Anatomic nerve-sparing laparoscopic radical prostatectomy: comparison of retrograde and antegrade techniques

To compare the anatomic retrograde and antegrade preservation of the neurovascular bundle (NVB) during laparoscopic radical prostatectomy.

Anatomic studies were reviewed, focusing on the fascial layers surrounding the prostate and NVB and the terminology used as described by Walsh and colleagues. Important operative steps have been illustrated using video clips. For the retrograde technique, after incision of levator fascia, the NVBs were released from the apex before division of the urethra. Along the plane between the laterally incised Denonvilliers and perirectal fascia, the prostate was mobilized from the rectum. Isolated clipping of the seminal vesicle arteries was performed in an antegrade manner, followed by control of the lateral pedicles, and identification of the course of the NVB. For the antegrade technique, after dissection of the seminal vesicles, the levator fascia was incised to develop a lateral NVB groove. After bladder neck division and lateral pedicle ligation, the lateral NVB groove was used as a guide for antegrade preservation of the NVB. During anastomosis, the NVBs located at the 5-o'clock and 7-o'clock positions were avoided in both techniques.

A questionnaire-based potency rate of 67% and 76%, respectively, was reported after bilateral nerve sparing using retrograde and antegrade laparoscopic radical prostatectomy techniques.

Both techniques allowed replication of open surgical principles. The video magnification enabled excellent demonstration of the periprostatic anatomy. The principles of interfascial dissection of the NVB, use of task-specific instrumentation, and avoiding energy sources around the NVB may be more important than the actual nerve-preservation technique used.