Articles

Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function

By: Mehrdad Alemozaffara, Antoine Duclosb, Nathanael D. Heveloneb, Stuart R. Lipsitzb, Tudor Borzaa, Hua-Yin Yua, Keith J. Kowalczykc and Jim C. Hud lowast

Published online: 01 June 2012

Keywords: Learning curve, Sexual function, Robotic, Radical prostatectomy, Nerve-sparing, Neurapraxia

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Abstract

Background

While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes.

Objective

Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP).

Design, setting, and participants

We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction.

Surgical procedure

Our approach to RARP has been described previously. A single-console robotic system was used for all cases.

Outcome measurements and statistical analysis

Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function.

Results and limitations

Greater surgeon experience was associated with better 5-mo sexual function (p=0.007) and a trend for better 12-mo sexual function (p=0.061), with improvement plateauing after 250–300 cases. Additionally, younger patient age (both p<0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p=0.021), while unilateral nerve sparing/non–nerve sparing was associated with worse 5-mo sexual function (p=0.009). Limitations include the retrospective single-surgeon design.

Conclusions

With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement.

Take Home Message

Blunt dissection and peeling the neurovascular bundle away from the prostate should be minimized to attenuate neurapraxia; there is a significant learning curve to shift from blunt to sharp dissection with minimal displacement of the neurovascular bundle. The subtle finesse to minimize stretch neuropathy during nerve sparing must be emphasized during training to maximize early recovery of sexual function.

Keywords: Learning curve, Sexual function, Robotic, Radical prostatectomy, Nerve-sparing, Neurapraxia.

Footnotes

a Division of Urologic Surgery, Brigham and Women's, Harvard Medical School, Boston, MA, USA

b Center for Surgery and Public Health, Brigham and Women's, Harvard Medical School, Boston, MA, USA

c Department of Urology, Georgetown Medical Center, Washington, DC, USA

d Institute of Urologic Oncology, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

lowast Corresponding author. Institute of Urologic Oncology, Department of Urology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.