Steps in Neurovascular Bundle Preservation

This step impacts greatly on the functional outcome and is the main reason why the operative time has not shortened with experience; any time saved on other steps of the dissection is allocated to the preservation of the nerves.

These nerves are very fragile and any trauma of any nature can definitively damage them and compromise erectile function. The goal is to dissect the nerves in as delicate a way as possible and with the least manipulation. Developing the appropriate plane of dissection close to the prostate is ideal; however, oncological safety must not be compromised.

Only an extended preoperative work-up and a complete comprehension of the anatomy will help in achieving this task. The use of hemostatic tools (clips, bipolar coagulation, and suture) for ligation of the pedicles is of no consequence—as long as this is performed close to the prostate, and is not performed "en bloc." The dissection of the neurovascular bundle itself should be done without any hemostatic means, as long as an intrafascial plane is developed. Bleeding during this step most likely means that the dissection is taken in the neurovascular bundle itself (i.e., interfascial plane): the intracapsular vessels arising from the neurovascular bundle and entering the prostate, usually found at the base and apex, are the source of easily controlled bleeding.

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