Nerve-sparing laparoscopic radical prostatectomy: Replicating the open surgical technique

Objectives To present a detailed demonstration of a nerve-sparing laparoscopic radical prostatectomy (LRP) technique that replicates anatomic nerve-sparing radical retropubic prostatectomy (RRP). Techniques for neurovascular bundle preservation during open RRP have undergone several decades of careful refinement. Identifying pre-existing anatomic planes and the avoidance of thermal injury near the nerves are principles considered paramount during nerve-sparing RRP. During LRP and robotic-assisted radical prostatectomy, the use of cautery for hemostasis during nerve dissection is common despite its unknown effects on cavernous nerve function. Methods We describe a combined antegrade and retrograde laparoscopic approach to neurovascular bundle dissection. The technique is demonstrated in the accompanying video segments. The use of specialized laparoscopic instrumentation, including a fine-tipped right-angle clamp and curved dissector, is discussed. The principles of meticulous tissue handling and avoidance of electrocautery are stressed. The preliminary outcomes are presented using data obtained using an abridged version of the International Index of Erectile Function and the Expanded Prostate Cancer Index Composite questionnaires. Results To date, our technique has been applied to LRP in more than 177 patients. Blood loss has been minimal (less than 300 mL), and intraoperative anatomic nerve preservation appeared excellent. On the basis of our early experience, 76% of patients engaging in sexual intercourse preoperatively who underwent bilateral nerve preservation (n = 21) reported the ability to engage in sexual intercourse 1 year after LRP. Conclusions Our nerve-sparing LRP technique replicates established open surgical principles of anatomic nerve-sparing RRP. The techniques described here minimize the potential for cavernous nerve damage from electrical energy or heat. Early functional outcomes appear comparable to the results obtained with open RRP performed at our institution.