Tag Archive for: end-to-side neurorrhaphy

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Residents’ Podcast: Long term follow up of erectile dysfunction after RP using nerve grafts

 Jesse Ory, Kyle Lehmann and Jeff Himmelman

Department of Urology, Dalhousie University
Halifax, NS, Canada

Abstract

Objective

To study a novel penile reinnervation technique using four sural nerve grafts and end-to-side neurorraphies connecting bilaterally the femoral nerve and the cavernous corpus and the femoral nerve and the dorsal penile nerves.

Patients and Methods

Ten patients (mean [± sd; range] age 60.3 [± 4.8; 54–68] years), who had undergone radical prostatectomy (RP) at least 2 years previously, underwent penile reinnervation in the present study. Four patients had undergone radiotherapy after RP. All patients reported satisfactory sexual activity prior to RP. The surgery involved bridging of the femoral nerve to the dorsal nerve of the penis and the inner part of the corpus cavernosum with sural nerve grafts and end-to-side neurorraphies. Patients were evaluated using the International Index of Erectile Function (IIEF) questionnaire and pharmaco-penile Doppler ultrasonography (PPDU) preoperatively and at 6, 12 and 18 months postoperatively, and using a Clinical Evolution of Erectile Function (CEEF) questionnaire, administered after 36 months.

Results

The IIEF scores showed improvements with regard to erectile dysfunction (ED), satisfaction with intercourse and general satisfaction. Evaluation of PPDU velocities did not reveal any difference between the right and left sides or among the different time points. The introduction of nerve grafts neither caused fibrosis of the corpus cavernosum, nor reduced penile vascular flow. CEEF results showed that sexual intercourse began after a mean of 13.7 months with frequency of sexual intercourse varying from once daily to once monthly. Acute complications were minimal. The study was limited by the small number of cases.

Conclusions

A total of 60% of patients were able to achieve full penetration, on average, 13 months after reinnervation surgery. Patients previously submitted to radiotherapy had slower return of erectile function. We conclude that penile reinnervation surgery is a viable technique, with effective results, and could offer a new treatment method for ED after RP.

Article of the Week: Treatment of ED after RP using nerve grafts and end-to-side somatic-autonomic neurorraphy

Every week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Long-term follow-up of treatment of erectile dysfunction after radical prostatectomy using nerve grafts and end-to-side somatic-autonomic neurorraphy: a new technique

Jose Carlos Souza Trindade*, Fausto Viterbo, Andre Petean TrindadeWagner Josen Favaro§ and Jose Carlos Souza Trindade-Filho*

 

*Department of Urology, † Divisions of Plastic Surgery,‡ Radiology, Botucatu School of Medicine, State University of Sao Paulo, Sao Paulo, and §Department of Anatomy, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil

 

Abstract

Objective

To study a novel penile reinnervation technique using four sural nerve grafts and end-to-side neurorraphies connecting bilaterally the femoral nerve and the cavernous corpus and the femoral nerve and the dorsal penile nerves.

Patients and Methods

Ten patients (mean [± sd; range] age 60.3 [± 4.8; 54–68] years), who had undergone radical prostatectomy (RP) at least 2 years previously, underwent penile reinnervation in the present study. Four patients had undergone radiotherapy after RP. All patients reported satisfactory sexual activity prior to RP. The surgery involved bridging of the femoral nerve to the dorsal nerve of the penis and the inner part of the corpus cavernosum with sural nerve grafts and end-to-side neurorraphies. Patients were evaluated using the International Index of Erectile Function (IIEF) questionnaire and pharmaco-penile Doppler ultrasonography (PPDU) preoperatively and at 6, 12 and 18 months postoperatively, and using a Clinical Evolution of Erectile Function (CEEF) questionnaire, administered after 36 months.

Results

The IIEF scores showed improvements with regard to erectile dysfunction (ED), satisfaction with intercourse and general satisfaction. Evaluation of PPDU velocities did not reveal any difference between the right and left sides or among the different time points. The introduction of nerve grafts neither caused fibrosis of the corpus cavernosum, nor reduced penile vascular flow. CEEF results showed that sexual intercourse began after a mean of 13.7 months with frequency of sexual intercourse varying from once daily to once monthly. Acute complications were minimal. The study was limited by the small number of cases.

Conclusions

A total of 60% of patients were able to achieve full penetration, on average, 13 months after reinnervation surgery. Patients previously submitted to radiotherapy had slower return of erectile function. We conclude that penile reinnervation surgery is a viable technique, with effective results, and could offer a new treatment method for ED after RP.

Editorial: Somatic-autonomic neurorrhaphy for erectile function restoration after radical prostatectomy

The authors of the present study [1] are to be commended for their efforts in describing their 3-year experience with a novel bilateral end-to-side somatic-autonomic neurorrhaphy intended to restore erectile function at least 24 months after radical prostatectomy, after which spontaneous return of erectile function is unlikely [2]. Using the principles of brain plasticity and neurotization, the authors describe, for the first time, bilateral sural neurografting between the femoral nerve and both the corpus cavernosum and the dorsal nerve of the penis to achieve penile re-innervation. The employed side-to-end neurorrhaphy theoretically limits functional damage during axonal sprouting, reinforces sensory–motor communications to the cavernous nerves, and promotes glans penis sensitivity, although direct evidence of these physiological and clinical outcomes is yet to be demonstrated. Furthermore, the authors astutely capitalize on the potential advantages of using a femoral donor nerve, including its proximity to the proximal penis, its diameter, the sufficient axon count, the mixed composition of sensory and motor fibres, and its secretion of acetylcholine which is an essential neurotransmitter in the nitric oxide-mediated pathway leading to penile tumescence.

What is especially singular about this technique is its application months after radical prostatectomy following demonstrated post-surgical loss of erectile function. Previous studies have focused on unilateral or bilateral sural [3-6] or genitofemoral [7] neurografting of the cavernous nerves at the time of radical prostatectomy before post-surgical loss of erectile function could be substantiated. Such studies have had mixed results, attributable in part to the success of the nerve-sparing radical prostatectomy technique in the hands of experienced high-volume surgeons [3, 6], and post-surgical exposure of the cavernous nerves to androgen deprivation or radiation therapy in some patients [3, 5]. Whereas post-radical prostatectomy re-innervation of the cavernous nerves may not be feasible or efficacious secondary to post-surgical and post-radiation fibrosis, the described technique does not require abdominopelvic access, is associated with a quick recovery time and minimal complications, and does not preclude subsequent penile prosthesis implantation if necessary.

The results of the present study show significant improvement in general sexual satisfaction from baseline to 6 months post intervention corresponding to achievement of flaccid erection for all patients; significant improvement in erectile dysfunction from baseline to 12 months post intervention corresponding to achievement of semi-rigid or rigid erections in 8/10 patients; and significant improvement in satisfaction with sexual intercourse from baseline to 18 months post intervention corresponding to achievement of penetration for 6/10 patients. It should be noted, however, that administration of the Clinical Evolution of Erectile Function instrument at 36 months postoperatively may have introduced recall bias in patient-reported erectile function. As would be expected, no significant differences were noted in sexual desire or orgasm satisfaction during the study period. These results were achieved without evidence of atrophy, fibrosis, or significant differences in vascular flow of the bilateral corpora cavernosa; and with minimal complications over the study period.

The present study provides preliminary data regarding the safety, feasibility and efficacy of bilateral sural neurografting between the femoral nerve and both the corpus cavernosum and the dorsal nerve of the penis to restore post-radical prostatectomy erectile function in a limited pool of 10 men. If these preliminary results are substantiated with long-term follow-up in a significant number of patients, it should prompt multi-institutional collaborations to appropriately power comparative effectiveness analyses of post-radical prostatectomy neurorrhaphy, such as the described technique to a regulatory-approved ethical sham intervention, vacuum assist device therapy, urethral suppository therapy, or intracavernosal injection therapy. Ideally, patients should be matched or statistical analyses should be controlled for patient age, relevant comorbidities, prostate cancer stage, pre-radical prostatectomy erectile function, nerve-sparing radical prostatectomy technique, androgen deprivation therapy, radiation therapy, response to phosphodiesterase-5 inhibition, and time interval between radical prostatectomy and intervention. Such multi-institutional studies would benefit from: standardized protocols for preoperative evaluation, operative technique, peri-operative care and post-surgical sexual stimulation; repeated-measure analyses of both objective assessments of the quality and duration of penile tumescence, as well as patient-reported outcomes of erectile function and disease-specific quality of life using validated instruments; report of oncological outcomes; and long-term follow-up. We would encourage the authors to produce a technical video demonstrating their technique so that it may be attempted and validated by other programmes. Urological surgeons with expertise in oncology, sexual function, and reconstruction may collaborate and pool patient data to achieve high-powered quality studies of novel techniques, such as the one described in the present study, for post-radical prostatectomy erectile function restoration.

Jaime A. Cavalloand Ashutosh K. Tewari, Chairman
Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at M ount Sinai, New York, NY, USA

 

How to Cite

Cavallo, J. A. and Tewari, A. K. (2017), Somatic-autonomic neurorrhaphy for erectile function restoration after radical prostatectomy. BJU International, 119: 816–818. doi: 10.1111/bju.13858

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