land Folie: 24 K. Kuhnt D. Schulz NESA DAYS 2006 PSM Thank you !