Platinum Priority – Review – Prostate CancerEditorial by Peter C. Albertsen on pp. 365–367 of this issueSystematic Review and Meta-analysis of Studies Reporting Potency Rates After Robot-assisted Radical Prostatectomy☆
Introduction
International guidelines support opportunistic prostate-specific antigen (PSA) screening in well-informed patients and recommend a baseline PSA at 40 yr of age [1], [2], [3]. Although some relevant controversies continue about the real benefit of the screening program, the undisputable finding is that an increasing percentage of young men have an early prostate cancer diagnosis [4], [5]. This, in turn, has led to an increase in the number of young candidates for radical prostatectomy with the expectation of curing cancer and minimizing the risk of urinary incontinence and erectile dysfunction.
Initially, Walsh's description of the anatomic nerve-sparing technique in 1982 was based on the concept that the neurovascular bundles (NVBs) are situated posterolaterally and symmetrically to the prostate in the space among the levator fascia, prostatic fascia, and Denonvilliers’ fascia [6]. A comprehensive review of the literature including radical retropubic prostatectomy (RRP) series published between 1990 and 2005 showed a wide range of estimates after a minimum follow-up of 12 mo, with patients who received bilateral nerve-sparing RRP showing potency rates ranging from 31% to 86% [7]. Similar ranges of outcomes from 42% to 76% were reported after nerve-sparing laparoscopic radical prostatectomy (LRP) [8].
In the last decade, deeper insight into the distribution and course of the cavernous nerves showed that, especially in men with a small prostate, NVBs may have either an anterolateral position or, rarely, an asymmetric posterolateral position on one side while lateral on the other [9], [10], [11]. These new anatomic concepts supported the incision of the periprostatic fascia anteriorly and parallel to the NVBs to preserve cavernous nerves located at both the posterolateral and anterolateral surfaces of the prostate [9]. The multiple compartments that could be developed from the levator fascia to the prostate capsule by entering fascial planes during surgery explain the possibility of realizing a different extension of the nerve-sparing procedure according to cancer risk stratification and patient preoperative characteristics [12].
Although some surgeons demonstrated the feasibility of the anterior incision of the periprostatic fascia and the possibility of realizing an interfascial or intrafascial surgical plane in open surgery [13], [14], it was hypothesized that the tridimensional magnification, scaling of movements, and 7 degrees of freedom associated with the robotic technology could significantly simplify and improve the results of nerve-sparing procedures [15], [16]. Previously published surgical series showed 12-mo potency recovery after robot-assisted radical prostatectomy (RARP) in between 70% and 80% of cases [8]. Tewari et al. [17] supported these promising results, showing a significantly shorter time to reach erections in patients who underwent RARP compared with those receiving RRP. However, the very few available comparative studies did not permit any definitive conclusion about the superiority of RARP in comparison with RRP or LRP in terms of the recovery of potency.
The aims of this systematic review were to evaluate the current prevalence and the potential risk factors of erectile dysfunction after RARP, to identify surgical techniques able to improve potency recovery after RARP, and to perform a cumulative analysis of all available studies comparing RARP with RRP or LRP.
Section snippets
Evidence acquisition
To update the previous systematic review by two of the current authors [8], [16], a literature search was performed in August 2011 using the Medline, Embase, and Web of Science databases. The Medline search included only a free-text protocol using the term radical prostatectomy across the title and abstract fields of the records. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. The searches of the Embase and Web of Science databases used the
Quality of the studies and level of evidence
Figure 1 shows the flowchart of this systematic review of the literature. We selected 44 records reporting potency rates after RARP. Thirteen abstracts or meeting reports were excluded. The remaining studies included 15 case series (level 4), 6 studies comparing different techniques in the context of RARP (4 studies, level 3; 2 studies, level 4), 6 studies comparing RARP with RRP (3 studies, level 3; 3 studies, level 4), and 4 studies comparing RARP with LRP (1 study, level 2; 3 studies, level
Discussion
Nerve-sparing RARP was associated with an incidence of 12- and 24-mo erectile dysfunction ranging from 10% to 46% and from 6% to 37%, respectively. These widely different rates of erectile dysfunction are attributable to several factors: (1) Different definitions and measures of erectile dysfunction have been used from study to study, (2) characteristics of the surgery and patient selection have varied across studies, and (3) postsurgical rehabilitation varies greatly from center to center. Our
Conclusions
Potency rates after RARP are influenced by numerous factors including baseline patient characteristics, nerve-sparing extension and techniques, definition of potency, and methods used to collect data. Our analysis showed a progressive increase in potency rates with follow-up after RP. Patient selection criteria and surgical techniques must be taken into consideration to attain excellent results after nerve-sparing RARP. Although the definition of potency remains a nonstandardized parameter,
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