World Journal of Urology

, Volume 37, Issue 2, pp 309–315 | Cite as

The value of periprostatic fascia thickness and fascia preservation as prognostic factors of erectile function after nerve-sparing robot-assisted radical prostatectomy

  • Nikolaos GrivasEmail author
  • Rosanne C. van der Roest
  • Clarize M. de Korne
  • Gijs H. KleinJan
  • Karolina Sikorska
  • Ivo G. Schoots
  • Corinne Tillier
  • Bram van der Broek
  • Kees Jalink
  • Stijn W. T. J. P. Heijmink
  • Tessa Buckle
  • Fijs W. B. van Leeuwen
  • Henk G. van der Poel
Original Article



To determine the correlation of preoperative fascia thickness (FT) and intraoperative fascia preservation (FP) with erectile function (EF) after nerve-sparing robot-assisted radical prostatectomy (RARP).


Our analysis included 106 patients, with localized prostate cancer and no erectile dysfunction (ED) before RARP, assessed with preoperative 3 Tesla (3 T) multiparametric magnetic resonance imaging (MRI). FP score was defined as the extent of FP from the base to the apex of the prostate, quantitatively assessed by the surgeon. Median fascia thickness (MFT) per patient was defined as the sum of the median FT of 12 MRI regions. Preserved MFT (pMFT) was the sum of the saved MFT. The percentage of pFMT (ppMFT) was also calculated. Fascia surface (FS) was measured on MRI and it was combined with FP score resulting in preserved FS (pFS) and percentage of pFS (ppFS).


FP score, pMFT, ppMFT, pFS and ppFS were significantly lower (p < 0.0001) in patients with ED. In the multivariate regression analysis, lower FP score [odds ratio (OR) 0.721, p = 0.03] and lower ppMFT (OR 0.001, p = 0.027) were independent predictors of ED. ROC analysis showed the highest area under the curve for ppMFT (0.787) and FP score (0.767) followed by pMFT (0.755) and ppFS (0.743).


MRI-determined periprostatic FT combined with intraoperative FP score are correlated to postprostatectomy EF. Based on the hypothesis that a thicker fascia forms a protective layer for the nerves, we recommend assessing FT preoperatively to counsel men for the odds of preserving EF after RARP.


Erectile dysfunction Fascia Magnetic resonance imaging Prostate cancer Tissue preservation 



We would like to sincerely thank Mark Page (MR consultant at St Vincent’s Hospital, University of Melbourne, Australia) and Lih-Ming Wong (urologist at St Vincent’s Hospital, University of Melbourne, Australia) for their contributions delineating the prostate and periprostatic fascia.

Author contributions

Project development: all authors. Data collection: NG, RVDR, CK, GK, HVDP. Data analysis: all authors. Manuscript writing & approval: all authors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

For this type of study formal consent is not required.

Supplementary material

345_2018_2387_MOESM1_ESM.tif (1.5 mb)
Supplementary material 1 Fig. 1. T2-weighted transversal MR image at mid-prostate level with drawn contours and - clockwise - the 12 parts (corresponding with the FP score – ‘L’ stands for FP-region on the left side of the prostate and ‘R’ for the right side, respectively) consisted of 360 radial lines, color-coded for the prostate-fascia distance: pink = thick fascia, blue = thin fascia. FP, fascia preservation (TIFF 1572 kb)
345_2018_2387_MOESM2_ESM.tif (995 kb)
Supplementary material 2 Fig. 2. ICC for median fascia distance per location (mid-prostate, apex and base) and per FP region for the different observers. Highest agreement in mid-prostate Sect. (0.36; 0.31 and 0.26 respectively for apex and base). With respect to the FP region: highest ICCs in L4, R4 and R5. Lowest ICCs in regions L6, R6 and R2. FP, fascia preservation; ICC, intraclass correlation coefficient (TIFF 994 kb)
345_2018_2387_MOESM3_ESM.tif (2.4 mb)
Supplementary material 3 Fig. 3. A schematic picture of the prostate and a mid-prostate section. F: Fascia, R: Rectum, U: Urethra. B. A mid-prostate section stained with a s100-staining (nerve staining). C-F. Spiderplots which show the (C) FT (D) the FS (E) the peripheral nerve density (F) and the blood vessel density for the different FP regions of 10 patients who had a non-sparing prostatectomy. All graphs are normalized. FP, fascia preservation; FS, fascia surface; FT, fascia thickness (TIFF 2488 kb)
345_2018_2387_MOESM4_ESM.tif (1.1 mb)
Supplementary material 4 Fig. 4. These spiderplots show the variation in (A) FT, (B) FS, (C) peripheral nerve density and (D) blood vessel density per FP region for 5 individual patients. All graphs are normalized. FP, fascia preservation; FS, fascia surface; FT, fascia thickness (TIFF 1141 kb)
345_2018_2387_MOESM5_ESM.tif (1.3 mb)
Supplementary material 5 Fig. 5. The predictive value of the five factors which were significantly related to postoperative ED varied dependent on the cut-off chosen. The highest AUC values were reached with a cut-off IIEF score ≤ 12 or ≤ 13. AUC, area under the curve; ED, erectile dysfunction; IIEF, International Index of Erectile Function-Erectile Function (TIFF 1309 kb)
345_2018_2387_MOESM6_ESM.docx (24 kb)
Supplementary material 6 (DOCX 23 kb)
345_2018_2387_MOESM7_ESM.docx (13 kb)
Supplementary material 7 (DOCX 13 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Nikolaos Grivas
    • 1
    Email author
  • Rosanne C. van der Roest
    • 1
  • Clarize M. de Korne
    • 2
  • Gijs H. KleinJan
    • 1
    • 2
  • Karolina Sikorska
    • 3
  • Ivo G. Schoots
    • 4
    • 5
  • Corinne Tillier
    • 1
  • Bram van der Broek
    • 6
  • Kees Jalink
    • 6
  • Stijn W. T. J. P. Heijmink
    • 4
  • Tessa Buckle
    • 2
  • Fijs W. B. van Leeuwen
    • 2
  • Henk G. van der Poel
    • 1
  1. 1.Department of UrologyThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  2. 2.Department of Radiology, Interventional Molecular Imaging LaboratoryLeiden University Medical CenterLeidenThe Netherlands
  3. 3.Department of BiometricsThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  4. 4.Department of RadiologyThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  5. 5.Department of Radiology and Nuclear MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
  6. 6.Department of Cell BiologyThe Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands

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