Anatomic grading of nerve sparing during robot-assisted radical prostatectomy.
BACKGROUND
Because of the lack of intraoperative visual cues, the amount of nerve sparing (NS) intended by the surgeon does not always correspond to what is actually performed during surgery.


OBJECTIVE
Describe a standardized NS grading system based on intraoperative visual cues.


METHODS
A total of 133 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon were evaluated. The surgeon intraoperatively graded the NS independently for either side as follows: 1=no NS; 2=<50% NS; 3=50% NS; 4=75% NS; 5= ≥ 95% NS.


METHODS
RARP; detailed description of a five-point NS grading system.


METHODS
The area of residual nerve tissue on prostatectomy specimens was compared with the intraoperative NS score (NSS). The rate of positive surgical margins (PSMs) according to the NSS is also reported.


CONCLUSIONS
In all, 52.6% of operated sides (140 of 266 sides) had NSS 5, 30.1% (80 of 266) had NSS 4, 2.3% (6 of 266) had NSS 3, 13.2% (35 of 266) had NSS 2, and 1.9% (5 of 266) had NSS 1. The area of residual nerve tissue was significantly different among the different NSSs: median area (interquartile range) for NSS 5: 0.5 (0-2) mm(2); for NSS 4: 3 (0-8) mm(2); for NSS 3: 13 (7-23) mm(2); for NSS 2: 14 (8-24) mm(2); and for NSS 1: 57 (56-165) mm(2) (p<0.001). Overall, 9.02% of the patients (12 of 133 patients) had a PSM, with 8.3% (9 of 108) for pT2 and 12% (3 of 25) for pT3. Side-specific PSMs according to NSS were 3.6% (5 of 140) for NSS 5, 7.5% (6 of 80) for NSS 4, 16.7% (1 of 6) for NSS 3, 5.7% (2 of 35) for NSS 2, and 0% (0 of 5) for NSS 1. A limitation of our study is that the key anatomic landmarks are not recognizable in every case, and this technique might not be easy to perform during the early learning curve.


CONCLUSIONS
We believe that the visual cues exposed in this article will help surgeons achieve more consistent NS during RARP.
Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA.
Oscar
O
Schatloff
Sanket
S
Chauhan
Ananthakrishnan
A
Sivaraman
Darian
D
Kameh
Kenneth J
KJ
Palmer
Vipul R
VR
Patel
D000368:Aged; D059925:Anatomic Landmarks; D002983:Clinical Competence; D003463:Cues; D007172:Erectile Dysfunction / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D005431:Florida; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D018365:Neoplasm, Residual; D010413:Penis / Q000294:innervation*; D011446:Prospective Studies; D011467:Prostate / Q000294:innervation / Q000473:pathology / Q000601:surgery*; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects; D016896:Treatment Outcome; D014785:Vision, Ocular