Cavernous Nerve Reconstruction with Sural Nerve Grafting Using Fibrin Glue and Collagen Nerve Guides

Erective dysfunction remains a significant concern after radical retropubic prostatectomy (RRP), especially after one or both neurovascular bundles (NVBs) are intentionally resected for high-risk, localized disease. Cavernous nerve reconstruction using sural nerve grafting techniques has significantly impacted potency rates following this procedure. The authors evaluated the use of collagen nerve guides and fibrin glue to simplify the technique of sural nerve grafting during RRPs in patients with high-risk, localized prostate cancer.

Since early 2002, patients with unilateral or bilateral high-grade, localized disease were offered cavernous nerve reconstruction using sural nerve grafting. During the course of RRP ± pelvic lymph node dissection, the NVBs were identified bilaterally, both proximally and distally, with the CaverMap nerve stimulator. Reversed sural nerve grafts were coapted between the proximal and distal ends of the resected NVBs using a 1.0-cm segment of longitudinally bisected collagen nerve guide and fibrin glue. This obviated the need for microsuture deep within the pelvis. Only patients who were a minimum of 12 months postoperative were evaluated.

Seven patients have been followed for more than 1 year since surgery – six unilateral and 1 bilateral nerve graft. All patients exhibited unassisted potency preoperatively. Patient mean age was 59 years. Of the unilateral patients, 4 of 6 experienced unassisted potency, 1 requires oral medication, and 1 has yet to respond (15 months postoperative). The single bilateral patient obtains functional erections with oral medication.

Sural nerve grafting is an effective means of preserving potency in higher risk patients where non-nerve-sparing techniques are employed. Early experience with the use of fibrin glue and collagen nerve guides would indicate that this approach does not interfere with nerve regeneration and may improve the outcomes of this procedure, while simplifying the microsurgical technique. Larger studies and longer follow-up are needed to further characterize effectiveness.