Preserving Erections: The daVinci Robotic Prostatectomy Approach

The daVinci Robotic Prostatectomy for Prostate Cancer: What Every Patient Should Know

Prostate cancer is one of the most common cancers affecting men worldwide. When diagnosed, patients face a crucial decision: choosing the most effective treatment that not only targets the cancer but also preserves their quality of life. Among the various treatment options available, the daVinci robotic prostatectomy has emerged as a leading choice for many patients. One of the primary concerns for many men undergoing prostate cancer treatment is the potential impact on their sexual function, particularly erectile function.

As a Urologist and Urologic surgeon with over 22 years of experience performing robotic surgery, I thought I would share my thoughts on the impact of erections after the daVinci Robotic Prostatectomy. Let’s delve into the anatomy of the prostate, the importance of nerve-sparing techniques, and how surgeons make critical decisions on how to preserve erections without leaving cancer behind.

Understanding The Robotic Prostatectomy

The Robotic prostatectomy is an advanced surgical technique used to remove the prostate gland in men diagnosed with prostate cancer. This minimally invasive procedure utilizes the state-of-the-art da Vinci Surgical System, which allows surgeons to operate with enhanced precision, control, and visualization. The daVinci platform shrinks down the surgeon’s hands and places them at the end of chopsticks, enabling them to perform surgeries in minute areas with the utmost precision. The surgeon controls the robot with small joysticks at the adjacent console. Fortunately, AI has not taken control of the robot yet; you need an experienced surgeon to do the work.

How The Robotic Prostatectomy Works

During a robotic prostatectomy, the surgeon sits at a console controlling robotic arms equipped with surgical instruments and a high-definition 3D camera. The surgeon’s hand movements are translated into smaller, more precise movements of the instruments inside the patient’s body. This level of precision is crucial when operating near delicate structures such as the nerves responsible for erectile function.

Benefits of The Robotic Prostatectomy

• Minimally Invasive: The procedure requires only a few small incisions, resulting in less scarring and reduced post-operative pain.
• Enhanced Precision: The robotic system provides magnified 3D visualization, allowing for more accurate dissection and preservation of critical structures. The surgeon literally becomes immersed in the 3D procedure on the console.
• Reduced Blood Loss: The precision of the robotic instruments helps minimize blood loss during surgery.
• Shorter Hospital Stay: Most patients can return home the next day after the procedure.
• Faster Recovery: The minimally invasive nature of the surgery often leads to a quicker return to normal activities.
• Improved Continence Outcomes: The precise control offered by the robotic system may lead to better urinary continence results.
• Potential for Better Erectile Function Preservation: The enhanced visualization and precision can help preserve the nerves responsible for erectile function.

–Catheter-free – Dr. Bevan-Thomas will send patients home with a tube from the lower abdomen into the bladder, NOT a catheter in the penis – this is the suprapubic tube. This is much more comfortable for the patients, and this suprapubic tube is routinely removed 5-7 days after the procedure.

Anatomy and Nerve-Sparing Techniques

Prostate Anatomy

The prostate is a small, walnut-sized gland located just below the bladder and in front of the rectum. It surrounds the urethra, the tube that carries urine and semen out of the body. The prostate’s primary function is to produce fluid that nourishes and protects sperm. FYI, the prostate size varies between patients due to multiple variables.

Neurovascular Bundles

On either side of the prostate lie two bundles of nerves and blood vessels, known as neurovascular bundles. These structures are crucial for erectile function:

• Nerve Function: These bundles contain the cavernous nerves responsible for initiating and maintaining erections. When stimulated, these nerves trigger a series of events that lead to increased blood flow to the penis, resulting in an erection. Impulses travel through the nerves to the penis, which then releases a chemical to increase blood flow to the penis and cause an erection.
• Blood Supply: The neurovascular bundles also contain blood vessels that supply the penis with the increased blood flow necessary for an erection. The blood supply to the nerves is also crucial for them to function.

Importance for Erectile Function

The preservation of these neurovascular bundles is critical for maintaining erectile function after prostate surgery. Damage to these structures can result in erectile dysfunction, which is why nerve-sparing techniques are so crucial in robotic prostatectomy. The more nerves that are spared, the better the chances for erections after surgery.

Nerve-Sparing Techniques

Surgeons employ several nerve-sparing techniques to achieve the delicate balance of treating cancer while preserving erectile function.

Urologists can perform nerve-sparing prostatectomy through different layers, primarily categorized into three techniques based on the fascial planes of dissection.

There are different degrees of nerve-sparing, just like different ways to peel an orange. This is an oversimplified analogy but should work to help understand the process. The deeper we peel the orange, the more orange is left behind in the body, thus leaving more nerves and improving erections.

Peeling the orange perfectly, leaving the fruit pristine and untouched by any pith, is like a full nerve-sparing procedure, where the nerves are meticulously preserved. This is the complete nerve-sparing procedure or interfacial nerve sparing, where the nerves are left in the body and not removed along with the prostate.

• Peeling the orange but leaving some of the white pith on the fruit is akin to a partial nerve-sparing procedure. Some nerves are preserved but some may be damaged. This is the partial nerve-sparing “interfascial.”
• Peeling the orange completely, including the bitter white pith, is like a non-nerve sparing procedure where the nerves are removed along with the prostate. This is similar to the extrafascial removing more of the nerves.

The goal is to remove all of the fruit (the cancerous prostate) while keeping the peel (the nerves) as intact as possible. The challenge is to leave as many nerves as possible without leaving cancer behind. Unfortunately, most prostate cancer can not be seen while doing surgery, so planning ahead of time with a prostate MRI and looking at the volume of cancer can help the surgeon make the best decision about which layers they will remove.

Each technique aims to preserve the neurovascular bundles (NVB) to maintain erectile function and urinary continence while effectively removing the prostate. And, yes, some of these nerves can also help with urinary function.

1. Intrafascial Nerve-Sparing

In the intrafascial technique, the dissection occurs within the plane between the prostatic capsule and the prostatic fascia. This approach aims to preserve as many nerve fibers as possible by staying close to the prostate. The intrafascial technique is associated with better functional outcomes, such as higher potency rates and quicker return of continence. Still, it may carry a higher risk of positive surgical margins in some instances, particularly in patients with more advanced disease (pT3).

2. Interfascial Nerve-Sparing

The interfascial technique involves dissection between the prostatic fascia and the lateral pelvic fascia (levator fascia). This method preserves the prostatic fascia and aims to strike a balance between preserving nerve function and ensuring oncological safety. It is the traditional approach initially described by Walsh and is widely used due to its balance of functional and oncological outcomes.

3. Extrafascial Nerve-Sparing

In the extrafascial technique, dissection occurs outside the prostatic fascia, under the Denonvilliers’ fascia, further away from the prostate and the NVB. This technique is less commonly used for nerve-sparing purposes because it is more likely to compromise the preservation of the NVB, thus potentially leading to poorer functional outcomes[1][2].

Comparative Outcomes

• Intrafascial Technique: Offers superior functional outcomes, particularly in erectile function and urinary continence, but may have a higher risk of positive surgical margins in advanced disease cases. This is precisely why a pre-operative MRI and evaluation of the disease volume helps the surgeon estimate how many layers to spare during the surgery. If cancer is left behind, those patients have a higher risk of recurrence, which may require radiation if the PSA rises after surgery. This can be utilized with patients with lower-volume prostate cancer and minimally suspicious prostate MRIs.
• Interfascial Technique: Provides a balanced approach with reasonable functional outcomes and oncological safety. It is the most commonly used technique and is considered the standard approach for many surgeons. This spares most of the nerves while simultaneously limiting leaving cancer behind (surgical margin)
• Extrafascial Technique: Generally not preferred for nerve-sparing due to the higher likelihood of compromising the NVB, leading to poorer functional outcomes. This is routinely utilized for patients with a higher volume of disease, higher grade of disease (Gleason 8,9,10), or with an MRI suspicious for cancer outside of the prostate

In summary, the choice of technique depends on various factors, including the patient’s anatomy, the extent of the cancer, and the surgeon’s experience and preference. Each technique has advantages and trade-offs, and the optimal approach is often tailored to the patient’s needs.

Ideal Candidates for Nerve Sparing

Selecting suitable candidates for nerve-sparing prostatectomy is crucial for maximizing both oncological and functional outcomes. Prostate MRI and detailed pathology play a significant role in this selection process.

Prostate MRI: A preoperative prostate MRI can provide detailed images of the prostate and surrounding tissues, helping to identify the exact location and extent of the tumor. This imaging technique detects extracapsular extension (ECE) and other features that might influence the surgical approach. MRI findings can guide surgeons in deciding whether nerve-sparing is feasible without compromising cancer control.

Pathology: The pathology report from a prostate biopsy provides critical information about the cancer’s aggressiveness (Gleason score) and extent. This information helps assess whether the cancer is confined to the prostate or has spread to nearby tissues.

Criteria for Nerve-Sparing Surgery

• Tumor Location and Size: Cancer confined to the prostate and not involving the neurovascular bundles. Dr. Bevan-Thomas relies on the MRI and will routinely go over this with his patients so they understand the plan for the surgery.
• Overall Health: Good general health with no significant comorbidities. For patients with pre-existing erectile dysfunction, an aggressive nerve-sparing procedure is rarely warranted.

Factors Excluding Patients

• Extensive Tumor Involvement: Cancer involving or close to the neurovascular bundles. MRI findings that suggest significant extracapsular extension (ECE) or seminal vesicle invasion may preclude nerve-sparing surgery.
• Significant Comorbidities: Severe heart or lung conditions or other health issues complicating surgery.
• Previous Surgeries or Conditions: Prior surgeries or conditions affecting the pelvic area may make the nerve-sparing more challenging.

Post-Surgery Recovery and Erectile Function

Recovery Timeline

The recovery of erectile function after nerve-sparing prostatectomy can vary widely among patients. Factors influencing recovery include age, pre-surgery erectile function, and the extent of nerve preservation.

• Early Recovery: Some patients may begin to see improvements in erectile function within a few months post-surgery.
• Long-Term Recovery: Full recovery of erectile function can take up to 12-24 months or sometimes even longer.

Aids to improve Erectile Function Recovery

• Medical Therapy: Early postoperative use of medications such as phosphodiesterase inhibitors (e.g., Viagra, Cialis) can aid in the recovery of erectile function. Dr. Bevan-Thomas recommends daily Cialis, and the data supports this protocol. Remember that taking Cialis does not cause a man to get an erection; it simply improves the man’s ability to obtain and maintain the erection better.
• Improve blood flow post-surgery: Stimulation can help maintain healthy erectile tissue and promote recovery. Dr Bevan-Thomas recommends a vacuum erection device to pull blood flow into the penis after surgery to assist in regaining the erections as well.

Success Rates and Long-Term Outcomes

Success Rates

Robotic prostatectomy with nerve-sparing techniques has shown promising success rates in preserving erectile function. Studies indicate that patients who undergo a bilateral nerve-sparing surgery have better postoperative erectile function compared to those who have only unilateral nerve-sparing (one side). The more nerves are spared, the more the nerves can cause the impulse to the penis to cause the dilation of the blood vessels.

Long-Term Outcomes

Bilateral Nerve-sparing (sparing nerves on both sides of the prostate) has the highest chance of returning erections after surgery and can be as high as 90%, however, patients that do the best are routinely younger (under 60 years old), have very good erections before surgery and are in excellent health.

Unilateral nerve sparing (only sparing nerves on one side of the prostate) has erectile function up to 75% after surgery. It routinely takes longer for these patients to recover as there are fewer nerves to conduct the impulse to the penis to obtain an erection.

Important points

• Erections should improve after surgery but will not be any better than the erections before surgery. This is why the validated questionnaire (SHIM score) is essential to fill out before and after surgery.
• Erections can continue to improve for years after surgery, so utilizing the Vacuum Erection Device and daily Cialis is vital as part of the rehabilitative process.

For patients struggling with erectile dysfunction, penile injection therapy is an excellent option. This requires the patient to inject a small amount of medication into the penis to obtain the erection. Studies have shown that up to 75% of men respond very well to this and can obtain erections suitable for intercourse.

Conclusion

The Robotic prostatectomy is a highly effective and minimally invasive treatment option for prostate cancer. It offers numerous benefits, including reduced pain, faster recovery, and enhanced precision. The nerve-sparing techniques employed during this procedure are crucial for preserving erectile function and maintaining quality of life. If you are newly diagnosed with prostate cancer, discussing the robotic prostatectomy with Dr. Bevan-Thomas can help you make an informed decision about your treatment options.

Dr. Bevan-Thomas’s Expertise

Dr. Rich Bevan-Thomas is a highly experienced urologic surgeon specializing in robotic prostatectomy. With over 22 years of experience in robotic surgery and thousands of successful surgeries, Dr. Bevan-Thomas is dedicated to providing his patients with the highest level of care. His expertise in using the da Vinci Surgical System ensures that patients receive the full benefits of this advanced surgical technique, leading to better outcomes and improved quality of life.