In potent, young patients diagnosed with clinically localized prostate cancer, sparing of the neurovascular bundles during radical prostatectomy is crucial for preservation of erectile function. Intraoperative ultrasound monitoring, combined with preoperative oncologic data, can greatly improve outcomes. Novel, emerging techniques and ultrasound-driven imaging technologies may further advance the practice of nerve preservation.
It is important that the final decision on the performance and extent of nerve sparing not be made until the patient's local anatomy and periprostatic tissue quality have been intraoperatively assessed. Precise intraoperative knowledge regarding the presence, location, and degree of microscopic ECE could potentially allow the surgeon to modify the surgical dissection by performing a site-specific, slightly wider excision at the "high-risk area" of ECE to secure negative margins, while still achieving partial nerve preservation. Such real-time intraoperative information is not currently available in an objective and reliable manner.
Complete versus partial nerve preservation. The goal of nerve preservation is the optimal maintenance of erectile function while still achieving negative surgical margins. The determination of whether complete or partial nerve sparing should be performed should be individualized for each patient at risk for ECE. Walsh and colleagues recommend intraoperative inspection by digital palpation during open RP to facilitate:
Concern was recently raised that the muted tactile feedback afforded by laparoscopic radical prostatectomy (LRP) may potentially compromise such individualized intraoperative assessment of prostate induration suggestive of ECE.1