Robotic Cavernous Nerve Reconstruction with Sural Nerve Grafts: An Initial Experience

Cavernous nerve reconstruction has been an innovative advancement in the restoration of potency for patients undergoing radical prostatectomy with unilateral or bilateral excision of neurovascular bundles. These authors described the largest experience of cavernous nerve reconstruction with sural nerve graft, exclusively using the da Vinci robot (Intuitive Surgical, Mountain View, CA).

Robotic cavernous nerve reconstruction with sural nerve graft was successfully performed in four consecutive potent patients undergoing an entirely robotic radical prostatectomy, with planned wide excision of one or both neurovascular bundles for oncologic control. Patients 1 and 2 had immediate reconstruction of bilateral cavernous nerves, while patients 3 and 4 had immediate reconstruction of unilateral cavernous nerves. All nerve harvests, using a minimal scar technique, and all nerve reconstructions, using the da Vinci robot were performed by a single plastic surgeon. Two to three interrupted 7-0 Prolene epineurial sutures were used for both proximal and distal neurorrhaphies.

The ages of the patients were 66, 52, 52, and 57 years, respectively. Mean additional operative time was 55 min. Surgical margins were free of tumor in all patients. Follow-up periods of 10, 8, 6, and 2 weeks, respectively, were not sufficient to assess either reported spontaneous penile engorgement or response to Sildenafil. There were no donor-site complications.

Several authors have described cavernous nerve reconstruction under loupe magnification after open radical prostatectomy with promising results. However, reconstruction has proven to be technically challenging, as the nerve endings are poorly visualized, positioned deep, and posterior in the pelvis in a relatively blood filled cavity. These authors described the most extensive experience to date of cavernous nerve reconstruction performed entirely using the da Vinci robot. This has technically facilitated the reconstruction by providing a X10 magnified, stereoscopic, direct, and clear visualization of the nerve endings. Long-term potency assessment would be essential to validate the superiority over open techniques.