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European UrologyVolume 61, issue 3, pages e13-e22, March 2012
Words of Wisdom
Re: Stepwise Approach for Nerve Sparing Without Countertraction During Robot-Assisted Radical Prostatectomy: Technique and Outcomes
Published online 28 January 2012, page 621
Kowalczyk KJ, Huang AC, Hevelone ND, et al
Eur Urol 2011;60:536–47
These authors present the short- and intermediate-term outcomes on erectile function for reduction of assistant intervention and traction on the neurovascular bundle (NVB) during robot-assisted radical prostatectomy (RARP).
In this study, 268 men underwent RARP with the surgeon and the assistant exerting traction and countertraction on the NVB to clearly elucidate the intrafascial plane and to achieve better preservation of the NVB. The technique was modified after Walsh was observed performing a RARP in which assistant intervention was minimized. Another 342 men subsequently underwent RARP with this modified technique. The two groups are compared in terms of expected blood loss, operative times, and positive surgical margins (PSMs) as well as functional outcomes using Expanded Prostate Index Composite (EPIC) sexual function and potency scores at 5 mo and 12 mo postoperation. Minimizing physical detraction between the prostate and the NVB resulted in a modest increase in blood loss but not in operating times or PSMs and resulted in significantly superior EPIC sexual function scores at 5 mo postop.
As urologists, we continue to refine our surgical technique in the quest to optimally attain the trifecta of radical prostatectomy (RP). Laparoscopic RP has traditionally relied on the surgeon and the assistant tracting and countertracting to visualize the intrafascial plane and to preserve the NVB. With increasing evidence suggesting that stretch or overmanipulation can negatively affect the functional outcome , the technique moved in favor of judicious application of stretch to avoid neuropraxia, which can adversely affect both continence and erectile function, at least in the short term. Furthermore, increasing awareness of the location of the urethral sphincter and the nerve plexuses has led to favorable functional outcomes and oncologic control  and . Improvements in the da Vinci system, incorporating three-dimensional high-definition images as well as a fourth arm, have led to a multitude of benefits: The superior view makes visualization of anatomic planes easier and minimizes dissection. Furthermore, reliance on the assistant to retract and aid in dissection is reduced.
Despite these improvements, however, it must be borne in mind that the primary goal of RARP is cancer control. Although erectile function remains a key functional outcome, surgical refinements toward nerve preservation must be assessed carefully in the context of their oncologic outcome. Although assistance may not be necessary in exerting countertraction of the NVB, the assistant should not be lulled into a sense of complacency and should be actively involved in identification, retraction, mobilization, and preservation of various structures encountered not just in RARP but in all robotic procedures. Subtle operative interventions such as “reduction of countertraction” cannot be measured objectively. Their impact is best judged in hindsight, years after they have been implemented. Only then do their effects become truly manifest. Importantly, data must always be collected prospectively and evaluated independently to maintain objectivity and to avoid bias that may occur when this review is done by the same surgical team. This paper attains this standard.
Conflicts of interest
The authors have nothing to disclose.
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© 2011 Published by Elsevier B.V.
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