Artery sparing radical prostatectomy--myth or reality?

ABSTRACT

PURPOSE: Not all patients in whom the neurovascular bundles are preserved recover erectile function after radical prostatectomy. A significant proportion of these men have vascular abnormalities that can impact erectile function recovery after radical prostatectomy. We describe the available evidence supporting the need to spare not only the nerves, but also the arteries to improve erectile function recovery after radical prostatectomy. MATERIALS AND METHODS: A literature review was done to determine the available evidence supporting vascular insufficiency as a contributor to erectile dysfunction after radical prostatectomy. RESULTS: There is no question that preservation of the cavernous nerves is key to erectile function recovery after radical prostatectomy. In addition, it is believed that erectile tissue requires oxygenation to maintain its integrity, which can be significantly affected if the arteries irrigating the cavernous bodies are damaged intraoperatively, such as the accessory pudendal arteries. In approximately 1 of every 4 patients undergoing laparoscopic radical prostatectomy accessory pudendal arteries of different calibers are identified. Thus, accumulating evidence supports the concept that the accessory pudendal arteries have a role in erectile function and its recovery after radical prostatectomy and, furthermore, supports the idea that preserving the accessory pudendal arteries may contribute to erectile function recovery. CONCLUSIONS: Based on the evidence at hand we believe that it is appropriate to build on the notion of nerve sparing radical prostatectomy by introducing the urological community to the concept of artery sparing radical prostatectomy in an attempt to make the urological community aware of the potential need to spare the accessory pudendal arteries. The crux of the difficulty is in deciding which arteries should be preserved and which may be sacrificed. Thus, defining the role of the accessory pudendal arteries in erectile function recovery requires intraoperative analysis of the functional role of these vessels.