Retrograde Nerve-Sparing (NS) Laparoscopic Radical Prostatectomy (LRP): Technical Aspects and Early Results

european urology supplements 5 (2006) 925 933 available at www.sciencedirect.com journal homepage: www.europeanurology.com Retrograde Nerve-Sparing (NS) Laparoscopic Radical Prostatectomy (LRP): Technical Aspects and Early Results Jens J. Rassweiler *, Marto Sugiono, Marcel Hruza, Ahmet Tefekli, Christian Stock, Dogu Teber Department of Urology, SLK-Klinikum Heilbronn, University of Heidelberg, Heidelberg, Germany Article info Keywords: Laparoscopy Nerve-sparing Potency Radical prostatectomy Abstract Objective: To evaluate the early results of nerve-sparing laparoscopic radical prostatectomy (NSLRP) in our institution based on the apical approach to NS, focusing on evolution in techniques and oncologic as well as functional results. Methods: Of 1500 consecutive patients, 330 underwent bilateral NSLRP, 210 unilateral NSLRP, and 960 non-nslrp. LRP was performed using the ascending extraperitoneal approach (Heilbronn technique). Oncologic and functional outcomes were assessed in the first 1000 patients by analysing a prospective database and using validated questionnaires for follow-up. Results: In the first 300 cases, 5 patients (1.6%) underwent NS compared to 143 (47.7%) in the last 300 patients. Clinical and pathologic stages of the patients were similar over this period. Forty-three men (16.3%) had positive margins compared to 53 (17.7%) when the first and last 300 cases were assessed. Prostate-specific antigen recurrence occurred in 20 (11%) in the NS versus 85 (15.7%) in the non-ns group ( p = 0.076). Potency rates for bilateral NS were maximal at 61% without erectile aids versus 82.9% when all treatment modalities for erectile dysfunction were used, respectively, 34.1% versus 69.8% for unilateral, and 8.2% versus 53.3% in non-ns group ( p < 0.05). Conclusions: With increasing experience and expertise, we are performing more NS procedures during LRP despite similar clinicopathologic parameters. Improved functional outcomes such as preservation of erectile function can be achieved without oncologic compromise. All appropriate patients should be considered for the NS approach. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. SLK Klinikum Heilbronn, Am Gesundbrunnen 20, D-77074 Heilbronn, Germany. Tel. +49 7131 492400; Fax: +49 7131 492429. E-mail address: jens.rassweiler@slk-kliniken.de (J.J. Rassweiler). 1569-9056/$ see front matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eursup.2006.07.010

926 european urology supplements 5 (2006) 925 933 1. Introduction The widespread use of prostate-specific antigen (PSA) testing, increasing patient awareness, and changes in prostate biopsy strategies have resulted in more localised prostate cancers being diagnosed in a younger group of patients [1]. In parallel, the development of minimally invasive surgical techniques has resulted in a greater focus on achieving optimal functional outcomes in those undergoing radical prostatectomy [2,3]. Preservation of the neurovascular bundles (NVBs), which are essential for erectile function, and continence are therefore important considerations in the continuous efforts at improving quality of life [4,5]. Once the learning curve has been mastered, the nerve-sparing (NS) approach might be greatly aided by the superior visual and magnifying abilities of the laparoscopic technique. Laparoscopic radical prostatectomy (LRP) can be broadly classified into an ascending (apex of prostate to pedicles) or descending (pedicles to apex) approach, depending on the general direction of the dissection [6]. Similarly, the NS part of the operation can be described as retrograde (from apex towards the operator) or antegrade (away from the operator towards the apex). However, it is common to combine the NS approaches. In addition, retrograde NS is also termed the apical approach and antegrade NS as lateral approach, both of which have undergone further modifications [7,8]. In our centre, we currently perform an ascending LRP via the extraperitoneal route and use the retrograde (apical) NS approach. In this study, we examined the changes in NS practice in our institution, with particular emphasis on patient factors, technical evolution, and functional and oncologic outcomes. 2. Patients and methods We reviewed data on 1500 patients who underwent LRP in our centre since March 1999. All data are collected prospectively onto an Excel database and include preoperative PSA, Gleason score, biopsy results, clinical stage, and erectile function. Intraoperatively, all unilateral or bilateral NS procedures were noted together with any significant intraoperative findings. 2.1. Patient selection All patients with stage < T3, Gleason <8, and PSA <10 ng/ml were considered for the NS approach. Those with suspected extracapsular invasion ( T3) on digital rectal examination or transrectal ultrasound (TRUS), presence of perineural invasion in the core biopsies, and intraoperative findings of periprostatic inflammation either due to previous biopsies or neoadjuvant hormone therapy did not undergo NS. Also, those with positive biopsies on one side of the apex were considered only for NS on the contralateral side. All technical modifications were digitally stored directly via a computer linked to the monitor for future analysis. Pathologists were also involved in the final analysis process. 2.2. Anatomic considerations The NVB runs along the posterolateral part of the prostate and contains branches from the inferior vesical arteries running medial to cavernosal nerve branches originating from the pelvic plexus. These vessels enter the capsule through the prostatic fascia and are useful as a landmark for identification of the bundle. The nerve fibres initially form a group about 12 mm wide and converge at the prostate level to around 6 mm wide, being found at the 5 and 7 o clock positions at the level of the membranous urethra. For the periprostatic fascial anatomy, we follow the description by Walsh [7]. Essentially three layers cover the anterolateral surface: the innermost prostatic fascia (covering the prostatic capsule and in continuity with it) and the overlying levator fascia, with both layers fusing laterally to form the lateral pelvic fascia. This is covered by the third layer, the endopelvic fascia, as it reflects off the transversalis fascia of the abdominal wall. The NVBs travel between the levator and prostatic fascia. On the posterior plane, there are only two fascial layers: Denonvilliers (prostatorectal) fascia and the prostatic capsule, although the capsule is, strictly speaking, not a fascial layer as such. 2.3. Steps of retrograde (apical) NS technique 2.3.1. Incision of endopelvic fascia and control of dorsal vein complex After incision of the endopelvic fascia and blunt detachment of the prostate from the levator ani muscles, the apex is exposed using a 1208 blunt-tipped endodissector as retractor [9]. One back bleeding and two distal stitches gather the dorsal vein complex (DVC) similar to a Babcock clamp. The DVC is divided to expose the anterior plane of the gland by rotating the apex cranially until the prostatourethral junction can be identified. 2.3.2. Apical dissection with detachment of NVBs For detaching the apex from NVBs, the plane between the two leaves of the lateral pelvic fascia (i.e., between levator and prostatic fascia) is developed laterally to the prostatourethral junction. Blunt dissection of the posterior prostatic plane down to the Denonvilliers fascia is carried out after inflation of the rectal balloon with 80 100 cc of air. Denonvilliers fascia is perforated medial to the NVBs to gain a safe dissection plane between the apex and rectum (Fig. 1A). Prior to division of the urethra, the levator fascia is incised anterolaterally from the base of the prostate to the apex exposing the NVB (Fig. 1B), while the endodissector grasps the prostatic fascia to pull the gland medially. Interfascial dissection is thus performed by developing a lateral NVB groove, keeping as close to the prostatic fascia as possible to maximise preservation while avoiding use of electrocautery. Small vessels originating from the inferior rectal arteries are clipped (5 mm titanium) at the apex (Fig. 1C). Electrocautery is

european urology supplements 5 (2006) 925 933 927 Fig. 2 Ligation of right prostate pedicle. of NVBs and lateral pedicles cannot be identified optimally at this step, we proceed to a descending technique beginning at the bladder neck. 2.3.4. Bladder-neck incision The apex is pulled ventrally by applying traction on the catheter. The space between the bladder and the anterior leaf of Denonvilliers fascia is accessed laterally and the bladder divided at the level of the bladder neck. The catheter is then used as a loop-like retractor to facilitate exposure of the lateral pedicles. 2.3.5. Division of vas deferens and dissection of seminal vesicles Following division of the vas deferens, the seminal vesicles (SVs) are detached after clipping their vascular supply located medial to the lateral pedicles. These vessels can be safely ligated without interfering with the NVBs, which travel posteriorly to the pedicles (Fig. 2). Fig. 1 (A) Detaching NVB from apex of prostate. (B) Interfascial dissection between levator and prostatic fascia. (C) Clipping of small vessels medial to the right NVB. also avoided at this step. Using blunt dissection, the apex is then detached from the rectum until the medial fusion of Denonvilliers fascia [10]. 2.3.3. Division of urethra and ascending dissection of prostate Once the apex is free, the anterior and posterior wall of the urethra is divided. The gland is retracted cranially with the catheter and residual attachments between Denonvilliers fascia and rectum are incised. Because the exact relationship 2.3.6. Antegrade division of lateral pedicles The plane between the lateral pedicles and SVs is developed and the pedicles divided stepwise after placing polyurethane clips (Hem-o-lok 1, Teleflex Medical, Research Triangle Park, NC) close to the base of the prostate. The precise course of the NVBs is defined by retracting the prostate with the looped catheter (Fig. 3A). Following entrapment of the prostate, the course of the preserved NVBs can be clearly seen (Fig. 3B). 2.3.7. Vesicourethral anastomosis The anastomosis is performed using a continuous single-knot running suture as described by van Velthoven et al. [11]. Great care is taken to avoid inadvertent injury to the NVB by the needle as it runs adjacent to the urethral stump at approximately 5 and 7 o clock. 2.4. Patient follow-up The first 1000 cases were analysed for oncologic and functional outcome to provide an adequate follow-up time.

928 european urology supplements 5 (2006) 925 933 Fig. 4 Changes in frequency of the nerve-sparing approach (n = 1500). underwent bilateral NS, 210 unilateral NS, and 960 non-ns. 3.2. Changes in practice Fig. 3 (A) Anterior retraction of the prostate reveals course of right NVB. (B) Course of NVBs after prostate entrapment. A total of 760 patients (76%) responded and were available for evaluation. A standardised questionnaire concerning oncologic parameters (i.e., actual PSA, deferred antiandrogen treatment), potency, and quality of life was sent, consisting of validated instruments such as the International Index of Erectile Function (short form with 5 items [IIEF-5]) [12,13]. The data were transferred onto an Excel database (Microsoft) and statistical analysis carried out using the Statistical Package for Social Science and Excel. The numeric parameters in both groups were expressed as mean standard deviation (SD) and were compared by using the 2-tailed Student t test. x 2 was used for comparison of nominal data. A p value of <0.05 was considered statistically significant. In addition, the preliminary analysis for potency rates was stratified according to the age of patient (i.e., <55 yr, 55 65 yr, >65 yr). Analysis of the numbers of NS procedures showed a steady increase in the proportion of bilateral NS procedures for every subsequent 300 cases performed, in contrast to the proportion of unilateral NS procedures (Fig. 4). However, the proportion of men with clinically localised disease did not change over the same period (Fig. 5). There was a similar pathologic stage distribution between the NS and non-ns groups for pt2 stages but a lower frequency of pt3 and pt4 (TNM classification; Union Internationale Contre le Cancer [UICC], 2002) in the NS group (28.7% and 2.6%) compared to the non-ns group (41.3% and 5.9%; Table 1). Three patients in the NS (0.5%) and eight in the non-ns group (0.8%) did not have any focus of carcinoma in the final histology despite all having clinical stage T1. 3. Results 3.1. Patient demographics Over a period of >6 yr, the mean age of patients in our series did not change significantly when compared yearly, with a combined mean age of 63.7 yr (range: 40 82 yr). A total of 330 patients Fig. 5 Proportion of clinically localised (T1 + T2) versus locally advanced (T3 + T4) tumours (n = 1500).

european urology supplements 5 (2006) 925 933 929 Table 1 Patient distribution according to TNM stage TNM stage NS (bilateral + unilateral; n = 540) Non-NS group (n = 952) pt0 3 (0.5%) 8 (0.8%) pt2a 79 (14.6%) 121 (12.7%) pt2b-t2c 289 (53.5%) 374 (39.3%) pt3a 112 (20.7%) 256 (26.9%) pt3b 43 (8.0%) 137 (14.4%) pt4 14 (2.6%) 56 (5.9%) NS = nerve-sparing. Dividing the pathologic stage into localised (pt2) and locally advanced (pt3/pt4) tumours, the initial increase in proportion of localised tumours seen in the first 3 yr was followed by a decrease and then a plateau in the last 3 yr (Fig. 6). Mean preoperative PSA level was 8.5 6.2 ng/ml (range: 0.6 69.0 ng/ml) in the NS group versus 10.7 7.4 ng/ml (range: 0.1 99.0 ng/ml) in the non- NS group ( p < 0.001; Student t test). Gleason scores, mean tumour volumes, and prostate size are also shown in Table 2. 3.3. Positive margin status Overall, when analysing the positive margin rates for patients with NS and non-ns procedures according to pathologic stage (both prostate lobes considered), 77 patients (14.3%) in the NS group had positive margins compared to 255 (26.6%) in the Fig. 6 Distribution of pathologically confirmed localised (pt2) versus locally advanced (pt3 T4) tumours with time (n = 1500). non-ns group, the difference being statistically significant ( p < 0.001; x 2 test). The prostate apex was the most common site of positive margin occurrence (Table 3). In addition, we observed a lower positive margin rate for all pt stages in the NS group except for stage pt2a (Table 4). In the last 900 patients, positive margin status also showed reduced rates in the most recent 300 patients compared to previous groups of 300 (Fig. 7). 3.4. PSA recurrence We examined data for the first 1000 patients with a minimum follow-up of 20 mo and a mean of 43 mo Table 2 Clinicopathologic parameters NS (n = 540) Non-NS (n = 960) p value * Preoperative parameter Mean PSA SD, ng/ml 8.5 6.2 (range: 0.6 69.0) 10.7 7.4 (range: 0.1 99.0) p < 0.05 Gleason score, mean SD 6.2 0.9 (range: 4 9) 6.5 1.0 (range: 4 10) p > 0.05 Postoperative parameters Tumour volume SD, cc 2.2 2.1 (range: 0.01 40) 3.5 3.8 (range: 0.01 21) p < 0.05 Prostate weight SD, g 42.5 15.6 (range: 15 125) 44.4 17.1 (range: 8 135) p > 0.05 NS = nerve-sparing; PSA = prostate-specific antigen; SD = standard deviation. * The p value is significant at <0.05. Table 3 Localisation of positive margin Positive margin status and location NS group (n = 540; bilateral + unilateral) Non-NS group (n = 960) No positive margin 463 (85.7%) 705 (73.4%) Apex 47 (8.7%) 148 (15.4%) Dorsolateral 15 (2.8%) 17 (1.8%) Base of bladder 8 (1.5%) 45 (4.7%) Other locations 7 (1.3%) 45 (4.7%) TOTAL positive margin rate 77 (14.3%) 255 (26.6%) * NS = nerve-sparing. * Significantly lower positive margin rate in the NS group ( p < 0.001; x 2 test).

930 european urology supplements 5 (2006) 925 933 Table 4 Positive margin status for all groups according to TNM stage TNM stage Non NS (n = 955) NS (n = 539) Overall (n = 1494) pt2a 2 (1.7%) 3 (3.8%) 5 (2.5%) pt2b-t2c 33 (17.6%) 13 (11.8%) 46 (14.5%) pt3a 92 (35.9%) 34 (30.4%) 126 (34.2%) pt3b 74 (54.4%) 17 (39.5%) 91 (50.8%) pt4 54 (96.4%) 10 (71.4%) 164 (91.4%) NS = nerve-sparing. (range: 20 82 mo). The last 500 patients were not included because follow-up time was too short. Biochemical recurrence was defined as PSA >0.2 ng/ ml postoperatively. Of 181 patients undergoing NS procedures (bilateral and unilateral) in the first 1000 cases, 20 patients (11%) had PSA recurrence compared to 85 (15.7%) in the non-ns group ( p = 0.076; x 2 ) with no statistical difference between the two groups. 3.5. Sexual function Of the 1000 patients followed, we evaluated 220 who had no evidence of significant erectile dysfunction (ED) preoperatively and who wished to resume sexual activity after surgery. They had a minimum follow-up time of 23 mo and a mean of 47 mo (range: 23 80 mo). 3.5.1. Potency rates The number of patients after bilateral NS, unilateral NS, or non-ns procedures who were able to have penetrative intercourse when using different erectile aids showed a cumulative effect when combining different treatment modalities (Fig. 8). The best outcome was achieved when all treatment options were used. This resulted in 34 men in the bilateral NS group, 30 in the unilateral NS, and 72 in the Fig. 7 Overall positive margin status with increasing experience (n = 1500). Fig. 8 Percentage of patients of all ages after non-ns, unilateral NS, or bilateral NS procedures who were able to have penetrative intercourse when using different erectile aids. NS = nerve-sparing; +/S = with or without; PDE5 = phosphodiesterase type 5; Inh = inhibitor. non-ns being able to have sexual intercourse, corresponding to success rates for bilateral NS at 61% without erectile aids versus 82.9% when all treatment modalities for ED were used, respectively, 34.1% versus 68.2% for unilateral, and 8.2% versus 53.3% in non-ns groups ( p < 0.05). The differences between the three groups (bilateral NS, unilateral NS, and non-ns) were significant for all therapeutic options and among those who did not require any treatment ( p < 0.05; x 2 test). However, there was no statistical difference between the bilateral NS and unilateral NS groups when patients used a combination of all treatment modalities (i.e., with or without phosphodiesterase type 5 inhibitors, intracavernosal injections, or vacuum device). 3.5.2. Potency rates according to age Among the 25 patients who underwent bilateral NS and were able to have penetrative sex without aids (Table 5), 7 were <55 yr, 15 between 55 and 65 yr, and 3 > 65 years of age, giving potency rates of 77.8%, 60.0%, and 42.9%, respectively (Table 6). The corresponding rates for those who had unilateral NS procedures were 36.4% for <55 yr, 31.0% between 55 65 yr, and 33.3% >65 yr. These results are comparable to NS techniques in open radical prostatectomy [14].

european urology supplements 5 (2006) 925 933 931 Table 5 Number of patients able to achieve sexual intercourse with increasing treatment modalities Bilateral NS (n = 41) Unilateral NS (n = 44) Non-NS (n = 135) Total (n = 220) Penetration without aids 25 (61.0%) 15 (34.1%) 11 (8.2%) 51 (23.2%) Penetration +/ PDE5 inhibitors 27 (65.9%) 19 (43.2%) 14 (10.4%) 60 (27.3%) Penetration +/ PDE5 inhibitors +/ 33 (80.5%) 25 (56.8%) 53 (39.3%) 111 (50.5%) intracavernous injections Penetration +/ PDE5 inhibitors +/ intracavernous injections +/ vacuum device 34 (82.9%) 30 (68.2%) 72 (53.3%) 136 (61.8%) p < 0.05 between all groups except between unilateral and bilateral NS groups when all treatment modalities are used; x 2 test. NS = nerve-sparing; +/ = with or without; PDE5 = phosphodiesterase type 5. Table 6 Capability of sexual intercourse without aid after NS LRP in patients with no significant preoperative ED according to age <55 yr 55 65 yr >65 yr Total Able to have intercourse Total Able to have intercourse Total Able to have intercourse Bilateral NS (n = 41) 9 7 (77.8%) 25 15 (60.0%) 7 3 (42.9%) Unilateral NS (n = 44) 11 4 (36.4%) 29 9 (31.0%) 4 2 (50.0%) NS = nerve-sparing; LRP = laparoscopic radical prostatectomy; ED = erectile dysfunction. 4. Discussion 4.1. Technical aspects Regardless of the technical variations in NS procedures, the principles essential for success are constant and include maintaining early control of the pedicles to minimise blood loss and improve visualisation, avoiding traction to the NVBs, omitting the use of any thermal energy in the vicinity of the bundles, and using a high incision of the levator fascia to ensure optimal preservation of more anteriorly postioned fibres. The role of the first assistant is critical in this respect because inadvertent neurapraxia can ensue from inexperienced usage of the instruments. The course of the NVBs must also be borne in mind during formation of the vesicourethral anastomosis to prevent any injury by the needle or its holder. Recently, a descending NS technique that avoids the incision of the endopelvic fascia has been proposed and involves intrafascial dissection between the prostatic capsule and prostatic fascia to release the NVB with the intention of preserving as many nerve fibres on the anterolateral surface of the prostate as possible [15,16]. This was supported by anatomic cadaveric studies demonstrating additional fibres running on the anterolateral surface of the gland, distinct from the classically described posterolateral NVBs [17,18]. However, the physiologic role of these nerve fibres has yet to be fully elucidated and because the fibrous prostatic fascia is in direct continuity with the true prostatic capsule, the risk of positive margins from the intrafascial technique must be considered carefully [16]. In contrast, the prostatic fascia provides an easily identifiable medial landmark during interfascial dissection. Thus, the real benefit of the intrafascial versus interfascial NS remains to be confirmed. Future goals in technical refinements are therefore aimed at optimising all these factors, possibly by combining the apical and lateral NS approach, having early pedicle control by using instruments that dissipate minimal thermal energy, and avoiding retraction of the NVB by deleting steps that require the prostate to be lifted up anteriorly. Finally, although many other methods, such as real-time TRUS guidance, electrophysiologic testing, robotic surgery, and use of harmonic scalpels [3,19,20], can be used to facilitate NVB preservation intraoperatively, our study shows that a thorough appreciation of the periprostatic anatomy together with meticulous attention to technical details within an experienced team is sufficient to achieve similar satisfactory results. 4.2. Oncologic and functional outcomes The objective of radical prostatectomy is complete excision of the tumour with preservation of continence and potency. In theory this is only achievable in pt2 stages, with an increasing consensus that they should all undergo bilateral preservation of the NVBs including a precise apical dissection with

932 european urology supplements 5 (2006) 925 933 minimal trauma to the sphincter apparatus of the urethra. In reality, up to 11% of positive margins are found and maximally 70% of patients are potent at 12-mo follow-up [2]. Therefore, urologic surgeons must continuously update their technique and anatomic knowledge [21 23]. This has resulted in a process of modifications to the classical open NS technique including early release of the NVBs, the partial or non-incision of the puboprostatic ligaments and high incision of the levator fascia for the reasons stated previously. With regard to potency rates in our study, because only those with normal erectile function or mild ED have been included, the improved rates of the bilateral NS group over the unilateral and the non- NS group reflects the efficacy of the former approach in maintaining erectile function. This is especially clinically relevant because all forms of treatment modalities may be used to treat postoperative ED to achieve maximum results of 82.9%, 68.2%, and 53.3% after bilateral, unilateral, and non- NS surgery, respectively (last row of Fig. 8). Although this might suggest only a weak relationship between potency and NS, the difference in potency rates become much more marked as fewer erectile aids are used, with rates of 61%, 34.1%, and 8.2% for bilateral, unilateral, and non-ns procedures when no aids are used (Table 5). Oncologically, the increase in number of NS procedures did not correspond to any increasing trend in positive surgical margin rate or PSA recurrence, as shown in Fig. 7. Although the significantly lower preoperative PSA and tumour volume in the NS group (Table 2) may in part account for this, there was, in fact, an improvement in the positive margin rate for every subsequent group of 300 patients in the last 900 cases, probably as a result of the learning curve. These results are thus comparable to other published series [2,4,6,24] and lend further support to the oncologic safety of the NS approach. procedures (366 of 1213 open radical retropubic prostatectomy) over a period of 7 yr. However, the majority of these (206 of 366) were performed only in the last 2 yr of the series. Therefore, one must distinguish between the learning curve for the actual NS part of LRP and the learning curve of NS radical prostatectomy itself, be it a laparoscopic or an open approach. Furthermore, whereas the United States has seen a downward stage migration towards T1c and pt2 in radical prostatectomy candidates [26], there has been no sustained change in the pt2 stage in our series, which remains at around 56 58% of all LRP cases over the last 900 patients (Fig. 6). Therefore, attempting to do a bilateral NS procedure for 47.7% of our patients may be close to the best that we can achieve. Recently, important centres of open and laparoscopic radical prostatectomy analysed their results based on the triple-set ( trifecta ) of optimal oncologic control, continence, and potency of their patients yielding a rate of almost 60% 4 yr after surgery [27]. We feel, that despite the large number of patients we have treated, our experience with NS LRP still needs to mature. However, there is no doubt, that in the future, laparoscopic centres have to present their data in a similar way [28]. 5. Conclusion In conclusion, over the last 6 yr, an increasing proportion of patients undergoing LRP in our centre have undergone the NS approach. The results are comparable to other open series in terms of optimising potency rates without compromising oncologic outcomes. Therefore, all patients with appropriate clinicopathologic parameters (i.e., T1-2, Gleason <8, PSA <10 ng/ml) should be considered as candidates for NVB preservation during LRP. 4.3. Trends in practice of the NS approach Increasing experience and continuous refinements in surgical techniques have contributed to the steadily increasing number of NS procedures for patients undergoing LRP in our centre. During the first 150 cases, the policy in our centre was not to perform the NS procedure due to the learning curve of LRP. Subsequently, it has taken 5 yr to achieve a bilateral NS rate of 29.4% and >1200 cases to reach the level of 47.7%. Although there is no direct comparison in other series of this learning curve, Noldus et al. [25] reported an overall 30% rate of NS References [1] Moul JW. Population screening for prostate cancer and emerging concepts for young men. Clin Prostate Cancer 2003;2:87 97. [2] Rassweiler J, Schulze M, Teber D, Seemann O, Frede T. Laparoscopic radical prostatectomy: functional and oncological outcomes. Curr Opin Urol 2004;14:75 82. [3] Kaul S, Savera A, Badani K, Fumo M, Bhandari A, Menon M. Functional outcomes and oncological efficacy of Vattikuti Institute prostatectomy with veil of Aphrodite nerve-sparing: an analysis of 154 consecutive patients. BJU Int 2005;97:467 72.

european urology supplements 5 (2006) 925 933 933 [4] Graefen M, Walz J, Huland H. Open retropubic nervesparing radical prostatectomy. Eur Urol 2006;49:38 48. [5] Menon M, Kaul S, Bhandari A, Shrivastava A, Tewari A, Hemal A. Potency following robotic radical prostatectomy: a questionnaire based analysis of outcomes after conventional nerve-sparing and prostatic fascia sparing techniques. J Urol 2005;174:2291 6. [6] Rassweiler JJ, Hruza M, Teber D, Su L-M. Laparoscopic and robotic assisted radical prostatectomy critical analysis of the results. Eur Urol 2006;49:612 24. [7] Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol 1998;160:2418 24. [8] Gontero P, Kirby RS. Nerve-sparing radical retropubic prostatectomy: techniques and clinical considerations. Prost Cancer Prost Dis 2005;8:133 9. [9] Rassweiler J, Seemann O, Hatziger M, Schulze M, Frede T. Technical evolution of laparoscopic radical prostatectomy after 450 cases. J Endourol 2003;17:143 54. [10] Huland H, Noldus J. An easy and safe approach to separating Denonvillier s fascia from rectum during radical retropubic prostatectomy. J Urol 1999;161:1533 4. [11] Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis: the single knot method. Urology 2003;61:699 702. [12] Rosen RC, Riley A, Wagner G. The International Index of ErectileFunction(IIEF): amultidimensionalscaleforassessment of erectile dysfunction. Urology 1997;49:822 30. [13] Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM. Development and evaluation of an abridged, 5 item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. J Impot Res 1999;11:319 26. [14] Michl U, Graefen M, Noldus J, Eggert T, Huland H. Functional results of various surgical techniques for radical prostatectomy. Urologe A 2003;42:1196 202. [15] Stolzenburg JU, Rabenalt R, Tannapfel A, Liatsikos EN. Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy. Urology 2006;67:17 21. [16] Curto F, Benijts J, Pansadoro A, et al. Nerve sparing laparoscopic radical prostatectomy: our technique. Eur Urol 2006;49:344 52. [17] Zvara P, Spiess PE, Merlin SL, Begin LR, Brock GB. Neurogenic erectile dysfunction: the course of nicotinamide adenine dinucleotide phosphate diaphorase-positive nerve-fibres on the surface of the prostate. Urology 1996;447:146 51. [18] Takenaka A, Murakami G, Soga H, Han S-H, Arai Y, Fujisawa M. Anatomical analysis of the neurovascular bundle supplying penile cavernous tissue to ensure a reliable nerve graft after radical prostatectomy. J Urol 2004;172: 1031 5. [19] Ukimura O, Gill IS. Real-time transrectal ultrasound guidance during nerve sparing laparoscopic radical prostatectomy: pictorial essay. J Urol 2006;175:1311 9. [20] Namiki S, Terai A, Nakagawa H, et al. Intraoperative electrophysiological confirmation of neurovascular bundle preservation during radical prostatectomy: long term assessment of urinary and sexual function. Jpn J Clin Oncol 2005;35:660 6. [21] Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into aetiology and prevention. J Urol 1982;128:492 7. [22] Lepor H, Gregerman M, Crosby R, Mostofi FK, Walsh PC. Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis. J Urol 1985;133: 207 12. [23] Villers A, Steg A, Boccon-Gibod L. Anatomy of the prostate: review of the different models. Eur Urol 1991;20: 261 8. [24] Palisaar RJ, Noldus J, Graefen M, Ebersdobler A, Haese A, Huland H. Influence of nerve-sparing (NS) procedure during radical prostatectomy (RP) on margin status and biochemical failure. Eur Urol 2005;47:176 84. [25] Noldus J, Michl U, Graefen M, Haese A, Hammerer P, Huland H. Patient-reported sexual function after nervesparing radical retropubic prostatectomy. Eur Urol 2002; 42:118 24. [26] Jang TL, Han M, Roehl KA, Hawkins SA, Catalona WJ. More favorable tumor features and progression-free survival rates in a longitudinal prostate cancer screening study: PSA era and threshold-specific effects. Urology 2006;67: 343 8. [27] Saranchuk JW, Kattan MW, Elkin E, Touijer KA, Scardino PT, Eastham JA. Achieving optimal outcomes after radical prostatectomy. J Clin Oncol 2005;23:4146 51. [28] Touijer K, Guillonneau B. Laparoscopic radical prostatectomy. A critical analysis of surgical quality. Eur Urol 2006;49:625 32.