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Research shows that surgical technique—not just experience—predicts erectile function recovery after robotic-assisted radical prostatectomy for prostate cancer.

The small, moment-to-moment steps  ̶  the “surgical gestures” ̶  a surgeon performs during radical prostatectomy are associated with how well their patients recover sexual function, results of a cohort study suggest.

“We found that surgical gestures and technical skills evaluate different facets of surgical performance and are both associated with surgical outcomes in varying degrees,” senior study author Andrew J. Hung, MD, and his colleagues reported in JAMA Surgery.

Video-Based Assessment of Surgical Techniques

Erectile function recovery after robotic-assisted radical prostatectomy (RARP) for prostate cancer ranges from 27% to 81% worldwide, and patient characteristics alone cannot explain this variation, the authors noted.

To investigate how surgical practices may affect long-term erectile function, Dr. Hung and his colleagues analyzed roughly 235 hours of videos of RARP procedures on 157 men at five hospitals in the United States and Germany. The 28 faculty surgeons and surgical fellows performing the procedures had prior RARP caseloads ranging from 45 to over 10,000, with a median of 653 cases.

At the time of surgery, the patients had clinically localized prostate cancer and erections sufficient for sexual penetration. Their median age was 64 years, and median body mass index was 28.

Each surgical video focused on the bilateral nerve-sparing step, where nerves crucial for erectile function are dissected off the prostate. Blinded raters assigned a specific gesture to every surgical movement and annotated each gesture, including those associated with neurovascular bundle (NVB) trauma. They annotated 80,957 gestures and evaluated 2,568 technical skill scores. The analyzed gestures included spread, peel/push, hook, cold cut, hot cut, burn dissect, pedicalize, two-hand spread, and coagulate-then-cut.

The researchers calculated the proportion of each gesture type for both sides of the prostate and applied the Dissection Assessment for Robotic Technique (DART) to assess each surgeon’s skill. They then used logistic regression to analyze the association between surgical performance and recovery of erectile function at 12 months. Multivariable models accounted for standard predictors of age and nerve-sparing extent, and mixed-effects models addressed multiple cases per surgeon.

Gesture Patterns Associated With Erectile Function Recovery

At 12 months post-surgery, the 53 (34%) patients who recovered their erectile function had been operated on by surgeons with higher technical skill scores and specific surgical gestures.

• Recovery was associated with greater proportion of peel/push gestures (OR, 1.72; 95% CI, 1.24-2.42, per 0.1 increase; P=0.001), lower proportion of energy gestures applied to the neurovascular bundle (OR, 0.35; 95% CI, 0.13-0.81, per 0.1 increase; P=0.03), and less grabbing of the neurovascular bundle (OR, 0.02; 95% CI, 0.00-0.47, per 0.1 increase; P=0.02).
• Erectile function recovery was associated with higher scores on tissue handling skills (OR, 3.43; 95% CI, 1.23-10.90; P=0.03).
• The link between peel/push gestures and erectile function recovery remained significant (OR, 1.66; 95% CI, 1.18-2.39, per 0.1 increase; P=0.005) on multivariable regression.
• Erectile function recovery was linked with younger patient age (61 years vs. 66 years; P<0.001), full rather than partial NVB preservation (P=0.03), higher preoperative erectile function measured by the Sexual Health Inventory for Men (SHIM) score (22 vs 24; P=0.005), and smaller prostate size (36 mL vs. 48 mL; P=0.009).
• Surgeon experience was not associated with erectile function recovery.

Limitations & Need for Further Surgical Performance Research

The authors noted that the diversity of surgeons, hospitals, and countries supports the generalizability of the findings. They also acknowledged the study’s limitations, including the modest sample size and the time required to analyze the videos.

“This study is, to our knowledge, the first to evaluate both surgical gestures and technical skills for individual procedures and represents a significant step toward the comprehensive quantification of surgical performance,” the authors wrote.

“Our results suggest that surgical gestures and skills assessment can be used together as metrics of surgical performance and warrant further data-driven research to provide actionable feedback on surgical quality and improve patient outcomes,” they concluded.