Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

Carvalho, Paulo Afonso; Barbosa, João Arthur Brunhara Alves; Guglielmetti, Giuliano; Cordeiro, Maurício; Rocco, Bernardo; Nahas, William Carlos; Patel, Vipul; Coelho, Rafael F.

doi:10.1016/j.eururo.2018.07.003

Cited by 58 publications

(42 citation statements)

References 30 publications

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“…Using a validated sexual function SHIM questionnaire at 1 month after RARP, 71.4% of our patients returned to their baseline preoperative sexual function scores, which increased to 81.9%, 88.6%, 92.4%, and 94.3% at 3, 6, 9, and 12 months, respectively. These recovery rates are favorable compared with a previous RARP study that used the same questionnaire (53.1%, 69.9%, 82.3%, and 86.7% at 1, 3, 6, and 12 months, respectively) 26 . Although the surgical techniques used in the clipless intrafascial neurovascular bundle-sparing approach are not particularly novel, we found that their combined use can result in excellent postoperative functional outcomes.…”

Section: Discussionsupporting

confidence: 48%

Robot-assisted radical prostatectomy with clipless intrafascial neurovascular bundle-sparing approach: surgical technique and one-year functional and oncologic outcomes

Shin

Lee

2020

Sci Rep

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Various neurovascular bundle-sparing techniques have been introduced to maximize recovery of erectile function after robot-assisted radical prostatectomy (RARP). The clipless intrafascial neurovascular bundle-sparing technique aims to preserve periprostatic structures and neurovascular bundles as much as possible by avoiding clipping of the vascular pedicles. This study reports 1-year functional and oncologic outcomes and postoperative complications in 105 patients with intact preoperative erectile function who underwent a modified clipless intrafascial neurovascular bundle-sparing RARP. Intact erectile function was defined as score ≥ 21 on the Sexual Health Inventory for Men questionnaire or ability to have sexual intercourse. Median follow-up was 26.5 months (IQR 15.25–48). Postoperative erectile function recovery rates were 71.4%, 81.9%, 88.6%, 92.4%, and 94.3% at 1, 3, 6, 9, and 12 months, respectively. The rate of positive surgical margins was 16.2% overall and 11.8% in patients with stage pT2 disease. The biochemical recurrence rate was 6.7% overall. The modified clipless intrafascial neurovascular bundle-sparing technique is safe and feasible and can achieve excellent recovery of erectile function after RARP. Further large-scale prospective comparative studies are warranted.

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Section: Discussionsupporting

confidence: 48%

Robot-assisted radical prostatectomy with clipless intrafascial neurovascular bundle-sparing approach: surgical technique and one-year functional and oncologic outcomes

Shin

Lee

2020

Sci Rep

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“…Continence (no pads/d) rates were 77.6% vs. 44.7% at 6 weeks and 87.9% vs. 66.7% at 3 months (MAD/LPFP vs. control group) (p<0.001, both) ( Table 2, unpublished data). Similarly, de Carvalho et al [43], using a similar technique of MAD, reported that continence was reached immediately in 85.9% of the patients and in 98.4% at 3 months postoperatively.…”

Section: Minimal Apical Dissectionmentioning

confidence: 72%

Lessons learned from 12,000 robotic radical prostatectomies: Is the journey as important as the outcome?

et al. 2020

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Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).

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“…Recent studies have shown that NVB preservation during LRP is conducive to the preservation and recovery of sexual function and an improvement in urination after surgery. 32 If NVB preservation is required, attention should be paid to the base of the prostate: the thin fascia covering the neurovascular bundle should be carefully incised and the NVB should be released from the base of the prostate to the pelvic floor muscle on the posterolateral side of the urethra using blunt and sharp dissection. In the present study, LRP lasted about 30 min longer if the NVB was preserved than if it was not (159.5±44.9 vs 129.2±39.2 min).…”

Section: Discussionmentioning

confidence: 99%

<p>Predictors of Prolonged Laparoscopic Radical Prostatectomy and the Creation of a Scoring System for the Duration</p>

Chen

et al. 2020

CMAR

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To identify the relevant factors, and create and validate a predictive scoring system for the duration of laparoscopic radical prostatectomy (LRP). Patients and Methods: We retrospectively analyzed clinicopathological data from 436 patients who underwent LRP between January 2014 and January 2019, of whom 304 cases were used as a model creation group and 132 were used as a validation group. Uni/multivariate linear regression analysis was performed to determine the predictors of the duration of the procedure and a novel scoring system was created using these predictors. External validation of the scoring system was performed. The Hosmer-Lemeshow test was used to determine the goodness-of-fit of the model and calibration plots were created for visual assessment. Results: "Prolonged duration" was defined as a duration of the procedure that was longer than the mean (>150 min) duration. Multivariate analysis showed that body mass index (BMI), prostate volume, intravesicular protrusion of the prostate (IPP), the ratio of the crosssectional areas of the prostate and the Retzius space (P/R), pelvic lymph node dissection, and neurovascular bundle (NVB) preservation were significant predictors of prolonged duration. A scoring system that included these six parameters was created and the area under the curve achieved during receiver operating characteristic analysis using this scoring system was 0.874 (95% confidence interval [CI]: 0.836-0.913). The Hosmer-Lemeshow test showed that the scoring system was well calibrated (X 2 =5.339, P=0.376). The external validation showed that the model had high predictive accuracy (AUC=0.835, 95% CI: 0.764-0.906) and goodness-of-fit (X 2 =4.401, P=0.493). Conclusion: The following factors were significantly associated with prolonged duration of laparoscopic radical prostatectomy: BMI, prostate volume, IPP, P/R, pelvic lymph node dissection, and NVB preservation. The novel scoring system created can be used to accurately predict the duration of the procedure, assess the difficulty of surgery, and improve perioperative efficiency.

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Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

Cited by 58 publications

References 30 publications

Robot-assisted radical prostatectomy with clipless intrafascial neurovascular bundle-sparing approach: surgical technique and one-year functional and oncologic outcomes

Robot-assisted radical prostatectomy with clipless intrafascial neurovascular bundle-sparing approach: surgical technique and one-year functional and oncologic outcomes

Lessons learned from 12,000 robotic radical prostatectomies: Is the journey as important as the outcome?

<p>Predictors of Prolonged Laparoscopic Radical Prostatectomy and the Creation of a Scoring System for the Duration</p>

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