Surgery in Motion Anatomic Grading of Nerve Sparing During Robot-Assisted Radical Prostatectomy Oscar Schatloff a , Sanket Chauhan a,b , Ananthakrishnan Sivaraman a , Darian Kameh a , Kenneth J. Palmer a,b , Vipul R. Patel a,b, * a Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA; b University of Central Florida School of Medicine, Orlando, FL, USA 1. Introduction Before the discovery of the neurovascular bundles (NVBs) by Walsh and Donker [1], the cause of erectile dysfunction following radical prostatectomy (RP) was not completely understood. These authors demonstrated that erectile dysfunction following RP occurred secondary to injury to the cavernosal nerves (CNs), a group of parasympathetic nerves originating from the pelvic plexus and running together with arteries and veins (capsular vessels of the prostate) on a prominent NVB on the posterolateral aspect of the prostate and eventually ending in the corpus cavernosum of the penis. Further insight into the distribu- tion of nerves within the NVB has demonstrated that these nerves are organized into three functional compartments, in which the CNs are located on the anteromedial aspect of the EUROPEAN UROLOGY 61 (2012) 796–802 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted December 23, 2011 Published online ahead of print on January 3, 2012 Keywords: Robot assisted radical prostatectomy Prostate cancer Nerve sparing Please visit www.europeanurology.com and www.urosource.com to view the accompanying video. Abstract Background: Because of the lack of intraoperative visual cues, the amount of nerve sparing (NS) intended by the surgeon does not always correspond to what is actually performed during surgery. Objective: Describe a standardized NS grading system based on intraoperative visual cues. Design, setting, and participants: A total of 133 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon were evaluated. The surgeon intraoperatively graded the NS independently for either side as follows: 1 = no NS; 2 = <50% NS; 3 = 50% NS; 4 = 75% NS; 5 = 95% NS. Surgical procedure: RARP; detailed description of a five-point NS grading system. Measurements: The area of residual nerve tissue on prostatectomy specimens was compared with the intraoperative NS score (NSS). The rate of positive surgical margins (PSMs) according to the NSS is also reported. Results and limitations: In all, 52.6% of operated sides (140 of 266 sides) had NSS 5, 30.1% (80 of 266) had NSS 4, 2.3% (6 of 266) had NSS 3, 13.2% (35 of 266) had NSS 2, and 1.9% (5 of 266) had NSS 1. The area of residual nerve tissue was significantly different among the different NSSs: median area (interquartile range) for NSS 5: 0.5 (0–2) mm 2 ; for NSS 4: 3 (0–8) mm 2 ; for NSS 3: 13 (7–23) mm 2 ; for NSS 2: 14 (8–24) mm 2 ; and for NSS 1: 57 (56–165) mm 2 ( p < 0.001). Overall, 9.02% of the patients (12 of 133 patients) had a PSM, with 8.3% (9 of 108) for pT2 and 12% (3 of 25) for pT3. Side-specific PSMs according to NSS were 3.6% (5 of 140) for NSS 5, 7.5% (6 of 80) for NSS 4, 16.7% (1 of 6) for NSS 3, 5.7% (2 of 35) for NSS 2, and 0% (0 of 5) for NSS 1. A limitation of our study is that the key anatomic landmarks are not recognizable in every case, and this technique might not be easy to perform during the early learning curve. Conclusions: We believe that the visual cues exposed in this article will help surgeons achieve more consistent NS during RARP. # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. 410 Celebration Pl, Suite 200, Celebration, FL 34747, USA. E-mail address: vipul.patel.md@flhosp.org (V.R. Patel). 0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2011.12.048