Objective: Advanced local stage prostate and bladder cancers frequently require wide local resection and sacrifice of cavernous nerves for negative surgical margin leading to erectile dysfunction. This study documents preliminary experience with unilateral cavernous nerve reconstruction using sural nerve graft, its safety and efficacy in recovery of erectile function.

Material and methods: Sural nerve grafting was performed unilaterally after primary resection. Postoperative treatment with sidenafil and alprostadil was given until recovery of spontaneous function. Recovery was documented on the International Index of Erectile Function (IIEF).

Results: 12 unilateral nerve grafts were performed, 10 during radical prostatectomy and 2 during radical cystoprostatectomy. Mean age was 57.5 years and the mean follow up was 16.1 months. Surgical margins were positive in 5 while 2 had positive lymph nodes. At the most recent follow up 4 patients were fully potent while 1 had improving partial erections. The only complication was one superficial donor site wound infection.

Discussion: Animal studies using genitofemoral nerve grafts have documented recovery of erectile function in denervated rats. In humans this is a technically challenging procedure due to the complexity of cavernous nerves, short distal cavernous stumps, difficulty using a microscope in the depth of the plexus, a bleeding resection bed and an uneven operating field. 4/12 patients in our study had return of spontaneous erectile function with a score >20 while1 had partial recovery. The average time to return of function was 16 months with faster recovery seen in younger patients. Patients receiving external beam radiation or hormonal therapy had no recovery as irradiation compromises the revascularization of the nerve graft. Kim et al reported 3/12 patients with rigid erections while 9 had varying degree of recovery after sural nerve graft. They indicated that full benefits might not be appreciated until 24 – 36 months. Sural nerve grafts are extensively used in peripheral nerve surgery and may be a better donor tissue than genitofemoral nerve. Our study indicates that unilateral sural nerve grafts after radical resections are technically feasible and associated with minimum morbidity. Younger patients and patients with negative surgical margins (4/7) can have restored potency. Extracapsular spread is a vexing problem since it carries a high risk of recurrence and also needs adjuvant hormonal or radiation therapy, which further compromises recovery. This technique may provide patients with wide local disease, the opportunity of a spontaneous erectile function and allow surgeons to perform more aggressive tumor resection.