Urology Resident NewYork-Presbyterian / Weill Cornell Medicine
Introduction: Proficient preservation of the nerves during radical prostatectomy (RP) is critical to achieving post-operative erectile function (EF). However, terms such as nerve-sparing (NS) vs. non-NS do not explain the significant and currently unexplained heterogeneity in observed EF outcomes among high-volume surgeons. Utilizing the novel “NERVE” tool in a virtual video-based Delphi method, we report the degree of consensus regarding optimal NS technique among RP experts. Methods: Eleven RP experts (from 5 centers) reviewed four NS videos sourced from the public domain comprising of 3 "expert" videos (C-SATS repository) and 1 video presented at a live surgical demonstration (YouTube). Experts graded videos using the NERVE tool (Fig. 1) and predicted 1-year EF outcome in quintiles assuming perfect preoperative EF. Degree of expert agreement and correlation between total NERVE score and predicted EF outcome was evaluated by the intraclass and Pearson correlation coefficient, respectively. Results: Overall NS technical skill assessment using the NERVE tool demonstrated a higher degree of expert agreement (ICC 0.75, p<0.001) than predicting EF outcome (ICC 0.41, p<0.01). Experts demonstrated significant variation in the degree of concordance using the NERVE tool: Nerve Plane (ICC 0.44, p<0.01), Electrocautery (ICC 0.83, p<0.01), Retraction (ICC 0.33, p<0.01), Visualization (ICC 0.50, p<0.01), and Effect (ICC 0.40, p<0.01). A strong positive correlation existed between total NERVE scores and predicted EF outcome (r = 0.63, p<0.01) (Fig. 2). Conclusions: There is expert consensus that improved NS performance is significantly correlated with EF outcomes; however, uncertainty remains on how likely better technical proficiency will produce a good outcome. Furthermore, near complete agreement in Electrocautery and poor agreement in Retraction highlights areas of considerable disagreement on what constitutes optimal NS technique. Future directions include recruiting more RP experts and incorporating videos with known 1-year EF outcomes. SOURCE OF Funding: UCF Residency Research Award
