Neurovascular bundle preservation in robotic-assisted radical prostatectomy

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madman

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Abstract

Despite the neuroanatomy knowledge of the prostate described initially in the 1980s and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article, we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.




Introduction

The surgical treatment for localized prostate cancer has been described beginning in the early 1900s (1). However, the lack of neuroanatomy knowledge associated with potency recovery following radical prostatectomy had led to high rates of erectile dysfunction at that time. Fortunately, in the 1980s, Walsh and Donker described the basis of prostate anatomy in their first report of nerve-sparing (NS) radical prostatectomy (2). This study marked the beginning of a new era by increasing postoperative potency rates and establishing the anatomic basis of erectile preservation in patients undergoing radical prostatectomy.

In the following years, open retropubic radical prostatectomy with nerve-sparing technique became the standard of care for patients diagnosed with localized prostate cancer. However, the advent of robotic surgery changed the standard treatment.
But even with the advantages of this technology over the open and laparoscopic approaches, erectile outcomes remain a challenge for patients and surgeons (3- 6). Recent studies have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI) (7, 8). After performing 15,000 cases, in this article, we describe our current RARP technique with details and considerations regarding the optimal approach to neurovascular preservation (9).





*Neurovascular bundles (NVB) anatomic considerations

*Different degrees and planes of NVB preservation

-Intrafascial
-Interfascial
-Extrafascial


*Nerve-sparing RARP technique

*Anterograde NVB dissection

*Veil of Aphrodite

*Retrograde NVB dissection

*Our technical considerations for NS-RARP after 15.000 cases

-Full nerve-sparing considerations
-Partial nerve-sparing considerations





Conclusions

After performing more than 15,000 cases, we believe that the NS-RARP learning curve and surgical technique are continuously evolving because the rates of postoperative functional and oncological outcomes are still inferior to 100%. Evaluating the results of our previous techniques is a crucial factor in identifying surgical steps that can be modified and improved. In addition, it is vital to know the prostate anatomy and physiology to respect the planes with careful dissection. We also consider that basic concepts, such as minimizing the amount of traction used on dissection, avoiding excessive cautery (energy) during hemostasis, and neural preservation based on anatomical landmarks (arteries and planes of dissection), should be common to all Nerve-sparing techniques.
 

Attachments

  • 2021NOV20-NVB-RARP-20229904.pdf
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madman

Super Moderator
Figure 1 - Posterior medial prostatic artery on the right side.
Screenshot (9232).png
 

madman

Super Moderator
Figure 7 - Prostate anatomy describing the arterial landmarks used to guide the nerve-sparing on the right side.
Screenshot (9236).png
 
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