title: Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP).
abstract: OBJECTIVE
  • To report the potency and oncological outcomes of patients undergoing robot-assisted radical prostatectomy (RARP) using a risk-stratified approach based on layers of periprostatic fascial dissection. • We also describe the surgical technique of complete hammock preservation or nerve sparing grade 1.
  
  
  METHODS
  • This is a retrospective study of 2317 patients who had robotic prostatectomy by a single surgeon at a single institution between January 2005 and June 2010. • Included patients were those with ≥ 1 year of follow-up and who were potent preoperatively, defined as having a sexual health inventory for men (SHIM) questionnaire score of >21; thus, the final number of patients in the study cohort was 1263. • Patients were categorized pre-operatively by a risk-stratified approach into risk grades 1-4, where risk grade 1 patients received nerve-sparing grade 1 or complete hammock preservation and so on for risk grades 2-4, as long as intraoperative findings permitted the planned nerve sparing. • We considered return to sexual function post-operatively by two criteria: i) ability to have successful intercourse (score of ≥ 4 on question 2 of the SHIM) and ii) SHIM >21 or return to baseline sexual function.
  
  
  RESULTS
  • There was a significant difference across different NS grades in terms of the percentages of patients who had intercourse and returned to baseline sexual function (P < 0.001), with those that underwent NS grade 1 having the highest rates (90.9% and 81.7%) as compared to NS grades 2 (81.4% and 74.3%), 3 (73.5% and 66.1%), and 4 (62% and 54.5%). • The overall positive surgical margin (PSM) rates for patients with NS grades 1, 2, 3, and 4 were 9.9%, 8.1%, 7.2%, and 8.7%, respectively (P = 0.636). • The extraprostatic extension rates were 11.6%, 14.3%, 29.3%, and 36.2%, respectively (P < 0.001). • Similarly, in patients younger than 60, intercourse and return to baseline sexual function rates were 94.9% and 84.3% for NS grade 1 as compared to 85.5% and 77.2% for NS grades 2, 76.9% and 69% for NS grades 3, and 64.8% and 57.7% for NS Grade 4 (P < 0.001).
  
  
  CONCLUSIONS
  • The risk-stratified approach and anatomical technique of neural-hammock sparing described in the present manuscript was effective in improving potency outcomes of patients without compromising cancer control. • Patients with greater degrees of NS had higher rates of intercourse and return to baseline sexual function without an increase in PSM rates.
authors.affiliation: LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York, NY 10065, USA. ashtewarimd@gmail.com
authors.forename: Ashutosh K
authors.initials: AK
authors.lastname: Tewari
authors.forename: Abhishek
authors.initials: A
authors.lastname: Srivastava
authors.forename: Michael W
authors.initials: MW
authors.lastname: Huang
authors.forename: Brian D
authors.initials: BD
authors.lastname: Robinson
authors.forename: Maria M
authors.initials: MM
authors.lastname: Shevchuk
authors.forename: Matthieu
authors.initials: M
authors.lastname: Durand
authors.forename: Prasanna
authors.initials: P
authors.lastname: Sooriakumaran
authors.forename: Sonal
authors.initials: S
authors.lastname: Grover
authors.forename: Rajiv
authors.initials: R
authors.lastname: Yadav
authors.forename: Nishant
authors.initials: N
authors.lastname: Mishra
authors.forename: Sanjay
authors.initials: S
authors.lastname: Mohan
authors.forename: Danielle C
authors.initials: DC
authors.lastname: Brooks
authors.forename: Nusrat
authors.initials: N
authors.lastname: Shaikh
authors.forename: Abhinav
authors.initials: A
authors.lastname: Khanna
authors.forename: Robert
authors.initials: R
authors.lastname: Leung
mesh_terms: D004210:Dissection / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D059348:Peripheral Nerve Injuries; D011183:Postoperative Complications / Q000517:prevention & control; D011467:Prostate / Q000294:innervation* / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D012371:Robotics; D012735:Sexual Dysfunction, Physiological / Q000517:prevention & control*; D025321:Surgery, Computer-Assisted / Q000379:methods; D016896:Treatment Outcome