RELRP Associated Anatomy And Standard Programmed Surgical Procedures

[Background]As we all know,anatomy has fundamental significance to surgery.A famous doctor,Robert P.Myer once said:a surgeon with better understanding of anatomy,gives patients less bleeding,better cut edge and more functional preservation.And that is absolute true.Nowadays,laparoscopic radical prostatectomy(LRP)has become the mainstream surgical method for localized prostate cancer since it was first performed in 1992 by Schuessler.As experience accumulates,we develope many surgical skills and even modify some surgical procedures of LRP.However,LRP still remains a great even the greatest hallenge for urologists.The main reason lies in not only its own complicating procedure itself but also the poor knowledge of the local anatomy of operating regions.Prostate locates in the deep pelvic,it itself and its surrounding structures are very complicating--many structures such as the puboprostatic ligaments(PPL),dorsal vascular complex(DVC),neurovascular bundle(NVB),apical urethra(AU)and pelvic floor musculature(PFM),etc,their position,shape,and function have not been well confirmed.But on the other hand,these structures have great influence on urine continence and potence and thus play crucial role and need to be managed with special surgical skills during the surgery.For example,the function of the urethral sphincter depends on the integrity of its anatomical structure and its good interaction with the PFM.To well protect the apical urethra,the urethral sphincter,the surrounding NVB and PFM,surgeons must be aware of the local anatomy.However,the relationship between the Denonvillier fascia(DF)and the median dorsal raphe(MDR)and the relative location among PPLs,DVC and AU is not clear.In addition,maintaining the physiological angle between the AU and the urogenital diaphragm is helpful to the early recovery of urinary continence,however there is no quantitive data available for urologists to refer to and it is still a research gap before our study.All these problems demonstrate that we must pay more attention to the regional applied anatomy of the prostate,especially the apical region and the bladder neck,where there are many elaborate structures that of great significance for function preservation after LRP.We try to make some quantitive measurement of important structures if possible,and to those difficult in taking quantitive measurement,we strive to get some meticulous quanlitative description.[Objective]1.Measure length of the apical urethra and the angle it running through the urogenital diaphragm.2.Quatify the geometric data of the puboprostate ligament.3.Explore the scope of the anterior detrusor apron covering the anterior surface of the prostate.4.Descibe the characteristics of the bladder neck migrates to the prostate.[Methods]1.In collaboration with Department of Anatomy,School of Medicine,Shandong University,20 male 10%formalin fixed bodies(10 of which were complete with pelvis and 10 with pelvic dissection in the midline)were obtained.The lower extremities of all the specimens were cut off,and the midline and sagittal incision was made in 10 specimens of the pelvis using wire saw.The complete urethra was exposed and marked with red lines.The angle and length of the posterior urethra through the urogenital diaphragm was measured respectively with protractor and ruler.Stripping the adipose tissue in front of the bladder and prostate,completely revealing(?)the two sides of the pubic symphysis ligament,the length of PPL from the pubic end to the prostate end and its width are measured with the ruler.2.The other 10 specimens were cut with a wire saw from the lateral 5 cm of pubic symphysis,stripping down the pelvic organs from the pelvic wall completely,but avoiding damaging prostate and the surrounding structures.Observe the shape and relative location of the bladder neck and the prostate base.Then use forceps to clear the retropubic loose connective tissue,and gradually reveal the detrusor apron,the puboprostate ligament,the dorsal vascular complexe and other adjacent structures,and take close observation and measurement.[Results]1.Posterior urethra passes through the urogenital diaphragm with the angle of 70.3° to 87.6 °,averaged 82.2±5.3°,the length of apical urethra to the genitals diaphragm are 12.1 ± 2.3mm.2.PPL's width at pubic end is 7.5 ± 1.3mm,at middle is 6.2± 1.1mm,at prostate end is 12.6 ± 2.2mm,length from the pubic end to the prostate end is about 9.3 ±1.2mm.The distance between two pubic ends is about 10.7 ± 1.8mm,and between two prostate ends is about 12.8 ± 2.6mm.3.Detrusor apron almost covers the full length of the prostate with an inverted triangle-shaped distribution.At the bottom of prostate,its distribution ranges from about 10 o'clock to 2 o'clock,At the prostate apex it ranges from about 11 o'clock to 1 o'clock.The middle part of it is thickest,which gradually becomes thinner and finally disappear bilaterally.4.The contact surface between bladder neck and prostate base is not a standard plane,but a concave to the middle of the prostate.Besides,it varies more in patients with larger prostate volume,especially those with obvious intravesical prostatic protrusion.[Conclusion]Bladder neck and prostate apical region which always need to be cut off and subsequently reconstructed in the LRP are of great importance for the surgery itself and its postoperative functional recovery.Surgeons should be aware of the detailed(?)anatomy of the adjacent elaborate structures such as the physiological angle between the posterior urethra and the pelvic diaphragm,the length of the posterior urethra distal to the prostate apex,and the geometric data of PPL,which should all be well preserved in the surgey.Besides,the shape of bladder neck may have great variation as the prostate volume changes.surgeons should keep careful in dissociating the bladder neck from the prostate base to get satisfying preservation of bladder neck.[Objective]To make the suigical procedure of RELRP standardized and programmed by modifying and sequencing ail of the the traditional steps of RELRP[Methods]By videolizing and observing the surgical procedure of RELRP in addition to a comprehensive Iherature review,we comb and fine every solitary surgical step ofthe RELRP surgery~modifying technical details,inducting key points,and defining operating speciflcations.Then,we rearrange all the steps above in a definik and high-efficient sequence,and so that the surgical procedure of RELRP become standardized and programmed.[Results]Standard programmed RELRP can be summarized as 21 steps:1.Setting body position for operation2.Sterilization and draping3.Indwelling catheter4.Blunt expansion of retropubic extmperitoneal space5.Laparoscopic operation channel and retropubic extraperitoneal pneumoperitx)neum establishment6.Place laparoscope and establish bilateral operating channels under direct vision7.Posterior pubic fat clearance,hemostasis,and anatomical landmark revealing8.Pelvic lymph node dissection9.DVC revealing and suture10.Bladder neck direction11.Denonvilliers fascia incision and separating the whole posterior wall of prostate to prostate apex12.Lateral prostate "gament and puboprostatic ligament dissection13.Dissecting urethra distal prostate apex,freeing and bagging prostate14.Digital Rectal Examination15.Posterior wall of anasmosis reconstruction16.Bladder neck and urethra anastomosis17.Detection of anastomosis leakproofness and operation field hemostasis18.Anterior suspension of the anastomosis19.Indwelling drainage tube20.Specimen extraction21.Incision closing[Conclusion]Though we have gained some experience in RELRP,it remains a great challenge for urologists.Whafs more,great variations not only in echnique details but also in step sequence exit widely between different medical centres even between different surgeons in the same centre.These problems make it difficult even impossible for further research with tools of evidence based medicine or big analysis.So, is urgent for us develop a standard programmed suigical procedure of RELRP,which be helpful guarantee the efficacy and safety of the surgery,strengthen the comparaWlity of different and smoothen the learning curve in technique promotion.[Objective]To evaluate the efficacy and safety of standardized retropubic extraperitoneal laparoscopic radical prostatectomy(s-RELRP).[Methods]Retrospective review of the data of 45 cases in total,including 20 cases of s-RELRP and25 cases of ns-RELRP,who underwent RELRP in the Department of Urology in Qilu Hospital from October,2015 to October,2016 due to prostate cancer,which was pathologically confirmed before and after the surgery in all cases.By collecting and sortingthe clinic data of these cases,we made comparative analysis of general demographic information(age,weight and so on),preoperative PSA and Gleason score,time-consuming of operation,blood loss during operation,drainage time,bowel movemenf s recovery time,hospital stay,complications,positive surgical margin,hospitalization expenses and postoperative continence rate.The workload for the doctors and nurses were interviewed by questional(Likert Scale).Data was analyzed with SPSS 19.0,the measurement data were analyzed by independent-sample t-test,the enumeration data were analyzed by test or Fisher accurate probabilities according its characteristic.And P < 0.05 was defined as statistically signi cant.[Results]The preoperative baseline data such as age,weight,tPSA value,PSA/tPSA,Gleason scoie in prostate puncture have no significant difference between s-RELRP and ns-RELRP groups(P>0.05),which means the two groups were comparable.All the 45 cases were operated success under general anesthesis and the was no surgery method change in all the operations.The average operaticn time was 218.25±20.47 minutes in S-RELRP group and 254.20±40.25 minutes in ns-RELRP group,which has a sign difference(P=0.008).No blood transfiision was done in all the cases.The intraoperative blood loss was130.00±57.12 ml in s-RELRP group and 194.00±119.30 ml in ns-RELRP group,which suggests that the blood loss of s-RELRP was significantly less than ns-RELRP group(P=0.041).The posU)perative drainage time and hospital stay of s-RELRP and ns-RELRP groups was respectivly 7.22.14d5 55±2.06 d and 9.92±3.11 d,12.76±4.04 d,both ofwhich are of significant difference(P=0.028,P=0.033).No severe complications occurred in both two groups.Postoperative urine leakage and lymphorrhagia in s-RELRP group and ns-RELRP group was respectively 0%, and 4% 16%,both of which have no sign difference(P>0.05).As the positive surgical margin,there was no significant difference between the two groups(5% vs 8%,P>0.05).The 3 months follow-up results suggested a signiScantly higher rate of urinary continence in s-RELRP group than in ns-RELRP group(85% vs 56% P=0.037),but 1:0 the postopertive PSA level,no difference was found between the two groups 3 months after the surgery.The average hospitalization expense was 57217.91±75S>3.28 China Yuan in s-RELRP group and 58873±11089.31 China Yuan in ns-RELRP group,with no sign difference(P=0.701)ides,s-RELRP showed sigidficantly lower workload than ns-RELRP(3.55±0.52 vs 4.09±0.54,P=0.025)for doctors;but for nurses,no significant difference in workload was found between the two groups1.20 vs 3.13±0.83,P=0.732).[Conclusion]Comparing with the ns-RELRP procedure,s-RELRP showed obvious advantages of shorter operation time,less intraoperative blood loss,shorter drainaging time and postoperative hospital stay,better early urinary continence rate and lower workload for doctors.Therefore,s-RELRP could be considered an effective and safe surgery mode for PCa patients...