Current Strategies to Improve Erectile Function in Patients Undergoing Radical Prostatectomy - Intraoperative Scenario

Prostate cancer (CaP) is one of the tumors where cancer cells try to escape through perineural invasion thus complicating the task of nerve preservation, as both decision for, and technique of nerve-sparing could have an impact on outcomes. Due to competing goals, this is one procedure in which success is defined not just by achieving one but all three goals: negative margins, continence, and return of erectile function-Trifecta. Preservation of nerves is not a simple process of saving one bundle on the right and left side, rather it is about saving a complex network of nerves that are organized like a hammock and each of its components has some role to play either on erection or orgasm. Extraprostatic extension (EPE) can be minimal, just creeping outside the capsule, or significant in terms of broad face and/or deep protrusion into the periprostatic tissue. Identification of the extent of EPE has an impact on choosing the plane for incision that is adequate for negative margins yet is able to save uninvolved nerves. In this paper, we present a detailed anatomical description of the neural hammock. Additionally, we have included different techniques for nerve-sparing and highlighted critical steps during surgery where a traction-free and athermal dissection is important (see figure below). Strategies directed to preservation of the accessory pudendal artery, stimulation of periprostatic nerves regeneration, and organ-preserving approaches are as well included in this review.

Figure showing critical steps during RARP where potential injury to the neural hammock may occur. PNP = Proximal neurovascular plate, PNB = Prominent neurovascular bundle, ANP = Accessory neural pathways, NVB = Neurovascular bundle, PLND = Pelvic lymph node dissection.

In conclusion, a careful surgical technique should be implemented as an intraoperative strategy to optimized functional outcomes. Given the deeper knowledge of periprostatic nerves arrangement and the anatomical magnification provided by the robotic approach, an effort must be made to perform a tailored nerve-sparing in each patient according to his clinical and functional characteristics. With precision medicine, the field is evolving to accomplish intraoperative real-time assessment of surgical margins and prostatic histological architecture to improve the balance between oncologic resection and functional preservation. Further investigation is needed in this scenario.

Written by: Adriana M Pedraza, Krunal Pandav, Mani Menon, Mohit Khera, Vinayak Wagaskar, Zachary Dovey, Nihal Mohamed, Sneha Parekh, Ashutosh K Tewari

Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY., Scott Department of Urology, Baylor College of Medicine, Houston, TX., Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY.

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