The role of the prostatic vasculature as a landmark for nerve sparing during robot-assisted radical prostatectomy

Background: Macroscopic landmarks are lacking to identify the cavernosal nerves (CNs) during radical prostatectomy. The prostatic and capsular arteries run along the lateral border of the prostate and could help identify the location of the CNs during robot-assisted radical prostatectomy (RARP). Objective: Describe the visual cues that have helped us achieve consistent nerve sparing (NS) during RARP, placing special emphasis on the usefulness of the prostatic vasculature (PV). Design, setting, and participants: Retrospective video analysis of 133 consecutive patients who underwent RARP in a single institution between January and February 2011. Surgical procedure: NS was performed using a retrograde, antegrade, or combined approach. Measurements: A landmark artery (LA) was identified running on the lateral border of the prostate corresponding to either a prostatic or capsular artery. NS was classified as either medial or lateral to the LA. The area of residual nerve tissue on surgical specimens was measured to compare the amount of NS between the groups. Results and limitations: We could identify an LA in 73.3% (195 of 266) of the operated sides. The area of residual nerve tissue was significantly different whether the NS was performed medial (between the LA and the prostate) or lateral to the LA (between the LA and pelvic side wall): median (interquartile range) of 0 (0-3) mm 2 versus14 (9-25) mm 2; p < 0.001, respectively. Conclusions: The PV is an identifiable landmark during NS. Fine tailoring on the medial border of an LA can consistently result in a complete or almost complete NS, whereas performing the NS on its lateral border results in several degrees of incomplete NS.