Da Vinci prostatectomy: athermal nerve sparing and effect of the technique on erectile recovery and negative margins

As da Vinci prostatectomy (dVP) grows in use, urologists continue to work to achieve improved sexual function while maintaining oncologic outcomes. This author set out to evaluate the impact of three different nerve-sparing techniques on not only 12-month and early erectile functional recovery but on negative margin rates as well. The author completed 400 dVP procedures, 300 of which were nerve-sparing. Series 1 utilized selective bipolar cautery for nerve sparing, series 2 used an athermal "clip and peel" posterior dissection technique, and series 3 used an athermal combined anterior and posterior dissection technique with clips and sharp dissection alone. Operative times, blood loss, and margin rates were recorded for all cases, and erectile function was measured by means of pre- and post-operative Sexual Health Inventory for Men (SHIM) score. For series 1, 2, and 3, the average total operative time was 111, 83, and 75 min, average console time was 78, 53, and 58 min, average blood loss was 125, 137, and 150 ml, respectively. Erections capable of intercourse at 3 months were seen in 14% of patients in series 1, 24% of the men in series 2, and 71% of the men in series 3. Negative margin rates were 78% for series 1, 76% for series 2, and 83% for series 3. Recovery of erectile function in the author's dVP series favors an athermal technique. Short-term data on the combined anterior/posterior approach, including the preservation of the lateral prostatic fascia in the nerve sparing, was the superior of the two athermal techniques evaluated. In addition, this combined anterior and posterior method of nerve sparing using sharp dissection and clips also resulted in the lowest positive margin rates in the author's series.