Athermal Versus Ultrasonic Nerve‑Sparing Laparoscopic Radical Prostatectomy: A Comparison of Functional and Oncological Outcomes - Beyond the Abstract 

Radical prostatectomy (RP) remains the gold standard treatment for organ-confined prostate cancer. Nonetheless, it may impact on the quality of life (QoL),1 as many men complain about sexual dysfunction and urinary incontinence.2 There are several variables impacting on QoL after surgery, so there is a large variability in reported functional outcomes; i.e., the impairment of erectile function (EF) following radical prostatectomy ranges from 25 to 75%.3 One important determinant is the surgical technique, as the majority of urologists emphasize the concept of heat-related damage, and strongly suggest avoiding the use of “any” energy device during the crucial steps of a nerve-sparing procedure.4

To our knowledge, our retrospective study is the only available clinical evidence comparing in a significant population, and with a long-term follow-up, a nerve-sparing RP performed with and without the use of an energy device, specifically ultrasonic shears.5 Although we found a significantly better recovery of EF after 3 months of follow-up in the cohort of patients receiving cautery-free dissection (p=0.002), in the long term, we could not find a statistically significant difference in terms of potency recovery between the cohorts (p=0.09 at 12 months, and p=0.14 at 24 months). The only variables significantly associated with postoperative erection recovery at multivariate analysis were age (p<0.001), and extension of neural preservation, being those undergoing bilateral nerve-sparing laparoscopic RP (p<0.001) more likely to regain potency.

The type of energy device used during surgery is relevant. Several scientific reports agree in demonstrating that ultrasonic instruments spread less thermal energy and cause smaller damage to surrounding tissue.6-8 In fact, an ultrasonic device was used in the present study whenever performing a thermal dissection of the neurovascular bundle. Importantly, we employed specific actions to avoid thermal damage, specifically, the neurovascular bundle was incised as close as possible to the periprostatic fascia, keeping the active blade twisted toward the prostate; during the time of energy delivery, the suction device was used to irrigate and disperse the heat within the interfascial plane.

Therefore, the use of an ultrasonic energy device, coupled with other means to increase heat dispersion, may explain the comparable recovery results observed in our study. Nonetheless, other factors such as nerve stretch and compression may be involved in the mechanism of nerve damage. We believe, although cannot support any evidence, that during an athermal dissection the cavernous nerves are more often exposed to these injuries when compared to ultrasonic dissection.

Written by: Vincenzo Pagliarulo, Department of Urology, DETO, University “Aldo Moro," Bari, Italy

References: 

  1. Penson DF, McLerran D, Feng Z, et al. "5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study." J Urol. 2005 173(5):1701–1705.
  2. Boorjian SA, Eastham JA, Graefen M, et al. "A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes." Eur Urol. 2012 61(4):664–675.
  3. Capogrosso P, Vertosick EA, Benfante NE, et al. "Are we improving erectile function recovery after radical prostatectomy? Analysis of patients treated over the last decade." Eur Urol. 2019 75(2):221–228. 
  4. Montorsi F, Wilson TG, Rosen RC, et al. "Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel." Eur Urol. 2012 62(3):368–381.
  5. Pagliarulo V, Alba S, Gallone MF, et al. "Athermal versus ultrasonic nerve-sparing laparoscopic radical prostatectomy: a comparison of functional and oncological outcomes" World J Urol. 2020 Online ahead of print.
  6. Hruby GW, Marruffo FC, Durak E, et al. "Evaluation of surgical energy devices for vessel sealing and peripheral energy spread in a porcine model." J Urol 2007 178(6):2689–2693.
  7. Phillips CK, Hruby GW, Durak E, et al. "Tissue response to surgical energy devices." Urology. 2008 71(4):744–748.
  8. Carlander J, Koch C, Brudin L, et al. "Heat production, nerve function, and morphology following nerve close dissection with surgical instruments." World J Surg. 2012 36(6):1361–1367.
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