Ep. 44 Surgical Tips and Tricks for Prostatectomy with Dr. Rafael Coelho

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses tips and tricks for radical and partial prostatectomies with Dr. Rafael Coelho, Chief of Urology Oncology at the University of Sao Paulo School of Medicine.

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SHOW NOTES

First, the doctors discuss which preoperative information is most important to obtain. Dr. Coelho orders an MRI for every patient scheduled to undergo a prostatectomy because it is specific for extraprostatic extension of the tumor and indicates whether patients are viable candidates for the nerve-sparing technique. However, because negative MRIs are inconclusive, microscopic extraprostatic extension is still possible in patients with clear imaging. He also notes that nomograms for intermediate-risk patients with local disease.

Next, he delves into his surgical tips for a successful prostatectomy. To avoid incontinence, he uses a partial bladder neck sparing technique but also notes that a good bladder neck reconstruction at the end of the prostatectomy case can resolve postoperative incontinence as well. He generally avoids interfering with the dorsal venous complex as well. As far as lymph node dissections go, he follows evidence-based research and only performs an extended lymph node dissection on patients with a Gleason score of 8, 9, or 10. However, infected lymphoceles are serious complications of lymph node dissections. The doctors then discuss their individual initial approaches to radical prostatectomy and weigh the pros and cons of each one.

Additionally, Dr. Coelho strongly prefers to use a nerve-sparing technique, a decision that balances the oncological outcome and functional outcome of a patient. This technique requires a retrograde release of the neurovascular bundle and helps the surgeon define the border between the pedicle prostate and bundle more clearly. Dr. Coelho notes that this approach is also optimal for preservation of the dorsal venous complex. Dr. Bagrodia recommends using non-thermal energy sources if the nerve-sparing technique is used. A partial nerve-sparing is also an option if the surgeon determines that a small pathological margin may not affect long-term oncological outcome of a patient. Once again, Dr. Coelho emphasizes that the nerve-sparing technique of a prostatectomy is complicated, and surgeon experience matters most when optimizing outcomes.

Lastly, the doctors talk about the preservation of postoperative complications–mainly continence and sexual potency. Although some patients may experience incontinence, long-term incontinence is rare. However, long-term potency is much harder to predict because potency is multifactorial; factors such as sexual partner, anxiety, age, baseline sexual function prior to surgery all affect postoperative potency. Dr. Coelho adds that, based on his research, age and baseline sexual function are most important in predicting postoperative potency.

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RESOURCES

Lestingi, J., Guglielmetti, G. B., Trinh, Q. D., Coelho, R. F., Pontes, J., Jr, Bastos, D. A., Cordeiro, M. D., Sarkis, A. S., Faraj, S. F., Mitre, A. I., Srougi, M., & Nahas, W. C. (2021). Extended Versus Limited Pelvic Lymph Node Dissection During Radical Prostatectomy for Intermediate- and High-risk Prostate Cancer: Early Oncological Outcomes from a Randomized Phase 3 Trial. European urology, 79(5), 595–604. https://doi.org/10.1016/j.eururo.2020.11.040

PubMed link: https://pubmed.ncbi.nlm.nih.gov/33293077/

de Carvalho, P. A., Barbosa, J., Guglielmetti, G. B., Cordeiro, M. D., Rocco, B., Nahas, W. C., Patel, V., & Coelho, R. F. (2020). Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes. European urology, 77(5), 628–635. https://doi.org/10.1016/j.eururo.2018.07.003

PubMed link: https://pubmed.ncbi.nlm.nih.gov/30041833/