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| Nerve-sparing robot-assisted radical prostatectomy: Current perspectives |
Anup Kumara,*( ),Vipul R. Patelb,Sridhar Panaiyadiyanc,Kulthe Ramesh Seetharam Bhatb,Marcio Covas Moschovasb,Brusabhanu Nayakc
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a Department of Urology,Robotics and Renal Transplant, Vardhman Mahaveer Medical College and Safdarjang Hospital, New Delhi, India
b Department of Robotic Surgery, AdventHealth Global Robotics Institute, Celebration, FL, USA
c Department of Urology, All India Institute of Medical Sciences, New Delhi, India |
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Abstract Robotic-assisted radical prostatectomy (RARP) is the current standard of care with long term cure in organ-confined disease. The introduction of nerve-sparing (NS) to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes. This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes, the neurovascular bundle (NVB), various NS techniques and postoperative functional outcomes. A non-systematic review was done using PubMed, Embase and Medline databases to retrieve and analyse articles in English, with following keywords “prostate cancer”, “robotic radical prostatectomy”, “nerve-sparing”. The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies. The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other. Variables such as preoperative risk assessments, baseline potency, surgical anatomy of individual patients and surgeons’ expertise play a major role in the outcomes. A tailored approach for each patient is required for applying the NS approach during RARP.
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Received: 23 December 2019
Available online: 20 January 2021
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Corresponding Authors:
Anup Kumar
E-mail: anup_14k@yahoo.com
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Landmark artery on anterolateral aspect of prostate.
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Left retrograde dissection towards the base of the prostate to completely detach the NVB from the prostatic pedicle. NVB, neurovascular bundle.
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| Grade | Percentage of NS | Description | | Grade 5 | Complete NS (≥95% NS) | After LA is identified and NVB delineated, the NS is performed medial to LA between the prostate and the NVB. The correct plane is confirmed by the pink colour of the prostate. | | Grade 4 | Near-complete NS (75%) | After LA is identified, NS is completed by a sharp dissection between LA and the prostate capsule across the NVB and the correct planed is confirmed by the strip of fat over the prostate. | | Grade 3 | Partial NS (50%) | After LA identification, NS is performed by developing a plane lateral to the LA. The correct plane of dissection is denoted by the identification of fat strip over the prostate. | | Grade 2 | <50% NS | Herein, the NS is performed several millimeters lateral to the LA. | | Grade 1 | Non-NS (0% NS) | Herein, wide resection of the NVB is performed. The correct plane of dissection is denoted by the presence of levator fascia which is not incised. |
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Anatomic grading of the proportion of nerve-sparing.
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dHAM placed over as right sided nerve wrap on NVB. dHACM, dehydrated human amnion/chorion membrane; NVB, neurovascular bundles.
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Landmark artery seen as green fluorescent structure over lateral surface of prostate in near infrared fluorescence mode.
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| Year of the study | Author | Number of patients | Mean age (year) | NS technique | Definition of potency | Follow-up (month) | Potency rate (unilateral NS) | Potency rate (bilateral NS) | Potency rate (overall) | | 2007 | Menon et al. [14] | 721 | 60.2 | Antegrade | Adequate erection for intercourse±PDE 5 inhibitors | 12 | - | 79.2% | 79.2% | | 2009 | Potdevin et al. [8] | 147 | 58.5 vs. 58.7 | Retrograde (Interfascial-77 vs. intrafascial-70) | Adequate erection for intercourse±PDE 5 inhibitors | 9 | - | - | 3 months-16.67% vs. 24.24%
6 months-43.75% vs. 81.81%
9 months-66.67% vs. 90.9% | | 2009 | Shikanov et al. [9] | 813 | 60 vs. 58.5 | Antegrade (Extrafascial-110 vs. interfascial- 703) | Adequate erection for intercourse±PDE 5 inhibitors | 8 vs. 13 | - | - | 3 months-22% vs. 42%
6 months-34% vs. 47%
12 months-40% vs. 64% | | 2010 | Patel et al. [47] | 404 | 58 | Retrograde | Adequate erection for intercourse in >50% of attempts±PDE 5 inhibitors | 18 | - | 53.5%-6 weeks
68.8%-3 months
91.5%-6 months
97.4%-12 months
96.6%-18 months | - | | 2011 | Patel et al. [46] | 332 | 58.5 | Retrograde | Adequate erection for intercourse in >50% of attempts±PDE 5 inhibitors | 12 (minimum) | - | 53.9%-6 weeks
68%-3 months
86.1%-6 months
89.8%-1 year | - | | 2011 | Kowalczyk et al. [45] | 342-NS-0C vs.
268-NS-C | 59.6 vs. 57.9 | Antegrade | Adequate erection for intercourse±PDE 5 inhibitors | 12 | - | 5 months-45% vs. 28.4%
12 months-50% vs. 54.1% | - | | 2012 | Alemozaffar et al. [48] | 400 | 59.8 | Retrograde | Adequate erection for intercourse±PDE 5 inhibitors | 12 | - | - | 5 months-33.3%
12 months-59.3% | | 2013 | Ko et al. [18] | 344 | 57.9 vs. 57.2 | Antegrade NS-172 vs.
Retrograde NS-172 | Adequate erection for intercourse in >50% of attempts±PDE 5 inhibitors | 12 (minimum) | - | 3 months-65% vs. 80.8%
6 months-72.1% vs. 90.1%
9 months-85.3% vs. 92.9% | - | | 2013 | Ficarra et al. [2] | 183 | 62.3 | Antegrade | Adequate erection for intercourse±PDE 5 inhibitors | 81.3 | - | - | 10%-3 months
53%-6 months
82%-12 months |
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Various non comparative studies reporting potency outcomes in patients undergoing robot-assisted radical prostatectomy.
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| Year | Author | Study design | Number of patients (n) | Mean age (year) | Follow-up (month) | Inclusion criteria | Definition of potency | NS technique | Potency rate (unilateral NS) | Potency rate (bilateral NS) | Potency rate (overall) | | 2009 | Krambeck et al. [51] | RRP vs. RARP: Matched cohort analysis | 588 vs. 294 | 61 vs. 65 | 12 | All patients | Adequate erection for intercourse in last 4 weeks ± PDE 5 inhibitors | Antegrade | | | 62.8% vs. 70% | | 2009 | Rocco et al. [50] | RRP vs. RARP:
Matched cohort analysis | 105 vs. 103 | 63 vs. 63 | 12 | All patients | Adequate erection for intercourse in last 4 weeks ± PDE 5 inhibitors | Retrograde | - | - | 41% vs. 61% | | 2009 | Ficarra et al. [49] | RRP vs. RARP: Non randomised prospective study | 588 vs. 294 | 61 vs. 65 | 12 | Consecutive patients with bilateral NS | 11 EF >17 | Antegrade | - | 49% vs. 81% | |
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Studies comparing outcomes between RARP vs. RRP.
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| Year | Author | Study design | Number of patients (n) | Mean age (year) | Follow-up (month) | Inclusion criteria | Definition of potency | Nerve-sparing technique | Potency rate (unilateral NS) | Potency rate (bilateral NS) | Potency rate (overall) | | 2012 | Willis et al. [58] | RARP vs. LRP | 174 vs. 175 | 58.1 vs. 58.2 | 12 | Consecutive patients with localized prostate cancer | Adequate erection for intercourse in last 4 weeks±PDE 5 inhibitors | Antegrade | - | - | 3 months-59.8% vs. 42.2%
6 months-71.2% vs. 51.3%
12 months-73.7% vs. 66.2% | | 2013 | Berge et al. [53] | LRP vs. RARP | 210 vs. 210 | 61.7 vs. 61.7 | 36 | Consecutive patients with localized prostate cancer | Adequate erection for intercourse±PDE 5 inhibitors | Antegrade | 40.2% vs. 45.9% (at 36 months) | 57.3% vs. 61.3% (at 36 months) | - | | 2013 | Porpiglia et al. [54] | RARP vs. LRP (RCT) | 60 vs. 60 | 63.9 vs. 64.7 | 12 | Consecutive patients with localized prostate cancer | IIEF-5 score >17 | Antegrade | - | - | 80% vs. 54.2% (12 months) | | 2013 | Asimakopoulos et al. [55] | LRP vs. RARP | 91 vs. 136 | 63 vs. 60 | 18 vs. 21 | Age ≤70 years, clinically localized prostate cancer, preoperativepotent, with bilateral NS | Adequate erection for intercourse in last 4 weeks ± PDE 5 inhibitors | Antegrade | - | - | 66.2% vs. 39.6% |
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Studies comparing outcomes between robot-assisted RARP vs. LRP.
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