J Korean Med Sci.  2022 Jan;37(1):e6. 10.3346/jkms.2022.37.e6.

Toggling Technique Allows Retrograde Early Release to Facilitate Neurovascular Bundle Sparing During Robot-Assisted Radical Prostatectomy: A Propensity ScoreMatching Study

• Shim JS
• Tae JH
• Noh TI
• Kang SH
• Cheon J
• Lee JG
• Patel VR
• Kang SG

• KMID: 2524183
• DOI: http://doi.org/10.3346/jkms.2022.37.e6

Abstract

Background
This study aimed to present the surgical facilitation of neurovascular bundle (NVB) sparing using the toggling technique (30° lens down/up switching) and to evaluate erectile dysfunction (ED) recovery after robot-assisted radical prostatectomy (RARP).
Methods
We assessed 144 patients (group with toggling, n = 72; group without toggling, n = 72) who underwent RARP with bilateral NVB sparing using propensity score matching. Inclusion criteria were ≥ 1 year follow-up and preoperative potency as per the Sexual Health Inventory for Men (SHIM) questionnaire (≥ 17 points). Recovery of ED after RARP was defined as return to baseline sexual function or self-assessment regarding successful intercourse. The subjective surgeon’s nerve sparing (SNS) score and tunneling success rates were used to evaluate surgical facilitation. The recovery rate of ED between the groups was analyzed using Kaplan-Meier analysis.
Results
A better ED recovery trend was confirmed according to the SNS score (R ² = 0.142, P = 0.004). In the analysis of NVB sparing ease, the toggling group showed higher SNS scores (on right/left side: P = 0.011 and < 0.001, respectively) and overall tunneling success rates (87% vs. 74%, P = 0.001) than the group without toggling. Overall, ED recovery rates were 82% (59/72) and 75% (54/72) in the groups with and without toggling, respectively, at the 1-year follow-up (P = 0.047), and the toggling group showed a faster ED recovery rate at 3 months (47% vs. 35%, P = 0.013). In a specific analysis of the potent cohort (< 60 years, bilateral full NVB spared, SHIM score ≥ 22), the ED recovery rate reached 87% (14/16) in the toggling group.
Conclusion
The retrograde early release with the toggling technique improves the facilitation of NVB sparing, leading to improved ED recovery.

Figure

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  Fig. 1 Key surgical steps for retrograde early release using toggling technique. (A) 30° down view: The appropriate dissection approach into the interfascial plane is important in this step. The deeper dissection plane between the prostate fascia and the neurovascular bundle is rarely seen in this view. (B) 30° up view: After the proper dissection of the interfascial plane followed by toggling, the medial side of the neurovascular bundle is visible. The accomplishment of this process guarantees sparing of the whole neurovascular bundle. (C) 30° down view: After toggling again, the final step of the neurovascular bundle sparing process is performed anteriorly. Tunneling, defined as a connection between the anterior aspect of the prostrate and the Denonvillier’s fascia following separation of the neurovascular bundle, can be observed here.NVB = neurovascular bundle.

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  Fig. 2 Surgeon’s subjective nerve-sparing score on right and left sides in both groups.Data are shown as mean ± SD.

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  Fig. 3 Kaplan-Meier curve showing erectile dysfunction reduction rate over time. Numbers along the Y-axis represent rate of men at risk (those who were still impotent) at beginning of the corresponding timeline (weeks). Specific percentages depicted in the separate table represent proportion of those men who were potent by the end of the corresponding timeline.

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