Investig Clin Urol.  2016 Dec;57(Suppl 2):S172-S184. 10.4111/icu.2016.57.S2.S172.

Nerve-sparing techniques and results in robot-assisted radical prostatectomy

• Tavukçu H
• Aytac O
• Atug F

• KMID: 2361683
• DOI: http://doi.org/10.4111/icu.2016.57.S2.S172

Abstract

Nerve-sparing techniques in robot-assisted radical prostatectomy (RARP) have advanced with the developments defining the prostate anatomy and robotic surgery in recent years. In this review we discussed the surgical anatomy, current nerve-sparing techniques and results of these operations. It is important to define the right and key anatomic landmarks for nerve-sparing in RARP which can demonstrate individual variations. The patients' risk assessment before the operation and intraoperative anatomic variations may affect the nerve-sparing technique, nerve-sparing degree and the approach. There is lack of randomized control trials for different nerve-sparing techniques and approaches in RARP, therefore accurate preoperative and intraoperative assessment of the patient is crucial. Current data shows that, performing the maximum possible nerve-sparing using athermal techniques have better functional outcomes.

Keyword

Erectile dysfunction; Prostate neoplasms; Prostatectomy; Surgical diagnostic techniques

MeSH Terms

Anatomic Landmarks
Diagnostic Techniques, Surgical
Erectile Dysfunction
Humans
Male
Prostate
Prostatectomy*
Prostatic Neoplasms
Risk Assessment

Figure

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  Fig. 1 (A) Visceral component (yellow arrow) and parietal component (blue arrow) of the endopelvic fascia, arcus tendineus fascia pelvis (red dashed line). (B) Dissection of interfascial and intrafascial (nerve-sparing) plane. (C) Dissection of extrafascial plane, levator ani muscle (red arrow).

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  Fig. 2 (A) Axial section of prostatic and periprostatic fascia at midprostate. (B) Midline sagittal section of prostate, bladder and striated sphincter. AFMS, anterior fibromuscular stroma; B, bladder; CS, colliculus seminalis (verumontanum); DA, detrusor apron; DVC, dorsal vascular complex; FTAP, fascial tendineus arch of pelvis; LAF, levator ani fascia; MDR, medial dorsal raphe; NVB, neurovascular bundle; PC, pseudocapsule of prostate; PPF, periprostatic fascia; PPF/SVF, posterior prostatic fascia/seminal vesical fascia; PRS, perirectal space; PS, pubic symphysis; PZ, peripheral zone; R, rectum; RU, rectourethralis muscle; SMS, smooth muscle sphincter; SS, striated sphincter; SV, seminal vesicle; TZ, transition zone; U, urethra; VEF, visceral endopelvic fascia; VPM, vesicoprostatic muscle; VS, vesical sphincter. Adapted from Walz et al. Eur Urol 2016;70:301-11, with permission of Elsevier B.V. [34].

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  Fig. 3 (A) Coronal section of prostate, sphincteric urethra, periprostatic fascias and associated musculature. (B) Axial section through base of seminal vesicles to neurovascular bundle (NVB). B, bladder; M, midprostate; A, apex; U, urethra; CS, colliculus seminalis; CZ, central zone; LAF, levator ani fascia; PPF, periprostatic fascia; PC, pseudocapsule of prostate; ED, ejaculatory duct; LA, levator ani muscle; PF, prostatic fascia; PP, pelvic plexus; PPF/SVF, posterior prostatic fascia/ seminal vesicle fascia (Denonvilliers fascia); PZ, peripheral zone; R, rectum; SMS, smooth muscle sphincter; SS, striated sphincter; SV, seminal vesicle; VD, vas deferens; VPM, vesicoprostatic muscle. Adapted from Walz et al. Eur Urol 2010;57:179-92, with permission of Elsevier B.V. [17].

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  Fig. 4 Posterior prostatic dissection plane. Yellow arrow means vas deferens; blue arrows mean Denonvillier fascia; asterisk means seminal vesicles.

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  Fig. 5 Right intrafascial dissection; prostate and right neurovascular bundle (NVB). Yellow arrows mean dissection plane; blue arrow means NVB; asterisk means prostate capsule.

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  Fig. 6 Schematic drawing of 2 different surgical techniques for nerve-sparing prostatectomy. (A) Interfascial nerve-sparing prostatectomy. (B) Intrafascial nerve-sparing prostatectomy. EF, endopelvic fascia; PF, periprostatic fascia; PC, prostatic capsula; PP, prostatic pedicle; NBV, neurovascular bundle. Adapted from Stolzenburg et al. Eur Urol 2007:51:629-39, with permission of Elsevier B.V. [39].

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  Fig. 7 (A) Three dissection planes according to the Pasadena consensus [45], (B) Four dissection planes according to Tewari et al. [45], 1, dissection below veins, 2, dissection on the veins, 3, dissection distant from the veins, 4, extrafascial dissection, (C) Five dissection planes according to Schatloff et al. [55]: 1, extrafascial dissection; 2, sharp dissection distant from arteries; 3, sharp dissection on arteries; 4, sharp dissection on the level of arteries; 5, blunt dissection below arteries. Adapted from Walz et al. Eur Urol 2016;70:301-11, with permission of Elsevier B.V. [34].

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  Fig. 8 View of prostate specimen, intrafascial dissection on right side, interfascial dissection on left side. Asterisk means prostate capsule; yellow line means posterior midline.

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  Fig. 9 (A) Antegrade neurovascular bundle (NVB) dissection on right side, (B) retrograde NVB dissection on left side. Yellow star means prostatic pedicle; blue arrow means prostate capsule; red dashed line and arrow mean NVB.

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  Fig. 10 Bilateral neurovascular bundle (NVB) after prostatectomy.

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  Fig. 11 Right landmark artery on right intrafascial dissection. Yellow arrows mean right landmark artery.

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