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

Patient reported health related quality of life outcomes after viable cryopreserved umbilical tissue placement directly over spared neurovascular bundles after robotic assisted radical prostatectomy

Incontinence and sexual dysfunction remain common side effects from robotic-assisted radical prostatectomy (RARP) despite nerve sparing (NS) and bladder neck reconstruction techniques. Placing growth factors and anti-inflammatory substances over neurovascular bundles is an emerging technique to enhance recovery of continence and potency. Viable cryopreserved umbilical tissue (vCUT) is FDA-approved for surgery. The objective is to determine if vCUT use in NS-RARP accelerates return of continence and sexual function. A retrospective cohort of 176 patients undergoing NS-RARPs with and without vCUT from 2015 to 2020 was identified through the Michigan Urological Surgery Improvement Collaborative (MUSIC). Return to social urinary continence at 3, 6, and 12 months, postoperatively was evaluated using MUSIC patient-reported outcomes (PRO), a validated questionnaire assessing urinary and sexual quality of life at baseline and post-treatment. A distinct cohort of 65 patients undergoing NS-RARP with and without vCUT was assessed for erections firm enough for intercourse at 12 and 24 months post-operatively using MUSIC-PRO. The association between vCUT use and social continence at 3 months was assessed via multivariable logistic regression. A descriptive analysis among patients with quality erections prior to surgery assessed the association between vCUT use and erection quality. Continence was achieved by 3 months post-op in 86% (99/115) of vCUT patients versus 74% (45/61) in non-vCUT patients (p = 0.044). In a multivariable analysis, although not reaching conventional statistical significance, vCUT patients were more likely to achieve continence than non-vCUT patients (OR = 2.21, p = 0.073). At 24 months post-op, 32% of vCUT patients reported good sexual function versus 33% in non-vCUT patients (p = 0.9). vCUT use during NS-RARP is associated with quicker return to social urinary continence. However, no differences were seen in return of potency. Further studies with longer follow-up and larger sample sizes may further evaluate effectiveness of vCUT in accelerating return of postoperative continence and potency.

Intraoperative angiography of the neurovascular bundle using indocyanine green and near-infrared fluorescence improves anatomical dissection during robot-assisted radical prostatectomy: initial clinical experience

Landmark artery identification in the neurovascular bundle (NVB) is important for nerve-sparing in radical prostatectomy. We aimed to investigate intraoperative angiography using indocyanine green and near-infrared fluorescence (ICG-NIRF) during robot-assisted radical prostatectomy (RARP) to identify the NVB, visualise vascularisation and haemostasis, and preserve erectile function. Our retrospective, unicentric study was performed in consecutive localised prostate cancer RARP patients (stage T1/T2, prostate-specific antigen < 10 ng/ml) who underwent ICG-NIRF angiography in France (2016-2021). When ready to dissect the NVB, the anaesthesiologist intravenously injected ICG (3 ml); the surgeon used alternating standard light or fluorescence to optimise NVB visualisation and facilitate microdissection. Primary outcomes: safety and feasibility of ICG-NIRF. Secondary outcomes: functional erectile dysfunction (Sexual Health Inventory for Men (SHIM) questionnaire) over 9 months, proportion of bilateral NVBs identified, ICG-related complications. Standard descriptive statistics were used; t test determined the significance of changes in SHIM scores versus baseline. Ninety-one patients received intraoperative angiography. The NVB was identified in all cases, without difficulties. No ICG-related complications or allergies were observed. There was no significant difference in the SHIM score at 9 months compared with baseline (p = 0.331), and erectile dysfunction returned to baseline levels in almost all patients. Intraoperative, real-time ICG-NIRF angiography is simple, non-invasive, and improves identification of key anatomical landmarks to optimise micropreservation of the NVB during RARP and preserve erectile function. Larger clinical studies should confirm preliminary results.

Different Nerve-Sparing Techniques during Radical Prostatectomy and Their Impact on Functional Outcomes

The purpose of this narrative review is to describe the different nerve-sparing techniques applied during radical prostatectomy and document their functional impact on postoperative outcomes. We performed a PubMed search of the literature using the keywords "nerve-sparing", "techniques", "prostatectomy" and "outcomes". Other potentially eligible studies were retrieved using the reference list of the included studies. Nerve-sparing techniques can be distinguished based on the fascial planes of dissection (intrafascial, interfascial or extrafascial), the direction of dissection (retrograde or antegrade), the timing of the neurovascular bundle dissection off the prostate (early vs. late release), the use of cautery, the application of traction and the number of the neurovascular bundles which are preserved. Despite this rough categorisation, many techniques have been developed which cannot be integrated in one of the categories described above. Moreover, emerging technologies have entered the nerve-sparing field, making its future even more promising. Bilateral nerve-sparing of maximal extent, athermal dissection of the neurovascular bundles with avoidance of traction and utilization of the correct planes remain the basic principles for achieving optimum functional outcomes. Given that potency and continence outcomes after radical prostatectomy are multifactorial endpoints in addition to the difficulty in their postoperative assessment and the well-documented discrepancy existing in their definition, safe conclusions about the superiority of one technique over the other cannot be easily drawn. Further studies, comparing the different nerve-sparing techniques, are necessary.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

Robotic-assisted radical prostatectomy with preceptor's assistance: the training experience and outcomes in South America

Prostate cancer is currently the second leading cause of cancer deaths in Brazilian men. In 2020, sixty-five thousand new prostate cancer cases were expected in Brazil, and almost 30% of these patients are estimated to be from the northeast region. However, from 75 robotic platforms available in the country, only one is accessible in the state of Ceará since 2015. This study reports the intraoperative, functional, and oncological outcomes of patients who underwent radical prostatectomy for prostate cancer performed by robotic surgeons during a training period supervised by a proctor. We also compared these results with the literature reporting the experience of different Brazilian centers. We retrospectively analyzed prospectively collected data of 58 initial cases of robotic-assisted radical prostatectomy at a private Brazilian hospital in Fortaleza, Ceará. The surgeries were performed by two robotic surgeons during the training period under proctor supervision. We reported the epidemiological and intraoperative data, complications, pathological report, functional and oncological outcomes. The median operative time was 180 min. None of the patients needed conversion or blood transfusion. The pathology report described 21.81% of positive surgical margins (16.27% of all pT2 and 45.45% of all pT3 patients). The median follow-up was 40 months. Biochemical recurrence occurred in 21.73%, continence in 92%, and potency in 79.54%. No major complications (Clavien grades III-V) were reported. In our experience, robotic-assisted radical prostatectomy performed by surgeons training with proctor's assistance is feasible and safe. The operative time, complication rates, functional and oncological outcomes were satisfactory and compatible with the literature.

Recommendations on robotic-assisted radical prostatectomy: a Brazilian experts' consensus

Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.

[Robot-assisted radical prostatectomy. Functional result. Part I. (in Russian only)]

Robot-assisted operations as widely used in urology, gynecology, general and cardiovascular surgery are considered by many experts as a new 'gold standard' of surgical treatment of various diseases in developed countries. Robot-assisted radical prostatectomy for prostate cancer is the most common robotic procedure. Better functional outcomes of robot-assisted radical prostatectomy are due to another (new) understanding of pelvic surgical anatomy, new approach implying dissection and preservation of external urethral sphincter and neurovascular structures. Prostate neuroanatomy, various approaches to preserve neurovascular structures and own experience of nerve-sparing robot-assisted radical prostatectomy with functional results are reviewed in the article.

A novel intraoperative physician-assigned grading score to predict postoperative return of potency at 1 year after robotic-assisted laparoscopic prostatectomy

Introduction:

We examined a novel method of grading nerve sparing in robotic-assisted laparoscopic radical prostatectomy to better predict the potency outcomes of patients at 1-year after surgery. This grading (scale) was based on the surgeon's criteria of intraoperative findings during completion of nerve sparing. This grading was then analyzed statistically to validate its association with potency outcomes.

Methods:

We devised a study module based on measurable visual cues intraoperatively where the surgeon risk stratified the surgery into four grades depending on the completeness of nerve sparing, keeping in mind the known parameters influencing potency outcomes. A novel grading scale was then proposed and used in this study for the same. We prospectively collected data and retrospectively analyzed 425 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) at a high-volume center by a single surgeon.

Results:

At 1 year of follow-up, it was found that age, laterality of nerve preservation, weight of prostate, and the surgeon-assigned grading were all statistically significant independent predictors of return of potency in terms of satisfactory penetrative intercourse >50% of times and Sexual Health Inventory for Men ≥17. However, prostate-specific antigen was found not to be a predictor of the same.

Conclusions:

Intraoperative physician-assigned grading was found to be the single most significant predictor of the return of potency at 1-year post-RALP.

Indications, surgical technique, and long-term results of nerve sparing

Radical prostatectomy is frequently performed as a curative approach for clinically localized prostate cancer. In order to reduce the adverse effects of this operation on erectile function, preservation of neurovascular bundles was introduced as part of this operation. The decision of nerve sparing must be carefully tailored in each patient according to the stage of the disease. Patient selection has a critical importance in performing nerve sparing radical prostatectomy. In organ-confined cancers a nerve sparing surgery can be performed in the majority of the cases without jeopardizing tumor control. Individualized decision making in each case may allow more patients to receive a nerve sparing approach, and therefore, better functional outcomes. However, it continues to be difficult to predict postoperative functional outcomes accurately due to many influencing factors.

Current status of various neurovascular bundle-sparing techniques in robot-assisted radical prostatectomy

Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.

Histological evaluation of nerve sparing technique in robotic assisted radical prostatectomy

Introduction:

The objective of this study is to compare intrafascial nerve-sparing (NS), interfascial NS and non-NS prostatecomy specimens to assess the feasibility of NS technique in Robot-assisted radical prostatectomies (RARP).

Materials and Methods:

The records of the first 43 consecutive patients (86 prostatic sides (lobe) who underwent NS RARP (6 intrafascial NS, 46 interfacial NS, 34 non-NS) were reviewed and histopathological examinations were performed. The presence and distribution of periprostatic neurovascular structures were histologically evaluated using mid-gland section of each prostate lobe in the prostatectomy specimen and it was immunostained with the S-100 antibody for quantitative analysis of nerves.

Results:

The average number of nerve fibers per prostatic half was 37.2 ± 20.6. The number of resected peri-prostatic nerves counted was 13.7 ± 13.5, 30.5 ± 15.0 and 50.4 ± 20.4 in intrafascial NS, interfascial NS and non-NS specimens, respectively. The difference in the number of nerve bundle counts in the three groups was statistically significant (P < 0.05). Patients with urinary continence at 6 months after surgery had significantly less number of nerve fibers resected with the prostate than the incontinence group (P = 0.013) and the number of nerve fibers resected in the potent group were lower than in the impotent group but did not reach statistical significance (P = 0.057).

Conclusions:

Our study showed that NS RARP could be performed according to surgeons’ intention (intrafascial, interfascial or non-NS) and urinary continence significantly correlated to the number of nerve fibers resected with the prostate.

Does robotic prostatectomy meet its promise in the management of prostate cancer?

Following Walsh's advances in pelvic anatomy and surgical technique to minimize intraoperative peri-prostatic trauma more than 30 years ago, open retropubic radical prostatectomy (RRP) evolved to become the gold standard treatment of localized prostate cancer, with excellent long-term survival outcomes [1•]. However, RRP is performed with great heterogeneity, even among high volume surgeons, and subtle differences in surgical technique result in clinically significant differences in recovery of urinary and sexual function. Since the initial description of robotic-assisted radical prostatectomy (RARP) in 2000 [2], and U.S. Food and Drug Administration approval shortly thereafter, RARP has been rapidly adopted and has overtaken RRP as the most popular surgical approach in the management of prostate cancer in the United States [3]. However, the surgical management of prostate cancer remains controversial. This is confounded by the idolatry of new technologies and aggressive marketing versus conservatism in embracing tradition. Herein, we review the literature to compare RRP to RARP in terms of perioperative, oncologic, and quality-of-life outcomes as well as healthcare costs. This is a particularly relevant, given the absence of randomized trials and long-term (more than 10-year) follow-up for RARP biochemical recurrence-free survival.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes

Prostate cancer is the second leading cause of cancer death among men in the USA. Use of robot-assisted radical prostatectomy (RARP) for the management of localized prostate cancer has increased dramatically in recent years. This review focuses on comparing quality of life following RARP versus retropubic radical prostatectomy. RARP is associated with improved perioperative outcomes, such as reduced blood loss and fewer transfusions. In addition, cancer control after RARP versus retropubic radical prostatectomy is equivalent, with similar incidences of positive surgical margins and comparable early oncological outcomes. RARP appears to provide advantages in recovery of continence, potency and quality of life compared with retropubic radical prostatectomy; however, methodological limitations exist in current literature.

Cavernosal nerve preservation during robot-assisted radical prostatectomy is a graded rather than an all-or-none phenomenon: objective demonstration by assessment of residual nerve tissue on surgical specimens

OBJECTIVE

To demonstrate the existence of different degrees of nerve sparing (NS) (graded NS) by comparing the surgeon's intent of NS with the residual nerve tissue on prostatectomy specimens.

METHODS

We performed a prospective study of 133 consecutive patients who underwent robot-assisted radical prostatectomy in January and February of 2011. The surgeon graded the amount of NS intraoperatively independently for either side as follows: 1, no NS; 2, <50% NS; 3, 50% NS; 4, 75% NS; and 5, ≥ 95% NS. A pathologist who was unaware of the surgeon's score measured the area of residual nerve tissue on the posterolateral surface of the prostate.

RESULTS

A greater NS score correlated significantly with a decreasing area of residual nerve tissue on the prostatectomy specimens (P < .001). Overall, the area of residual nerve tissue on the prostatectomy specimens was significantly different among the NS groups (P < .001). On specific intergroup analysis, significant differences were found in the area of residual nerve tissue on the prostatectomy specimens between the greater NS groups: NS score 3 versus 4, median 13 mm(2) (interquartile range [IQR] 7-23) versus 3 mm(2) (IQR 0-8; P = .01); NS score 4 versus 5, median 3 mm(2) (IQR 0-8) versus 0.5 mm(2) (IQR 0-2; P = .001).

CONCLUSION

Subjective NS classification using the surgeon's intraoperative perception correlated significantly with the area of residual nerve tissue on the prostatectomy specimens determined by the pathologist. It is possible to intentionally tailor the amount of NS performed at surgery. This finding demonstrates that NS is a graded rather than an all-or-none phenomenon that can even go beyond the traditional concept of complete, partial, or no NS.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study

PURPOSE

Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies.

MATERIALS AND METHODS

We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2).

RESULTS

The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001).

CONCLUSIONS

The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.