Nerve-sparing Radical Cystectomy: A New Technique

BackgroundThe 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.ObjectiveWe 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, participantsBetween 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%.InterventionThe 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.MeasurementsPatients 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 limitationsFour 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).ConclusionWith correct patient selection, excellent functional results can be obtained.