A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

Abstract

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1:2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤ 65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.

Figure 1

The solid line indicates the direction of the intrafascial dissection between the prostatic capsule and the prostatic fascia. The dashed line indicates the direction of the interfascial dissection between the prostatic fascia and the endopelvic fascia. EF, endopelvic fascia; NVB, neurovascular bundles; PC, prostatic capsule; PF, prostatic fascia.

Figure 2

In the interfascial dissection, the Denonvilliers' fascia was opened horizontally (a). In the interfascial dissection, the endopelvic fascia was incised, the puboprostatic ligament was dissected and the DVC was ligated (b). In the intrafascial dissection, the Denonvilliers' fascia was not opened. Along the prostatic capsule, blunt dissection was performed between the prostatic capsule and the prostatic fascia (c). In the intrafascial dissection, the endopelvic fascia was not incised, the puboprostatic ligament was not dissected and the DVC was not ligated (d). bn, bladder neck; Df, Denonvilliers' fascia; DVC, Dorsal venous complex; ef, endopelvic fascia; NVB, neurovascular bundles; U, urethra; P, prostate.