Robot-assisted radical prostatectomy is the gold standard for treating localised prostate cancer.

Although the procedure achieves excellent cancer control, postoperative urinary incontinence and erectile dysfunction significantly affect patients’ quality of life.

Nerve-sparing surgery aims to preserve the neurovascular bundles, which are responsible for erectile function and help maintain urinary continence.

However, achieving maximal functional recovery while ensuring complete tumour removal—especially in patients at risk of extracapsular extension—remains a major clinical challenge.

This review provides a comprehensive overview of nerve-sparing techniques during RARP.

It begins by describing the neuroanatomy of the neurovascular bundles (NVBs), which run posterolaterally along the prostate.

A key concern in nerve-sparing surgery is extracapsular extension (ECE), where the tumour extends beyond the prostatic capsule and increases the risk of positive surgical margins.

The review then summarises three primary fascial dissection planes: the intrafascial plane (maximal nerve preservation but highest risk of positive margins in patients with ECE), the interfascial plane (moderate nerve preservation with wider surgical margins), and the extrafascial plane (non-nerve-sparing, recommended for high-risk ECE).

It also discusses antegrade and retrograde dissection strategies, noting that the retrograde approach may reduce traction on the NVBs and facilitate earlier functional recovery.

FIGURE 1 provides an intraoperative demonstration of these three dissection planes.

The review further covers innovative techniques, including the Veil of Aphrodite, modified clipless antegrade nerve-sparing RARP, Retzius-sparing RARP, hypothermic nerve protection, and biological membrane wraps.

It introduces objective grading systems for standardised intraoperative assessment.

Patient selection tools, including multiparametric magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography (PSMA-PET), as well as risk stratification strategies, are also discussed to help clinicians balance oncologic safety with functional preservation.

This review stands out by integrating anatomical knowledge with practical surgical tips for complex cases, such as large prostates or prior pelvic surgery.

It introduces objective grading systems for standardised intraoperative assessment of nerve-sparing extent.

The review also highlights emerging technologies, including neurovascular structure adjacent frozen section examination (NeuroSAFE) and PSMA-PET, which may further improve the precision and safety of nerve-sparing surgery.

This review provides urologists with a practical framework from patient selection to surgical decision-making.

The integration of emerging technologies may further improve surgical precision and patient outcomes.

The work titled “Preserving the neurovascular bundle during radical robotic prostatectomy: Tips and tricks” was published on UroPrecision.

Source: Higher Education Press