title: A feasible and time-efficient adaptation of NeuroSAFE for da Vinci robot-assisted radical prostatectomy.
abstract: BACKGROUND
  The benefit of intraoperative neurovascular structure-adjacent frozen section examination (NeuroSAFE) of the prostate was demonstrated in open radical prostatectomy. In da Vinci robot-assisted prostatectomy (DVP), this approach is often avoided due to suspected difficulties in harvesting the prostate, loss in pneumoperitoneum, increased blood loss, and prolonged operating room (OR) time.
  
  
  OBJECTIVE
  To provide a detailed description of the technique, feasibility, and impact of the NeuroSAFE technique on OR time, blood loss, frequency of nerve sparing (NS), and positive surgical margins (PSMs) in DVP.
  
  
  METHODS
  We analyzed 1570 consecutive patients undergoing DVP from 2004 to 2012. NeuroSAFE was performed in 1178 patients.
  
  
  METHODS
  The prostate was intraoperatively harvested via an extension of the camera trocar incision without undocking the robotic arms. Blood spillage from the dorsal vein complex due to the loss of pneumoperitoneum was avoided by upward traction on the transurethral catheter. After prostate removal, pneumoperitoneum was reestablished by closing the extended incision with running sutures and repositioning the optical trocar. The NeuroSAFE procedure consisted of intraoperative bilateral frozen sections covering the entire neurovascular bundles adjacent prostate surface.
  
  
  METHODS
  We compared OR time, blood loss, NS frequency, and PSMs in non-NeuroSAFE versus NeuroSAFE DVP.
  
  
  CONCLUSIONS
  There was no significant difference in blood loss (253.5 ± 204.4 ml vs 265.8 ± 246.7 ml; p=0.49) and OR time (220 min ± 51 vs 224 min ± 64; p=0.22). No complications associated with specimen harvesting occurred. NS rate increased significantly with versus without NeuroSAFE (overall 97% vs 81%; pT2 99% vs 90%, pT3a 94% vs 74%, pT3b 91% vs 30). PSM rate dropped significantly with NeuroSAFE (overall 16% vs 24%; pT2 8% vs 15%, pT3a 22% vs 39%, pT3b 49% vs 67%; all p<0.05).
  
  
  CONCLUSIONS
  We demonstrate a time-efficient and safe adaption of the NeuroSAFE technique to DVP.
  
  
  RESULTS
  We describe a feasible and secure adaption of the neurovascular structure-adjacent frozen section examination (NeuroSAFE) procedure for da Vinci robot-assisted prostatectomy. We showed that there was no increased blood loss and operating room time. We maximized the nerve-sparing frequency and could reduce positive surgical margins even in non-organ-confined tumors.
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Burkhard
authors.initials: B
authors.lastname: Beyer
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Schlomm
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Pierre
authors.initials: P
authors.lastname: Tennstedt
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Katharina
authors.initials: K
authors.lastname: Boehm
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Meike
authors.initials: M
authors.lastname: Adam
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Jonas
authors.initials: J
authors.lastname: Schiffmann
authors.affiliation: The Institute of Pathology, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Guido
authors.initials: G
authors.lastname: Sauter
authors.affiliation: The Institute of Pathology, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Corina
authors.initials: C
authors.lastname: Wittmer
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Steuber
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Graefen
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany.
authors.forename: Hartwig
authors.initials: H
authors.lastname: Huland
authors.affiliation: The Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany. Electronic address: haese@uke.de.
authors.forename: Alexander
authors.initials: A
authors.lastname: Haese
mesh_terms: D016063:Blood Loss, Surgical; D001808:Blood Vessels / Q000473:pathology*; D005629:Frozen Sections; D006801:Humans; D008297:Male; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D018365:Neoplasm, Residual; D061646:Operative Time; D059351:Organ Sparing Treatments; D010525:Peripheral Nerves / Q000473:pathology* / Q000601:surgery; D011028:Pneumoperitoneum, Artificial; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D065287:Robotic Surgical Procedures / Q000379:methods*
keywords: Frozen section analysis; Nerve sparing; NeuroSAFE; Robotic prostatectomy