Nerve-sparing Radical Cystectomy: A New Technique
Article in Press
Background: The results of post-radical cystectomy (RC) erectile function are notoriously disappointing, except when a prostate-sparing technique is used. However, valid concerns regarding oncologic safety still predominate, and protocols for patient selection and technique are not well defined. Objective: We describe a new technique for nerve-sparing RC and orthotopic diversion with preservation of the vasa deferentia, seminal vesicles, and neurovascular bundles (NVB). No prostatic tissue is left behind, thus eliminating the risk of local recurrence from bladder cancer (BCa) as well as de novo prostate cancer. Design, setting, participants: Between March 2008 and October 2009, nine patients with intact erectile function and non-muscle-invasive bladder cancer (NMIBC) or stage ≤pT3a away from the trigone underwent this type of procedure. Prostatic carcinoma was excluded by normal digital rectal examination (DRE) and transurethral ultrasound (TRUS), a prostate-specific antigen (PSA) value ≤4.0 ng/ml, and a free-to-total PSA ratio >20%. Intervention: The procedure starts as a standard nerve-sparing radical prostatectomy (RP). After transection of the urethra with Denonvillier's fascia still intact, vasa deferentia and seminal vesicles are transected at the base of the prostate, and the trigone is undermined to the space of Douglas. The cystectomy is completed in ascending or preferably descending fashion. Measurements: Patients were evaluated pre- and postoperatively using the International Index of Erectile Function (IIEF) questionnaire. Patients were followed up regularly at 2 mo, 6 mo, and 12 mo. Results and limitations: Four out of nine patients maintained spontaneous complete tumescence, and five patients had partial tumescence using sildenafil as a successful erectogenic aid. PSA was <0.1 ng/ml in all cases. All patients showed no evidence of disease (NED). Conclusion: With correct patient selection, excellent functional results can be obtained. © 2010 European Association of Urology.