Nerve advancement with end-to-end reconstruction after partial neurovascular bundle resection:a feasibility study.
OBJECTIVE
It is clear that some patients with prostate cancer require a total or partial neurovascular bundle (NVB) resection for oncologic safety to be guaranteed. Nerve grafting is an alternative for these patients to maintain erectile function; however, we report on a feasible option where the NVB is released, and both terminal nerve fibers are approximated; this is the "nerve advancement technique (NAT)."


METHODS
Since 2005, a total of 215 men aged 48 to 70 years (mean 59 years) with a Sexual Health Inventory for Men (SHIM) score of 22 have undergone robotic radical prostatectomy for cancer. We selected prospectively seven men to have NAT performed because of clinical high-risk criteria (serum prostate specific antigen [PSA] concentration >20 mg/dL, Gleason score = 8, and stage cT(2c) or higher), intraoperative criteria (difficulty separating the tissues around the prostate), and evidence of extracapsular extension (ECE) on magnetic resonance imaging. We performed unilateral partial resection, nerve advancement, and, finally, end-to-end anastomosis in six patients, whereas in one patient, we did a bilateral partial excision. We analyzed the results in terms of oncologic safety (positive surgical margins and PSA) and SHIM score after 18 months of follow-up.


RESULTS
Pathologic examination revealed stage T3 disease in six patients; one had a positive surgical margin. Two patients are receiving salvage radiotherapy for PSA relapse, and five continue to have undetectable PSA concentrations after a median follow-up of 20 months. Five of the seven men recovered erectile potency with or without a phosphodiesterase inhibitor, and their median SHIM score is 18.


CONCLUSIONS
We are encouraged by the initial results of NAT. The procedure may be an alternative for men who require extensive NVB dissection. However, further experience, longer follow-up, and independent trials are necessary.
Martinez-Salamanca
Juan I
JI
Weill Medical College of Cornell University, New York, New York, USA.
Rao
Sandhya
S
Ramanathan
Rajan
R
Gonzalez
Javier
J
Mandhani
Anil
A
Yang
Ximing
X
Tu
Jiangling
J
Vaughan
E Darracott
ED
Tewari
Ashutosh
A
D000368:Aged; D007172:Erectile Dysfunction / Q000517:prevention & control; D005240:Feasibility Studies; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011183:Postoperative Complications / Q000517:prevention & control; D011446:Prospective Studies; D011467:Prostate / Q000294:innervation / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D020127:Recovery of Function; D012371:Robotics; D016896:Treatment Outcome