Advances in the impact of cold versus thermal dissection on functional recovery during nerve-sparing robot-assisted radical prostatectomy

doi:10.3877/cma.j.issn.1674-3253.2026.05.013

Abstract

Abstract:

Erectile dysfunction and urinary incontinence remain common complications following robot-assisted radical prostatectomy (RARP) in patients suffer from prostate cancer. Preservation of the neurovascular bundles (NVBs) is a critical surgical step for promoting functional recovery, with techniques continuously refined through advances in prostatic anatomy research and robotic platforms. However, the relative merits of cold versus thermal dissection of the neurovascular bundles remain controversial, and pertinent evidence-based investigations have advanced considerably in recent years. This review comprehensively examines cold and thermal techniques in NVBs preservation during nerve-sparing RARP and their impact on postoperative functional outcomes, aiming to provide evidence-based references for clinical decision-making.

Key words: Radical prostatectomy, Neurovascular bundles, Thermal injury, Erectile function, Urinary continence

Chenqi Zhang, Yu Chen, Pei Feng, Long Gao, Guofeng Shi, Shaonan Li, Jingxi Hu, Xiaoming Cao. Advances in the impact of cold versus thermal dissection on functional recovery during nerve-sparing robot-assisted radical prostatectomy[J]. Chinese Journal of Endourology(Electronic Edition), 2026, 20(05): 573-580.

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References 56

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文献	研究设计	样本量	技术细节	主要功能结局及定义	随访时间或随访时间点	主要结论
Hofmann等^[23](2022)	回顾性非随机队列研究	冷：323例热：230例	冷：无热分离+PVPs缝扎热：点触单极电凝(30～40 W)+4 ℃冷水冲洗	勃起功能(ESI，IIEF-5≥15，勃起充盈度百分比>75%综合评估)	冷：52.7个月热：54.8个月	多变量分析显示，两组勃起功能恢复无显著差异
Pagliarulo等^[45](2021)	回顾性队列研究	冷：111例热：120例	冷：止血夹夹闭PVPs后锐性离断热：超声刀止血+主动冲洗散热	完全尿控(0尿垫/d) 勃起功能(IIEF-5≥15)	3、12、24个月	短期(3个月)冷处理组勃起功能更优；在12个月和24个月的长期随访中，两组无显著差异
Basourakos等^[46](2022)	回顾性队列研究	冷：194例热：144例	冷：Hem-o-lok夹闭PVPs +剪刀锐性离断热(无夹)：双极电凝PVPs +剪刀锐性离断	尿控(EPIC-CP，0尿垫/d或1尿垫/d) 勃起功能(EPIC-CP，能够性交)	3、9、15、18个月	多变量分析显示，两组在勃起功能、尿控及肿瘤学结局上均无显著差异
Carbin等^[47](2025)	回顾性病例系列	138例（仅热）	热(无夹)：精准双极/单极电凝(Retzius保留入路)	完全尿控(0尿垫/d) 勃起功能(能够性交)	6周、3、6个月	证实无夹热处理安全性；研究人群中6个月尿控恢复率93.4%，勃起功能恢复率79%
Guimarães等^[48](2019)	回顾性匹配队列研究	冷：228例热：456例	冷：标准经腹膜RARP 热(无夹)：腹膜外入路，谨慎使用双极能量	完全尿控(0尿垫/d) 勃起功能(能够性交)	1、3、6、12个月	热处理组显示出显著更优的勃起功能恢复；尿控恢复两组无显著差异
Ahlering等^[49](2006)	回顾性队列研究	冷：51例热：36例	冷：Bulldog夹临时阻断+PVPs缝扎热：双极电凝	勃起功能(能够完成性交)	3个月	冷处理组短期(3个月)勃起功能恢复率显著更高
Gill等^[50](2007)	回顾性队列研究	冷：54例热：22例	冷：Bulldog夹临时阻断+剪刀锐性离断+ PVPs缝扎热：超声刀+Hem-o-lok夹	勃起功能(能够性交)	3、6、12、18个月	冷处理组勃起功能较热处理组恢复更优
Fuschi等^[4](2025)	前瞻性随机对照试验	冷：97例热：98例	冷：剪刀锐性离断+Hem-o-lok夹闭PVPs 热：单极/双极点触电凝	完全尿控(0尿垫/d) 勃起功能(IIEF-5≥17)	尿控：15、30、90 d 勃起：30、90、180 d	冷处理组术后早期尿控和勃起功能恢复显著优于热处理组
Ahlering等^[51](2008)	回顾性队列研究	500例（初始两组共纳入500例，但各时间点有效样本量不同）	冷：Bulldog夹临时阻断热：单极或双极电凝	勃起功能(能够性交且效果满意)	3、9、15、24个月	避免热损伤使早期(3～9个月)勃起功能恢复率提高约4.7倍；大部分热损伤患者在24个月内可恢复
Ahlering等^[52](2008)	回顾性病例系列	38例(仅热)	热：单极/双极电凝	勃起功能(能够性交且效果满意)	3、9、15、24个月	热损伤导致严重早期神经失用，12～18个月内恢复率极低；但长期(24个月)近2/3患者功能最终恢复
Shin等^[53](2020)	回顾性病例系列	105例(仅冷)	冷(无热无夹)：筋膜内钝性及锐性分离NVBs，缝扎止血	勃起功能(SHIM ≥21或能够性交)	1、3、6、9、12个月	该冷处理技术安全可行，术后12个月勃起功能恢复率极佳
Chien等^[54](2005)	回顾性病例系列	45例(仅冷)	冷(改良无夹)：避免单极手术器械的使用，仅对穿透包膜小血管慎用双极电凝	勃起功能(UCLA PCI)，功能恢复百分比=(随访期平均性功能得分/术前平均性功能得分)×100%	1、3、6、12个月	该研究中冷处理可实现性功能早期恢复
Beck等^[39](2012)	回顾性队列研究	冷：148例(其中TA缝扎：74例，对照：74例)	冷：(1)：对PVPs采用"8字"缝扎+Hem-o-lok夹形成张力可调止血结构(TA缝扎组)； (2)：Bulldog夹临时阻断+剪刀锐性离断+常规缝扎(对照组)	勃起功能(IIEF-5 ≥15)	9、15个月	该缝扎技术为安全有效的冷处理方法，早期勃起功能恢复两组无显著差异
张雪培等^[40](2021)	回顾性病例系列	23例(仅冷)	冷(卷管法)：Hem-o-lok夹闭PVPs+剪刀锐性离断，后采用4-0倒刺线缝合PVPs和直肠前壁筋膜使PVPs向内侧翻卷成管样结构	尿控与勃起功能(文中未标准化)	8个月(部分患者)	创新的"卷管法"冷处理技术有望促进功能恢复，需要进一步开展大规模研究以明确该技术的影响
Mattei等^[55](2007)	前瞻性病例系列	100例(仅冷)	冷：无能量、无张力侧向入路筋膜间分离，采用2 mm止血夹	完全尿控(0尿垫/d) 勃起功能(IIEF-EF≥17)	4个月	该冷处理技术安全可行，提供优异早期功能恢复
Fagin^[56](2007)	回顾性队列研究	300例(文中未明确各组样本量)	冷(系列2 & 3)：采用止血夹+钝性及锐性分离NVBs，分别采用后入路及前后联合入路进行分离。热(系列1)：选择性双极电凝	完全尿控(0尿垫/d) 勃起功能(SHIM，能够性交的患者比例) 切缘阴性率	3个月	冷处理带来更优的早期勃起功能恢复，且不损害肿瘤学结局

文献	研究设计	样本量	技术细节	主要功能结局及定义	随访时间或随访时间点	主要结论
Hofmann等^[23](2022)	回顾性非随机队列研究	冷：323例热：230例	冷：无热分离+PVPs缝扎热：点触单极电凝(30～40 W)+4 ℃冷水冲洗	勃起功能(ESI，IIEF-5≥15，勃起充盈度百分比>75%综合评估)	冷：52.7个月热：54.8个月	多变量分析显示，两组勃起功能恢复无显著差异
Pagliarulo等^[45](2021)	回顾性队列研究	冷：111例热：120例	冷：止血夹夹闭PVPs后锐性离断热：超声刀止血+主动冲洗散热	完全尿控(0尿垫/d) 勃起功能(IIEF-5≥15)	3、12、24个月	短期(3个月)冷处理组勃起功能更优；在12个月和24个月的长期随访中，两组无显著差异
Basourakos等^[46](2022)	回顾性队列研究	冷：194例热：144例	冷：Hem-o-lok夹闭PVPs +剪刀锐性离断热(无夹)：双极电凝PVPs +剪刀锐性离断	尿控(EPIC-CP，0尿垫/d或1尿垫/d) 勃起功能(EPIC-CP，能够性交)	3、9、15、18个月	多变量分析显示，两组在勃起功能、尿控及肿瘤学结局上均无显著差异
Carbin等^[47](2025)	回顾性病例系列	138例（仅热）	热(无夹)：精准双极/单极电凝(Retzius保留入路)	完全尿控(0尿垫/d) 勃起功能(能够性交)	6周、3、6个月	证实无夹热处理安全性；研究人群中6个月尿控恢复率93.4%，勃起功能恢复率79%
Guimarães等^[48](2019)	回顾性匹配队列研究	冷：228例热：456例	冷：标准经腹膜RARP 热(无夹)：腹膜外入路，谨慎使用双极能量	完全尿控(0尿垫/d) 勃起功能(能够性交)	1、3、6、12个月	热处理组显示出显著更优的勃起功能恢复；尿控恢复两组无显著差异
Ahlering等^[49](2006)	回顾性队列研究	冷：51例热：36例	冷：Bulldog夹临时阻断+PVPs缝扎热：双极电凝	勃起功能(能够完成性交)	3个月	冷处理组短期(3个月)勃起功能恢复率显著更高
Gill等^[50](2007)	回顾性队列研究	冷：54例热：22例	冷：Bulldog夹临时阻断+剪刀锐性离断+ PVPs缝扎热：超声刀+Hem-o-lok夹	勃起功能(能够性交)	3、6、12、18个月	冷处理组勃起功能较热处理组恢复更优
Fuschi等^[4](2025)	前瞻性随机对照试验	冷：97例热：98例	冷：剪刀锐性离断+Hem-o-lok夹闭PVPs 热：单极/双极点触电凝	完全尿控(0尿垫/d) 勃起功能(IIEF-5≥17)	尿控：15、30、90 d 勃起：30、90、180 d	冷处理组术后早期尿控和勃起功能恢复显著优于热处理组
Ahlering等^[51](2008)	回顾性队列研究	500例（初始两组共纳入500例，但各时间点有效样本量不同）	冷：Bulldog夹临时阻断热：单极或双极电凝	勃起功能(能够性交且效果满意)	3、9、15、24个月	避免热损伤使早期(3～9个月)勃起功能恢复率提高约4.7倍；大部分热损伤患者在24个月内可恢复
Ahlering等^[52](2008)	回顾性病例系列	38例(仅热)	热：单极/双极电凝	勃起功能(能够性交且效果满意)	3、9、15、24个月	热损伤导致严重早期神经失用，12～18个月内恢复率极低；但长期(24个月)近2/3患者功能最终恢复
Shin等^[53](2020)	回顾性病例系列	105例(仅冷)	冷(无热无夹)：筋膜内钝性及锐性分离NVBs，缝扎止血	勃起功能(SHIM ≥21或能够性交)	1、3、6、9、12个月	该冷处理技术安全可行，术后12个月勃起功能恢复率极佳
Chien等^[54](2005)	回顾性病例系列	45例(仅冷)	冷(改良无夹)：避免单极手术器械的使用，仅对穿透包膜小血管慎用双极电凝	勃起功能(UCLA PCI)，功能恢复百分比=(随访期平均性功能得分/术前平均性功能得分)×100%	1、3、6、12个月	该研究中冷处理可实现性功能早期恢复
Beck等^[39](2012)	回顾性队列研究	冷：148例(其中TA缝扎：74例，对照：74例)	冷：(1)：对PVPs采用"8字"缝扎+Hem-o-lok夹形成张力可调止血结构(TA缝扎组)； (2)：Bulldog夹临时阻断+剪刀锐性离断+常规缝扎(对照组)	勃起功能(IIEF-5 ≥15)	9、15个月	该缝扎技术为安全有效的冷处理方法，早期勃起功能恢复两组无显著差异
张雪培等^[40](2021)	回顾性病例系列	23例(仅冷)	冷(卷管法)：Hem-o-lok夹闭PVPs+剪刀锐性离断，后采用4-0倒刺线缝合PVPs和直肠前壁筋膜使PVPs向内侧翻卷成管样结构	尿控与勃起功能(文中未标准化)	8个月(部分患者)	创新的"卷管法"冷处理技术有望促进功能恢复，需要进一步开展大规模研究以明确该技术的影响
Mattei等^[55](2007)	前瞻性病例系列	100例(仅冷)	冷：无能量、无张力侧向入路筋膜间分离，采用2 mm止血夹	完全尿控(0尿垫/d) 勃起功能(IIEF-EF≥17)	4个月	该冷处理技术安全可行，提供优异早期功能恢复
Fagin^[56](2007)	回顾性队列研究	300例(文中未明确各组样本量)	冷(系列2 & 3)：采用止血夹+钝性及锐性分离NVBs，分别采用后入路及前后联合入路进行分离。热(系列1)：选择性双极电凝	完全尿控(0尿垫/d) 勃起功能(SHIM，能够性交的患者比例) 切缘阴性率	3个月	冷处理带来更优的早期勃起功能恢复，且不损害肿瘤学结局

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