From the Guidelines
Robotic prostatectomy is feasible even when the neurovascular bundle is involved, with the approach potentially needing modification to accommodate the extent of involvement, as indicated by recent guidelines and studies 1. When the neurovascular bundle is involved, the surgical strategy may require adjustment, potentially involving a non-nerve-sparing procedure on the affected side while preserving nerves on the unaffected side, known as a unilateral nerve-sparing approach. The use of robotic platforms in such complex cases offers several advantages, including enhanced visualization, precise dissection capabilities, and reduced blood loss compared to traditional open surgery 1.
Key considerations in planning robotic prostatectomy with neurovascular bundle involvement include:
- Preoperative imaging, such as multiparametric MRI, to accurately assess the extent of neurovascular bundle involvement and guide surgical planning 1.
- The potential for higher risk of postoperative erectile dysfunction if the neurovascular bundle must be removed due to cancer involvement, although urinary continence is generally less affected.
- The importance of patient counseling on the potential outcomes and recovery process, including the use of erectile rehabilitation protocols for appropriate candidates.
The recovery process typically involves:
- Catheterization for 1-2 weeks postoperatively.
- Gradual return to normal activities over 4-6 weeks.
- Potential use of medications like sildenafil or tadalafil as part of erectile rehabilitation protocols, starting shortly after catheter removal for suitable candidates. Given the advancements in surgical techniques and technology, robotic prostatectomy remains a viable option for patients with neurovascular bundle involvement, offering the potential for effective cancer control while minimizing impacts on quality of life 1.
From the Research
Robotic Prostatectomy with Neurovascular Bundle Involvement
- Robotic prostatectomy is a viable option for patients with prostate cancer, and the involvement of the neurovascular bundle does not necessarily preclude the procedure 2, 3.
- Studies have shown that robotic prostatectomy with preservation of the neurovascular bundle can result in excellent oncological and functional outcomes, including early recovery of continence and sexual function 2, 3.
- The use of preoperative multiparametric magnetic resonance imaging (MRI) can help identify patients who are candidates for neurovascular bundle preservation and improve the accuracy of surgical planning 4.
- However, intraoperative changes to the surgical plan may be necessary in some cases, and factors such as age, tumor grade, prostate volume, and laterality can predict the likelihood of deviation from the planned neurovascular bundle preservation technique 5.
Surgical Techniques and Outcomes
- Various surgical techniques have been developed to preserve the neurovascular bundle during robotic prostatectomy, including the retrograde release of the neurovascular bundle and the clipless intrafascial neurovascular bundle-sparing approach 2, 3.
- These techniques have been shown to result in high rates of potency and continence recovery, as well as low rates of positive surgical margins and biochemical recurrence 2, 3.
- The use of cognitive task analysis and visual cues can help surgeons navigate complex surgical situations and avoid errors during robotic prostatectomy 6.
Predictors of Deviation in Neurovascular Bundle Preservation
- Several factors have been identified as predictors of deviation from the planned neurovascular bundle preservation technique, including older age, higher tumor grade, prostate volume, and laterality 5.
- Patients with these factors may be at higher risk of unplanned incomplete nerve sparing, which can result in poorer functional outcomes 5.
- Careful preoperative planning and the use of adjuncts such as multiparametric MRI can help identify patients who are at risk of deviation from the planned surgical technique and improve overall outcomes 5.