Prostate cancer is one of the most common cancers affecting men, and for localized disease, surgical removal of the prostate gland, known as a radical prostatectomy, is a primary treatment option. This procedure aims to eliminate the cancer while minimizing side effects that significantly impact a patient’s quality of life. Surgeons employ different techniques during the prostatectomy, broadly categorized into nerve-sparing and non-nerve-sparing approaches. The choice between these two surgical strategies involves balancing cancer removal and preserving vital functions, such as sexual health and urinary control.
Defining the Surgical Approaches
The fundamental difference between the two prostatectomy techniques centers on the handling of the neurovascular bundles, which are delicate structures located on either side of the prostate. These bundles contain the cavernous nerves responsible for controlling erectile function. The nerves travel alongside the prostate, encased within layers of fascia, before innervating the penis.
A nerve-sparing (NS) prostatectomy is a meticulous dissection where the surgeon carefully separates these bundles from the prostate capsule, preserving their integrity as the gland is removed. The goal is to leave the nerves intact to maximize the potential for functional recovery. The degree of preservation can vary, with approaches ranging from an intrafascial dissection to an interfascial dissection.
In contrast, a non-nerve-sparing (NNS) prostatectomy involves removing the neurovascular bundles along with the entire prostate gland. This technique is a wider excision designed to create the broadest possible margin of healthy tissue around the tumor, sacrificing the nerves that mediate erectile function for maximum cancer clearance.
Impact on Sexual Function and Continence
The preservation status of the neurovascular bundles is the strongest predictor of sexual function recovery following prostatectomy. The NS procedure significantly increases the likelihood of regaining erections sufficient for intercourse, though the nerves can still suffer from stretching or thermal injury during the delicate dissection. Men who undergo a bilateral nerve-sparing procedure, where both bundles are preserved, have the highest chance of functional return.
Patients undergoing a non-nerve-sparing procedure face a very low probability of recovering natural erectile function, as the nerves have been removed. Functional recovery in NS patients is often gradual, taking 12 to 24 months to reach a plateau. Factors such as a patient’s age and erectile function before surgery also influence the final outcome, with younger men generally experiencing better results.
The nerve-sparing status also influences the recovery of urinary continence. Studies show that NS procedures are associated with a faster return of urinary control compared to NNS procedures, particularly in the first six months after surgery. At the 12-month mark, recovery rates for continence become comparable between the two groups, but the early advantage of NS is notable.
When Nerve Sparing Is Not an Option
The decision to perform a nerve-sparing procedure is always secondary to the primary goal of cancer control. A non-nerve-sparing approach becomes mandatory when there is a high risk that cancer cells have spread to or are dangerously close to the neurovascular bundles. This trade-off prioritizes oncological safety over functional preservation.
Surgeons use several preoperative and intraoperative criteria to determine if NS is safe. Preoperative information, such as the stage and grade of the cancer from biopsy results, is important. Indicators that the cancer may be invading the nerve bundles include high-grade tumors, a large number of positive biopsy cores on one side of the prostate, or imaging evidence of extra-capsular extension.
If the tumor is determined to be too close to or has breached the prostate capsule in the area where the nerves are located, the surgeon must perform a non-nerve-sparing dissection on that side. This is often an intraoperative decision, where the surgeon assesses the margin of tissue around the tumor visually or through frozen-section analysis. If there is any doubt about leaving cancer behind, the neurovascular bundle is sacrificed to maximize the chance of a clear surgical margin and prevent recurrence.
Recovery Timelines and Rehabilitation Efforts
While the immediate surgical recovery period, including hospital stay and catheter use, is similar for both NS and NNS prostatectomies, the long-term rehabilitation efforts differ significantly. Patients who undergo a nerve-sparing procedure are encouraged to participate in penile rehabilitation. This process involves using medications, such as PDE-5 inhibitors like sildenafil or tadalafil, often in conjunction with vacuum erection devices, to encourage blood flow to the penis.
The purpose of rehabilitation is to prevent tissue changes, such as fibrosis, that can occur in the absence of regular erections, keeping the erectile tissue healthy while the nerves recover from surgical trauma. Recovery of function is a slow process, with full potential recovery taking up to two years. Early initiation of penile rehabilitation, beginning shortly after catheter removal, is associated with better long-term erectile function outcomes.
For patients who undergo a non-nerve-sparing procedure, this specific form of sexual function rehabilitation is generally not applicable, as the nerves required for a natural erection are no longer present. These patients may instead explore other options for sexual function, such as penile implants or injection therapies. Regardless of the nerve-sparing status, all patients are advised to perform pelvic floor muscle exercises to aid in the recovery of urinary continence.