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. 2021 Apr 15;16(4):e0249991.
doi: 10.1371/journal.pone.0249991. eCollection 2021.

Novel anatomical apical dissection utilizing puboprostatic "open-collar" technique: Impact on apical surgical margin and early continence recovery

Fumitaka Koga  1 , Masaya Ito  1 , Madoka Kataoka  1 , Hiroshi Fukushima  1 , Yasukazu Nakanishi  1 , Kosuke Takemura  1 , Hiroaki Suzuki  1 , Kazumasa Sakamoto  1 , Shuichiro Kobayashi  1 , Ken-Ichi Tobisu  1
Affiliations

Novel anatomical apical dissection utilizing puboprostatic "open-collar" technique: Impact on apical surgical margin and early continence recovery

Fumitaka Koga et al. PLoS One. .

Abstract

Purpose: To evaluate the impact of modifications to anatomical apical dissection including a puboprostatic open-collar technique, which visualizes the lateral aspect of the apex and dorsal vein complex (DVC) covering the rhabdosphincter while preserving the puboprostatic collar, on positive surgical margin (PSM) and continence recovery.

Methods: One-hundred-and-sixty-seven patients underwent gasless single-port retroperitoneoscopic radical prostatectomy using a three-dimensional head-mounted display system. Sequentially modified surgical techniques comprised puboprostatic open-collar technique, sutureless transection of the DVC, retrograde urethral dissection, and anterior reconstruction. The associations of these modifications with PSM and continence recovery were assessed.

Results: The puboprostatic open-collar technique, sutureless DVC transection, and retrograde urethral dissection were significantly associated with lower apical PSM (P = 0.003, 0.003, and 0.010, respectively). The former two also showed similar associations in 84 patients with anterior apical tumor (P = 0.021 and 0.030, respectively). Among 92 patients undergoing all of these three procedures, overall and apical PSM rates were 13.0% and 3.3%, respectively. Retrograde urethral dissection (odds ratio [OR] 2.73, P = 0.004) together with nerve sparing (OR 2.77, P = 0.003) and anterior apical tumor (OR 0.45, P = 0.017) were independently associated with immediate continence recovery. A multivariable model for 3-month continence recovery included anterior apical tumor (OR 0.28, P = 0.003) and puboprostatic open-collar technique (OR 3.42, P = 0.062). Immediate and 3-month continence recovery rates were 56.3% and 85.4%, respectively, in 103 patients undergoing both the puboprostatic open-collar technique and retrograde urethral dissection.

Conclusion: Novel anatomical apical dissection utilizing a puboprostatic open-collar technique may favorably impact on both apical surgical margin and continence recovery.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Surgical techniques for novel anatomical apical dissection and anterior reconstruction in gasless single-port retroperitoneoscopic radical prostatectomy.
(A) The 3-dimensional head-mounted display system. (B-K) Puboprostatic open-collar technique. The surgical procedures consist of three steps: 1) Separating the endopelvic fascia (EF) lateral to the prostate (B), 2) separating the EF medial to the puboprostatic ligament (PPL) (C), and 3) transecting apical attachment of the pubococcygeus muscle (D). The EF is bluntly separated lateral to the prostate toward the apical attachment of the pubococcygeus muscle (B and E). Black arrowheads indicate preserved arcus tendinous (AT). Similarly, the EF is bluntly separated medial to the PPL, as indicated by an asterisk (C and F). The EF covering the apical attachment of the pubococcygeus muscle is incised to preserve the puboprostatic collar (D and G). Apical attachment of the pubococcygeus muscle (H) is transected using a bipolar sealing device (I). These procedures visualize the lateral aspect of the apical and urethral structures while preserving the puboprostatic collar (D and J). Open collar-shaped PPL-AT complexes (blue shadow) are preserved (K). (L and M) Sutureless transection of the dorsal vein complex (DVC). DVC is transected distally enough to secure apical surgical margins in cases of anterior apical tumor (L). The rhabdosphincter, indicated by an arrow, is exposed (M). (N) Retrograde urethral dissection. Overlying DVC tissues are retrogradely dissected from the rhabdosphincter and urethra toward the apex to secure apical surgical margins and to preserve the functional urethral length. The urethra is sharply divided. (O and P) Anterior reconstruction. Following vesico-urethral anastomosis, the detrusor muscle is anchored to the puboprostatic collar at its original apical attachment site (O) using a 3–0 Vicryl stich (P).
Fig 2
Fig 2. Modifications of anatomical apical dissection and pelvic floor reconstruction during the study period.
Procedures ① and ⑤ remained unchanged throughout the study period. Transection of the puboprostatic ligament (PPL)-arcus tendinous (AT) complex, and distal clamp and suture ligation of the dorsal vein complex (DVC) were replaced by procedures ② and ③, respectively. Procedures ④ and ⑥ were newly introduced during the study period.
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