Minimally invasive (robotic or laparoscopic) surgery has been widely adopted for the treatment of cancer despite few randomized, controlled trials assessing outcomes.¹ In the Laparoscopic Approach to Cervical Cancer (LACC) Trial, the results of which were reported by Ramirez et al.² in the Journal in November 2018, patients with early-stage cervical cancer were randomly assigned to undergo minimally invasive surgery or open abdominal radical hysterectomy. Minimally invasive surgery was associated with worse disease-free and overall survival than open surgery. A population-based study³ and a meta-analysis⁴ showed similar associations. Accordingly, guidelines now favor open surgery (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). Nevertheless, the extent to which practice has changed is unknown.

Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) 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 NS 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 NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires 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 NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, 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 after RARP to optimize postoperative potency.