Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy

Abstract

Purpose: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). Materials and Methods:We performed a MEDLINE search from 2001 to 2009 using the keywords "robotic prostatectomy", "cavernosal nerve", "pelvic neuroanatomy", "potency", "outcomes" and "comparison". Extended search was also performed using the references from these articles. Results: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, "the veil of Aphrodite", "athermal retrograde neurovascular release", "clipless antegrade nerve sparing" and "clipless cautery free technique". The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. Conclusions: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.

Robot-assisted prostatectomy: the new standard of care

“…Another advantage is three-dimensional and magnified view as well as 6 degrees of movement with the robotic laparoscopy instruments. This allows the surgeon a better identification of corresponding layers and fascia as well as better and sophisticated dissection of the tissue [62].…”

“…Another advantage that comes along with RARP is the complete new view to the prostatic anatomy and therefore resulting innovative operation techniques such as new nerve sparing methods [28,62,64] or urethral suspension stitches for reconstruction of the urinary retention system [53]. These findings can be carried on to open surgery as done by Rocco et al The authors presented the reconstruction of posterior rhabdosphincter after gaining a new view to prostatic anatomy due to laparoscopy [52].…”

“…Today, intrafascial, interfascial, and extrafascial dissection are known. Due to magnified view, it is possible to identify the corresponding fascia [62].…”

“…Kaul, Menon and their colleagues presented the "veil of Aphrodite" or high anterior release technique, a preservation of the prostatic fascia with better outcome for erectile function after radical prostatectomy. Therefore, a plane is developed between the prostatic capsule and the prostatic fascia, starting cranially at the base of the seminal vesicles and developed to the prostatic apex using blunt and sharp dissection without thermal coagulation [62][63][64]. Menon et al evaluated the outcome of 2,652 patients (mean age 60 years and 62% men > 60 years, although this difference was not statistical significant (p=0.14) [55].…”

Ürolojik Laparoskopik Cerrahide Lazer Kullanımı

“…Seçilen cerrahi yaklaşımdan bağımsız olarak, penil erektil fonksiyonun korunabilmesi için operasyon sırasında, prostatın posterolateralinde yoğunlaşan ve nörovasküler demet (NVD) olarak da bilinen periprostatik parasempatik liflerin korunması gerekmektedir (17). Günümüzde diseksiyon ve hemostaz amacı ile kullanılan koterler (monopolar veya bipolar) ile ultrasonik kesicilerin çevre dokulara termal hasar verdiği ve bu yüzden kavernozal sinir fonksiyonunu etkiledikleri bilinmektedir (18).…”