Optimizing erectogenic outcomes during athermal robotic prostatectomy: A risk-stratified tri-zonal approach


This article describes a risk-stratified approach based on a three-zone anatomic layout to the periprostatic neural architecture and a modified athermal robotic technique for better continence and potency outcomes without compromising surgical margin rates.

Key Points

Pioneering work by Walsh and Donker in the 1980s delineated the course and composition of neurovascular bundles (NVB) involved in potency, and their seminal studies led to the concept of the anatomic nerve-sparing radical prostatectomy, which has since been embraced by urologists as conventional practice for men with clinically localized prostate cancer displaying good preoperative erectile function and low risk of extraprostatic tumor extension.3,4 Despite the improved sexual outcomes with conventional nerve-sparing prostatectomy, 20% to 50% of patients remain impotent at 1 year following nerve-sparing surgery. Even patients considered potent (ie, able to sustain an erection firm enough for intercourse) often experience a reduction in rigidity, duration of intercourse, and pleasure during orgasm.5,6

In recent years, robot-assisted radical prostatectomy using the da Vinci surgical platform (Intuitive Surgical, Sunnyvale, CA) has become increasingly popular with both urologists and their patients. Its benefits include better intraoperative dexterity and visualization of periprostatic tissue architecture with up to 12-fold optical magnification for the surgeon. Patients experience less intraoperative blood loss, less painful recovery, and shorter hospital stays. Menon et al recently reported encouraging 5-year results of patients undergoing robotic prostatectomy.7 Various meta-analyses comparing open, laparoscopic, and robotic prostatectomy have also similarly affirmed the above-mentioned benefits of the robotic approach.8,9

Over the past few years, our research group has made several advances in mapping out a tri-zonal approach to the complex periprostatic neural architecture through cadaveric and real-time operative dissections. Based on fresh cadaveric dissections done at the Weill Medical College of the Cornell University, New York, in active collaboration with the University of Innsbruck in Austria, we developed the athermal robotic technique for optimizing potency.11 Our subsequent appreciation of the course of the tri-zonal lattice of nerves around the prostate in different fascial planes enveloping the prostatic capsule led us to elucidate the presence of the neurovascular hammock and adopt a risk-stratified approach to nerve preservation while maintaining adequate clearance of cancer. We describe here our current technique of athermal nerve-sparing robotic prostatectomy and present an overview of our results to date.

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