Robotic Assisted Laparoscopic Sural Nerve Grafting During Radical Prostatectomy: Initial Experience

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Abstract
Sural nerve grafting has been done in select patients undergoing radical prostatectomy with unilateral or bilateral wide excision of the neurovascular bundle in an effort to preserve potency. We describe a novel technique of laparoscopic sural nerve grafting after radical prostatectomy using the da Vinci (Intuitive Surgical, Mountain View, California) robot. The procedure was performed successfully in 3 potent men 48, 49 and 59 years old, respectively. In patient 1 the entire procedure was performed robotically using a 6 port transperitoneal approach. In patients 2 and 3 the robot was used only for sural nerve grafting and urethrovesical anastomosis, while radical prostatectomy was performed by conventional laparoscopy. After the completion of radical prostatectomy with deliberate wide resection of the 2 neurovascular bundles in patients 1 and 3, and unilateral excision of the left neurovascular bundle in patient 2 a plastic surgery team harvested 10 to 15 cm of sural nerve from the left calf. Sural nerve grafts were interposed robotically by placing 4 to 6 interrupted perineural stitches of 6 or 7-zero polypropylene sutures. Mean operative time was 6.5 hours, mean blood loss was 216 cc and mean hospital stay was 2.3 days. Surgical margins were focally positive at the apex in the patients 1 and 3. During a followup of 7, 5 and 1 months patient 1 reported penile engorgement with sildenafil not sufficient for penetration, patient 2 with unilateral nerve preservation was potent without any medication and patient 3 did not achieve any degree of erection, respectively. The da Vinci remote robotic system technically facilitates sural nerve grafting during laparoscopic radical prostatectomy. Long-term potency data are essential to validate the technical success.