Cavernous nerve graft reconstruction during radical prostatectomy or radical cystectomy: safe and technically feasible

High local stage prostate and bladder cancers frequently require wide local resection and sacrifice of one or both cavernous nerves to achieve a negative surgical margin, thus resulting in erectile dysfunction. This is a report on preliminary experience with cavernous nerve graft reconstruction using sural nerve grafts with radical prostatectomy or radical cystectomy. Pre-operative evaluation was performed and consent was obtained in 14 potent men with prostate (11) or bladder (three) cancer. Sural nerve grafts of resected cavernous nerves were performed using a microsurgical technique. Post-operative treatment (Sildenafil or Alprostadil) was pursued until return of spontaneous function, documented by interview and adequate scores (>20) in the erectile function (EF) domain of the International Index of Erectile Function (IIEF). Twelve unilateral nerve grafts were performed, 10 during radical prostatectomy and two during radical cystoprostatectomy. Two procedures were technically not possible because of locally advanced disease. Mean age was 57.5y (36-68y). Mean follow up was 16.1 months (7-28 months). Pathological stage of prostate cancer was pT2 in 2, pT3 in 7 and pT4 in one. Surgical margins were positive in five out of 10 (50%), and two (20%) had positive lymph nodes. Four patients (three post prostatectomy and one post cystectomy) were fully potent. Additionally, one patient post prostatectomy had improving partial erections. Six patients post prostatectomy and one patient post cystectomy had no erections. The only complication was one superficial wound infection in the sural nerve donor site. Preliminary experience shows that sural nerve grafts are feasible and safe after radical prostatectomy and cystectomy. However, candidates usually present with high stage disease, high risk for recurrence and frequent requirement for adjuvant therapy that further compromises erectile function. Randomized studies with more patients and long follow-up periods are necessary in order to define the ideal candidate for nerve graft procedures.