Advertisement

World Journal of Urology

, Volume 37, Issue 2, pp 309–315 | Cite as

The value of periprostatic fascia thickness and fascia preservation as prognostic factors of erectile function after nerve-sparing robot-assisted radical prostatectomy

  • Nikolaos GrivasEmail author
  • Rosanne C. van der Roest
  • Clarize M. de Korne
  • Gijs H. KleinJan
  • Karolina Sikorska
  • Ivo G. Schoots
  • Corinne Tillier
  • Bram van der Broek
  • Kees Jalink
  • Stijn W. T. J. P. Heijmink
  • Tessa Buckle
  • Fijs W. B. van Leeuwen
  • Henk G. van der Poel
Original Article

Abstract

Purpose

To determine the correlation of preoperative fascia thickness (FT) and intraoperative fascia preservation (FP) with erectile function (EF) after nerve-sparing robot-assisted radical prostatectomy (RARP).

Methods

Our analysis included 106 patients, with localized prostate cancer and no erectile dysfunction (ED) before RARP, assessed with preoperative 3 Tesla (3 T) multiparametric magnetic resonance imaging (MRI). FP score was defined as the extent of FP from the base to the apex of the prostate, quantitatively assessed by the surgeon. Median fascia thickness (MFT) per patient was defined as the sum of the median FT of 12 MRI regions. Preserved MFT (pMFT) was the sum of the saved MFT. The percentage of pFMT (ppMFT) was also calculated. Fascia surface (FS) was measured on MRI and it was combined with FP score resulting in preserved FS (pFS) and percentage of pFS (ppFS).

Results

FP score, pMFT, ppMFT, pFS and ppFS were significantly lower (p < 0.0001) in patients with ED. In the multivariate regression analysis, lower FP score [odds ratio (OR) 0.721, p = 0.03] and lower ppMFT (OR 0.001, p = 0.027) were independent predictors of ED. ROC analysis showed the highest area under the curve for ppMFT (0.787) and FP score (0.767) followed by pMFT (0.755) and ppFS (0.743).

Conclusions

MRI-determined periprostatic FT combined with intraoperative FP score are correlated to postprostatectomy EF. Based on the hypothesis that a thicker fascia forms a protective layer for the nerves, we recommend assessing FT preoperatively to counsel men for the odds of preserving EF after RARP.

Keywords

Erectile dysfunction Fascia Magnetic resonance imaging Prostate cancer Tissue preservation 

Notes

Acknowledgements

We would like to sincerely thank Mark Page (MR consultant at St Vincent’s Hospital, University of Melbourne, Australia) and Lih-Ming Wong (urologist at St Vincent’s Hospital, University of Melbourne, Australia) for their contributions delineating the prostate and periprostatic fascia.

Author contributions

Project development: all authors. Data collection: NG, RVDR, CK, GK, HVDP. Data analysis: all authors. Manuscript writing & approval: all authors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

For this type of study formal consent is not required.

Supplementary material

345_2018_2387_MOESM1_ESM.tif (1.5 mb)
Supplementary material 1 Fig. 1. T2-weighted transversal MR image at mid-prostate level with drawn contours and - clockwise - the 12 parts (corresponding with the FP score – ‘L’ stands for FP-region on the left side of the prostate and ‘R’ for the right side, respectively) consisted of 360 radial lines, color-coded for the prostate-fascia distance: pink = thick fascia, blue = thin fascia. FP, fascia preservation (TIFF 1572 kb)
345_2018_2387_MOESM2_ESM.tif (995 kb)
Supplementary material 2 Fig. 2. ICC for median fascia distance per location (mid-prostate, apex and base) and per FP region for the different observers. Highest agreement in mid-prostate Sect. (0.36; 0.31 and 0.26 respectively for apex and base). With respect to the FP region: highest ICCs in L4, R4 and R5. Lowest ICCs in regions L6, R6 and R2. FP, fascia preservation; ICC, intraclass correlation coefficient (TIFF 994 kb)
345_2018_2387_MOESM3_ESM.tif (2.4 mb)
Supplementary material 3 Fig. 3. A schematic picture of the prostate and a mid-prostate section. F: Fascia, R: Rectum, U: Urethra. B. A mid-prostate section stained with a s100-staining (nerve staining). C-F. Spiderplots which show the (C) FT (D) the FS (E) the peripheral nerve density (F) and the blood vessel density for the different FP regions of 10 patients who had a non-sparing prostatectomy. All graphs are normalized. FP, fascia preservation; FS, fascia surface; FT, fascia thickness (TIFF 2488 kb)
345_2018_2387_MOESM4_ESM.tif (1.1 mb)
Supplementary material 4 Fig. 4. These spiderplots show the variation in (A) FT, (B) FS, (C) peripheral nerve density and (D) blood vessel density per FP region for 5 individual patients. All graphs are normalized. FP, fascia preservation; FS, fascia surface; FT, fascia thickness (TIFF 1141 kb)
345_2018_2387_MOESM5_ESM.tif (1.3 mb)
Supplementary material 5 Fig. 5. The predictive value of the five factors which were significantly related to postoperative ED varied dependent on the cut-off chosen. The highest AUC values were reached with a cut-off IIEF score ≤ 12 or ≤ 13. AUC, area under the curve; ED, erectile dysfunction; IIEF, International Index of Erectile Function-Erectile Function (TIFF 1309 kb)
345_2018_2387_MOESM6_ESM.docx (24 kb)
Supplementary material 6 (DOCX 23 kb)
345_2018_2387_MOESM7_ESM.docx (13 kb)
Supplementary material 7 (DOCX 13 kb)

References

  1. 1.
    Siegel RL, Miller KD, Jemal A (2017) Cancer statistics, 2017. CA Cancer J Clin 67:7–30CrossRefGoogle Scholar
  2. 2.
    Savera AT, Kaul S, Badani K et al (2006) Robotic radical prostatectomy with the “Veil of Aphrodite” technique: histologic evidence of enhanced nerve sparing. Eur Urol 49:1065–1073CrossRefGoogle Scholar
  3. 3.
    Stolzenburg JU, Rabenalt R, Do M et al (2008) Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy. Eur Urol 53:931–940CrossRefGoogle Scholar
  4. 4.
    Tewari A, Peabody JO, Fischer M et al (2003) An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy. Eur Urol 43:444–454CrossRefGoogle Scholar
  5. 5.
    Villeirs GM, Verstraete LK, De Neve WJ, De Meerleer GO (2005) Magnetic resonance imaging anatomy of the prostate and periprostatic area: a guide for radiotherapists. Radiother Oncol 76:99–106CrossRefGoogle Scholar
  6. 6.
    Secin FP, Bianco FJ (2010) Surgical anatomy of radical prostatectomy: periprostatic fascial anatomy and overview of the urinary sphincters. Arch Esp Urol 63:255–266CrossRefGoogle Scholar
  7. 7.
    Eichelberg C, Erbersdobler A, Michl U et al (2007) Nerve distribution along the prostatic capsule. Eur Urol 51:105–110CrossRefGoogle Scholar
  8. 8.
    Sievert KD, Hennenlotter J, Laible I et al (2008) The periprostatic autonomic nerves–bundle or layer? Eur Urol 54:1109–1116CrossRefGoogle Scholar
  9. 9.
    de Rooij M, Hamoen EH, Fütterer JJ et al (2014) Accuracy of multiparametric MRI for prostate cancer detection: a meta-analysis. AJR Am J Roentgenol 202:343–351CrossRefGoogle Scholar
  10. 10.
    McClure TD, Margolis DJ, Reiter RE et al (2012) Use of MR imaging to determine preservation of the neurovascular bundles at robotic-assisted laparoscopic prostatectomy. Radiology 262:874–883CrossRefGoogle Scholar
  11. 11.
    Tanaka K, Shigemura K, Muramaki M et al (2013) Efficacy of using three-tesla magnetic resonance imaging diagnosis of capsule invasion for decision-making about neurovascular bundle preservation in robotic-assisted radical prostatectomy. Korean J Urol 54:437–441CrossRefGoogle Scholar
  12. 12.
    Tewari AK, Srivastava A, Huang MW et al (2011) Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP). BJU Int 108:984–992CrossRefGoogle Scholar
  13. 13.
    Schatloff O, Chauhan S, Sivaraman A et al (2012) Anatomic grading of nerve sparing during robot-assisted radical prostatectomy. Eur Urol 61:796–802CrossRefGoogle Scholar
  14. 14.
    van der Poel HG, de Blok W (2009) Role of extent of fascia preservation and erectile function after robot-assisted laparoscopic prostatectomy. Urology 73:816–821CrossRefGoogle Scholar
  15. 15.
    Kowalczyk KJ, Huang AC, Hevelone ND et al (2013) Effect of minimizing tension during robotic-assisted laparoscopic radical prostatectomy on urinary function recovery. World J Urol 31:515–521CrossRefGoogle Scholar
  16. 16.
    Asimakopoulos AD, Corona Montes VE, Gaston R (2012) Robot-assisted laparoscopic radical prostatectomy with intrafascial dissection of the neurovascular bundles and preservation of the pubovesical complex: a step-by-step description of the technique. J Endourol 26:1578–1585CrossRefGoogle Scholar
  17. 17.
    Rosen RC, Riley A, Wagner G et al (1997) The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 49:822–830CrossRefGoogle Scholar
  18. 18.
    Kwon T, Lee C, Jung J, Kim CS (2017) Neurovascular bundle size measured on 3.0-T magnetic resonance imaging is associated with the recovery of erectile function after robot-assisted radical prostatectomy. Urol Oncol 35:542CrossRefGoogle Scholar
  19. 19.
    Di Paola V, Cybulski A, Belluardo S et al (2018) Evaluation of periprostatic neurovascular fibers before and after radical prostatectomy by means of 1.5 T MRI diffusion tensor imaging. Br J Radiol 91:20170318CrossRefGoogle Scholar
  20. 20.
    Ficarra V, Novara G, Ahlering TE et al (2012) Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy. Eur Urol 62:418–430CrossRefGoogle Scholar
  21. 21.
    Walz J, Burnett AL, Costello AJ et al (2010) A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol 57:179–192CrossRefGoogle Scholar
  22. 22.
    Weiss E, Hess CF (2003) The impact of gross tumor volume (GTV) and clinical target volume (CTV) definition on the total accuracy in radiotherapy theoretical aspects and practical experiences. Strahlenther Onkol 179:21–30CrossRefGoogle Scholar
  23. 23.
    Fuller CD, Nijkamp J, Duppen JC et al (2011) Prospective randomized double-blind pilot study of site-specific consensus atlas implementation for rectal cancer target volume delineation in the cooperative group setting. Int J Radiat Oncol Biol Phys 79:481–489CrossRefGoogle Scholar
  24. 24.
    Kalpathy-Cramer J, Awan M, Bedrick S et al (2014) Development of a software for quantitative evaluation radiotherapy target and organ-at-risk segmentation comparison. J Digit Imaging 27:108–119CrossRefGoogle Scholar
  25. 25.
    Bekelman JE, Wolden S, Lee N (2009) Head-and-neck target delineation among radiation oncology residents after a teaching intervention: a prospective, blinded pilot study. Int J Radiat Oncol Biol Phys 73:416–423CrossRefGoogle Scholar
  26. 26.
    Li XA, Tai A, Arthur DW et al (2009) Variability of target and normal structure delineation for breast cancer radiotherapy: an RTOG Multi-Institutional and Multiobserver Study. Int J Radiat Oncol Biol Phys 73:944–951CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Nikolaos Grivas
    • 1
    Email author
  • Rosanne C. van der Roest
    • 1
  • Clarize M. de Korne
    • 2
  • Gijs H. KleinJan
    • 1
    • 2
  • Karolina Sikorska
    • 3
  • Ivo G. Schoots
    • 4
    • 5
  • Corinne Tillier
    • 1
  • Bram van der Broek
    • 6
  • Kees Jalink
    • 6
  • Stijn W. T. J. P. Heijmink
    • 4
  • Tessa Buckle
    • 2
  • Fijs W. B. van Leeuwen
    • 2
  • Henk G. van der Poel
    • 1
  1. 1.Department of UrologyThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  2. 2.Department of Radiology, Interventional Molecular Imaging LaboratoryLeiden University Medical CenterLeidenThe Netherlands
  3. 3.Department of BiometricsThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  4. 4.Department of RadiologyThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  5. 5.Department of Radiology and Nuclear MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
  6. 6.Department of Cell BiologyThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands

Personalised recommendations