CT prostate angiogram for nerve-sparing robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is a widely used treatment for clinically localised prostate cancer. Preserving neurovascular bundles (NVB), are crucial for erectile function and urinary continence. However, it remains challenging due to accurate identification of the NVB. Branches of the prostatic artery can act as a reference for nerve-sparing (NS) prostatectomy surgery. Due to anatomical variations, vascular mapping utilising CT prostate angiography (CTPA) could assist in prostate artery localisation during RARP, to impact surgical outcomes.

This is a hypothesis-generating narrative review in which the anatomy of the prostate, NVB and vasculature is described in addition to the current scope of RARP. CTPA in preoperative planning for RARP is evaluated, with a focus on its potential to enhance preservation of erectile function through improved identification of prostatic vasculature.

CTPA is used for pre-procedure planning in prostate artery embolization (PAE) to manage symptomatic benign prostatic hyperplasia (BPH). Currently, pre-procedure planning for NS RARP includes prostate biopsy and MRI for staging. The mainstay of research on RARP is primarily focused on techniques to preserve the NVB, but the role of arterial anatomy warrants additional exploration. Factors such as cost, time and radiation exposure must be considered before CTPA could be included in routine preoperative assessment.

By enabling precise identification of critical prostate arterial anatomy, CTPA could facilitate easier localization of the NVB intraoperatively, contributing to improved surgical outcomes. Further investigations are required to ascertain if preoperative CTPA can be a standard to improve functional outcomes and recovery after RARP.