RECONSTRUCTIVE UROLOGY

Robotic assisted laparoscopic sural nerve grafting during radical prostatectomy: initial experience
Kaouk JH, Desai MM, Abreu SC, Papay F, Gill IS
From the Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute and Department of Plastic Surgery, Cleveland, Clinic Foundation, Cleveland, Ohio, USA
J Urol. 2003; 170: 909-12

• Purpose: Sural nerve grafting has been done in select patients undergoing radical prostatectomy with unilateral or bilateral wide excision of the neurovascular bundle in an effort to preserve potency. We describe a novel technique of laparoscopic sural nerve grafting after radical prostatectomy using the da Vinci (Intuitive Surgical, Mountain View, California) robot.
• Materials and Methods: The procedure was performed successfully in 3 potent men 48, 49 and 59 years old, respectively. In patient 1 the entire procedure was performed robotically using a 6 port transperitoneal approach. In patients 2 and 3 the robot was used only for sural nerve grafting and urethrovesical anastomosis, while radical prostatectomy was performed by conventional laparoscopy. After the completion of radical prostatectomy with deliberate wide resection of the 2 neurovascular bundles in patients 1 and 3, and unilateral excision of the left neurovascular bundle in patient 2 a plastic surgery team harvested 10 to 15 cm of sural nerve from the left calf. Sural nerve grafts were interposed robotically by placing 4 to 6 interrupted perineural stitches of 6 or 7-zero polypropylene sutures.
• Results: Mean operative time was 6.5 hours, mean blood loss was 216 cc and mean hospital stay was 2.3 days. Surgical margins were focally positive at the apex in the patients 1 and 3. During a followup of 7, 5 and 1 months patient 1 reported penile engorgement with sildenafil not sufficient for penetration, patient 2 with unilateral nerve preservation was potent without any medication and patient 3 did not achieve any degree of erection, respectively.
• Conclusions: The da Vinci remote robotic system technically facilitates sural nerve grafting during laparoscopic radical prostatectomy. Long-term potency data are essential to validate the technical success.
  
  
• Editorial Comment
  Many pitfalls of laparoscopic surgery in recent years have been tried to overcome with the assistance of computerized robots. In the current paper an experienced group of laparoscopic surgeons from the Cleveland Clinic Foundation tried to laparoscopically reconstruct the peri prostatic autonomic nerve system resected during laparoscopic radical prostatectomy. In addition to optical magnification and illumination provided by normal endoscopic surgery they also took advantage of the da Vinci computerized robotic system enabling them to suture the nerve transplants with three dimensional magnification, improved manual dexterity, movement scaling and tremor elimination. In the few cases in which the autonomic nerve reconstruction was performed they achieved both a surgical and functional success.
  The success is remarkable in several aspects. A procedure which requires otherwise microscopic or lens magnification if done in an open fashion and which requires special skills because of the depth and illumination of the operating field can be done laparoscopically this circumventing these problems. Furthermore functional restoration of potency was achieved despite the fact that sural nerve interposition was thought to be an unlikely successful method for re-innervation of the extremely fine and branching autonomic nerve fibers. What we definitely see in this paper is the possibility to perform laparoscopic surgery by benefiting from the endoscopic magnification and illumination in conjunction with the improved dexterity of robots. What still needs clarification is whether sural nerve grafting is really responsible for potency preservation or whether young age as in these patients, anatomical variations in autonomic nerves, or possible alternative physiological pathways for maintaining erections could be an explanation for the favorable results.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany