Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation.

Erectile dysfunction (ED) remains a significant problem in up to 63% of men following robotic-assisted radical prostatectomy (RARP). Following the discovery of the neurovascular bundle, additional anatomic description and variation in nerve-sparing techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP nerve sparing technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP nerve sparing surgical techniques provide better outcomes compared to standard nerve-sparing RARP. The use of validated quality of life questionanires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best nerve-sparing approach. Overall, there is significant variation in RARP nerve sparing techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importane of anatomically dissecting the neurovascular bundle, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes following RARP to optimize postoperative potency.