Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery

Abstract

A nerve-sparing procedure during robot-assisted radical prostatectomy has been considered one of the most important techniques for preserving postoperative genitourinary function. The reason is that adequate nerve-sparing procedures could preserve both erectile function and lower urinary tract function after surgery. When a nerve-sparing procedure is carried out, the cavernous nerves themselves cannot be visualized, despite the magnified viewing field during robot-assisted radical prostatectomy. Thus, nerve-sparing procedures have been considered challenging operations, even now. However, because not all surgeons have carried out a sufficient number of nerve-sparing procedures, the development of new nerve-sparing procedures or new methods for mapping the cavernous nerves is required. Recently, various new operative techniques, for example, Retzius-sparing robot-assisted radical prostatectomy, transvesical robot-assisted radical prostatectomy and retrograde release of neurovascular bundle technique during robot-assisted radical prostatectomy, have been developed. In addition, new surgical devices, for example, biological/bioengineering solutions for cavernous nerve protection and devices for identifying the cavernous nerves during radical prostatectomy, have developed to preserve the cavernous nerves. In contrast, limitations or problems in preserving cavernous nerves and postoperative erectile function have become apparent. In particular, the recovery rate of erectile function, the positive surgical margin rate at the site of nerve-sparing and the indications for nerve sparing have become obvious with the accumulation of much evidence. Furthermore, predictive factors for postoperative erectile function after nerve-sparing procedures have also been clarified. In this article, the importance of a comprehensive approach for early recovery of erectile function in the robot-assisted radical prostatectomy era is discussed.

Impact of nerve sparing in robot‐assisted radical prostatectomy on the risk of positive surgical margin and biochemical recurrence

“…2 To conserve sexual potency and urinary continence is fundamental to perform a NS in RP by avoiding the resection of the neurovascular bundle. [3][4][5] Nevertheless, NS increases the risk of PSM. 6 Therefore, there exists a delicate balance between the amount of tissue resected for the preservation of the neurovascular bundle and the risk of PSM.…”

Different Nerve-Sparing Techniques during Radical Prostatectomy and Their Impact on Functional Outcomes

“…To begin with, electrical nerve stimulation devices can be used and the erectile response can be evaluated both indirectly by physiological measurements, such as penis tumescence, and directly by measuring the neuroelectrical activity in the corpus cavernosum. Moreover, fluorescence imaging can precisely detect the cavernous nerves, applying fluorescein or indocyanine green, either by local injection into the cavernous nerves by way of the penis or by systemic injection intravenously [ 75 ]. Finally, transrectal ultrasonography and laparoscopic Doppler ultrasound (LDU) probe can both help identification of these nerves [ 69 , 75 ].…”

“…Moreover, fluorescence imaging can precisely detect the cavernous nerves, applying fluorescein or indocyanine green, either by local injection into the cavernous nerves by way of the penis or by systemic injection intravenously [ 75 ]. Finally, transrectal ultrasonography and laparoscopic Doppler ultrasound (LDU) probe can both help identification of these nerves [ 69 , 75 ]. A detailed description of these methods exceeds the purposes of this article.…”

Advances in Nanoparticle Delivery System for Erectile Dysfunction: An Updated Review

“… 3 , 4 , 5 ED has been reported to be associated with diabetes 6 and radical prostatectomy (RP) used in the treatment of prostate cancer. 7 , 8 , 9 Other risk factors for ED include hypertension, cardiovascular diseases, obesity, alcohol intake, cigarette smoking, drug abuse, and poor physical activity. 2 , 10 …”

“…[3][4][5] ED has been reported to be associated with diabetes 6 and radical prostatectomy (RP) used in the treatment of prostate cancer. [7][8][9] Other risk factors for ED include hypertension, cardiovascular diseases, obesity, alcohol intake, cigarette smoking, drug abuse, and poor physical activity. 2,10 Currently, oral phosphodiesterase type 5 (PDE5) inhibitors for example, sildenafil have been endorsed for use by the United States Food and Drug Administration (FDA) as the initial medications for the alleviation and treatment of male ED.…”