title: Stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes.
abstract: BACKGROUND
  Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified.
  
  
  OBJECTIVE
  To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction.
  
  
  METHODS
  This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011.
  
  
  METHODS
  RARP.
  
  
  METHODS
  We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM).
  
  
  CONCLUSIONS
  In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p ≤ 0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p < 0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p < 0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p = 0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p < 0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01-2.83; p = 0.046). NS-0C versus NS-WC was associated with shorter operative times (p = 0.001) and higher EBL (p = 0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison.
  
  
  CONCLUSIONS
  Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency.
authors.affiliation: Division of Urologic Surgery, Brigham and Women's/Faulkner Hospital, Harvard Medical School, Boston, MA 02130, USA.
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Kowalczyk
authors.forename: Andy C
authors.initials: AC
authors.lastname: Huang
authors.forename: Nathanael D
authors.initials: ND
authors.lastname: Hevelone
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.forename: Hua-yin
authors.initials: HY
authors.lastname: Yu
authors.forename: William D
authors.initials: WD
authors.lastname: Ulmer
authors.forename: Joshua R
authors.initials: JR
authors.lastname: Kaplan
authors.forename: Sunil
authors.initials: S
authors.lastname: Patel
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
authors.forename: Jim C
authors.initials: JC
authors.lastname: Hu
mesh_terms: D000368:Aged; D001900:Boston; D016009:Chi-Square Distribution; D007172:Erectile Dysfunction / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010410:Penile Erection; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome