From the Guidelines
Nerve-sparing techniques during radical prostatectomy should prioritize the preservation of neurovascular bundles to minimize postoperative erectile dysfunction and improve urinary continence, as supported by recent guidelines 1.
Current Methods for Nerve Sparing
Current methods for nerve sparing during radical prostatectomy include:
- The interfascial technique, where dissection occurs between the prostatic fascia and the levator fascia
- The intrafascial technique, which involves even closer dissection to the prostatic capsule for maximum nerve preservation
- A graded nerve-sparing approach based on cancer location and risk, ranging from complete preservation to partial or no nerve-sparing
Advanced Technologies for Nerve Sparing
Advanced technologies that enhance visualization and precision include:
- Robotic-assisted surgery
- Intraoperative nerve monitoring
- Magnification with surgical loupes or microscopes
Preoperative and Intraoperative Considerations
Preoperative MRI helps identify tumor location relative to neurovascular bundles, while frozen section analysis during surgery confirms negative surgical margins 1. Minimizing traction and thermal injury to nerves is essential, often achieved through selective use of bipolar cautery, harmonic scalpels, or clips for hemostasis rather than extensive monopolar cautery.
Postoperative Care
Postoperatively, early penile rehabilitation with PDE5 inhibitors (sildenafil 50mg, tadalafil 5mg daily), vacuum erection devices, or intracavernosal injections may be initiated within weeks of surgery to promote tissue oxygenation and prevent fibrosis, potentially improving long-term erectile function recovery 1.
Key Considerations
Key considerations for nerve-sparing radical prostatectomy include:
- Preservation of as much urethral length as possible to maximize the chance of early return to continence
- Use of multiparametric MRI to select an nerve-sparing approach and predict the likelihood of extraprostatic extension
- Individualized approach based on cancer location, risk, and patient factors to optimize outcomes and minimize morbidity 1.
From the Research
Current Methods for Nerve Sparing during Radical Prostatectomy
The current methods for nerve sparing during radical prostatectomy include various techniques and approaches, with the goal of preserving sexual function and urinary continence in prostate cancer patients. Some of the key methods include:
- Anterior approach, which involves early retrograde nerve release, improving early potency rates 2
- Lateral approach, using hybrid techniques and extra-fascial dissection, providing clear nerve visualization and reducing nerve injuries, enhancing continence and potency recovery 2
- Posterior approach, particularly the hood technique, effectively preserving periurethral structures, leading to high continence rates within a year post-surgery 2
- Combined antegrade and retrograde laparoscopic approach to neurovascular bundle dissection, using specialized laparoscopic instrumentation and avoiding electrocautery 3
- Nerve-sparing robotic-assisted radical prostatectomy, which involves preserving the neurovascular bundle and using anatomical landmarks, such as the prostatic artery, to guide dissection 4
Key Considerations for Nerve Sparing
Some key considerations for nerve sparing during radical prostatectomy include:
- Minimizing the amount of traction used on dissection 4
- Avoiding excessive cautery 3, 4
- Neural preservation based on anatomical landmarks, such as arteries and planes of dissection 4
- Tailored approach for each patient, taking into account preoperative risk assessments, baseline potency, surgical anatomy, and surgeons' expertise 5
Comparison of Nerve Sparing Techniques
Studies have compared the outcomes of different nerve sparing techniques, including:
- Bilateral nerve sparing robotic-assisted radical prostatectomy (BNS-RARP) versus retropubic radical prostatectomy (RRP), showing faster continence recovery but not improved erectile function recovery with BNS-RARP 6
- Various nerve sparing techniques, including anterior, lateral, and posterior approaches, with no randomized studies to suggest the superiority of one over the other 5