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
Received May 20, 2013; revised June 22, 2013; accepted June 30, 2013
Copyright © 2013 Tiejun Pan et al. This is an open access article distributed under the Creative Commons Attribution License,
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
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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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