Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

Background: Robot-assisted laparoscopic radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP which preserves the nerves and vascular structures anterior to the prostate aiming to optimize functional outcomes. Objective: To present oncological and functional results of a modified technique for RARP. Design, setting, and participants: Prospective, noncontrolled case series including 128 consecutive patients undergoing RARP performed by a single surgeon (R.F.C). Surgical procedure: RARP with retrograde release of the neurovascular bundle and preservation of dorsal venous complex. Measurements: Potency was defined as a Sexual Health Inventory for Men score of ≥17; continence was defined as use of no pads. Oncological results analyzed were positive surgical margins (PSM) rates and biochemical recurrence (BCR)-free survival. BCR was defined as prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo classification. Results and limitations: Median patient age was 63.5 yr. Median skin-to-skin time was 78 min. Median length of hospital stay was 1 d, with seven patients (5.5%) hospitalized for more than 24 h. Median intraoperative bleeding was 200 ml and two patients required postoperative blood transfusion (1.6%). Four patients (3.1%) had grade ≥3 complications. Biochemical recurrence (BCR) occurred in nine of 128 patients (7%) and median time to BCR was 6 mo. Overall PSM rate was 13.3% (17 of 128 patients). PSM rate was 9% among patients with pT2 disease (8/89) and 27% in patients with pT3 (9/38). Continence was reached immediately in 85.9% of the patients and 98.4% were continent at1 yr. At 1 mo postoperatively, 60 patients were potent (53%), while 98 patients among 113 (86%) were potent 1 yr after surgery. A limitation of this study is that it was a noncomparative study. Conclusions: Retrograde release of the neurovascular bundle with preservation of dorsal venous complex during RARP is safe and associated with excellent oncological and functional outcomes. Future comparative studies are needed. Patient summary: Robot-assisted radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP aiming to preserve the nerves and vascular structures anterior to the prostate. We evaluated 128 consecutive patients with clinically localized or locally advanced prostate cancer undergoing RARP with our modified technique of retrograde release of the neurovascular bundles with dorsal vein sparing. We have shown that this technique is safe, effective and associated with early recovery of continence and sexual function after surgery.