ERUS 2018: Anatomical Key Elements and Basics of Nerve-sparing Prostatectomy - Graefen

Marseille, France (UroToday.com) This was an exceptional session, presented initially by Dr. Graefen, and later by Dr. Rocco, and Dr. Walz, with each one giving his perspective on how to best perform nerve sparing (NS) in radical prostatectomy (RP).

Dr. Graefen began presenting his point of view on nerve sparing and additional important functional issues in robotic radical prostatectomy (RARP). The first point discussed was the individualization of the apical dissection. Multivariable analysis demonstrated that only a certain prostate shape (Figure 1) was associated with early continence after radical prostatectomy.

Figure 1
Figure 1 – Multivariable analysis demonstrated that Type D prostate shape was the only one associated with early continence after radical prostatectomy:

Dr. Graefen also believes that it is also important to preserve the maximal possible functional length of the urethral sphincter during radical prostatectomy (RP).2

Another important point according to Dr. Graefen was the performance of a posterior reconstruction, demonstrating a significant advantage regarding urinary continence recovery in the first 90 days postoperatively.

The concept of NS during RP was also discussed. It has been shown that it improves not only the sexual function but also the long-term continence rates after RP.4 Therefore, we need to recognize true organ-confined disease whenever it is there and expand the indication to perform NS, even if the patient is not sexually active. When performing NS, it is crucial to understand the anatomy, and not use energy or traction. To improve the NS technique, Dr. Graefen recommended the use of neurovascular structure-adjacent frozen section examination (Neurosafe). This has been shown to increase NS frequency and to reduce the positive surgical margins rate in both open and RARP.5

Dr. Graefen continued to discuss the importance of understanding the anatomy in the surgical technique. It is important to understand the difference and the implications of an intrafascial, interfascial, or extrafascial approach (Figure 2).

Figure 2
Figure 2 – Intrafascial, interfascial, and extrafascial surgical approach in nerve sparing:

In intrafascial approach, we attempt a full NS technique, while in interfascial we perform only a partial NS technique, and finally, in extrafascial technique, almost no NS is done. For an acceptable NS procedure, an anterior high release of the nerve bundles should be done, as it has been shown that nerves at the ventral prostatic capsule contribute to erectile function6 (Figure 3).

Figure 3
Figure 3 – Importance of anterior high release for nerve-sparing:

Lastly, Dr. Graefen discussed the role of penile rehabilitation after surgery, which is still unclear. Unfortunately, no specific recommendation can be given regarding the structure of the optimal rehabilitation regimen, although data suggest that there is no difference between on demand and daily PDE5Is treatment for erectile function recovery. In other words, although there are many erectile function rehabilitation programs using PDE5Is, intracavernosal injections, and vacuum therapy, there is no definitive evidence to support their usage.

Presented by: M. Graefen, Hamburg, Germany

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the EAU Robotic Urology Section (ERUS) Meeting - September 5 - 7, 2018 - Marseille, France

References:

1.Lee SE, Byun SS, Lee HJ, et al. Impact of variations in prostatic apex shape on early recovery of urinary continence after radical retropubic prostatectomy. Urology 2006; 68(1): 137-41.
2.Schlomm T, Heinzer H, Steuber T, et al. Full functional-length urethral sphincter preservation during radical prostatectomy. European urology 2011; 60(2): 320-9.
3.Grasso AA, Mistretta FA, Sandri M, et al. Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis. BJU international 2016; 118(1): 20-34.
4.Michl U, Tennstedt P, Feldmeier L, et al. Nerve-sparing Surgery Technique, Not the Preservation of the Neurovascular Bundles, Leads to Improved Long-term Continence Rates After Radical Prostatectomy. European urology 2016; 69(4): 584-9.
5.Schlomm T, Tennstedt P, Huxhold C, et al. Neurovascular structure-adjacent frozen-section examination (NeuroSAFE) increases nerve-sparing frequency and reduces positive surgical margins in open and robot-assisted laparoscopic radical prostatectomy: experience after 11,069 consecutive patients. European urology 2012; 62(2): 333-40.
6.Kaiho Y, Nakagawa H, Saito H, et al. Nerves at the ventral prostatic capsule contribute to erectile function: initial electrophysiological assessment in humans. European urology 2009; 55(1): 148-54.