Department of Urology, David Geffen School of Medicine at University of California, Los Angeles, California, USA.
Curr Opin Urol. 2013 Jan;23(1):88-94. doi: 10.1097/MOU.0b013e32835b6602.
Although cure of prostate cancer is the primary goal of radical prostatectomy, preserving erectile function is also tantamount, given the indolent clinical course of most prostate cancers, particularly low-risk disease. In order to optimize postprostatectomy erectile function during a robotic-assisted radical prostatectomy, there must be a detailed understanding of pelvic anatomy to recognize the optimal nerve-sparing plane and technical finesse to minimize stretch injury to the neurovascular bundle.
The magnified, well illuminated robotic-operative field coupled with less blood loss has paralleled greater understanding of the periprostatic 'fascial' planes, leading to differentiation of intrafascial versus interfascial nerve-sparing approaches. However, refinement of tissue handling during nerve-sparing to minimize lateral displacement of the neurovascular bundle and attenuate neurapraxia enables earlier and better recovery of erectile function.
The critical maneuvers to preserving erectile function are atraumatic dissection of the prostate away from the optimal nerve-sparing plane to maximally preserve nerve fibers while minimizing neurapraxia. Therefore, attaining these principles involves a conceptual paradigm shift from 'radical' prostatectomy to neurosurgery of the prostate.
虽然根治性前列腺切除术的主要目标是治愈前列腺癌，但鉴于大多数前列腺癌（尤其是低危疾病）的惰性临床病程，保留勃起功能也同样重要。为了在机器人辅助根治性前列腺切除术中优化术后勃起功能，必须详细了解盆腔解剖结构，以识别最佳的神经保留平面，并采用精细的技术，将对神经血管束的拉伸损伤降至最低。
放大、照明良好的机器人手术视野和较少的失血，使人们对前列腺周围的“筋膜”平面有了更深入的了解，从而区分了筋膜内和筋膜间的神经保留方法。然而，在神经保留过程中精细处理组织，以最小化神经血管束的侧向移位并减轻神经损伤，有助于更早、更好地恢复勃起功能。
保留勃起功能的关键操作是在不损伤神经的最佳平面上无创伤地分离前列腺，以最大程度地保留神经纤维，同时将神经损伤降至最低。因此，实现这些原则涉及从“根治性”前列腺切除术到前列腺神经外科的概念性思维转变。
