Robotic RP technique helps preserve sexual function

Mumbai, India-Safeguarding sexual function following radical prostatectomy remains a great concern for patients undergoing the procedure. Preservation of the posterior-lateral prostatic neurovascular bundles at the time of surgery is critical for recovery of erectile function. The experience gained with the open radical retro-pubic prostatectomy has allowed urologists performing robotic prostatectomy to utilize an anatomic nerve-sparing approach to maximize the potential for recovery of sexual function.

Although to date no significant differences have been seen in the recovery of potency between the laparoscopic (34% to 67%) and open approaches (31% to 79%), the advent of the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) has imparted a surgical advantage to urologists. Increased magnification, stereoscopic vision, and endowristed instrumentation have facilitated dissection around the prostatic apex and the neurovascular bundles. Robotics has also allowed for modification and evolution of the nerve-sparing technique, as is the case with the preservation of the "Veil of Aphrodite," which appears to improve postoperative sexual function.

Urologists from the Vattikuti Urology Institute at Henry Ford Hospital, Detroit, reported a technical modification to nerve sparing that not only preserves the main neurovascular trunk but incorporates a wide band of peri-prostatic fascia and the neurovascular tissues contained therein, extending from its reflection from pelvic fascia proximally, puboprostatic ligaments distally, Denonvillers' fascia posteriorly, and a free edge anteriorly. At the completion of the operation, the spared fascia and enclosed neurovascular bundle resembles a veil and hence has been termed the "Veil of Aphrodite" for lack of a better scientific term.

In this prospective, nonrandomized study that started in January 2003, all patients had normal erections preoperatively, defined by an International Index of Erectile Function-5 (IIEF-5) score greater than 21 without any PDE-5 inhibitors. Typically, postoperative recovery of potency is reported in terms of erections strong enough for penetration, although these erections may not necessarily be of the same quality (rigidity and duration) the patients had preoperatively.

At 12 months postoperatively, 97% of patients who underwent the Veil of Ap-hrodite technique were able to engage in intercourse as opposed to 78% who underwent the standard nerve-sparing technique. This is a significant improvement over the results reported with other techniques, said Sanjeev Kaul, MD, MCh, a fellow in robotic urology working with Mani Menon, MD, and colleagues.

The Henry Ford group also used a more stringent endpoint, namely recovery of the same quality of erections the patient en-joyed preoperatively (IIEF-5 score greater than 21), Dr. Kaul said. At 1 year follow-up, 80% of the patients who underwent the Veil of Aphrodite technique were able to recover the same quality of erections they had preoperatively with or without PDE-5 inhibitors, as opposed to 13% of patients who underwent the standard nerve-sparing procedure.

"The cavernosal nerves lie posterolaterally, but accessory neurovascular channels extend ventrally within the peri prostatic fascia. In addition, it is hypothesized that this extra tissue protects the main neurovascular bundle from traction, thermal injury, or ischemic stress. We have described a technique that appears to enhance the quality of nerve preservation during robotic prostatectomy," Dr. Kaul said.