Case report: Fluorescence-guided laparotomic radical prostatectomy with heightened nerve visualization

Abstract

Introduction and importance: Iatrogenic injury to the cavernous nerve and its branches results in post-operative erectile dysfunction in up to 85 % of men undergoing a radical prostatectomy. Here, we describe using a novel fluorescence-imaging system developed to detect nerve autofluorescence in a 66-year-old gentleman with prostate adenocarcinoma (Gleason Score 8 [4 + 4], prognostic group 4, indicating a highly-aggressive prostate cancer) who underwent laparotomic radical prostatectomy.

Case presentation: Under general anesthesia, a laparotomic radical prostatectomy was performed using standard operative techniques. During surgery, a Dendrite imaging camera (Dendrite® Imaging, Germany) was employed to permit the surgical team to toggle freely between standard operating room (white) light and near-ultraviolet light (NUVL), with the specific purpose of enhancing visualization of the periprostatic nerve plexus, including the cavernous nerve and all its branches. Under white light, neither the cavernous nerve nor any of its branches were clearly visible. However, under NUVL, all fluoresced brightly and were easily avoided during prostate resection. Prostate resection proceeded with no intra-operative or post-operative complications. Moreover, upon one-month follow-up in the surgery clinic, the patient reported no erectile dysfunction, difficulties voiding, or other neurological or non-neurological complaints.

Clinical discussion: In this case, autofluorescence of the cavernous nerve and its branches during radical prostatectomy aided in their visualization and appeared to help prevent post-operative erectile dysfunction and all other potential neurological deficits.

Conclusion: Novel intra-operative technology enabling nerves to auto-fluoresce warrants larger series and comparative trials to assess its effectiveness reducing iatrogenic nerve injury during radical prostatectomies.

Keywords: Case report; Erectile dysfunction; Fluorescence imaging; Nerve autofluorescence; Nerve preservation; Prostatectomy.

Fig. 1

A: Surgical field of the right hemipelvis in standard operating room light after radical prostatectomy. B: Surgical field in near-ultraviolet light, revealing autofluorescence of the right peri-prosthetic nerve plexus and right pudendal nerve.