Extraperitoneal extrafascial combined ante- and retrograde nerve sparing cystectomy for bladder cancer in males

To present the extraperitoneal extrafascial approach for performing a nerve sparing radical cystectomy (NSRC) in males. The technique started with a suprapubic midline extraperitoneal approach, followed by ligation and division of vas deferens, and bilateral iliac lymphadenectomy. The endopelvic fascia was kept intact. The superior vesical artery was controlled, and the ureter was dissected, and divided. The plane between the rectum posteriorly and the seminal vesicles anteriorly was developed and non-thermal dissection was carried out in the proper plane, beginning proximally anterolateral to the seminal vesicles and then proceeding distally close to the bladder and prostate and anterior to the line of the neurovascular bundle (NVB). The dorsal venous complex (DVC) was controlled, followed by retrograde urethral dissection, incising its anterior circumference, holding it with three stay sutures, transecting the remaining posterior urethral circumference and combined ante- and retro-grade dissection along the lateral prostatic wall anterior to the NVB plane. The posterior urethral circumference was held with stay sutures. The result was bilateral NVB preservation, in a scene similar to the Veil of Aphrodite. This technique was performed in three patients between March and June 2022, who were followed-up till January 2025. All of the patients were continent to urine. Potency was preserved in two of them who showed spontaneous erection. The third patient had a soft tumescence at first and became potent after six months with the aid of PDE5-I. No local recurrence or distant metastasis was noted in any patient. The small sample size is a definite limitation. Extraperitoneal extrafascial combined ante- and retro-grade NSRC is efficient in maintaining the erectile function of men. It does not compromise the oncological outcome. It preserves the endopelvic fascia. However, randomized controlled trials with bigger sample size are needed for further investigation of this approach.