Retrospective Concomitant Nonrandomized Comparison of “Touch” Cautery Versus Athermal Dissection of the Prostatic Vascular Pedicles and Neurovascular Bundles During Robot-assisted Radical Prostatectomy



      During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and “touch” monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed.


      To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs.

      Design, setting, and participants

      A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had “thin” pedicles, easily suitable for suture ligation. TC was based on “thick” pedicles (n = 230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n = 180).

      Surgical procedure

      Single-surgeon RARP.


      Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; “are erections firm enough for penetration?” and “are the erections satisfactory?”), IIEF-5 scores 15–25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery.

      Results and limitations

      In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p = 0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15–25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously.


      During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT.

      Patient summary

      Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.


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        • Bill-Axelson A.
        • Holmberg L.
        • Ruutu M.
        • et al.
        Radical prostatectomy versus watchful waiting in early prostate cancer.
        N Engl J Med. 2011; 364: 1708-1717
        • Bill-Axelson A.
        • Holmberg L.
        • Filén F.
        • et al.
        Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial.
        J Natl Cancer Inst. 2008; 100: 1144-1154
        • Cooperberg M.R.
        • Vickers A.J.
        • Broering J.M.
        • Carroll P.R.
        Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer.
        Cancer. 2010; 116: 5226-5234
        • Walsh PC
        Anatomic radical prostatectomy: evolution of the surgical technique.
        J Urol. 1998; 160: 2418-2424
        • Steiner M.S.
        • Morton R.A.
        • Walsh P.C.
        Impact of anatomical radical prostatectomy on urinary continence.
        J Urol. 1991; 145 (discussion 514–515): 512-514
        • Quinlan D.M.
        • Epstein J.I.
        • Carter B.S.
        • Walsh P.C.
        Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles.
        J Urol. 1991; 145: 998-1002
        • Wei J.T.
        • Dunn R.L.
        • Sandler H.M.
        • et al.
        Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer.
        J Clin Oncol. 2002; 20: 557-566
        • Johansson E.
        • Bill-Axelson A.
        • Holmberg L.
        • et al.
        Time, symptom burden, androgen deprivation, and self-assessed quality of life after radical prostatectomy or watchful waiting: the Randomized Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) clinical trial.
        Eur Urol. 2009; 55: 422-430
        • Pound C.R.
        • Partin A.W.
        • Eisenberger M.A.
        • Chan D.W.
        • Pearson J.D.
        • Walsh P.C.
        Natural history of progression after PSA elevation following radical prostatectomy.
        JAMA. 1999; 281: 1591-1597
        • Ahlering T.E.
        • Skarecky D.
        • Borin J.
        Impact of cautery versus cautery-free preservation of neurovascular bundles on early return of potency.
        J Endourol. 2006; 20: 586-589
        • Gill I.S.
        • Ukimura O.
        • Rubinstein M.
        • et al.
        Lateral pedicle control during laparoscopic radical prostatectomy: refined technique.
        Urology. 2005; 65: 23-27
        • Menon M.
        • Tewari A.
        • Peabody J.
        • VIP Team
        Vattikuti Institute prostatectomy: technique.
        J Urol. 2003; 169: 2289-2292
        • Gettman M.T.
        • Hoznek A.
        • Salomon L.
        • et al.
        Laparoscopic radical prostatectomy: description of the extraperitoneal approach using the da Vinci robotic system.
        J Urol. 2003; 170: 416-419
        • Chien G.W.
        • Mikhail A.A.
        • Orvieto M.A.
        • et al.
        Modified clipless antegrade nerve preservation in robotic-assisted laparoscopic radical prostatectomy with validated sexual function evaluation.
        Urology. 2005; 66: 419-423
        • Ong A.M.
        • Su L.-M.
        • Varkarakis I.
        • et al.
        Nerve sparing radical prostatectomy: effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model.
        J Urol. 2004; 172: 1318-1322
        • Khan F.
        • Rodriguez E.
        • Finley D.S.
        • Skarecky D.W.
        • Ahlering T.E.
        Spread of thermal energy and heat sinks: implications for nerve-sparing robotic prostatectomy.
        J Endourol. 2007; 21: 1195-1198
        • Gordon A.
        • Skarecky D.
        • Okhunov Z.
        • Hwang C.
        • Yoon R.
        • Ahlering T.
        Mp23-05 evaluation of tmax, thermal spread, and heat dissipation of monopolar “short burst” cautery mitigated by ice cold irrigation in a porcine model.
        J Urol. 2016; 195: e262-e263
        • Chang P.
        • Szymanski K.M.
        • Dunn R.L.
        • et al.
        Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP): development and validation of a practical health-related quality of life instrument for use in the routine clinical care of prostate cancer patients.
        J Urol. 2011; 186: 865-872
        • Rhoden E.L.
        • Telöken C.
        • Sogari P.R.
        • Vargas Souto C.A.
        The use of the simplified International Index of Erectile Function (IIEF-5) as a diagnostic tool to study the prevalence of erectile dysfunction.
        Int J Impot Res. 2002; 14: 245-250
        • Rosen R.C.
        • Riley A.
        • Wagner G.
        • Osterloh I.H.
        • Kirkpatrick J.
        • Mishra A.
        The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction.
        Urology. 1997; 49: 822-830
        • Huynh L.M.
        • Skarecky D.
        • Wilson T.
        • et al.
        Internal and external validation of a 90-day percentage erection fullness score model predicting potency recovery following robot-assisted radical prostatectomy.
        Eur Urol Oncol. 2020; 3: 657-662
        • Ficarra V.
        • Novara G.
        • Ahlering T.E.
        • et al.
        Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy.
        Eur Urol. 2012; 62: 418-430
        • Sridhar A.N.
        • Cathcart P.J.
        • Yap T.
        • et al.
        Recovery of baseline erectile function in men following radical prostatectomy for high-risk prostate cancer: a prospective analysis using validated measures.
        J Sex Med. 2016; 13: 435-443
        • Ficarra V.
        • Borghesi M.
        • Suardi N.
        • et al.
        Long-term evaluation of survival, continence and potency (SCP) outcomes after robot-assisted radical prostatectomy (RARP).
        BJU Int. 2013; 112: 338-345
        • Donzelli J.
        • Leonetti J.P.
        • Wurster R.D.
        • Lee J.M.
        • Young M.R.
        Neuroprotection due to irrigation during bipolar cautery.
        Arch Otolaryngol Head Neck Surg. 2000; 126: 149-153
        • Albertsen P.C.
        • Hanley J.A.
        • Barrows G.H.
        • et al.
        Prostate cancer and the Will Rogers phenomenon.
        J Natl Cancer Inst. 2005; 97: 1248-1253
        • Gofrit O.N.
        • Zorn K.C.
        • Steinberg G.D.
        • Zagaja G.P.
        • Shalhav A.L.
        The Will Rogers phenomenon in urological oncology.
        J Urol. 2008; 179: 28-33