Cavermap-assisted sural nerve interposition graft during radical prostatectomy

Wide excision of the neurovascular bundle and interposition nerve grafting of the cavernous nerves when there is suspected extracapsular extension at the posterolateral prostatic margin are logical applications of improved understanding of pelvic neuroanatomy. Although the indications for neurovascular bundle excision will remain controversial for the foreseeable future, evidence suggests that neurovascular bundle excision improves cancer control in some patients. The ability to predict extracapsular extension reliably at the neurovascular bundle would be a powerful addition to the urologist's armamentarium. The authors have shown, as proof of principle in bilaterally resected neurovascular bundle at the time of RRP, that sural nerve grafting can restore erectile function. The authors' data also support a role for sural nerve grafting in unilateral neurovascular bundle excision. Although the side effects of sural nerve harvest are minor, the ability to predict preoperatively which patients will benefit from such grafts would reduce the number of failures. The success of the authors' interposition nerve-grafting project has resulted, in part, from the use of a multidisciplinary team approach that includes experienced oncologic surgeons and a plastic surgeon with extensive microsurgical and nerve-grafting experience. The technique for sural nerve grafting described herein gives urologists an additional tool to improve patients' quality of life without compromising the chances of success in treating prostate cancer.