Nerve-sparing laparoscopic radical prostatectomy: replicating the open surgical technique1

Su, Li-Ming; Link, Richard E.; Bhayani, Sam B.; Sullivan, Wendy; Pavlovich, Christian P.

doi:10.1016/j.urology.2004.02.010

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Volume 64, Issue 1 , Pages 123-127, July 2004

Nerve-sparing laparoscopic radical prostatectomy: replicating the open surgical technique¹

Li-Ming Su
- James Buchanan Brady Urological Institute, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Reprint requests: Li-Ming Su, M.D., Department of Urology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Building A, Room A345, Baltimore, MD 21224, USA
Richard E. Link
- James Buchanan Brady Urological Institute, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Sam B. Bhayani
- James Buchanan Brady Urological Institute, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Wendy Sullivan
- James Buchanan Brady Urological Institute, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Christian P. Pavlovich
- James Buchanan Brady Urological Institute, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA

Received 2 December 2003; accepted 11 February 2004.

Abstract

Objectives

To present a detailed demonstration of a nerve-sparing laparoscopic radical prostatectomy (LRP) technique that replicates anatomic nerve-sparing radical retropubic prostatectomy (RRP). Techniques for neurovascular bundle preservation during open RRP have undergone several decades of careful refinement. Identifying pre-existing anatomic planes and the avoidance of thermal injury near the nerves are principles considered paramount during nerve-sparing RRP. During LRP and robotic-assisted radical prostatectomy, the use of cautery for hemostasis during nerve dissection is common despite its unknown effects on cavernous nerve function.

Methods

We describe a combined antegrade and retrograde laparoscopic approach to neurovascular bundle dissection. The technique is demonstrated in the accompanying video segments. The use of specialized laparoscopic instrumentation, including a fine-tipped right-angle clamp and curved dissector, is discussed. The principles of meticulous tissue handling and avoidance of electrocautery are stressed. The preliminary outcomes are presented using data obtained using an abridged version of the International Index of Erectile Function and the Expanded Prostate Cancer Index Composite questionnaires.

Results

To date, our technique has been applied to LRP in more than 177 patients. Blood loss has been minimal (less than 300 mL), and intraoperative anatomic nerve preservation appeared excellent. On the basis of our early experience, 76% of patients engaging in sexual intercourse preoperatively who underwent bilateral nerve preservation (n = 21) reported the ability to engage in sexual intercourse 1 year after LRP.

Conclusions

Our nerve-sparing LRP technique replicates established open surgical principles of anatomic nerve-sparing RRP. The techniques described here minimize the potential for cavernous nerve damage from electrical energy or heat. Early functional outcomes appear comparable to the results obtained with open RRP performed at our institution.