The effect of transvesical laparoscopic radical prostatectomy on sexual function and urinary continence

Abstract

Objective

To analyze the effect of transvesical laparoscopic radical prostatectomy (TVLRP) on sexual function and urinary continence.

Method

The data of 72 patients diagnosed with low-risk and localized prostate cancer, who underwent treatment at our hospital between January 2017 and June 2022, were retrospectively analyzed. All these patients underwent TVLRP under general anesthesia. Their serum prostate-specific antigen (PSA), urinary continence and erectile function were statistically analyzed.

Results

The operation went well with no intraoperative difficulties. The average surgical duration of 102 ± 22 min, coupled with the minimal intraoperative blood loss of 100 ± 32 mL, underscored the precision and efficacy of the surgical techniques employed. Following surgery, postoperative pathological assessments confirmed staging, revealing pT2a in 18 cases and pT2b in 54 cases, suggestive of localized tumors. Gleason scores ≤ 6 further indicated well-differentiated tumors, while consistently negative surgical margins affirmed the complete resection of tumors, reducing the likelihood of disease recurrence. Subsequent to the surgical intervention, the the average hospital stay was 13.94.1 days. A comprehensive 12-month follow-up revealed exceptionally high urinary continence rates, with 97.8% and 100% of patients achieving continence at 1 and 3 months postoperatively, respectively. Moreover, progressive improvement in erectile function recovery was observed, with recovery rates at 3, 6, and 12 months postoperatively reaching 82.2%, 88.4%, and 93.5%, respectively. There was no biochemical regression.

Conclusion

Treatment of low-risk and localized prostate cancer by TVLRP has a satisfactory urinary continence and recovery of erectile function after operation, less and complications and definite tumor-control effect.

Introduction

Prostate cancer is one of the most common tumors in the urinary system, and its morbidity has lately increased. The conventional therapy for localized prostate cancer is laparoscopic retropubic radical prostatectomy. Postoperative urine incontinence and sexual dysfunction are serious consequences that have a considerable impact on life quality [1]. Recently, function-preserving surgeries using various approaches, such as routine nerve sparing via retropubic extraperitoneal space, Retzius space sparing via retroperitoneal approach (Retzius sparing technique) [2], and extraperitoneal transvesical approach, have emerged to reduce above complications. Although the transvesical approach is mostly robot-assisted single port, it is constrained by trigonometry of reconstructive operation, device collision, linear vision, and suture approaches [3, 4]. In low-risk patients, we performed cystotomy and radical prostatectomy under laparoscopy, referring to open suprapubic cystotomy and enucleation of the prostate. The effectiveness was encouraging.

Clinical information

Clinical information of 72 patients who underwent transvesical laparoscopic radical prostatectomy (TVLRP) in Urology Surgery of The Sixth People’s Hospital Affiliated to Shanghai Jiaotong University from January 2017 to June 2022 were retrospectively analyzed. The written informed consent was received from all participants. Patients underwent TVLRP under general anesthesia. Periodic test of serum PSA after operation. Urinary continence at 1, 3 and 6 months and recovery of erectile function at 3, 6 and 12 months after operation were recorded. According to the latest TNM staging system for prostate cancer updated in 2018 (the American Joint Committee on Cancer (AJCC) 8th edition), staging should be performed. T2a and T2b in the text represent T2aN0M0 and T2bN0M0, respectively. This system divides Gleason scores into five distinct groups: Grade Group 1 (Gleason score ≤ 6); Grade Group 2 (Gleason score 3 + 4 = 7); Grade Group 3 (Gleason score 4 + 3 = 7); Grade Group 4 (Gleason score 8); Grade Group 5 (Gleason scores 9–10). The cases involved in this study with Gleason scores ≤ 6 were classified as Grade Group 1 (Gleason score ≤ 6). Urinary incontinence was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI Short Form). The International Index of Erectile Function-5 (IIEF-5) used in this study was a validated and authoritative questionnaire for assessing erectile dysfunction.

Inclusion criteria

(1) All patients are married or have a fixed sexual partner. (2) Able to engage in sexual activity independently before surgery, without the need for medication or other support. IEF-5 score of 18 and Rigiscan examination indicate that the penis can effectively erect. (3) There is no serious disease such as heart, lung, brain or diabetes, depression before operation and during follow-up. (4) Preoperative CT and MRI examinations indicate localized prostate cancer, no neurological invasion or distant metastasis, no history of endocrine therapy, and no metastasis during follow-up. (5) All patients underwent transrectal or perineal prostate biopsy before surgery, and the pathological result was PCa (T1 ∼ T2). (6) Radical prostatectomy with nerve preservation between or within the fascia was performed for all cases of prostate cancer, and the surgery was successfully completed without any conversion to open surgery. There were no serious complications after the surgery.

Exclusion criteria

(1) Preoperative sexual activity needs to be completed with the support of medication, or sexual activity cannot be completed before surgery, or preoperative IIEF-5. Score < 18 and Rigiscan suggest erectile dysfunction. (2) Preoperative severe diseases such as cardio cerebral Vascular disease and diabetes or other malignant tumors.

Surgical method

TVLRP was performed under general anesthesia on patients. One surgeon performed all of the surgeries. Trocar position and location were identical to those of standard extraperitoneal radical prostatectomy, either 3 or 4 ports. After the retropubic space was revealed, an ultrasonic knife was used to make a 4 cm incision in the front wall of the bladder top. The Veress needle. Hemlock clips were used to secure four corners of the bladder’s front wall (Fig. 1A). The bladder neck was visible. The bladder neck’s posterior margin was incised distal to the ureteral orifice, the bilateral deferent ducts were isolated and cut, the bilateral seminal vesicles were isolated (Fig. 1B), the Denonvilliers fascia was cut, and the posterior wall of the prostate was isolated. Pubic bone was isolated along the prostate bilaterally, pubicoprostatic ligament was cut close to prostate surface (Fig. 1C and D), retropubic vascular complex was exposed, the apex of prostate was isolated (Fig. 1E) and the urethra was cut. Vesicourethral anastomosis was performed by two 0 suture (Fig. 1F). The open anterior wall of bladder was continuously closed by absorbable suture (Fig. 1G, H and I).

Fig. 1

A: Veress needle. Four corners of anterior wall of bladder were fixed by Hemlock clips; B: Posterior margin of bladder neck was incised distal from ureteral orifice, bilateral deferent ducts were isolated and cut, bilateral seminal vesicles were isolated; C: Right prostate ligament was cut; D: Left prostate ligament was treated; E: Urethral apex of prostate was disconnected; F: Urethral reconstruction after bladder surgery; G: Continuous suture and closure of “unnecessary” bladder wall; H: Appearance of bladder after operation; I: Closure of bladder by continuous suture

Results

The number of IRB was 2021-IRB-107. The median age was 64 ± 10 years old (47 ∼ 70), BMI was 23.5 (20.3–25.4), there was no significant difference between healthy people and patients; preoperative total serum prostate-specific antigen (PSA) was 4.0∼9.2 µg/L (median 7.9 ± 2.1 µg/L); clinical TNM staging: cT1c stage, n = 24, cT2a, n = 48; The puncture Gleason scores of all patients were ≤ 6; the mean International Index of Erectile Function (IIEF) was 20.7 ± 1.2 (18 ∼ 23).

The successful completion of all surgical procedures without encountering any intraoperative complications ensured a seamless operation. The average surgical duration of 102 ± 22 min, coupled with the minimal intraoperative blood loss of 100 ± 32 mL, underscored the precision and efficacy of the surgical techniques employed. It is noteworthy that none of the patients necessitated blood transfusion, indicating the high level of intraoperative management and the maintenance of hemostasis.

Following surgery, postoperative pathological assessments confirmed staging, revealing pT2a in 18 cases and pT2b in 54 cases, suggestive of localized tumors. Gleason scores ≤ 6 further indicated well-differentiated tumors, while consistently negative surgical margins affirmed the complete resection of tumors, reducing the likelihood of disease recurrence. Subsequent to the surgical intervention, the average duration of indwelling catheterization spanning 11.2 ± 1.1 days, along with a mean hospitalization period of 13.9 ± 4.1 days, ensured adequate postoperative care and monitoring, contributing to favorable patient outcomes and recovery.

A comprehensive 12-month follow-up revealed exceptionally high urinary continence rates, with 97.8% and 100% of patients achieving continence at 1 and 3 months postoperatively, respectively, indicative of optimal functional recovery and bladder control restoration. Moreover, progressive improvement in erectile function recovery was observed, with recovery rates at 3, 6, and 12 months postoperatively reaching 82.2%, 88.4%, and 93.5%, respectively, suggesting the gradual restoration of normal sexual function and quality of life for patients.

Patients undergoing TVLRP have higher rates of positive ejaculation and higher MSHQ questionnaire scores postoperatively. MSHQ questionnaire scores during follow-up after surgery were also higher. Patients undergoing TVLRP reported better ejaculation frequency and overall ejaculatory sensation, as shown in Table 1. Univariate linear regression was performed between retained ejaculation function and other variables. Based on significant variables identified in the univariate analysis, a multivariate linear regression model was constructed to predict ejaculation preservation rates. Data analysis was conducted using SPSS version 22.0. Regression results indicated that at 3 months postoperatively, patient age (young) (OR 0.76, P = 0.0240) and absence of urethral obstruction (OR 0.86, p = 0.0320) were predictive factors for ejaculation recovery. At 12 months, only surgical age (OR 0.780, p = 0.016) influenced ejaculation recovery. We believe that the posterior urethra requires time to heal and may experience edema and mild inflammatory reactions after anastomosis with the bladder neck. Incomplete tissue and nerve repair may restrict physiological urethral contraction. These results assume consistent surgical outcomes (posterior urethra-bladder neck anastomosis) for each patient.

Table 1 The data on MSHQ and QoL

Encouragingly, no instances of biochemical relapse were observed throughout the follow-up period, highlighting the efficacy and durability of the surgical intervention in achieving disease control and long-term oncological outcomes. Overall, these findings underscore the success of the surgical approach in treating prostate cancer while preserving urinary and sexual function, thus enhancing patients’ quality of life and prognosis.

Discussion

Although radical prostatectomy remains the primary treatment for localized prostate cancer, it can lead to significant postoperative complications such as urinary incontinence and erectile dysfunction, affecting patients’ quality of life. Therefore, preserving the peripheral nerves and muscles surrounding the prostate is crucial for patients who prioritize maintaining a high quality of life. The anatomical basis for preserving these nerves, particularly the neurovascular bundle (NVB), lies in their role in regulating various functions related to male reproductive organs and the lower urinary tract. The sympathetic nerve fibers in the pelvic cavity regulate functions such as ejaculation, seminal vesicle and prostate secretory function, and urethral sphincter contraction. Damage to these fibers can result in postoperative urine incontinence and retrograde ejaculation. Similarly, parasympathetic nerve fibers primarily control artery dilation in the penis and bladder detrusor muscle contraction. Injury to these fibers can lead to urine retention, incontinence, and erectile dysfunction [5]. According to Walsh’s classical view of NVB anatomy, nerve branches from the seminal vesicle, prostate, and pelvic plexus innervate the prostate posterolaterally through arteriovenous arteries, forming discrete tiny bundles known as the posterolateral neurovascular bundle of the prostate. Anatomical radical prostatectomy techniques aim to preserve these nerve bundles to maintain urinary continence and erectile function [6, 7]. Techniques such as transvesical laparoscopic radical prostatectomy (TVLRP) avoid isolating or stretching the bladder’s posterior wall to protect the integrity of the posterior vesical pelvic plexus, prostatic plexus, and vesical plexus. The study by Yang et al. [1] demonstrates that using a robot-assisted radical prostatectomy with a combined longitudinal incision of the bladder neck and prostate yields favorable outcomes in the treatment of localized prostate cancer [8].

Characteristics of the surgery were summarized as follows:

• 1. The Trocar position and location were identical to those in standard extraperitoneal radical prostatectomy, either 3 or 4 ports. When the balloon was dilated to reveal the anterior apex of the bladder, 300 ml of air was injected. A tiny dilatation area could protect the anatomical integrity of the anterior vesical space, particularly the anterior space of the bladder neck [9, 10].

• 2. A 4–5 cm longitudinal incision was created in the anterior wall of the bladder. Four Hemlock clips were used to secure the incision margin. A suitable surgical field was created.

• 3. It was easier to isolate the spermatic duct and seminal vesicles. The spermatic duct and seminal vesicles were exposed after an arc-shaped cut was performed in the bladder neck’s posterior labium.Extensive isolation of bladder neck was unnecessary. It was strict intrafascial surgery [11, 12].

• 4. If the bladder neck was wide but the urethral cavity diameter was small after anastomosis of the bladder neck and posterior urethra, the anastomosis should be performed with the urethral cavity diameter to guarantee perfect alignment of the mucosa.

  The bladder neck that remained unsutured was constantly sutured and closed with fish suture. This could greatly improve anastomosis quality and reduce anastomotic strain [13, 14].

• 5. The bladder neck and urethra reconstruction were tough in the surgery. More posterior urethral sparing was favorable for postoperative bladder control and lowering anastomotic stress between the bladder neck and the posterior urethra. However, suture of the left wall margin was problematic; suture with the left hand might overcome this problem and simplify the operation [15, 16].

Urinary incontinence and erectile dysfunction are significant post-radical prostatectomy complications, negatively impacting patients’ quality of life. Transvesical laparoscopic radical prostatectomy (TVLRP) offers several advantages: it eliminates the need for bladder isolation and manipulation of the anterior bladder space, minimizes deep pelvic surgery around the prostate, and preserves pelvic floor structure integrity, crucial for nerve preservation. This technique reduces the risk of erectile nerve damage and promotes swift postoperative bladder control recovery. Studies demonstrate that TVLRP yields favorable outcomes for low-risk and localized prostate cancer, including improved bladder control and erectile function post-surgery, along with fewer complications and clear tumor control effects. However, its suitability may be limited for high-risk patients with large prostates. Future research may compare TVLRP with extraperitoneal laparoscopic radical prostatectomy or open radical prostatectomy to further assess its efficacy. During TVLRP, careful attention is paid to the position of the ureteral orifice to prevent inadvertent ultrasonic knife burns. In cases of severe penetration of the prostatic gland into the bladder, precautions such as separating the gland from the knife head and utilizing blunt finger separation during prostate removal are taken to safeguard the ureteral opening from damage. These techniques aim to maximize urinary control and sexual function preservation in the radical treatment of early-stage prostate cancer.

It appears that TVLRP demonstrates favorable outcomes in terms of urinary continence and erectile function recovery. However, it’s essential to consider potential complications associated with this procedure and how they might be addressed. Here’s how you could address these complications [17, 18]:

• 1. Hemorrhage Control: Despite the minimal intraoperative blood loss mentioned in the study, hemorrhage remains a potential complication of any surgical procedure. Techniques such as meticulous hemostasis, the use of hemostatic agents, and advanced surgical instruments can help minimize bleeding during TVLRP.

• 2. Urinary Continence Management: While the study reports high rates of urinary continence following TVLRP, it’s crucial to acknowledge that urinary incontinence can still occur postoperatively. To address this, preoperative assessment of pelvic floor muscle strength and postoperative pelvic floor exercises may be implemented to improve continence outcomes. Additionally, for cases where continence is not achieved, interventions such as artificial urinary sphincter placement or male slings may be considered.

• 3. Erectile Function Recovery: Although the study indicates progressive improvement in erectile function postoperatively, erectile dysfunction remains a potential complication of TVLRP. Strategies for managing erectile dysfunction may include preoperative counseling, early initiation of phosphodiesterase type 5 inhibitors (PDE5i), penile rehabilitation protocols, and the use of vacuum erection devices. Referral to sexual health specialists or urologists with expertise in erectile dysfunction management may also be beneficial for optimizing outcomes.

• 4. Bladder Neck Contracture: Bladder neck contracture (BNC) is a known complication following radical prostatectomy, including TVLRP. To minimize the risk of BNC, meticulous surgical technique during bladder neck reconstruction is crucial. Additionally, routine surveillance with cystoscopy postoperatively can facilitate early detection and intervention for BNC if it occurs.

• 5. Infection Prevention: Postoperative infections, such as urinary tract infections and surgical site infections, are potential complications following any surgical procedure, including TVLRP. Strict adherence to aseptic techniques, prophylactic antibiotic administration, and early detection and management of any signs of infection are essential for preventing and managing postoperative infections.

By acknowledging these potential complications and implementing appropriate preventive measures and management strategies, the overall safety and efficacy of TVLRP can be optimized, contributing to improved patient outcomes and satisfaction.