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.

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

Nerve-sparing robot-assisted radical prostatectomy: Current perspectives

Introduction:Indocyanine green (ICG) is a fluorescent molecule that provokes detectable photon emission. The use of ICG with near-infrared (NIR) imaging system (Akorn, Lake Forest, IL) has been des...

Robot-assisted nerve-sparing radical prostatectomy using near-infrared fluorescence technology and indocyanine green: initial experience.

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 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.

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

Simple Summary Optimum preservation of potency and continence after radical prostatectomy (RP) are equally important surgical endpoints as cancer control itself. Nerve-sparing technique during RP has a major impact to both oncological and functional outcomes of the procedure and various different techniques have been developed aiming to optimize its outcomes. This literature review aims to summarize all different nerve-sparing techniques applied during RP from its first description from Patrick C. Walsh to its newer trends. The review underlines that optimum nerve-sparing expands far beyond recognising and preserving the anatomical integrity of the neurovascular bundles. It also emphasises that nerve-sparing is a field under constant development, with new technologies entering continuously the nerve-sparing field corresponding to the evolving open, laparoscopic and robotic-assisted RP approaches. Abstract 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.

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

Introduction and Objectives: The “Landmark Artery” has been shown to be a valuable landmark during nerve-sparing (NS) robot assisted radical prostatectomy (RARP) in improving the quality of the neurovascular bundle (NVB) preservation. Sometimes, this landmark can be challenging to find due to inexperience of the surgeon or anatomical challenges. We performed the first ever study to evaluate the role of an innovative intraoperative tool, near-infrared fluorescence (NIRF) technology in conjunction with intravenous indocyanine green (ICG) in identification of this “Landmark Artery” during NS RARP. We demonstrate our technique in this video. Methods: Ten patients underwent NS RARP. Before clamping the pedicle or dissection of the NVB, 0.75 ml of ICG was given. The NIRF technology was engaged on the robotic console and a period of 20–40 seconds was allowed for the ICG to enter the vascular system. The landmark artery was then observed bilaterally. After this time period, we switched back to the non-NI...

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Papers

Using Indocyanine Green and Near-Infrared Fluorescence Technology to Identify the “Landmark Artery” During Robot-Assisted Radical Prostatectomy