Elsevier

European Urology

Volume 52, Issue 3, September 2007, Pages 687-695
European Urology

Surgery in Motion
Tension and Energy-Free Robotic-Assisted Laparoscopic Radical Prostatectomy with Interfascial Dissection of the Neurovascular Bundles

https://doi.org/10.1016/j.eururo.2007.05.029Get rights and content

Abstract

Objectives

To assess overall safety, histopathological outcomes, and early functional results after robotic-assisted laparoscopic radical prostatectomy (RALP) with a new lateral approach for the interfascial dissection of the neurovascular bundles without tension and any use of electrocautery.

Methods

Between April and September 2006, 100 consecutive patients with organ-confined prostate cancer (age < 70 yr, PSA  10 μg/dl, Gleason score  7, and IIEF  17) underwent RALP by the same senior surgeon. Pre-, intra-, and perioperative data were recorded. The operative technique is described step by step. Patients were assessed at the 4-mo follow-up.

Results

RALP was successfully completed in all patients. Neither blood transfusions nor reintervention were necessary. One week following catheter removal, complete early urinary continence was achieved in 80% of patients, and spontaneous erections or penile tumescence was reported by 46 patients. Positive surgical margins were 12.1% in the pT2 group and 29% in the pT3 group. Ninety-three patients were available for analysis at the 4-mo follow-up. Of them, 92.4% were completely continent, 5.4% used 1 pad a day, and 2.2% used 2 or more pads a day. Concerning the IIEF-EF domain score, 64.5% of the patients reported a total score  17, and 17.2% of them scored ≥26.

Conclusions

The novel approach described for RALP is safe and allows excellent dissection. It maintains good margin status and provides encouraging early continence and erectile functional results in selected patients. Long-term follow-up is necessary to assess the impact of this approach on oncological outcome.

Introduction

The main objectives of radical prostatectomy for clinically localised prostate cancer (PCa) are oncological clearance coupled with good functional outcomes in terms of urinary continence and erectile function (EF) [1]. Open retropubic radical prostatectomy (RRP) is still considered the gold standard, having passed the test of time, thanks to the continuous technical improvements adopted [2], [3]. Laparoscopic prostatectomy (LRP) is still regarded as a maturing technique, but it has demonstrated overall comparable results to the open technique with the advantages of a less-invasive approach [4], [5].

Despite improved results new techniques are being continually explored to improve the functional outcomes following radical surgery. In the last few years, several groups have documented encouraging results concerning tumor control, perioperative complications, and functional results, especially regarding postoperative continence and potency rates related to robot-assisted laparoscopic radical prostatectomy (RALP) [6], [7], [8], [9], [10]. The main advantages of the robotic system (daVinci® Surgical System; Intuitive Surgical, Inc, USA) are the improved vision provided by the three-dimensional (3D) optics, pinpoint precision, and maximal mobility. Thanks to these factors, dissection during the procedure allows the surgeon to perform functional surgery in an extremely anatomical fashion [11]. As an increasing number of cancers are being detected in a young population and at an early stage, patients are demanding a higher level of functional outcome. As a result, RALP is likely to gain progressively more importance in the standard treatment of PCa throughout Europe and the United States.

At our institution, RALP has been performed since January 2005 with the initial experience of almost 400 cases reproducing our laparoscopic technique, with results comparable to the RRP conventional technique [12]. Recently, we developed a new technique for the dissection of the neurovascular bundles (NVBs) characterised by a lateral approach to the tension- and cautery-free dissection and late mobilisation of the seminal vesicles. We describe our new operative technique, histopathological results, and short-term functional outcomes of contemporary tension and energy-free RALP.

Section snippets

Patient selection

Between April and September 2006, 100 patients with organ-confined PCa underwent RALP performed by the tension- and electrocautery-free, new lateral approach. The inclusion criteria consisted of age <70 yr, clinically organ-confined disease (cT1–cT2) staged by computed tomography (CT) scan, and total serum prostate-specific antigen (PSA) <10 μg/dl. Patients with neoadjuvant therapy or any previous prostate, urethra, or bladder-neck surgery were excluded. All patients were continent and potent

Results

RALP was successfully completed with the described technique in all patients. A bilateral nerve-sparing (NS) procedure was performed in all cases. No patient required either conversion to open surgery or conventional laparoscopy. No blood transfusions were necessary and no patient underwent reintervention for either bleeding or early complication. Detailed perioperative data are presented in Table 2. Eighty-seven patients (87%) were discharged on POD 5 with the catheter still in place and

Discussion

RALP is a rapidly growing surgical approach that is becoming a standardised alternative to both RRP and LRP for treatment of localised PCa [6]. However, the big challenge of RALP is to provide improved functional results in terms of potency and urinary continence, whilst maintaining oncological results at least comparable with the current gold standards such as open and laparoscopic surgery [11].

The main advantages of the robotic approach are related to the improved ergonomics provided by the

Conclusions

The novel lateral approach described for RALP is safe and allows excellent vision, facilitating the dissection and thus enabling the operator to perform precise functional surgery. This result can be achieved with the avoidance of traction, tension, and electrocautery. This approach provides encouraging margin status, early continence, and EF in our selected group of patients. Long-term follow-up is necessary to assess the impact of this approach on biochemical recurrence rates.

Conflicts of interest

The authors have nothing to disclose.

References (25)

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    Yet, as restoring anatomy is generally considered a basic principle of reconstructive surgery, one can advocate that this might justify its use as all reconstructive techniques seem feasible and safe. It might well be that functional outcomes may be dependent on transitory neuropraxia due to (counter)traction on the neurovascular bundle by the suction tip or robotic instruments [36,37]. Stretch neuropathy by lateral displacement of the neurovascular bundle was shown to be related to delayed and diminished sexual function, and might intuitively lead to short-term incontinence as well [37].

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