Current Technique of Open Intrafascial Nerve-Sparing Retropubic Prostatectomy

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1 EUROPEAN UROLOGY 56 (2009) available at journal homepage: Surgery in Motion Current Technique of Open Intrafascial Nerve-Sparing Retropubic Prostatectomy Lars Budäus a,b, *, Hendrik Isbarn a,b, Thorsten Schlomm a, Hans Heinzer a, Alexander Haese a, Thomas Steuber a, Georg Salomon a, Hartwig Huland a, Markus Graefen a a Martini-Clinic, Prostate Cancer Centre Hamburg-Eppendorf, Hamburg, Germany b University Hospital Hamburg-Eppendorf, Department of Urology, Hamburg, Germany Article info Article history: Accepted May 5, 2009 Published online ahead of print on May 29, 2009 Keywords: Open nerve-sparing retropubic prostatectomy Current technique Functional outcome Abstract Background: Open nerve-sparing retropubic prostatectomy (nsrp) is still the most common surgical approach for the treatment of localised prostate cancer. Even though the principles of the technique and its oncological efficacy have often been published, ongoing refinements allow further improvements in functional outcome and morbidity. Objective: To describe our current technique of open nsrp with data addressing urinary continence, potency, cancer control rates, and perioperative morbidity. Design, setting, and participants: Our analyses relied on 1150 patients who were treated with nsrp in the Martini-Clinic by two high-volume surgeons from April 2005 to December Surgical procedure: Key elements are a selective ligation of the dorsal vein complex and early release of the neurovascular bundles using a high anterior tension- and energy-free intrafascial technique. During dissection of the urethra, its posterior insertion at Denonvilliers fascia (DF) is preserved. DF is left in situ, and it is selectively opened above the seminal vesicles (SV). The SV are completely removed inside DF, and five muscle-sparing interrupted sutures are used for anastomosis. Measurements: Functional and oncological outcome data were prospectively assessed using validated questionnaires. Moreover, intra- and perioperative morbidity were evaluated. Results and limitations: Age and extent of nerve-sparing approach influenced urinary continence and potency. Complete urinary continence 1 yr after nsrp was found in 97.4% (men <60 yr) to 84.1% (men >70 yr) of patients. In preoperative potent men, erections sufficient for intercourse were reported between 84 92% and % of patients following bilateral and unilateral nerve sparing, respectively. Median blood loss was 580 ml (range: ml), and the transfusion rate was 4.3%. Median operative time was 165 min (range: min). In organ-confined cancers, recurrence-free survival and cancer-specific-survival 10 yr after retropubic prostatectomy were 87% and 98.3%, respectively. Conclusions: Open intrafascial nsrp combines excellent long-term cancer control rates with superior functional outcome and a low morbidity. # European Association of Urology Published by Elsevier B.V. All rights reserved. * Corresponding author. Martini-Clinic, Prostate Cancer Centre Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany. address: Lars_budaeus@web.de (L. Budäus) /$ see back matter # European Association of Urology Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 318 EUROPEAN UROLOGY 56 (2009) Introduction Open retropubic prostatectomy (RP) is one of the standard surgical approaches for the treatment of clinically localised prostate cancer [1]. In recent years, aside from the established open retropubic or perineal approach, conventional laparoscopic prostatectomy and, especially, roboticassisted radical prostatectomy (RALP) are increasing in popularity [2,3] Today, most institutions have a preferred surgical approach, based on their surgical school, and favourable outcomes are reported with respective techniques [2 8]. In a recent review article, no superiority was found for a certain technique, and the authors concluded that time will tell whether a certain surgical approach will be advantageous [9]. However, as such data are not available and all techniques are in a constant refinement process, it is important that updates of the existing techniques be published to allow an ongoing contemporary comparison of the available approaches. Such studies will permit a fair judgement of developments in each technique and make the assessment of functional outcome, efficacy, and morbidity easier. In this paper, we report our current technique of open nerve-sparing RP (nsrp), including cancer control rates, functional outcome, and perioperative morbidity. Fig. 1 The dorsal vein complex adjacent to the prostate, starting on the higher half of the prostate at the 2 o clock and the 10 o clock positions. 2. Methods and patients 2.1. General recommendations for performing nerve-sparing retropubic prostatectomy We are using a Bookwalter autoretractor system (Codman, Le Locle, Switzerland), 4- to 5-fold magnification glasses, and a xenon headlamp for optimal exposure and illumination of the operative field. No specific positioning of the patient is necessary. For performing nsrp, we recommend a spinal anaesthesia and additional total intravenous anaesthesia. Intravenous fluid replacement is restricted to 500 ml until the prostate is removed. Based on an individual fast-track concept, discharge from hospital in a good physical constitution is regularly possible 3 4 d after surgery (the German health system has directed that patients undergoing RP have to stay in hospital for at least 4 d) Incision of the endopelvic fascia and preparation of the dorsal venous complex After an 8 10-cm median skin incision, the retropubic space and the cavum recii is established. Then the endopelvic fascia is incised and fibres of the levator ani muscle are gently pushed away. However, fibres from the levator urethrae are preserved to maintain its anterior fixation. The attachment of the detrusor apron, known as the puboprostatic ligaments, are isolated and then sharply dissected. Throughout the operation, no coagulation should be used close to the neurovascular bundle or on the surface of the prostate in order to avoid damage of the nerves. A superficial stay suture is placed distally from the prostate, which will later be used for the selective ligation and for oversewing of the plexus. The lateral parts of the fascia of the sphincter muscle are not touched, as they separate the sphincter from the neurovascular bundle (Fig. 1). These structures are known as Mueller s ligaments, a continuation of the ventral fascia of the striated sphincter. Mueller himself called these structures ischioprostatic ligaments (Fig. 2). Fig. 2 Only the endopelvic fascia and the membrane of the external sphincter are included within the oversewn distal part of the dorsal vein complex. Mueller s ligaments, with the adjacent neurovascular bundles below the 10 o clock and the 2 o clock positions, are marked with red arrows. To avoid back bleeding, an additional Vicryl 2/0 suture is placed in the midline of the prostate. The incision of the exposed dorsal vein complex, situated between the continuation of the endopelvic fascia on top and the fascia of circular striated sphincter muscle below, starts close to the apex of the prostate. The dorsal vein complex is dissected without any ligation until the fascia of the external sphincter is visible. While the fascia of the external sphincter is superficially incised, care is taken that the underlying muscle fibres of the external sphincter are kept intact. The selective suturing of the distal parts of the dorsal vein complex between 10 and 2 o clock includes two layers: The ventral part of the dorsal vein complex consists of the continuation of the endopelvic fascia; the dorsal part is covered by the fascia of the external sphincter. This selective approach guarantees that functional tissue of either the sphincter fibres or the urethra is not incorporated into the ligation and that traction to the adjacent tissue is avoided (Fig. 3) The intrafascial nerve-sparing procedure The dissection of the neurovascular bundles starts high up on the anterior aspect of the prostate with incision of the parapelvic fascia

3 EUROPEAN UROLOGY 56 (2009) Fig. 4 Preparation of the apex and sphincter, with the circular and longitudinal muscle fibres dissected very close to the apex of the prostate, ensuring a maximum length of functional tissue. Fig. 3 Longitudinal section of the prostate; most of the fibres of the neurovascular bundles are running adjacent on the lateral and lower parts of the prostate, so the dissection should start high on the prostate. because the majority of nerves run adjacent on the lateral and lower part of the prostate. The neurovascular bundles are mobilised and lateralised before the urethra is dissected (Fig. 3). For subtle dissection, the attached levator fascia and periprostatic fascia isgentlylifted andincisedattheanterioraspect oftheprostateabove the 10 o clock and the 2 o clock positions and undermined by using small Overholt clamps. The underlying areolar space, including the nerves, fatty tissue, and small tethering vessels, can be identified. When the right dissection plane is entered, one will see the shiny, smooth, reflecting surface of the prostatic capsule. Veins overlying the prostatic capsule are undermined and can serve as a good landmark for entering the right dissection plane. The neurovascular bundles are carefully and gently pushed laterallyanddownwardsusingthebluntnibofthescissors, andthe dissected fascia and vessels are clipped. No haemostasis is performed in minor bleedings; 3- or 5-mm titanium clips or selective stitches (5/0 resorbable PDS sutures) are used to control arterial bleeding. The borders for the release of the neurovascular bundle are, distally, the periurethral area upuntil3 5 cmproximallyoftheprostatic base into theperivesicalfat inordertoavoidtension onthe bundleandtoexposetheprostaticpedicles Preparation of the sphincter and urethra For preserving as much functional tissue as possible, the preparation of the sphincter and urethra starts at the apex of the prostate. Fibres of the circular striated sphincter muscle, which cover the apex outside of the prostate, are gently pushed distally with blunt scissors until the longitudinal smooth muscle fibres become visible. Subsequently, the longitudinal smooth muscle fibres, which run inside the prostate, are incised. The transection of the longitudinal fibres is performed approximately 3 mm within the prostate, cranially of the apex of the prostate. Remaining muscle fibres are gently pushed distally for preservation. Then the urethra is incised, and the preparation is performed for two-thirds of its circumference. Bystartingthe subtle dissection with thefibrescoveringthe apex of the prostate, the complete length ofthe functional urethra is preserved (Fig. 4). Then the needle is passed through the mucosa of the urethra, and only a small part of the functional tissue is incorporated. The rest of the urethra is completely dissected, and the lower anastomotic sutures are placed at the 3 o clock, 9 o clock, and 6 o clock positions. At the 6 o clock position, the suture affixes the dorsal part of the sphincter to the DF and the raphe of the sphincter muscle for traction of the whole membranous urethra (Fig. 5), similar to the technique described by Rocco et al. [10]. As described above, the perivesical fat is mobilised during the nervesparing procedure to release the bundles and to avoid further traction during the operation. Furthermore, the release of the fatty tissue up to 3 5 cm proximally of the prostatic base allows a precise visualisation of the prostatic pedicles, which can then be selectively ligated or clipped. DF, which is left in situ at the apical region, is incised at the basal region for preparation of the seminal vesicles. By incision of DF, a ventral part of this fascia is left on the specimen to avoid positive surgical margins. The part of the DF covering the seminal vesicles is incised and is left in situ in order to protect the underlying neurovascular bundle. The tips of the seminal vesicles are identified, and the adjacent vessels are clipped and dissected. DF, covering the seminal vesicles, is left inside because it protects the neurovascular bundles. No coagulation is used in order to preserve the integrity of the nerves running close to the tips of the seminal vesicles. If necessary, bladder outlet is narrowed with a tennis-racket suture (Vicryl 4/0) with eversion of the mucosa. The operating field is checked; if bleeding close to the neurovascular bundle occurs, PDS 5/0 sutures or clips are used to control such bleeding Principle of anastomotic sutures and removal of the prostate At the 1 o clock and the 11 o clock positions, a 3/0 PDS with a UR6 needle is passed through the ligated dorsal vein complex, used as an anchor. Fig. 5 Principle of anastomotic sutures. The sutures are placed through the everted bladder mucosa. Traction of the whole membranous urethra is reached by including the Denonvilliers fascia and the raphe of the sphincter muscle within the 6 o clock suture.

4 320 EUROPEAN UROLOGY 56 (2009) Fig. 6 The (a) right side of the prostate (b) is inked green before removing the slice for frozen section analyses for intraoperative evaluation of the surgical margin. Fig. 7 The (a) different sides of the slice for frozen section analyses (b) are inked in a different colour (towards the prostate and towards the neurovascular bundle green or blue and yellow towards the prostate). This technique enables the pathologist to differentiate between trueand false-positive surgical margins. The stitches of the five anastomotic sutures are placed through the everted bladder mucosa and are tied in a single-knot technique to avoid any compromise of the blood supply. This technique results in a stricture rate of <1%. The wound is closed and the skin is closed using a selfresorbable intracutaneous suture, leading to good cosmetic results Indication for nerve sparing and lymph node dissection The indication to perform nerve-sparing surgery (bilateral vs unilateral vs none) and lymph node dissection is based on different nomograms predicting the probability of side-specific extraprostatic extension and lymph node invasion [11,12]. For supplementing the oncological safety of nsrp, frozen sections of the laterorectal surface of the prostate are now performed in nearly every patient [13]. In our institution, preoperative nomograms and intraoperative sections are used in two ways: first, to avoid positive surgical margins in inadequately indicated nerve-sparing procedures (ie, in patients with capsular penetration), and, second, to identify as many candidates for nsrp as possible. As the advantages of nsrp are obvious compared to non nerve-sparing RP, we consider it our task to identify as many suitable cancers for nsrp as possible. With a nomogram estimating the side-specific likelihood of organ confinement in conjunction with intraoperative frozen section, in our institution, the rate of patients undergoing an nsrp and having organ-confined disease at final pathology is as high as 98.3%. This finding underlines that we strive to expand the indication for nsrp as much as possible to minimise potential side-effects on functional outcome. Frozen sections reach from the apex to the base of the complete lateral-dorsal part of the prostate. The sides of the slice are inked in different colours (Figs. 6 and 7) [13]. If tumour cells extending to the outer surface are found, we remove the corresponding neurovascular bundle and its adjacent tissue. Although frozen section analyses do not invariably eliminate the risk of positive surgical margins, they minimise its risk in the most thorough way. 3. Results 3.1. Perioperative parameters and morbidity Preoperative parameters and morbidity were based on the data of 1150 patients, whereas the functional results reported below are based on preoperative potent men. Median operative time was 165 min (range: min). Median blood loss was 580 ml (range: ml), and the transfusion rate was 4.3%. There was no rectal injury, no ureteral injury, and no perioperative death. All patients were routinely investigated by pelvic ultrasound before discharge to detect a pelvic haematoma (5.3%) or lymphocele (7.5%). Revision for pelvic haematoma was necessary in 0.4% of patients. Lymphoceles were only treated when compression of the external iliac vein was observed by

5 EUROPEAN UROLOGY 56 (2009) Table 1 Postoperative urinary continence. Age <60 yr yr >70 yr No. of patients No. of pads per 24 h Bilateral NS (n = 153) Unilateral NS (n = 39) Bilateral NS (n = 253) Unilateral NS (n = 95) Bilateral NS (n = 58) Unilateral NS (n = 39) 0 1, % , % >2, % NS = nerve sparing. Doppler sonography; in those cases, they were managed by puncture (0.8%). No patient had to undergo marsupialisation for lymphoceles. Within 14 d postoperatively, deep vein thrombosis was observed in 1.3% of patients Functional outcome Urinary continence 1 year after surgery The reported number of required pads after nsrp is widely used to assess postoperative urinary continence. In our institution, validated questionnaires (International Continence Society [ICS], European Organisation for Research and Treatment of Cancer [EORTC] Quality of Life (QoL) C30 questionnaire) are routinely used 1 yr after surgery. Continence results were stratified by age and extent of nerve sparing (unilateral vs bilateral approach). In men aged 70 yr, urinary continence 1 yr after nsrp was reported between % and seemed not to be influenced by the extent of nerve sparing (see Table 1). In men >70 yr, urinary continence was observed in 94.5% after bilateral nsrp; however, after unilateral RP, only 84.1% achieved continence, suggesting an important effect of extent of nerve sparing on urinary continence in this patient group [14]. Some % of patients <70 yr reported needing two pads per day, and, again, this need seemed not to be influenced by the extent of nerve sparing. However, in men aged 70 yr, 3.7% needed two pads after bilateral nsrp and 10.7% needed two pads after unilateral nsrp. More than two pads were used by 0.7% of men <70 yr. In older patients, more than two pads were used by 1.8% and 5.2% of patients after bilateral and unilateral RP, respectively. There was no complete urinary incontinence Erectile function 1 year after surgery Evaluation of postoperative potency was restricted to men with documented good preoperative erectile function who underwent a uni- or bilateral nsrp and in whom information on postoperative erectile function by means of International Index of Erectile Function (IIEF) score 1 yr after surgery was available (n = 637). The abridged five-item version of the IIEF is used routinely before surgery and 12 mo after RP in all of our patients [15]. Men with a preoperative IIEF score below 19, indicating some degree of preoperative erectile dysfunction, were excluded from this analysis. We recently reported that preexistent age- and comorbidity-dependent erectile dysfunction affects up to 48% of all RP patients prior to surgery [15]. There are certain ways to report on erectile function. The abridged IIEF-5 score is probably the most frequently used questionnaire; however, many centres do not report postoperative IIEF scores but instead report patients ability to perform intercourse after RP. Certainly, such results strongly correlate; nevertheless, the number of potent patients substantially varies by the type of evaluation and the definition of being potent. Question 2 of the IIEF-5 questionnaire asks for erections sufficient for penetration after sexual stimulation. Patients who stated not having had sexual stimulation within the last 6 mo were excluded, and we considered patients who were able to penetrate their partner as potent. Using this definition, potency rates varied from 84% to 92% in men who underwent a bilateral procedure and from 58.3% to 70% following unilateral nsrp (Table 2). The use of phosphodiesterase type 5 (PDE-5) inhibitors was left to the patient s discretion, and 80% of men who completed the questionnaire did not use such medications. Table 2 Erections sufficient for sexual intercourse and postoperative International Index of Erectile Function (IIEF-5) score in preoperative potent patients (IIEF-5 score I19) *. Age (no. of patients) <60 yr (n = 192) yr (n = 348) >70 yr (n = 97) IIEF >19, % Ability to perform intercourse, % IIEF >19, % Ability to perform intercourse, % IIEF >19, % Ability to perform intercourse, % Degree of nerve sparing Bilateral Unilateral * Assessment was 12 mo after nerve-sparing retropubic prostatectomy, with or without phosphodiesterase type 5 (PDE-5) inhibitor use. Use of PDE-5-inhibitors was reported in approximately 20% of patients.

6 322 EUROPEAN UROLOGY 56 (2009) Table 3 Characteristics of 637 patients with complete pre- and postoperative data who underwent nerve-sparing retropubic prostatectomy between 2005 and Preoperative data Age, mean (range) 63 (43 76) PSA, mean (range) 7.88 (0.7 60) Clinical stage, % (n) T1c 83.6 (533) T (94) T3 1.5 (10) Postoperative data, % (n) Positive margin, % (n) Nerve sparing, % (n) Frozen section analyses, % Both sides One side pt2, 72.3 (460) 5.2 (24) 82.3 (379) 17.6 (81) 86 pt3, 27.7 (177) 27.1 (48) 36.2 (64) 63.8 (113) 92 PSA = prostate-specific antigen. If being potent was defined by a postoperative IIEF score >19, the corresponding potency rates (based on the same questionnaire) were 25 59% (Table 2). Such obvious discrepancies should be explained by a simple example: Patients with good erectile function (five points on question 1 of the IIEF-5) but without sexual stimulation will receive an overall score of 5 out of 25 points and, according to that, suffer from severe ED. This example demonstrates how the impact of the type of evaluation and the definition of postoperative potency can make it almost impossible to obtain comparable data from the literature Oncological outcome We describe our current technique of nsrp, and therefore, we cannot present meaningful oncological long-term follow-up data for this cohort. Using margin status as a surrogate parameter for cancer control, the positive margin rate was 5.2% in pt2 cancers and 27.1% in pt3 cancers (Table 3). All prostatectomy specimens were inked and underwent a 3-mm-step-section procedure for pathological work-up. However, because our surgical approach is based on previous reports from our institution, we report on longterm data addressing prostate-specific antigen (PSA) recurrence free survival and, more important, cancerspecific survival rates [4,16]. At 10 yr after RP, the biochemical recurrence free survival rates (biochemical recurrence strictly defined as a PSA level of 0.1 ng/ml and rising) ranged from %, depending on the pathological stage (Fig. 8), and cancer-specific survival rates ranged from % (Fig. 9). Fig. 8 Biochemical recurrence (BCR) free survival; long-term follow-up of patients treated between 1992 and 1997 with retropubic prostatectomy according to the pathological T stage. 4. Discussion RP has been performed for decades now, and the pioneering work on anatomy and surgical technique was published by Walsh and coworkers almost 30 yr ago [1]. In 2006, our group contributed to Surgery in Motion with the description of our open technique, and the current manuscript is based on the surgical principles shown in that previous publication [4]. The refinements that can be expected by such an update are certainly no reinvention of the technique, but small nuances of the prescribed approach have changed. Fig. 9 Long-term cancer-specific-mortality (CSM) free survival after retropubic prostatectomy according to the pathological T stage.

7 EUROPEAN UROLOGY 56 (2009) One modification in the current technique compared to the one published in 2006 is a more subtle dissection of the posterior urethra. The omega-shaped sphincter muscle inserts at the terminal end of DF, and the insertion of this area is not disrupted. Furthermore, when nerve sparing is performed, the DF is either left in situ or, if it is dissected in a v-shaped manner above the perirectal fat, the posterior part of the urethra is stitched to the remnants of the fascia, similar to the technique described by Rocco et al. [10].The complete continence rate 1 yr after surgery, defined as no pad at all or one protective pad, increased from 92% in 2006 to 95.5% in our latest questionnaire series on more recent patients. The above-mentioned modification might be responsible for that increase. However, another explanation might be that in the 2006 series, RPs from nine surgeons were evaluated. Conversely, in the current report, only the data of two very-high-volume surgeons (HH and MG, about 300 procedures per year per surgeon) were included. The strict intrafascial approach for the nerve-sparing procedure and the subsequently increased number of intraoperative frozen sections, including the complete capsule corresponding to the neurovascular bundle, is another difference from our previous series. The rate of frozen sections is now >90%, and the current positive surgical margin rate in pt2 cancers was lowered in recent years from 9.4% to 5.2% [16]. These data have to be considered in light of the fact that we try to expand the indication for a nerve-sparing procedure as far as is oncologically safe, and 98.3% of our patients harbouring organ-confined disease at final pathology are undergoing a nerve-sparing procedure. The strict intrafascial approach slightly increased potency rates in our patients, with % reporting having postoperative erections sufficient for intercourse. Potency assessment based on whether an IIEF score >19 was reached dropped potency rates to 25 59%, a phenomenon that has already been described by Menon et al. [3]. In that series, 70% of preoperative potent men had erections sufficient for intercourse 1 yr after surgery, while only half of these patients returned to a normal Sexual Health Inventors for Men (SHIM) score, indicating the necessity of using identical and validated assessment tools when differences in potency rates of published series are considered. Addressing cancer control rates, we cannot provide meaningful long-term data based on the present patient cohort. However, the presented data based on our patients operated on in earlier years showed favourable recurrencefree and cancer-specific survival rates. Even though it might be questioned whether such data can be extrapolated to the current patient cohort, we believe that long-term cancer control rates will further improve in the present series. This belief is based on the fact that positive margin rates are lower in the present series compared to our previous patients [16]. The importance of negative margins on outcome has been discussed extensively, and we believe that intraoperative frozen section is one of the keys to achieving favourable functional outcomes without compromising radicality of the procedure [17]. Furthermore, an underlying stage migration has the potential to further improve outcome, even within defined pathologic stages. Interestingly, the recurrence-free survival rate in a previous report from our institution in pt2 cancers at 10 yr was 80% and increased to 87% in our recent analysis [16]. This change might be due to favourable cancers within defined cohorts, which is often reported by the phenomenon that year of surgery might have prognostic impact [18]. Our study is not devoid of limitations. Considering the large number of patients operated on in the Martini-Clinic and the Department of Urology in Hamburg (n = 1541 in 2008), the reported patients considering functional outcome are limited. This limitation is mainly due to the fact that we excluded men with impaired erectile function before surgery and focused on those men who underwent a nerve-sparing procedure. Furthermore, we focused on the two most experienced surgeons to allow better comparability with other very high-volume surgical series, especially with very high-volume robotic surgeons [3,19]. We limited this comparison to emphasise that surgical experience seems to be more important than the surgical approach itself. Furthermore, functional outcome was only evaluated in men in whom all necessary data (ie, preoperative and postoperative IIEF score assessed exactly 12 mo after surgery) were available. In recent years, endoscopic procedures have gained an increasing popularity for the treatment of clinically localised prostate cancer, even though a recent review could not show superiority of one approach above the other [9]. Reports on comparisons of various techniques usually report more favourable results of the currently favoured technique compared to previous and abandoned techniques, and such reports have the tendency to demonstrate superiority of the new technique [9]. Nevertheless, it seems more valid to compare the results of proponents of each surgical approach to eliminate the effect of surgical experience. One of the aims of this report is to demonstrate that the decrease of morbidity of RP is not based on the instruments used but probably mainly on the experience of the surgical team. Complication rates and, especially, transfusion rates in the current series are in the range of those of high-volume endoscopic series, which underscores our hypothesis [9]. Prospective trials are needed to show whether or not any approach is advantageous over another. In our centre, we recently started a prospective trial in which we compare open and robotic RP, and we hope to create meaningful data in due time. 5. Conclusions Open radical prostatectomy is still the most frequently performed surgical approach for the treatment of localised prostate cancer. Surgical refinements include a strict intrafascial approach and subtle preservation of the posterior urethra and its insertion. In the hands of experienced surgeons, open radical prostatectomy provides excellent long-term cancer control rates, favourable functional outcome, and low perioperative morbidity.

8 324 EUROPEAN UROLOGY 56 (2009) Author contributions: Lars Budäus had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Budäus, Graefen, Isbarn, Huland, Haese, Heinzer, Steuber, Schlomm, Salomon. Acquisition of data: Budäus, Graefen, Isbarn, Huland. Analysis and interpretation of data: Budäus, Graefen, Isbarn, Huland. Drafting of the manuscript: Budäus, Graefen, Isbarn, Huland, Haese, Heinzer, Steuber, Schlomm, Salomon. Critical revision of the manuscript for important intellectual content: Budäus, Graefen, Isbarn, Huland, Haese, Heinzer, Steuber, Schlomm, Salomon. Statistical analysis: None. Obtaining funding: None. Administrative, technical, or material support: None. Supervision: Graefen, Huland. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. Appendix A. Supplementary data The Surgery in Motion video accompanying this article can be found in the online version at doi: / j.eururo and via Subscribers to the printed journal will find the Surgery in Motion DVD enclosed. References [1] Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 1982;128: [2] Stolzenburg J-U, Rabenalt R, Do M, et al. Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy. Eur Urol 2008;53: [3] Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51: [4] Graefen M, Walz J, Huland H. Open retropubic nerve-sparing radical prostatectomy. Eur Urol 2006;49: [5] Kessler TM, Burkhard FC, Studer UE. Nerve-sparing open radical retropubic prostatectomy. Eur Urol 2007;51:90 7. [6] Barré C. Open radical retropubic prostatectomy. Eur Urol 2007;52: [7] Secin FP, Touijer K, Mulhall J, Guillonneau B. Anatomy and preservation of accessory pudendal arteries in laparoscopic radical prostatectomy. Eur Urol 2007;51: [8] Mattei A, Naspro R, Annino F, Burke D, Guida Jr R, Gaston R. Tension and energy-free robotic-assisted laparoscopic radical prostatectomy with interfascial dissection of the neurovascular bundles. Eur Urol 2007;52: [9] Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol 2009;55: [10] Rocco F, Carmignani L, Acquati P, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol 2007;52: [11] Steuber T, Graefen M, Haese A, et al. Validation of a nomogram for prediction of side specific extracapsular extension at radical prostatectomy. J Urol 2006;175: [12] Briganti A, Chun FK-H, Salonia A, et al. Validation of a nomogram predicting the probability of lymph node invasion among patients undergoing radical prostatectomy and an extended pelvic lymphadenectomy. Eur Urol 2006;49: [13] Eichelberg C, Erbersdobler A, Haese A, et al. Frozen section for the management of intraoperatively detected palpable tumor lesions during nerve-sparing scheduled radical prostatectomy. Eur Urol 2006;49: [14] Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol 1996;156: [15] Salomon G, Isbarn H, Budaeus L, et al. Importance of baseline potency rate assessment of men diagnosed with clinically localized prostate cancer prior to radical prostatectomy. J Sex Med 2009;6: [16] Chun FK, Graefen M, Zacharias M, et al. Anatomic radical retropubic prostatectomy long-term recurrence-free survival rates for localized prostate cancer. World J Urol 2006;24: [17] Yossepowitch O, Bjartell A, Eastham JA, et al. Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences. Eur Urol 2009;55: [18] Cagiannos I, Karakiewicz P, Graefen M, et al. Is year of radical prostatectomy a predictor of outcome in prostate cancer? J Urol 2004;171: [19] Patel VR, Palmer KJ, Coughlin G, Samavedi S. Robot-assisted laparoscopic radical prostatectomy: perioperative outcomes of 1500 cases. Endourol 2008;22: