How to Meet Competing Goals During Robotic Radical Prostatectomy

Laparoscopic & Robotic CANCER CONTROL AND PRESERVATION OF NEUROVASCULAR TISSUE TEWARI ET AL. Laparoscopic and Robotic Urology Associate Editor Cancer control and the preservation of Ash Tewari neurovascular tissue: how to meet Editorial Board competing goals during robotic Ralph Clayman, USA Inderbir Gill, USA radical prostatectomy Roger Kirby, UK Mani Menon, USA Ashutosh Tewari, Sandhya Rao, Juan I. Martinez-Salamanca, Robert Leung, Rajan Ramanathan, Anil Mandhani, E. Darracott Vaughan, Mani Menon*, Wolfgang Horninger†, Jiangling Tu‡ and Georg Bartsch† The New York-Presbyterian Hospital, Departments of Urology and ‡Pathology, Weill Medical College of Cornell University, New York, NY, *Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA, and †The Institute of Urology, Innsbruck, Austria Accepted for publication 27 September 2007 RESULTS Study Type – Therapy (case series) Level of Evidence 4 The athermal technique addresses concerns about the use of thermal energy and OBJECTIVE bulldog clamps during nerve sparing, and emphasizes the importance of the trizonal To present early functional and oncological neural architecture. We analysed the data for the athermal trizonal nerve-sparing surgical outcomes of 215 consecutive technique of robotic radical prostatectomy patients from January 2005. The operative (RP), that addresses the concerns about duration was 120–240 min and the mean deviations from the principles of open RP and blood loss was 150 mL. In patients potent revisits the anatomical foundations of this before RP the potency rate at 1 year after surgery from the robotic perspective. bilateral nerve-sparing was 87%. The overall surgical margin rate was 6.5% and positive PATIENTS AND METHODS margin rates for organ-confined cancer were 4.7%. The study involved close collaboration between the Cornell Institute of Robotic Surgery in New York, USA, and the Institute CONCLUSION of Urology at the University of Innsbruck in Austria. The cadaveric studies and We describe the athermal technique of standardization of the athermal technique robotic RP and introduce the concept of were conducted at Innsbruck, and the trizonal nerve preservation. The immediate technique was used in 215 patients in oncological and sexual outcomes were New York. encouraging. © 2008 THE AUTHORS JOURNAL COMPILATION © 2008 BJU INTERNATIONAL | 101, 1013–1018 | doi:10.1111/j.1464-410X.2008.07456.x 1013 TEWARI ET AL. KEYWORDS FIG. 1. The trizonal neural architecture around the prostate comprising the PNP, the PNVB and the ANP. Fresh cadaveric dissection. athermal, neuroanatomical map, prostate cancer, robotic prostatectomy INTRODUCTION Surgery for prostate cancer (radical prostatectomy, RP) is challenging, with the competing goals of cancer control and maintenance of erection. The surgeon’s ability to develop a precise plane between the nerves and the prostatic capsule is hampered in RP because it is difficult to recognize microscopic invasion of neurovascular tissue by the cancer. The anatomical data for this study were Index Composite and the IIEF) and were These challenges are amplified in robotic obtained using 10 fresh and two fixed followed at 1, 3, 6 and 12 months after RP. surgery, where there is no tactile feedback. cadaveric dissections at the two institutions. Several experts in prostate cancer have voiced For the cadaver studies, we selected male concerns about deviating from the principles cadavers, aged >40 years, with no previous RESULTS of open RP during robotic surgery, e.g. about pelvic or urethral surgery. Cadavers were the use of thermal energy during nerve frozen <12–36 h after death and stored at Relevant neurovascular tissue around the sparing, and the inability to examine the −20 °C until dissection. No macroscopic prostate can be grouped into three broad specimen before completing the surgery. tumours were evident in the abdominal and zones: the proximal neurovascular plate pelvic regions of these cadavers. The cadavers (PNP), the predominant neurovascular bundle The present study was designed to address were dissected using a high-power operating (PNVB), and accessory neural pathways (ANP) these concerns, and included the following microscope, and they were documented using [1]; Fig. 1 shows these regions. broad aims: (i) to revisit the anatomical still and video cameras. foundations and to create a neurovascular The PNP is an integrating centre for the map related to the steps of robotic RP; (ii) to For the studies on patients, the Cornell robotic processing and relay of erectogenic neural abstain from using electrocautery and/or team visited Innsbruck to perform and signals; it is lateral to the bladder neck and bulldog clamps on the neurovascular tissue; standardize the AT technique in 15 patients. seminal vesicle, and is closely intermingled (iii) to devise strategies for deciding during The Cornell team then performed 215 with the branches of the inferior vesical robotic RP about the excision of nerve consecutive modified AT robotic RPs at the vessels. As a result, it can be damaged bundles; (iv) to standardise the steps of New York centre (between 1 January 2005 and during posterolateral incision of the bladder robotic RP based on the anatomical studies; 31 December 2005); all procedures were neck, lateral dissection of the seminal vesicle and (v) to collect data on the oncological and recorded digitally in three dimensions. and/or mass clipping or cautery of prostatic functional outcomes. pedicles. Baseline demographic data were collected To meet these goals, we present the athermal prospectively before RP and included age, The PNVB is the classical bundle that carries trizonal (AT) nerve-sparing technique of race, body mass index, serum PSA level, neuronal impulses to cavernous tissue; it robotic RP [1]. This new technique is unique prostate volume, Gleason score, TNM varies in shape and size from the proximal to in several important ways. In particular, it clinical staging, comorbidities, the IPSS and distal end, and in 65% of cases the PNVB has addresses concerns about the use of thermal International Index of Erectile Function (IIEF) a medial extension behind the prostate. energy and bulldog clamps during nerve score, and previous surgery. Intraoperative sparing, it incorporates steps to preserve and data included estimated blood loss, the The ANP lie within the layers of levator handle the trizonal neural structures, and it various steps of the operation, complications, fascia and/or lateral pelvic fascia on the presents a simplified manoeuvre to identify and video recording. Finally, postoperative anterolateral or posterior aspect of the the bladder neck. variables included any decline in the prostate. In 35% of cases the ANP form a haematocrit, hospital stay, pathological plexus near the apex. This plexus might serve stage, Gleason score, margin rates, PSA as a neural pathway for both cavernous tissue PATIENTS AND METHODS level, continence status, and sexual and the urethral sphincter. function. Potency after RP was defined as This study was conducted by the Cornell the return of erections sufficient for vaginal The prostatic capsule is surrounded by Institute of Robotic Surgery (New York, NY) penetration. prostatic fascia, lateral pelvic fascia, levator in close collaboration with the Institute of fascia, and finally levator muscles (Fig. 2). Urology at the University of Innsbruck in Patients completed standardized forms before Interposed between the prostatic fascia and Austria. and after RP (the Expanded Prostate Cancer lateral pelvic fascia are the neurovascular © 2008 THE AUTHORS 1014 JOURNAL COMPILATION © 2008 BJU INTERNATIONAL CANCER CONTROL AND PRESERVATION OF NEUROVASCULAR TISSUE FIG. 2. Endorectal MRI and three-dimensional representation of fascia around the prostate. We sharply incise the endopelvic fascia, leaving the condensed lateral tendon (arcus tendineus) intact. Dissection is kept to a minimum, and a plane is developed either within the lateral pelvic fascia or within the levator fascia. The incision is limited to the proximal third of the prostate, with the distal limit at the sickle-shaped extension of the puboprostatic ligaments (Fig. 3). We avoid over-zealous dissection at all cost, especially avoiding the PNP and periprostatic plexus. The distal plane of dissection must be extended sufficiently to allow for the secure placement of the dorsal venous suture. Disconnection of bladder from prostate; ‘the bladder neck pinch’ FIG. 3. Bilateral incision in the endopelvic fascia tissue and the periprostatic venous plexus, In the original description of the bladder neck with intact puboprostatic ligaments. which travel distally to supply the sphincter, dissection, surgeons were encouraged to start urethra and cavernous tissue. These neural in the distinct lateral plane demarcated by fibres usually travel close to the vessels, but fat between the bladder and prostate [3]. occasionally they can travel independently on Unfortunately, such an approach could place the surface of the prostate, or laterally on at risk the PNP, and vessels of the prostatic the rectum. Some of these vessels are also pedicle. To prevent this, we use the bimanual subcapsular for a short distance before bladder-neck pinch technique [4]. A back- dipping into the prostatic tissue. Accordingly, bleeding suture is placed on the anterior excessive blunt dissection of these vessels can surface of the prostate and, for traction, a create an artificial transcapsular plane, superficial suture is placed on the bladder. resulting in

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