Rassweiler Jens, Wagner Andrew A, Moazin Maher, Gözen Ali S, Teber Dogu, Frede Thomas, Su Li-Ming
Department of Urology, SLK Kiniken Heilbronn, University of Heidelberg, Heidelberg, Germany.
Urology. 2006 Sep;68(3):587-91; discussion 591-2. doi: 10.1016/j.urology.2006.03.082.
To compare the anatomic retrograde and antegrade preservation of the neurovascular bundle (NVB) during laparoscopic radical prostatectomy.
Anatomic studies were reviewed, focusing on the fascial layers surrounding the prostate and NVB and the terminology used as described by Walsh and colleagues. Important operative steps have been illustrated using video clips. For the retrograde technique, after incision of levator fascia, the NVBs were released from the apex before division of the urethra. Along the plane between the laterally incised Denonvilliers and perirectal fascia, the prostate was mobilized from the rectum. Isolated clipping of the seminal vesicle arteries was performed in an antegrade manner, followed by control of the lateral pedicles, and identification of the course of the NVB. For the antegrade technique, after dissection of the seminal vesicles, the levator fascia was incised to develop a lateral NVB groove. After bladder neck division and lateral pedicle ligation, the lateral NVB groove was used as a guide for antegrade preservation of the NVB. During anastomosis, the NVBs located at the 5-o'clock and 7-o'clock positions were avoided in both techniques.
A questionnaire-based potency rate of 67% and 76%, respectively, was reported after bilateral nerve sparing using retrograde and antegrade laparoscopic radical prostatectomy techniques.
Both techniques allowed replication of open surgical principles. The video magnification enabled excellent demonstration of the periprostatic anatomy. The principles of interfascial dissection of the NVB, use of task-specific instrumentation, and avoiding energy sources around the NVB may be more important than the actual nerve-preservation technique used.
比较腹腔镜前列腺癌根治术中神经血管束（NVB）的解剖性逆行和顺行保留。
回顾解剖学研究，重点关注前列腺和NVB周围的筋膜层以及Walsh及其同事所描述的术语。已使用视频片段展示重要的手术步骤。对于逆行技术，在切开提肌筋膜后，在尿道离断前从尖部分离NVB。沿着外侧切开的Denonvilliers筋膜和直肠周筋膜之间的平面，将前列腺从直肠游离。以顺行方式单独夹闭精囊动脉，随后控制外侧蒂，并确定NVB的走行。对于顺行技术，在解剖精囊后，切开提肌筋膜以形成外侧NVB沟。在膀胱颈离断和外侧蒂结扎后，外侧NVB沟用作顺行保留NVB的引导。在两种技术的吻合过程中，均避免位于5点和7点位置的NVB。
使用逆行和顺行腹腔镜前列腺癌根治术技术进行双侧神经保留后，分别报告基于问卷的勃起功能恢复率为67%和76%。
两种技术均能复制开放手术原则。视频放大功能能够出色地展示前列腺周围的解剖结构。NVB筋膜间解剖、使用特定任务器械以及避免在NVB周围使用能量源的原则可能比实际使用的神经保留技术更为重要。
