Nerve grafting at the time of radical prostatectomy: should we be doing it?

With increasing numbers of younger men being diagnosed with prostate cancer and subsequently undergoing radical prostatectomy, there is an increasing focus on quality of life postoperatively, especially potency. In patients with locally advanced disease, it has been suggested that use of nerve grafts at the time of radical prostatectomy may improve potency. The technique was first described in 1999 and several papers have been published about its utility. However, there is still controversy over its use because of the lack of any large, blinded trials, the anatomy of the cavernous nerves and the necessity of excising the neurovascular bundles (especially bilaterally). In addition, the results achieved with nerve grafting, a procedure not without significant morbidity and mortality, do not exceed those produced by surgeons carrying out nerve-sparing procedures.

In the published work reviewed, erections sufficient to produce vaginal penetration following unilateral nerve grafting (with contralateral nerve sparing) were evident in 41.7-63.6% of patients. This is similar to the rates of 23-64% with unilateral nerve sparing alone. The rates of erectile function sufficient to produce vaginal penetration following bilateral nerve grafting were 34-72%, whereas it is widely accepted that very few men without nerve grafting would have any degree of potency.

Currently, there does not appear to be a widespread role for nerve grafting at the time of radical prostatectomy.