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Surgery Insight: optimizing open nerve-sparing radical prostatectomy techniques for improved outcomes

Nature Clinical Practice Urology volume 4, pages 561–569 (2007)Cite this article

Abstract

Men with prostate cancer have a variety of treatment choices available, including expectant management with deferred treatment, brachytherapy, external-beam radiation therapy, or both of the latter options—with or without hormonal therapy, cryotherapy, and radical prostatectomy (RP). Physicians have long endeavored to guide patients through these choices on the basis of the health threat posed by the cancer, the potential effectiveness and complications associated with treatment, and the patient's life expectancy. As early detection programs now identify cancers much earlier in their natural history, individual patients have a longer life expectancy than in the past. The patient and physician must, therefore, weigh the potential benefit of the selected treatment with the risk of early or delayed complications that would detract from the patient's quality of life. Optimally, when a surgical approach is used to treat prostate cancer, the operation removes the cancer completely with negative surgical margins, avoids excessive blood loss or serious perioperative complications, and culminates in complete recovery of continence and potency. To achieve this, the surgeon must treat sufficient periprostatic tissue to achieve cure while preserving the cavernosal nerves required for erectile function and the neuromusculature required for normal urinary and bowel function. Evidence suggests that the small details of how a surgery is performed have a major impact on the outcome of RP. Here the role of surgical techniques in determining oncologic and quality of life outcomes after RP, focusing on open RP, are presented.

Key Points

  • Oncologic and quality of life outcomes after radical prostatectomy are dependent on surgical technique; in order to achieve optimal outcomes for the patient, the surgeon must continually assess and reassess his/her results and modify the operation accordingly

  • While many of the operative steps of radical prostatectomy will be similar, the procedure must be individualized based on the features of the patient's cancer and his anatomy

  • One of the key aspects to performing a successful radical prostatectomy is reducing blood loss, as it provides a surgical field where visualization is improved and the fine details of neurovascular bundle preservation can be meticulously performed

  • Nerve-sparing radical prostatectomy is, in large part, neurosurgery; the neurovascular bundles are fragile and susceptible to excessive tension, thermal injury and direct damage, and techniques that minimize trauma to these delicate tissues should be used

  • The incidence of positive surgical margins can be reduced by excising as much periprostatic tissue as possible after the neurovascular bundles have been mobilized off the prostate; a deliberate incision through Denonvilliers' fascia and a sharp dissection of the prostate together with the fascial layer and some of the perirectal fat off the anterior rectal wall will best excise the periprostatic tissue

  • Even with complete bilateral nerve sparing, several millimeters of tissue can be resected adjacent to the majority of the gland

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Figure 1: Control of the dorsal venous complex.
Figure 2: Steps to reduce the rate of positive margins while preserving the neurovascular bundles.
Figure 3: Endorectal MRI of the prostate defining the location of the various fascial planes surrounding the neurovascular bundles.
Figure 4: Standard technique for nerve-sparing surgery.
Figure 5: Modified technique for nerve-sparing surgery.

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  1. Division of Urology, Memorial Sloan–Kettering Cancer Center, Suite 527, 353 East 68th Street, New York, NY 10021, USA easthamj@mskcc.org

Authors and Affiliations

  1. JA Eastham is a Member in the Division of Urology, Memorial Sloan–Kettering Cancer Center, New York, NY, USA.,

    James A Eastham

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Eastham, J. Surgery Insight: optimizing open nerve-sparing radical prostatectomy techniques for improved outcomes. Nat Rev Urol 4, 561–569 (2007). https://doi.org/10.1038/ncpuro0916

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