Application of Intrafascial Neurovascular Bundle Spare Technique in Radical Cystectomy

doi:10.4236/oju.2013.34034

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Open Journal of Urology, 2013, 3, 185-187

http://dx.doi.org/10.4236/oju.2013.34034 Published Online August 2013 (http://www.scirp.org/journal/oju)

Application of Intrafascial Neurovascular Bundle Spare

Technique in Radical Cystectomy

Tiejun Pan, Yu Zhou, Guoqiu Shen, Handong Wen, Weihong Qian

Department of Urology, Wuhan General Hospital, Guangzhou Command, Wuhan, China

Email: [email protected]

Received May 20, 2013; revised June 22, 2013; accepted June 30, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Objective: To investigate the significance of intrafascial neurovascular bundle spare technique in radical cystectomy.

Methods: Between March 2010 and December 2011, a total of 26 bladder cancer patients were treated with radical cys-

tectomy, and intrafascial neurovascular bundle spare technique was applied in all these patients. Mean age of 26 pa-

tients was 56.1 y (45 - 66). Among 26 patients, 21 cases were in stage T2, 5 cases were in stage T3. All patients choose

Orthotopic neobladder as urinary diversion manner. We use intrafascial neurovascular bundle spare technique, dissect

between prostatic fascial and prostatic capsule, spare neurovascular bundle. Operating time, blood loss, complications,

continence and sexual function 3 months after surgery were recorded. Results: In all patients, mean operating time was

328 min, mean blood loss was 316 ml. Only 4 patients need transfusion during surgery. 1 case of urinary fistula was

found after surgery, and spontaneously cured 10 days after surgery. 1 case of bowel obstruction was found, and was

cured by conservative therapy. 4 cases of incontinence were found 3 months after surgery. 18 patients had a nomal

erectile function 3 months after surgery. Conclusions: Intrafascial neurovascular bundle spare technique can safely and

effectively reserve neurovascular bundle in radical cystecto my. Patients can reserve continence and erectile function b y

this technique.

Keywords: Radical Cystectomy; Neurovascular Bundle Spare; Intrafascial Technique

1. Introduction

Standard radical cystectomy should resect badder, pros-

tate and seminal vesicle. For most candidates for radical

cystectomy, we can reserve their neurovascular bundle to

preserve their continence and erectile function. From

March 2010 to December 2011, we have performed 26

cases of radical cystectomy with intrafascial technique to

reserve their neurovascular bundle.

2. Patients and Methods

2.1. Clinical Datas

All 26 patients, male, mean age 56.1 y (45 - 66 y), 21

cases in T2 stage and 5 cases in T3 stage. All patients

chose orthotopic neob ladder as ur inar y diversion manner .

Cystoscope was performed in all patients to rule out ure-

thral invasion. No metastasis evidence was found by CT

scan.

2.2. Methods

When aeroperitoneum was established, 5 Trocars were

inserted into abdominal cavity. Then pelvic cavity lym-

phonectomy were performed in both sides. Lymphonec-

tomy extent included internal iliac artery lymph nodes,

external iliac vessel lymph nodes and obturator nerve

lymph nodes. Peritoneum was cut open at Douglas’

Pouch, Vas deferens and seminal vesicle dissociation

was performed, and then Levator ani muscle fascia and

prostatic fascia were dissected to the prostatic capsule at

2 o’clock. Dissociation was performed between prostatic

capsule and prostatic fascia. Then the space among De-

nonviller fascia, neurovascular bundle and seminal vesi-

cle was found. Dissociation along the seminal vesicle

distally till the space between prostatic capsule and

prostatic fascia. And dissociation along this space to the

apex of prostate. Dissociation to the 12 o’clock of pros-

tate at the apex of prostate. Dorsal vein complex were

transfixed and dissected at the apex of prostate. Urethra

was dissected at the apex of prostate. Bladder pedicle and

prostatic pedicle were ligated by Hemlock clips and cut

off. An 8 cm incision was made at middle of lower ab-

dominal wall. And the specimen was taken out. 40 cm

ileum was chosen to make a pouch. Both ureters were

T. J. PAN ET AL.

186

anastomosed to the new pouch and then the new pouch

was anastomosed to the urethra. Operational time, blood

loss, complications after surgery, continence and erectile

function after surgery were recorded.

3. Results

There was no mortality during or after surgery. And no

patient converted to open surgery during operation. All

patients were preserved neurovascular bundle on both

sides with intrafascial technique. Mean operating time

was 328 min (265 - 430 min), mean blood loss 316 ml

(180 - 900 ml). 4 patients need transfu sion during opera-

tion. 1 case of urinary fistula was found after surgery and

was natural cured on the 10th day after surgery. 1 case of

intestinal obstruction was found after surgery, and was

cure by conservative treatment. 2 cases of hydronephro-

sis were found after surgery, and were stable during fol-

low up till one year. Continence and erectile function

were evaluated 3 months after surgery. All patients can

pass urine by themselves. 4 cases of incontinence were

found during follow up. 18 patients had normal erectile

function 3 months after surgery.

4. Disscusion

Radical cystectomy was standard treatment method for

muscle invasive bladder cancer. Standard radical cystec-

tomy should resect badder, prostate and seminal vesicle.

Traditionally, surgeons did not preserve neurovascular

bundle beside the prostate, so that patients’ continence

and erectile function were affected. For most radical

cystectomy candidates, they did not have prostate cancer

simultaneously, so most of their neurovascular bundles

can be preserved in order to preserve better continence

and erectile function. A lot of surgeon s were dedicated to

improve it [1-3].

Dr. Walsh first performed neurovascular bundle spa-

ring radical prostatectomy in 1983. N eurov ascular bund le

sparing radical prostatectomy greatly improved patients’

continence and erectile function after radical prostatec-

tomy. Then Dr. Walsh [4] applied this technique in radi-

cal cystectomy, and also improved continence and erec-

tile function after surgery. Neurovascular bundle located

posterolaterally of apex of seminal vesicle, and laterally

of prostatic capsule and Denonviller’s fascia, deeply of

Pelvic fascia. Neurovascular bundle extend laterally along

the prostate from bladder neck and form prostate pedicle.

It extends closely to urethral sphincter and crosses dia-

phragma urogenitale.

Most surgeons use interfascia technique to spare neu-

ronvascular bundle. They dissociate between prostate

fascia and pelvic fascia to preserve neurovascular bundle.

Since neurovascular bundle just locates at this area, dis-

sociation can cause bleeding and nerve damage. Stol-

zenburg et al. first use intra fascia technique in radical

prostatectomy to preserve neurovascular bundle in 2006.

They dissociate between prostate fascia and prostate cap-

sule, which can protect neurovascular bundle between

prostate fascia and prostate capsule. The dissociation

begins from 2 o’clock of the bottom of prostate, and then

dissociates neurovascular bundle from prostatic capsule.

So the operating instruments need not directly touch the

neurovascular bundle, and the view will be very clear

and nerve damage probability can be greatly reduced [5].

Many surgeons also use this technique in radical pros-

tatectomy [6-9].

In our group, mean operating time was 328 min, mean

blood loss 316 ml. No serious complications were found

after surgery. 84.6% patients were continent 3 months

after surgery. 69.2% patients had normal erectile function

3 months after surgery. It indicates intra fascia technique

can efficiently preserve patients’ continence and erectile

function in radical cystectomy. But we still need more

cases to identify tumor control and long term survival

benefit of this technique.

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