Real-time intraoperative cavernous nerve mapping and neurophysiological monitoring during radical prostatectomy: the...

The cavernous nerves are constitutive elements of the intrapelvic autonomic neuroregulatory input to the penis and pelvic floor, serving principally to mediate penile erection and likely urinary continence to some extent. Diffuse and variable in their topography surrounding the prostate, these neural structures are challenging for surgeons to discern and avoid injuring during radical prostatectomy, despite the use of modern surgical maneuvers for cavernous nerve preservation. Accordingly, objectives of patient retention of erectile function after surgery are insufficiently met.

This narrative review aims to present the evolutionary understanding of the detailed complex anatomy of the cavernous nerves and to appraise innovative methodologies that have been proposed for mapping cavernous nerves and monitoring their functional integrity intraoperatively during radical prostatectomy.

A non-systematic literature search was conducted to identify published literature pertaining to cavernous nerve anatomy and physiology with relevance to pelvic surgery, with particular focus on literature describing techniques and technologies for preserving cavernous nerves during radical prostatectomy.

The cavernous nerves represent a complex distribution of nerve fibers extending from the network of nerves surrounding the prostate that course to the proximal corpora cavernosa as well as to adjacent structures in the region of the pelvic floor. Their topography is diffuse and individually distinct across patients, with a precise portion that is active in producing penile erection. Cavernous nerve localization methods are being developed for real-time visualization of functionally active periprostatic erectogenic nerves during radical prostatectomy. Neurophysiological monitoring methods are also in development that guide the surgeon to avoid cavernous nerve injury when executing radical prostatectomy.

Improved functional recovery outcomes after radical prostatectomy can be expected with the advancement of intraoperative cavernous nerve mapping and real-time functional monitoring methodologies.