DESCRIPTION
Erectile dysfunction is a common problem after radical prostatectomy. Spontaneous erections are usually absent in men whose prostate cancer required bilateral resection of the neurovascular bundles as part of the radical prostatectomy procedure. There has been interest in sural nerve grafting to replace cavernous nerves resection to reduce the risk of postoperative erectile dysfunction. The sural nerve is considered expendable and has been extensively used in other nerve grafting procedures, such as brachial plexus and peripheral nerve injuries. As applied to prostatectomy, a portion of the sural nerve is harvested from one leg and then anastomosed to the divided ends of the cavernous nerve. Reports also indicate the use of other nerves (e.g., genitofemoral nerve) for grafting.
POLICY
Nerve grafting with radical prostatectomy and resection of one or both neurovascular bundles is considered investigational.
IMPORTANT REMINDERS
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ADDITIONAL INFORMATION
The evidence for nerve grafting in individuals who have radical prostatectomy with resection of neurovascular bundles includes one randomized controlled trial (RCT), cohort studies and case series. The RCT did not find that unilateral nerve grafting was associated with a statistically significant improvement in potency rates at two years post-surgery. Cohort studies, limited by lack of randomization and blinding, also did not result in better outcomes with nerve grafting. The evidence is insufficient to determine the effects of the technology on health outcomes.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (5:2023). Nerve graft with radical prostatectomy (7.01.81). Retrieved December 1, 2023 from https://www.bcbsaoca.com/eps/. (7 articles and/or guidelines reviewed)
Davis, J.W., Chang, D.W., Chevray, P., Wang, R., Shen, Y., Wen, S., et al. (2009). Randomized phase II trial evaluation of erectile function after attempted unilateral cavernous nerve-sparing retropubic radical prostatectomy with versus without unilateral sural nerve grafting for clinically localized prostate cancer. European Urology, 55 (5), 1135-1143. (Level 2 evidence)
Kung, T., Waljee, J., Curtina, C., Wei, J., Montie, J., & Cederna, P. (2015). Interpositional nerve grafting of the prostatic plexus after radical prostatectomy. Plastic & Reconstructive Surgery, 3, e452. (Level 4 evidence)
National Comprehensive Cancer Network. (2023, September). NCCN clinical practice guidelines in oncology (NCCN Guidelines®). Prostate cancer v. 4.2023. Retrieved December 1, 2023 from the National Comprehensive Cancer Network.
Siddiqui, K.M., Billia, M., Mazzola, C.R., Alzahrani, A., Brock, G.B., Scilley, C., & Chin, J.L. (2014). Three-year outcomes of recovery of erectile function after open radical prostatectomy with sural nerve grafting. The Journal of Sexual Medicine, 11 (8), 2119-2124. Abstract retrieved August 10, 2016 from PubMed database.
Souza Trindade, J.C., Viterbo, F., Petean Trindade, A., Fávaro, W.J., & Trindade-Filho, J.C.S. (2017). 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. BJU International, 119 (6), 948-954. Abstract retrieved June 6, 2018 from PubMed database.
ORIGINAL EFFECTIVE DATE: 3/1/2003
MOST RECENT REVIEW DATE: 1/11/2024
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