Early Retrograde Nerve Preservation During Robot-Assisted Radical Prostatectomy: Description of Technique and Potency Outcomes

Abstract

Introduction: Antegrade nerve sparing (ANS) is commonly performed during robot-assisted radical prostatectomy (RARP). However, this approach provides limited observation of the neurovascular bundle (NVB) course with the potential risk for injury. Objective: Our technique of retrograde, early release of the NVB is described. Mid-term outcomes are presented. Methods: Over 8 months, 200 consecutive patients with a preoperative sexual health index male (SHIM) score >21 underwent athermal, full bilateral retrograde nerve sparing (RNS). Data were compared to a previous cohort of 146 consecutive patients in whom ANS was performed. Surgical Procedure: Key aspects of the technique include initial athermal seminal vesicle dissection followed by thorough development of the posterior plane. An interfascial plane of dissection is developed on the prostate laterally until it meets with the previously developed posterior plane. The course of the NVB becomes clear and the pedicle is now transected. NVB dissection is completed antegrade toward the apex. Measurements: Postoperative potency was assessed objectively and defined as a score ≥4 on questions 2 and 3 of SHIM questionnaire, with or without use of phosphodiesterase‐5 (PDE-5) (–). Results: Groups were comparable regarding age, body–mass index, preoperative prostate specific antigen (PSA) clinical stage, Gleason grade, gland size, and postero-lateral positive surgical margins (PSM). Blood loss was higher and operating room (OR) time longer in the ANS group than in the retrograde group. Potency recovery was better in the RNS group at 6 weeks, 3 months, 6 months, and 12 months than in the ANS group (64%, 85%, 92.3%, 94.4% vs. 50%, 75%, 82.1%, 88.5%, respectively). On the log-rank test, patients undergoing RNS demonstrated a significantly improved probability of potency return compared to ANS. Conclusions: Retrograde early release of the NVB is feasible during RARP. It does not increase the risk for a PSM, but it allows for improved overall potency rates and earlier return of sexual function. No competing financial interests exist. Runtime of video: 7 mins 58 secs