A nerve sparing prostatectomy is a specialized surgical procedure designed to remove the prostate gland, typically for localized prostate cancer. This technique focuses on minimizing damage to the delicate nerve structures adjacent to the prostate that control erectile function and contribute to urinary control. The goal is to achieve oncologic safety—complete removal of the cancer—while maximizing the potential for a return to pre-operative sexual and urinary function.
Anatomy and the Nerve Sparing Technique
The success of this procedure hinges on understanding the location of the neurovascular bundles (NVBs), which transmit the signals necessary for a penile erection. These bundles are positioned on the outer surface of the prostate, running alongside the gland within the fascial layers. The nerves in these bundles are extremely fine and can be easily damaged by heat, traction, or direct cutting during prostate removal.
The surgical goal of nerve sparing is to meticulously dissect the prostate away from these NVBs, essentially peeling the gland from the surrounding tissue where the nerves reside. This dissection is performed along the fascial planes, which are the natural tissue layers that separate the prostate from the NVBs.
An “intrafascial” approach aims for the maximum extent of nerve preservation by dissecting closest to the prostate capsule. Conversely, an “interfascial” or “extrafascial” approach involves a wider dissection plane, which offers less functional preservation but may be necessary to ensure all cancerous tissue is removed.
Surgeons categorize preservation into “full” or “partial” nerve sparing, which may be done unilaterally or bilaterally. If pre-operative assessment suggests the cancer is close to or has breached the capsule on one side, a partial or no-sparing technique is used on that side to prioritize cancer control. This requires the surgeon to balance the risk of leaving cancer behind against the benefit of preserving function.
Patient Suitability for the Procedure
Selecting the appropriate patient for a nerve sparing procedure is paramount because oncologic safety must always take precedence over functional preservation. The primary limiting factor for performing a nerve sparing prostatectomy is the location and aggressiveness of the prostate cancer. If the tumor is large, high-grade, or appears to be close to the prostate’s edge, preserving the adjacent nerves may risk leaving cancerous cells behind, a condition known as extraprostatic extension (EPE).
To assess this risk, surgeons rely heavily on pre-operative diagnostic information, particularly multiparametric Magnetic Resonance Imaging (mpMRI) and biopsy results, including the Gleason score. An mpMRI can help visualize the prostate and identify areas where the tumor is suspected of having spread toward the neurovascular bundles. A high Gleason score or a large volume of high-grade cancer on biopsy increases the likelihood of EPE, making a wider, non-sparing dissection a safer choice.
If the cancer is confirmed or highly suspected to involve the NVBs, the surgeon will choose to perform a wider excision on that side, sacrificing the nerves to ensure a clear surgical margin. Therefore, the best candidates are those with low- or intermediate-risk localized cancer that appears confined to the prostate gland. Secondary considerations include the patient’s age and their pre-operative erectile function, as better function before surgery is a strong predictor of better function afterward.
Functional Outcomes and Recovery Timeline
The most common concerns following a nerve sparing prostatectomy relate to the recovery of urinary continence and sexual function. Nerve sparing does not guarantee an immediate or full return to pre-operative function, as the nerves are often stretched, bruised, or partially damaged during the meticulous dissection. Recovery is a gradual process that can extend over a significant period, sometimes taking up to 12 to 24 months for maximum improvement to be achieved.
Urinary continence typically recovers faster than sexual function, with many patients achieving control within the first few months. Recovery of sexual function, or potency, often takes longer, with a significant correlation to the extent of nerve sparing performed and the patient’s age. For patients who were potent before surgery and underwent maximal nerve sparing, recovery rates for erectile function range between 50% to 70% at 18 to 24 months.
Immediately following the procedure, a urinary catheter is typically left in place for about one to three weeks to allow the connection between the bladder and urethra to heal. Once the catheter is removed, most men experience some degree of temporary incontinence, which gradually improves with time and pelvic floor exercises. To aid in the return of erectile function, many physicians recommend a penile rehabilitation program, which may involve the use of medications, vacuum erection devices, or injections to encourage blood flow and oxygenation to the penile tissues during the recovery phase.
Different Surgical Approaches
The nerve sparing technique can be performed using several different access modalities, though the fundamental surgical principle of separating the NVBs from the prostate remains consistent.
Open Radical Prostatectomy
The traditional method is the Open Radical Prostatectomy, which requires a single, larger incision in the lower abdomen to provide direct access for the surgeon. This approach offers a tactile feel that some surgeons prefer when performing the delicate nerve dissection.
Laparoscopic Radical Prostatectomy
A less invasive option is the Laparoscopic Radical Prostatectomy, which uses small incisions and specialized long instruments guided by a two-dimensional camera. This technique reduces recovery time and blood loss compared to open surgery but can present a challenge for the fine movements required for nerve sparing.
Robotic-Assisted Laparoscopic Prostatectomy (RALP)
RALP is the most common approach for nerve sparing today. It provides the surgeon with a magnified, high-definition, three-dimensional view of the surgical field, which significantly enhances the visualization of the fine neurovascular bundles. The robotic instruments offer wrist-like articulation and tremor filtration, allowing for greater precision and control during the extremely delicate dissection required to separate the prostate from the nerves. This enhanced precision is why RALP has become the standard for maximizing the potential for a successful nerve sparing outcome.