E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4

Surgery in Motion

Current Technique of Open Intrafascial Nerve-Sparing Retropubic

Prostatectomy

Lars Budaus a,b,*, Hendrik Isbarn a,b, Thorsten Schlomm a, Hans Heinzer a, Alexander Haese a,Thomas Steuber a, Georg Salomon a, Hartwig Huland a, Markus Graefen a

a Martini-Clinic, Prostate Cancer Centre Hamburg-Eppendorf, Hamburg, Germanyb University Hospital Hamburg-Eppendorf, Department of Urology, Hamburg, Germany

ava i lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Article info

Article history:

Accepted May 5, 2009Published online ahead ofprint on May 29, 2009

Keywords:

Open nerve-sparing retropubic

prostatectomy

Current technique

Functional outcome

Abstract

Background: Open nerve-sparing retropubic prostatectomy (nsRP) is still the most

common surgical approach for the treatment of localised prostate cancer. Even though

the principles of the technique and its oncological efficacy have often been published,

ongoing refinements allow further improvements in functional outcome and

morbidity.

Objective: To describe our current technique of open nsRP with data addressing

urinary continence, potency, cancer control rates, and perioperative morbidity.

Design, setting, and participants: Our analyses relied on 1150 patients who were

treated with nsRP in the Martini-Clinic by two high-volume surgeons from April 2005

to December 2007.

Surgical procedure: Key elements are a selective ligation of the dorsal vein complex

and early release of the neurovascular bundles using a high anterior tension- and

energy-free intrafascial technique. During dissection of the urethra, its posterior

insertion at Denonvilliers’ fascia (DF) is preserved. DF is left in situ, and it is selectively

opened above the seminal vesicles (SV). The SV are completely removed inside DF, and

five muscle-sparing interrupted sutures are used for anastomosis.

Measurements: Functional and oncological outcome data were prospectively

assessed using validated questionnaires. Moreover, intra- and perioperative morbid-

ity were evaluated.

Results and limitations: Age and extent of nerve-sparing approach influenced urinary

continence and potency. Complete urinary continence 1 yr after nsRP was found in

97.4% (men <60 yr) to 84.1% (men >70 yr) of patients. In preoperative potent men,

erections sufficient for intercourse were reported between 84–92% and 58.3–70% of

patients following bilateral and unilateral nerve sparing, respectively. Median blood

loss was 580 ml (range: 130–1800 ml), and the transfusion rate was 4.3%. Median

operative time was 165 min (range: 85–210 min). In organ-confined cancers, recur-

rence-free survival and cancer-specific-survival 10 yr after retropubic prostatectomy

were 87% and 98.3%, respectively.

Conclusions: Open intrafascial nsRP combines excellent long-term cancer control

rates with superior functional outcome and a low morbidity.

# European Association of Urology Published by Elsevier B.V. All rights reserved.

* Corresponding author. Martini-Clinic, Prostate Cancer Centre Hamburg-Eppendorf, Martinistr. 52,20246 Hamburg, Germany.E-mail address: Lars_budaeus@web.de (L. Budaus).

0302-2838/$ – see back matter # European Association of Urology Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2009.05.044

Fig. 1 – The dorsal vein complex adjacent to the prostate, starting on thehigher half of the prostate at the 2 o’clock and the 10 o’clock positions.

Fig. 2 – Only the endopelvic fascia and the membrane of the externalsphincter are included within the oversewn distal part of the dorsal veincomplex. Mueller’s ligaments, with the adjacent neurovascular bundlesbelow the 10 o’clock and the 2 o’clock positions, are marked with redarrows.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4318

1. Introduction

Open retropubic prostatectomy (RP) is one of the standard

surgical approaches for the treatment of clinically localised

prostate cancer [1]. In recent years, aside from the

established open retropubic or perineal approach, conven-

tional laparoscopic prostatectomy and, especially, robotic-

assisted radical prostatectomy (RALP) are increasing in

popularity [2,3] Today, most institutions have a preferred

surgical approach, based on their surgical school, and

favourable outcomes are reported with respective techni-

ques [2–8]. In a recent review article, no superiority was

found for a certain technique, and the authors concluded that

time will tell whether a certain surgical approach will be

advantageous [9]. However, as such data are not available

and all techniques are in a constant refinement process, it is

important that updates of the existing techniques be

published to allow an ongoing contemporary comparison

of the available approaches. Such studies will permit a fair

judgement of developments in each technique and make the

assessment of functional outcome, efficacy, and morbidity

easier. In this paper, we report our current technique of open

nerve-sparing RP (nsRP), including cancer control rates,

functional outcome, and perioperative morbidity.

2. Methods and patients

2.1. General recommendations for performing nerve-sparing

retropubic prostatectomy

We are using a Bookwalter autoretractor system (Codman, Le Locle,

Switzerland), 4- to 5-fold magnification glasses, and a xenon headlamp

for optimal exposure and illumination of the operative field. No specific

positioning of the patient is necessary.

For performing nsRP, we recommend a spinal anaesthesia and

additional total intravenous anaesthesia. Intravenous fluid replacement

is restricted to 500 ml until the prostate is removed. Based on an

individual fast-track concept, discharge from hospital in a good physical

constitution is regularly possible 3–4 d after surgery (the German health

system has directed that patients undergoing RP have to stay in hospital

for at least 4 d).

2.2. Incision of the endopelvic fascia and preparation of the

dorsal venous complex

After an 8–10-cm median skin incision, the retropubic space and the

cavum recii is established. Then the endopelvic fascia is incised and

fibres of the levator ani muscle are gently pushed away. However, fibres

from the levator urethrae are preserved to maintain its anterior fixation.

The attachment of the detrusor apron, known as the puboprostatic

ligaments, are isolated and then sharply dissected. Throughout the

operation, no coagulation should be used close to the neurovascular

bundle or on the surface of the prostate in order to avoid damage of the

nerves.

A superficial stay suture is placed distally from the prostate, which

will later be used for the selective ligation and for oversewing of the

plexus. The lateral parts of the fascia of the sphincter muscle are not

touched, as they separate the sphincter from the neurovascular bundle

(Fig. 1). These structures are known as Mueller’s ligaments, a continuation

of the ventral fascia of the striated sphincter. Mueller himself called

these structures ischioprostatic ligaments (Fig. 2).

To avoid back bleeding, an additional Vicryl 2/0 suture is placed in

the midline of the prostate. The incision of the exposed dorsal vein

complex, situated between the continuation of the endopelvic fascia on

top and the fascia of circular striated sphincter muscle below, starts close

to the apex of the prostate. The dorsal vein complex is dissected without

any ligation until the fascia of the external sphincter is visible. While the

fascia of the external sphincter is superficially incised, care is taken that

the underlying muscle fibres of the external sphincter are kept intact.

The selective suturing of the distal parts of the dorsal vein complex

between 10 and 2 o’clock includes two layers: The ventral part of the

dorsal vein complex consists of the continuation of the endopelvic fascia;

the dorsal part is covered by the fascia of the external sphincter. This

selective approach guarantees that functional tissue of either the

sphincter fibres or the urethra is not incorporated into the ligation and

that traction to the adjacent tissue is avoided (Fig. 3).

2.3. The intrafascial nerve-sparing procedure

The dissection of the neurovascular bundles starts high up on the

anterior aspect of the prostate with incision of the parapelvic fascia

Fig. 3 – Longitudinal section of the prostate; most of the fibres of theneurovascular bundles are running adjacent on the lateral and lowerparts of the prostate, so the dissection should start high on the prostate.

Fig. 4 – Preparation of the apex and sphincter, with the circular andlongitudinal muscle fibres dissected very close to the apex of theprostate, ensuring a maximum length of functional tissue.

Fig. 5 – Principle of anastomotic sutures. The sutures are placed throughthe everted bladder mucosa. Traction of the whole membranous urethrais reached by including the Denonvilliers’ fascia and the raphe of thesphincter muscle within the 6 o’clock suture.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4 319

because the majority of nerves run adjacent on the lateral and lower part

of the prostate. The neurovascular bundles are mobilised and lateralised

before the urethra is dissected (Fig. 3).

For subtle dissection, the attached levator fascia and periprostatic

fascia is gently lifted andincised at the anterior aspect of the prostate above

the 10 o’clock and the 2 o’clock positions and undermined by using small

Overholt clamps. The underlying areolar space, including the nerves, fatty

tissue, and small tethering vessels, can be identified. When the right

dissection plane is entered, one will see the shiny, smooth, reflecting

surface of the prostatic capsule. Veins overlying the prostatic capsule are

undermined and can serve as a good landmark for entering the right

dissection plane. The neurovascular bundles are carefully and gently

pushed laterally and downwards usingthe blunt nib of the scissors, and the

dissected fascia and vessels are clipped. No haemostasis is performed in

minor bleedings; 3- or 5-mm titanium clips or selective stitches (5/0

resorbable PDS sutures) are used to control arterial bleeding. The borders

for the release of the neurovascular bundle are, distally, the periurethral

area upuntil3–5 cmproximallyof theprostatic base into theperivesical fat

in order to avoid tension on the bundleandto expose the prostatic pedicles.

2.4. Preparation of the sphincter and urethra

For preserving as much functional tissue as possible, the preparation of

the sphincter and urethra starts at the apex of the prostate. Fibres of the

circular striated sphincter muscle, which cover the apex outside of

the prostate, are gently pushed distally with blunt scissors until the

longitudinal smooth muscle fibres become visible. Subsequently, the

longitudinal smooth muscle fibres, which run inside the prostate, are

incised. The transection of the longitudinal fibres is performed

approximately 3 mm within the prostate, cranially of the apex of the

prostate. Remaining muscle fibres are gently pushed distally for

preservation. Then the urethra is incised, and the preparation is

performed for two-thirds of its circumference.

By starting the subtle dissection with the fibres covering the apex of the

prostate, the complete length of the functional urethra is preserved (Fig. 4).

2.5. Principle of anastomotic sutures and removal of the

prostate

At the 1 o’clock and the 11 o’clock positions, a 3/0 PDS with a UR6 needle

is passed through the ligated dorsal vein complex, used as an anchor.

Then the needle is passed through the mucosa of the urethra, and only a

small part of the functional tissue is incorporated. The rest of the urethra

is completely dissected, and the lower anastomotic sutures are placed at

the 3 o’clock, 9 o’clock, and 6 o’clock positions. At the 6 o’clock position,

the suture affixes the dorsal part of the sphincter to the DF and the raphe

of the sphincter muscle for traction of the whole membranous urethra

(Fig. 5), similar to the technique described by Rocco et al. [10].

As described above, the perivesical fat is mobilised during the nerve-

sparing procedure to release the bundles and to avoid further traction

during the operation. Furthermore, the release of the fatty tissue up to 3–

5 cm proximally of the prostatic base allows a precise visualisation of the

prostatic pedicles, which can then be selectively ligated or clipped.

DF, which is left in situ at the apical region, is incised at the basal

region for preparation of the seminal vesicles. By incision of DF, a ventral

part of this fascia is left on the specimen to avoid positive surgical

margins. The part of the DF covering the seminal vesicles is incised and is

left in situ in order to protect the underlying neurovascular bundle. The

tips of the seminal vesicles are identified, and the adjacent vessels are

clipped and dissected. DF, covering the seminal vesicles, is left inside

because it protects the neurovascular bundles. No coagulation is used in

order to preserve the integrity of the nerves running close to the tips of

the seminal vesicles.

If necessary, bladder outlet is narrowed with a tennis-racket suture

(Vicryl 4/0) with eversion of the mucosa. The operating field is checked;

if bleeding close to the neurovascular bundle occurs, PDS 5/0 sutures or

clips are used to control such bleeding.

Fig. 6 – The (a) right side of the prostate (b) is inked green beforeremoving the slice for frozen section analyses for intraoperativeevaluation of the surgical margin.

Fig. 7 – The (a) different sides of the slice for frozen section analyses (b)are inked in a different colour (towards the prostate and towards theneurovascular bundle green or blue and yellow towards the prostate).This technique enables the pathologist to differentiate between true-and false-positive surgical margins.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4320

The stitches of the five anastomotic sutures are placed through the

everted bladder mucosa and are tied in a single-knot technique to avoid

any compromise of the blood supply. This technique results in a stricture

rate of <1%. The wound is closed and the skin is closed using a self-

resorbable intracutaneous suture, leading to good cosmetic results.

2.6. Indication for nerve sparing and lymph node dissection

The indication to perform nerve-sparing surgery (bilateral vs unilateral

vs none) and lymph node dissection is based on different nomograms

predicting the probability of side-specific extraprostatic extension and

lymph node invasion [11,12]. For supplementing the oncological safety

of nsRP, frozen sections of the laterorectal surface of the prostate are now

performed in nearly every patient [13].

In our institution, preoperative nomograms and intraoperative

sections are used in two ways: first, to avoid positive surgical margins

in inadequately indicated nerve-sparing procedures (ie, in patients with

capsular penetration), and, second, to identify as many candidates for

nsRP as possible. As the advantages of nsRP are obvious compared to

non–nerve-sparing RP, we consider it our task to identify as many

suitable cancers for nsRP as possible. With a nomogram estimating the

side-specific likelihood of organ confinement in conjunction with

intraoperative frozen section, in our institution, the rate of patients

undergoing an nsRP and having organ-confined disease at final

pathology is as high as 98.3%. This finding underlines that we strive

to expand the indication for nsRP as much as possible to minimise

potential side-effects on functional outcome.

Frozen sections reach from the apex to the base of the complete

lateral-dorsal part of the prostate. The sides of the slice are inked in

different colours (Figs. 6 and 7) [13]. If tumour cells extending to the

outer surface are found, we remove the corresponding neurovascular

bundle and its adjacent tissue. Although frozen section analyses do not

invariably eliminate the risk of positive surgical margins, they minimise

its risk in the most thorough way.

3. Results

3.1. Perioperative parameters and morbidity

Preoperative parameters and morbidity were based on the

data of 1150 patients, whereas the functional results

reported below are based on preoperative potent men.

Median operative time was 165 min (range: 85–210 min).

Median blood loss was 580 ml (range: 130–1800 ml), and

the transfusion rate was 4.3%. There was no rectal injury, no

ureteral injury, and no perioperative death. All patients

were routinely investigated by pelvic ultrasound before

discharge to detect a pelvic haematoma (5.3%) or lympho-

cele (7.5%). Revision for pelvic haematoma was necessary in

0.4% of patients. Lymphoceles were only treated when

compression of the external iliac vein was observed by

Table 1 – Postoperative urinary continence.

Age <60 yr 60–70 yr >70 yr

No. of patients 192 348 97

No. of padsper 24 h

Bilateral NS(n = 153)

Unilateral NS(n = 39)

Bilateral NS(n = 253)

Unilateral NS(n = 95)

Bilateral NS(n = 58)

Unilateral NS(n = 39)

0–1, % 95.9 97.4 93.8 93.2 94.5 84.1

2, % 3.3 2.6 5.5 6.8 3.7 10.7

>2, % 0.7 – 0.7 – 1.8 5.2

NS = nerve sparing.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4 321

Doppler sonography; in those cases, they were managed by

puncture (0.8%). No patient had to undergo marsupialisa-

tion for lymphoceles. Within 14 d postoperatively, deep

vein thrombosis was observed in 1.3% of patients.

3.2. Functional outcome

3.2.1. Urinary continence 1 year after surgery

The reported number of required pads after nsRP is

widely used to assess postoperative urinary continence.

In our institution, validated questionnaires (International

Continence Society [ICS], European Organisation for

Research and Treatment of Cancer [EORTC] Quality of

Life (QoL) C30 questionnaire) are routinely used 1 yr after

surgery. Continence results were stratified by age and

extent of nerve sparing (unilateral vs bilateral approach).

In men aged �70 yr, urinary continence 1 yr after nsRP

was reported between 93.2–97.4% and seemed not to be

influenced by the extent of nerve sparing (see Table 1). In

men >70 yr, urinary continence was observed in 94.5%

after bilateral nsRP; however, after unilateral RP, only

84.1% achieved continence, suggesting an important

effect of extent of nerve sparing on urinary continence

in this patient group [14]. Some 2.6–6.8% of patients <70

yr reported needing two pads per day, and, again, this

need seemed not to be influenced by the extent of nerve

sparing. However, in men aged �70 yr, 3.7% needed two

pads after bilateral nsRP and 10.7% needed two pads after

unilateral nsRP. More than two pads were used by 0.7% of

men <70 yr. In older patients, more than two pads were

used by 1.8% and 5.2% of patients after bilateral and

unilateral RP, respectively. There was no complete

urinary incontinence.

Table 2 – Erections sufficient for sexual intercourse and postoperativepreoperative potent patients (IIEF-5 score I19)*.

Age (no. of patients) <60 yr (n = 192)

IIEF >19, % Ability toperform intercourse, %

IIEF

Degree of nerve

sparing

Bilateral 59 92

Unilateral 44 58.3

* Assessment was 12 mo after nerve-sparing retropubic prostatectomy, with or w

was reported in approximately 20% of patients.

3.2.2. Erectile function 1 year after surgery

Evaluation of postoperative potency was restricted to men

with documented good preoperative erectile function who

underwent a uni- or bilateral nsRP and in whom informa-

tion on postoperative erectile function by means of

International Index of Erectile Function (IIEF) score 1 yr

after surgery was available (n = 637). The abridged five-item

version of the IIEF is used routinely before surgery and 12

mo after RP in all of our patients [15]. Men with a

preoperative IIEF score below 19, indicating some degree of

preoperative erectile dysfunction, were excluded from this

analysis. We recently reported that preexistent age- and

comorbidity-dependent erectile dysfunction affects up to

48% of all RP patients prior to surgery [15].

There are certain ways to report on erectile function. The

abridged IIEF-5 score is probably the most frequently used

questionnaire; however, many centres do not report

postoperative IIEF scores but instead report patients’ ability

to perform intercourse after RP. Certainly, such results

strongly correlate; nevertheless, the number of potent

patients substantially varies by the type of evaluation

and the definition of being potent.

Question 2 of the IIEF-5 questionnaire asks for erections

sufficient for penetration after sexual stimulation. Patients

who stated not having had sexual stimulation within the

last 6 mo were excluded, and we considered patients who

were able to penetrate their partner as potent. Using this

definition, potency rates varied from 84% to 92% in men who

underwent a bilateral procedure and from 58.3% to 70%

following unilateral nsRP (Table 2). The use of phospho-

diesterase type 5 (PDE-5) inhibitors was left to the patient’s

discretion, and 80% of men who completed the question-

naire did not use such medications.

International Index of Erectile Function (IIEF-5) score in

60–70 yr (n = 348) >70 yr (n = 97)

>19, % Ability toperform intercourse, %

IIEF >19, % Ability toperform intercourse, %

56 84.6 59 84

35 70 25 63.6

ithout phosphodiesterase type 5 (PDE-5) inhibitor use. Use of PDE-5-inhibitors

Table 3 – Characteristics of 637 patients with complete pre- and postoperative data who underwent nerve-sparing retropubicprostatectomy between 2005 and 2007.

Preoperative data

Age, mean (range) 63 (43–76)

PSA, mean (range) 7.88 (0.7–60)

Clinical stage, % (n)

T1c 83.6 (533)

T2 14.7 (94)

T3 1.5 (10)

Postoperative data, % (n) Positive margin, % (n) Nerve sparing, % (n) Frozen section analyses, %

Both sides One side

pT2, 72.3 (460) 5.2 (24) 82.3 (379) 17.6 (81) 86

pT3, 27.7 (177) 27.1 (48) 36.2 (64) 63.8 (113) 92

PSA = prostate-specific antigen.

Fig. 8 – Biochemical recurrence (BCR)–free survival; long-term follow-upof patients treated between 1992 and 1997 with retropubicprostatectomy according to the pathological T stage.

Fig. 9 – Long-term cancer-specific-mortality (CSM)–free survival afterretropubic prostatectomy according to the pathological T stage.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4322

If being potent was defined by a postoperative IIEF score

>19, the corresponding potency rates (based on the same

questionnaire) were 25–59% (Table 2). Such obvious

discrepancies should be explained by a simple example:

Patients with good erectile function (five points on question

1 of the IIEF-5) but without sexual stimulation will receive

an overall score of 5 out of 25 points and, according to that,

suffer from severe ED. This example demonstrates how the

impact of the type of evaluation and the definition of

postoperative potency can make it almost impossible to

obtain comparable data from the literature.

3.3. Oncological outcome

We describe our current technique of nsRP, and therefore,

we cannot present meaningful oncological long-term

follow-up data for this cohort. Using margin status as a

surrogate parameter for cancer control, the positive margin

rate was 5.2% in pT2 cancers and 27.1% in pT3 cancers

(Table 3). All prostatectomy specimens were inked and

underwent a 3-mm-step-section procedure for pathological

work-up. However, because our surgical approach is based

on previous reports from our institution, we report on long-

term data addressing prostate-specific antigen (PSA)

recurrence–free survival and, more important, cancer-

specific survival rates [4,16]. At 10 yr after RP, the

biochemical recurrence–free survival rates (biochemical

recurrence strictly defined as a PSA level of 0.1 ng/ml and

rising) ranged from 5.9–87%, depending on the pathological

stage (Fig. 8), and cancer-specific survival rates ranged from

72.2–98.3% (Fig. 9).

4. Discussion

RP has been performed for decades now, and the pioneering

work on anatomy and surgical technique was published by

Walsh and coworkers almost 30 yr ago [1]. In 2006, our group

contributed to ‘‘Surgery in Motion’’ with the description of

our open technique, and the current manuscript is based on

the surgical principles shown in that previous publication [4].

The refinements that can be expected by such an update are

certainly no reinvention of the technique, but small nuances

of the prescribed approach have changed.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4 323

One modification in the current technique compared to

the one published in 2006 is a more subtle dissection of the

posterior urethra. The omega-shaped sphincter muscle

inserts at the terminal end of DF, and the insertion of this

area is not disrupted. Furthermore, when nerve sparing is

performed, the DF is either left in situ or, if it is dissected in a

v-shaped manner above the perirectal fat, the posterior

part of the urethra is stitched to the remnants of the fascia,

similar to the technique described by Rocco et al. [10]. The

complete continence rate 1 yr after surgery, defined as no

pad at all or one protective pad, increased from 92% in 2006

to 95.5% in our latest questionnaire series on more recent

patients. The above-mentioned modification might be

responsible for that increase. However, another explana-

tion might be that in the 2006 series, RPs from nine

surgeons were evaluated. Conversely, in the current report,

only the data of two very-high-volume surgeons (HH and

MG, about 300 procedures per year per surgeon) were

included.

The strict intrafascial approach for the nerve-sparing

procedure and the subsequently increased number of

intraoperative frozen sections, including the complete

capsule corresponding to the neurovascular bundle, is

another difference from our previous series. The rate of

frozen sections is now >90%, and the current positive

surgical margin rate in pT2 cancers was lowered in recent

years from 9.4% to 5.2% [16]. These data have to be

considered in light of the fact that we try to expand the

indication for a nerve-sparing procedure as far as is

oncologically safe, and 98.3% of our patients harbouring

organ-confined disease at final pathology are undergoing a

nerve-sparing procedure. The strict intrafascial approach

slightly increased potency rates in our patients, with 58.3–

92% reporting having postoperative erections sufficient for

intercourse. Potency assessment based on whether an IIEF

score >19 was reached dropped potency rates to 25–59%, a

phenomenon that has already been described by Menon

et al. [3]. In that series, 70% of preoperative potent men had

erections sufficient for intercourse 1 yr after surgery, while

only half of these patients returned to a normal Sexual

Health Inventors for Men (SHIM) score, indicating the

necessity of using identical and validated assessment tools

when differences in potency rates of published series are

considered.

Addressing cancer control rates, we cannot provide

meaningful long-term data based on the present patient

cohort. However, the presented data based on our patients

operated on in earlier years showed favourable recurrence-

free and cancer-specific survival rates. Even though it might

be questioned whether such data can be extrapolated to the

current patient cohort, we believe that long-term cancer

control rates will further improve in the present series. This

belief is based on the fact that positive margin rates are

lower in the present series compared to our previous

patients [16]. The importance of negative margins on

outcome has been discussed extensively, and we believe

that intraoperative frozen section is one of the keys to

achieving favourable functional outcomes without com-

promising radicality of the procedure [17]. Furthermore, an

underlying stage migration has the potential to further

improve outcome, even within defined pathologic stages.

Interestingly, the recurrence-free survival rate in a previous

report from our institution in pT2 cancers at 10 yr was 80%

and increased to 87% in our recent analysis [16]. This change

might be due to favourable cancers within defined cohorts,

which is often reported by the phenomenon that year of

surgery might have prognostic impact [18].

Our study is not devoid of limitations. Considering the

large number of patients operated on in the Martini-Clinic

and the Department of Urology in Hamburg (n = 1541 in

2008), the reported patients considering functional out-

come are limited. This limitation is mainly due to the fact

that we excluded men with impaired erectile function

before surgery and focused on those men who underwent a

nerve-sparing procedure. Furthermore, we focused on the

two most experienced surgeons to allow better compar-

ability with other very high-volume surgical series,

especially with very high-volume robotic surgeons [3,19].

We limited this comparison to emphasise that surgical

experience seems to be more important than the surgical

approach itself. Furthermore, functional outcome was only

evaluated in men in whom all necessary data (ie,

preoperative and postoperative IIEF score assessed exactly

12 mo after surgery) were available.

In recent years, endoscopic procedures have gained an

increasing popularity for the treatment of clinically

localised prostate cancer, even though a recent review

could not show superiority of one approach above the other

[9]. Reports on comparisons of various techniques usually

report more favourable results of the currently favoured

technique compared to previous and abandoned techni-

ques, and such reports have the tendency to demonstrate

superiority of the new technique [9]. Nevertheless, it seems

more valid to compare the results of proponents of each

surgical approach to eliminate the effect of surgical

experience.

One of the aims of this report is to demonstrate that the

decrease of morbidity of RP is not based on the instruments

used but probably mainly on the experience of the surgical

team. Complication rates and, especially, transfusion rates

in the current series are in the range of those of high-volume

endoscopic series, which underscores our hypothesis [9].

Prospective trials are needed to show whether or not any

approach is advantageous over another. In our centre, we

recently started a prospective trial in which we compare

open and robotic RP, and we hope to create meaningful data

in due time.

5. Conclusions

Open radical prostatectomy is still the most frequently

performed surgical approach for the treatment of localised

prostate cancer. Surgical refinements include a strict

intrafascial approach and subtle preservation of the poster-

ior urethra and its insertion. In the hands of experienced

surgeons, open radical prostatectomy provides excellent

long-term cancer control rates, favourable functional out-

come, and low perioperative morbidity.

E U R O P E A N U R O L O G Y 5 6 ( 2 0 0 9 ) 3 1 7 – 3 2 4324

Author contributions: Lars Budaus had full access to all the data in the

study and takes responsibility for the integrity of the data and the

accuracy of the data analysis.

Study concept and design: Budaus, Graefen, Isbarn, Huland, Haese,

Heinzer, Steuber, Schlomm, Salomon.

Acquisition of data: Budaus, Graefen, Isbarn, Huland.

Analysis and interpretation of data: Budaus, Graefen, Isbarn, Huland.

Drafting of the manuscript: Budaus, Graefen, Isbarn, Huland, Haese,

Heinzer, Steuber, Schlomm, Salomon.

Critical revision of the manuscript for important intellectual content:

Budaus, Graefen, Isbarn, Huland, Haese, Heinzer, Steuber, Schlomm,

Salomon.

Statistical analysis: None.

Obtaining funding: None.

Administrative, technical, or material support: None.

Supervision: Graefen, Huland.

Other (specify): None.

Financial disclosures: I certify that all conflicts of interest, including specific

financial interests and relationships and affiliations relevant to the subject

matter or materials discussed in the manuscript (eg, employment/affilia-

tion, grants or funding, consultancies, honoraria, stock ownership or

options, expert testimony, royalties, or patents filed, received, or pending),

are the following: None.

Funding/Support and role of the sponsor: None.

Appendix A. Supplementary data

The Surgery in Motion video accompanying this article

can be found in the online version at doi:10.1016/

j.eururo.2009.05.044 and via www.europeanurology.com.

Subscribers to the printed journal will find the Surgery in

Motion DVD enclosed.

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