title: Retrograde versus antegrade nerve sparing during robot-assisted radical prostatectomy: which is better for achieving early functional recovery?
abstract: BACKGROUND
  Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated.
  
  
  OBJECTIVE
  To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes.
  
  
  METHODS
  Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups.
  
  
  METHODS
  RARP with antegrade NS (n=172) or RARP with retrograde NS (n=172).
  
  
  METHODS
  Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied.
  
  
  CONCLUSIONS
  Positive margin rates were similar (11.1% vs 6.9%; p=0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482-4.089; p=0.001) at 3, 4.024 (95% CI, 2.171-7.457; p<0.001) at 6, and 2.145 (95% CI, 1.019-4.514; p=0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study.
  
  
  CONCLUSIONS
  In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.
authors.affiliation: Global Robotics Institute, Florida Hospital Celebration Health, USA.
authors.forename: Young Hwii
authors.initials: YH
authors.lastname: Ko
authors.forename: Rafael F
authors.initials: RF
authors.lastname: Coelho
authors.forename: Ananthakrishnan
authors.initials: A
authors.lastname: Sivaraman
authors.forename: Oscar
authors.initials: O
authors.lastname: Schatloff
authors.forename: Sanket
authors.initials: S
authors.lastname: Chauhan
authors.forename: Haidar M
authors.initials: HM
authors.lastname: Abdul-Muhsin
authors.forename: Rair Jose Valero
authors.initials: RJ
authors.lastname: Carrion
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Palmer
authors.forename: Jun
authors.initials: J
authors.lastname: Cheon
authors.forename: Vipul R
authors.initials: VR
authors.lastname: Patel
mesh_terms: D000368:Aged; D007172:Erectile Dysfunction / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010410:Penile Erection; D057216:Propensity Score; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D020127:Recovery of Function; D012189:Retrospective Studies; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome