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The Effect of Bilateral, Unilateral, and Non-Nerve Sparing Robot-Assisted Laparoscopic Prostatectomy on Quality of Life Outcomes.
David Chalmers, MD1, Ilene Staff, Ph.D.2, Steven Shichman, MD2, Joseph R. Wagner, MD2, Stuart Kesler, MD2.
1University of Connecticut Health Center, Farmington, CT, USA, 2Hartford Hospital, Hartford, CT, USA.

Introduction: The impact of nerve sparing during radical prostatectomy on postoperative functional outcomes continues to evolve with a greater appreciation of the anatomy and advancements in surgical technique. Improved visualization and fine instrumentation now popularized in laparoscopic and robotic surgery have refined our understanding of the fascial planes enveloping the prostate and neurovascular bundles. Numerous studies have shown that preservation of the normal anatomy improves postoperative potency. Preliminary studies suggest that the degree of nerve sparing may affect urinary continence as well. Various definitions of nerve sparing have been proposed, including intrafascial, interfascial, and extrafascial. The approach is dictated by pre-operative, anatomical, and oncologic factors with a primary goal of cancer control. This study evaluates the impact of bilateral vs unilateral vs non-nerve sparing procedures on continence and potency outcomes.
Materials and Methods: 330 patients underwent robotic-assisted laparoscopic prostatectomy by a single surgeon between September, 2007 and February, 2010. Follow up was maintained in a prospectively managed database. Exclusion criteria included patients who received adjuvant, neoadjuvant or hyperbaric treatment, patients with inadequate preoperative continence or potency data, as well as patients who received an extrafascial nerve sparing component to their procedure. 138 patients met our criteria and had sufficient follow up data for inclusion in the study. Patients were categorized into groups according to the type of operation they received. Patients who received bilateral intra- or interfascial nerve sparing, unilateral intra- or interfascial nerve sparing, or non-nerve sparing operations were compared. The rates of continence and potency were analyzed cross-sectionally for each group at 3, 6, and 12 month intervals. Continence was defined as no pads during the last 4 weeks or patient perception of continence. Potency was defined as erections firm enough for intercourse or erections at least half the desired time.
Results: Perioperative characteristics between each group of patients appeared similar. Statistically significant differences in continence and potency outcomes were observed between the bilateral and unilateral nerve sparing groups, in addition to differences vs the non-nerve sparing group. At 12 months, continence rates were 71%, 89% and 98% in the non-nerve sparing, unilateral and bilateral nerve sparing groups respectively (p<0.05). Potency rates were 0%, 33% and 69% respectively at 12 months (p<0.05).

Continence
3 months6 months12 months
Bilateral NS85%93%98%
Unilateral NS57%73%89%
Non NS80%58%71%

Potency
3 months6 months12 months
Bilateral NS48%50%69%
Unilateral NS30%17%33%
Non NS0%0%0%

Conclusion: Quality of life outcomes appear significantly impacted by degree of nerve sparing operation. Bilateral nerve sparing improves post-operative potency dramatically and provides a benefit to continence when compared to unilateral nerve sparing. Non-nerve sparing robotic prostatectomy results in poor potency outcomes as well as decreased continence rates.
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