European Urology

Abstract

Background

Open nerve-sparing retropubic prostatectomy (nsRP) is still the most common surgical approach for the treatment of localised prostate cancer. Even though the principles of the technique and its oncological efficacy have often been published, ongoing refinements allow further improvements in functional outcome and morbidity.

Objective

To describe our current technique of open nsRP with data addressing urinary continence, potency, cancer control rates, and perioperative morbidity.

Design, setting, and participants

Our analyses relied on 1150 patients who were treated with nsRP in the Martini-Clinic by two high-volume surgeons from April 2005 to December 2007.

Surgical procedure

Key elements are a selective ligation of the dorsal vein complex and early release of the neurovascular bundles using a high anterior tension- and energy-free intrafascial technique. During dissection of the urethra, its posterior insertion at Denonvilliers’ fascia (DF) is preserved. DF is left in situ, and it is selectively opened above the seminal vesicles (SV). The SV are completely removed inside DF, and five muscle-sparing interrupted sutures are used for anastomosis.

Measurements

Functional and oncological outcome data were prospectively assessed using validated questionnaires. Moreover, intra- and perioperative morbidity were evaluated.

Results and limitations

Age and extent of nerve-sparing approach influenced urinary continence and potency. Complete urinary continence 1 yr after nsRP was found in 97.4% (men <60 yr) to 84.1% (men >70 yr) of patients. In preoperative potent men, erections sufficient for intercourse were reported between 84–92% and 58.3–70% of patients following bilateral and unilateral nerve sparing, respectively. Median blood loss was 580 ml (range: 130–1800 ml), and the transfusion rate was 4.3%. Median operative time was 165 min (range: 85–210 min). In organ-confined cancers, recurrence-free survival and cancer-specific-survival 10 yr after retropubic prostatectomy were 87% and 98.3%, respectively.

Conclusions

Open intrafascial nsRP combines excellent long-term cancer control rates with superior functional outcome and a low morbidity.

Take Home Message

This paper describes a current technique of open retropubic intrafascial nerve-sparing prostatectomy. Surgical refinements include a strict intrafascial approach and subtle preservation of the posterior urethra and its insertion. Considering these principles, favourable functional and oncological outcome combined with a low morbidity of the procedure can be achieved.