Nerve Sparing, or Nerve Guessing?

For approximately 50 percent of men facing prostate cancer treatment, sexual dysfunction is one of the most troubling potential side effects, according to the University of California, Irvine. But the main concern for men is urinary incontinence. Often, when patients ask their surgeons about the side effects of robot-assisted radical prostatectomy (RARP) surgery, and how they will be protected from these side effects, surgeons start discussing “nerve sparing” practices. Patients are told that nerves responsible for urinary and sexual function will be avoided and, where possible, left intact during the surgery. And while this may sound reassuring, nerve sparing alone is not enough: it doesn’t spare all the nerves related to urinary and sexual function. Men undergoing prostatectomies who want their cancer removed and the best chance at full quality of life post-surgery, should not choose surgeons who solely rely on traditional nerve sparing. It is quite a common occurrence for a surgeon to see two similar patients who have two different outcomes after their surgery. If traditional nerve sparing is as effective as it appears, how can outcomes differ like this?

Why Nerve Sparing Alone Won’t Work

It is often cited that the nerves responsible for erectile function are in the neurovascular bundles (NVB). Nerve sparing is a surgical approach by which surgeons use their textbook anatomy knowledge of NVBs, which are visible to the naked eye, and avoid damage to those areas wherever possible. However, 38–40 percent of patients experience sexual dysfunction, while 20–40 percent experience incontinence 12 months after prostatectomies, even though their surgeons may have employed nerve-sparing techniques. If nerve-sparing is so effective, why are these figures so high?

Surgeons who discuss nerve sparing with their patients do not always make clear a crucial piece of information: NVB are not the only part of the equation. Somatic nerves that lie outside the NVB are also key to urinary and sexual function, as they are critical for reaching full penile rigidity and urinary control. The exact locations of these somatic nerves vary from person to person and even from one side to the other in approximately 50 percent of cases. Because these somatic nerves are not visible to the human eye, “nerve sparing” could more accurately be called “nerve guessing”. Once the surgeon is operating, there is no way to know whether they are damaging somatic nerves key to urinary and sexual function. It is important to understand that the definition of “damage” isn’t limited to removing these nerves along with the cancerous tissue; damage can be done by cutting, heat (during cauterization) and even manipulation. Therefore, even the most skilled and experienced surgeons cannot guarantee the kind of results a patient would define as successful simply by employing nerve sparing. There is, however, a tool to assist surgeons in locating somatic nerves, which needs to be used alongside nerve sparing.

The Insight of Nerve Monitoring

Nerve monitoring technology was created with the aim of reducing damage caused to nerves by identifying the location of, and monitoring the integrity of, nerves during surgery. Nerve monitoring is standard of care in spine, maxillofacial and various orthopedic surgeries. During RARP in addition to helping the urologist locate the nerves responsible for sexual function, nerve monitoring also helps locate the somatic nerves that preserve urinary continence. By identifying the location of somatic nerves, the surgeon is more confident throughout the surgery and is able to decide whether particular nerves can be left intact. The more nerves left intact, the better the outcome for the patient. In fact, surgeons using nerve monitoring during their surgeries surveyed said 75 percent of patients achieve better outcomes regarding sexual function, as measured by the International Index of Erectile Function (IIEF) and the Sexual Health Inventory for Men (SHIM). 100 percent of surgeons report better patient continence as measured by the Expanded Prostate Cancer Index Composite (EPIC), after using nerve monitoring technology during the surgery.

Avoiding the Guessing Game

Even though nerve monitoring has been the standard of care for multiple surgical procedures for over 20 years, some urologists are still reluctant to use this technology for prostatectomies because they are focused on the most pressing issue: removing the cancerous tissue. They consider current nerve sparing techniques to be adequate.

It’s time that patients were given the full story about nerve sparing: that while it can certainly help preserve some of the nerves responsible for urinary and sexual function, it fails to detect — and therefore help surgeons preserve — somatic nerves. Nerve monitoring, on the other hand, can detect these important nerves. Patients should not be shy to ask their surgeons about the ProPep nerve monitoring system and how it differs from current nerve sparing techniques. If your surgeon will not use nerve monitoring during RARP, then you can find a surgeon that does.

For more information on nerve monitoring technology, please visit the ProPep Surgical website here.