Benjamin Lamb, Consultant urological and Robotic Surgeon
11th July 2023
Many patients are asking about the NeuroSAFE procedure, also known as intraoperative frozen section, in order to minimise sexual dysfunction after prostate cancer surgery. Below I have written a brief explainer, which I hope will be useful.
Introduction:
Robotic radical prostatectomy (RRP) has transformed the treatment of prostate cancer, offering improved outcomes and reduced side effects compared to traditional open surgery [1]. However, a potential complication of RRP is nerve damage, which can lead to erectile dysfunction and urinary incontinence. To address this concern, a technique called NeuroSAFE has emerged, aiming to safeguard the neurovascular bundles responsible for erectile function during prostatectomy [2]. This article explores the significance of NeuroSAFE in RRP and its impact on patient outcomes, supported by relevant citations.
Understanding the Neurovascular Bundles:
The neurovascular bundles are delicate structures located on either side of the prostate gland, containing the nerves responsible for erectile function. Preserving these bundles is crucial for post-prostatectomy sexual potency [3]. However, their intricate nature and proximity to the tumour pose a risk of accidental damage during surgery.
Introducing NeuroSAFE:
NeuroSAFE (Neurovascular Structure Adjacent to the Prostate) is an intraoperative technique that assists surgeons in identifying and preserving the neurovascular bundles during RRP. It involves collaboration among urologists, pathologists, and radiologists [2]. The procedure includes careful dissection of the prostate while obtaining real-time feedback from frozen section analysis of the tissue margins.
How NeuroSAFE Works [4]:
1. Preoperative Planning: Preoperative imaging, such as magnetic resonance imaging (MRI), helps identify the precise tumor location and neurovascular bundles. This information guides surgical planning.
2. Intraoperative Frozen Section Analysis: After removing the prostate gland during surgery, frozen sections of the surgical margins are sent for immediate analysis. Pathologists examine the tissue to identify cancer cells near the neurovascular bundles.
3. Immediate Decision-Making: If the frozen section analysis reveals cancer involvement near the neurovascular bundles, the surgeon can modify the extent of prostate resection. This real-time feedback enables nerve preservation while ensuring complete tumor removal.
Proposed benefits of NeuroSAFE in RRP [5]:
1. Improved Nerve Preservation: NeuroSAFE provides immediate feedback on tumor involvement near the neurovascular bundles, allowing surgeons to modify their approach. This precision enhances nerve preservation, which is hypothesised to improve postoperative sexual function outcomes.
2. Individualized Treatment: NeuroSAFE enables a personalized approach to RRP, tailoring techniques to each patient’s tumor characteristics. This ensures optimal cancer control while minimizing the risk of nerve damage.
3. Enhanced Surgical Confidence: Anecdotally, the availability of real-time analysis during surgery boosts surgical confidence, reducing intraoperative stress and enhancing outcomes.
4. Minimized Side Effects: Preservation of the neurovascular bundles is hypothesised to reduce the risk of erectile dysfunction and may also improve recovery of urinary incontinence, common side effects of prostatectomy, which improve patients’ quality of life post-surgery.
Conclusion:
NeuroSAFE represents a significant advancement in robotic radical prostatectomy, providing surgeons with a valuable tool to enhance precision and safety. Supported by real-time frozen section analysis, this technique allows optimal preservation of the delicate neurovascular bundles, reducing the risk of long-term side effects for patients. As technology evolves, NeuroSAFE holds promise for further improving the outcomes of prostate cancer surgery and enhancing patients’ overall quality of life.
References:
- Yaxley JW. Et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet. 2016 Sep 10;388(10049):1057-1066.
- van der Slot MA et al. Prostate Cancer Network. NeuroSAFE in radical prostatectomy increases the rate of nerve-sparing surgery without affecting oncological outcome. BJU Int. 2022 Nov;130(5):628-636. doi: 10.1111/bju.15771. Epub 2022 Jun 5.
- Ficarra V. et al. Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):418-430.
- Noël J et al. Neurovascular structure-adjacent frozen-section examination robotic-assisted radical prostatectomy: outcomes from 500 consecutive cases in the UK. J Robot Surg. 2022 Aug;16(4):951-956.
- Dinneen E et al. NeuroSAFE PROOF: study protocol for a single-blinded, IDEAL stage 3, multi-centre, randomised controlled trial of NeuroSAFE robotic-assisted radical prostatectomy versus standard robotic-assisted radical prostatectomy in men with localized prostate cancer. Trials. 2022 Jul 22;23(1):584.