Nerve Sparing Prostate Surgery: Everything You Need to Know

Prostate cancer is a common cancer and it can be deadly. In 2018, there were over a million new cases of prostate cancer. Most are low-grade but they grow slowly and have limited aggressiveness.

After getting diagnosed with prostate cancer, most patients are bent on getting rid of the ailment. But, after treating cancer, the side effects of the treatment itself start affecting their quality of life. People start feeling distressed the moment they are unable to resume a normal sex life.

Yet, at the time of diagnosis, the majority didn’t see the poor erectile function as a potential problem. Especially when they decided to choose their cancer treatment. 

In situations such as these, it is difficult to make the right call. That’s why we decided to talk more about your treatment opportunities.

Radical prostatectomy is the gold standard surgery for prostate cancer. But, because of the adverse events that come with this surgery, often active surveillance is recommended. 

Here, you can take a closer look at one particular option – nerve sparing prostate surgery. Its effects, benefits, and potential risks. Alongside other types of radical prostatectomy. 

What is Nerve Sparing Prostate Surgery?

So, what exactly is nerve sparing prostate surgery?

  • Surgery length – Approximately 3 to 4 hours (although operating time varies from person to person).

  • Unique trait – More minimally invasive and avoids unnecessary nerve damage.

  • Average hospital stay – 1 day (sometimes longer stays are necessary).

  • Benefits – Potential for good erectile recovery and preserving continence. 

  • Side effects – Sterility, lymphedema, reduction in penis length, and difficulty getting an erection.

Roughly 90,000 radical prostatectomies are done every year across the United States. Most men who seek definitive surgical treatment are between 55 and 65 years of age. They are estimated to enjoy 15-30 years overall life expectancy. 

Doctors suggest prostatectomy that spares the nerves if the cancer is not thought to have spread beyond the prostate gland. This surgery takes out the prostate gland together with some tissue, and the seminal vesicle. However, not every prostate surgery uses the same treatment methods. 

Depending on the size and location of the prostate tumor, doctors can suggest various types of prostatectomies. These include:

  • Nerve-sparing surgery 

  • Robotic-assisted laparoscopic operation

  • Radical perineal prostatectomy

  • Laparoscopic prostatectomy

  • Radical prostatectomy with a retropubic method

Here, we will pay closer attention to the nerve sparing procedure. In 2003, just 9.2% of radical prostatectomies were carried out using the minimally invasive surgical technique. By 2007, these numbers went up to a staggering 43.2%.

Nerve sparing radical prostatectomy (nsRP) ensures a safer and less invasive operation, explains the Department of Urology. Those with clinically localized prostate carcinoma can have their prostate gland removed, while preserving as much of the nerve structures around the area as possible. 

These structures are important for maintaining erections. That means the surgeon won’t cut the nerves close to the prostate. Patients who receive this kind of treatment have higher chances of maintaining a normal erection and urinary function after recovery. 

When Would It Be Performed?

The prostate features small nerve bundles responsible for controlling the erections. If the tumor gets coiled up around any of these nerves, then the surgeon can’t take it out without damaging the nerves. 

But, when the cancer is stuck inside the prostate or far from the nerves, then the doctor can use the nerve-sparing technique to take care of the tumor. 

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Who Can Be a Decent Candidate for the Surgery?

If the cancer is organ confined, then you would be a suitable candidate for the procedure. In other words, a well-differentiated, focal tumor. 

In comparison, patients with poorly differentiated or high-volume tumors may not be suitable for nerve sparing prostatectomy. 

The goal is to safeguard sexual potency in men as much as possible. But, the preservation will vary depending on the age, clinical cancer stage, and the state of the nerve bundles. 

How Does It Work?

For around 50% of men, sexual dysfunction is one of the most difficult side effects to deal with. This is especially true after a prostatectomy or any prostate cancer treatment. 

Roughly one year and a half after prostatectomy, erectile dysfunction rates range from 66%. Mainly among patients who had a non-nerve sparing procedure (nnsRP). 

When it comes to age, the risk of poor sexual functioning increases in older patients. Nerve sparing prostatectomy provides preservation of sexual potency that ranges from 20% to 70%. That’s why many couples can enjoy a normal erectile function. 

Nerve sparing prostatectomy works with the bundle of nerves of the side of the prostate. It’s a delicate and complex surgery. Like any other surgery for this type of cancer, nerve sparing prostatectomy uses a couple of different approaches. These are:

Open surgery (standard) 

The surgeon creates an incision in the abdomen just under the navel to the pubic bone. They then cut away the cancer and prostate while avoiding touching the nerves nearby.

Laparoscopic surgery (minimally invasive) 

There is a smaller incision compared to standard surgery. The surgeon takes cameras and laparoscopic tools to carry out the procedure. The tool goes inside the abdomen via narrow tubes. 

Robotic prostatectomy with nerve sparing 

Robotic radical prostatectomy is an advanced procedure. It is more practical than standard surgery. After cutting a small incision into the abdomen, the surgeon inserts adequate robotic tools. 

Then, they control the tool from a computer to carry out the entire surgery. Robotic prostatectomy enables the doctor to operate through tinner ports, rather than big incisions. It has quicker recovery time, shorter hospital stays, and fewer complications. 

During the procedure, the doctor will examine the positive surgical margin. With current technological advances, the typical open retropubic radical prostatectomy is often replaced with laparoscopic and robot-assisted radical prostatectomy.

Research shows that laparoscopic and robotic surgery create similar oncologic and functional outcomes. These results can be seen when compared with a typical open radical prostatectomy. 

They also decrease perioperative morbidity. In the U.S., robotic prostatectomy is the number one approach. Despite being more expensive than laparoscopic surgery.

Sometimes, complications can make nerve sparing tricky or impossible to carry out. For example, a bigger prostate, scarring, or abnormal blood vessel anatomy. These factors are difficult to predict before surgery. 

How Does The Procedure Compare to Typical Prostate Surgery?

With a minimally invasive procedure, people experience fewer respiratory complications (4.3%) than open surgery (6.6%). Nerve-sparing surgery provides better urinary function and erectile function than non nerve sparing or unilateral surgery. 

After studying 376 patients who took watchful waiting versus radical prostatectomy, the odds of erectile dysfunction were much higher in the surgery group. It reached 80% as opposed to 45% in the observational group. 

Nerve sparing prostatectomy is a lot more efficient in letting a patient maintain their erection compared to typical prostate surgery. Potency rates post unilateral nerve sparing are 30% and 76% with bilateral sparing surgery at three years. 

These rates tend to drop in older patients, including those who had erectile dysfunction before surgery. Also, sexual dysfunction and incontinence remain high in patients with robotic-assisted laparoscopic treatment. So, people shouldn’t expect fewer side effects with this latest treatment method. 

The Real Benefits and Effectiveness of This Surgery

It is difficult to measure the definite outcome of any cancer treatment. But, sparing the nerves does have its benefits. 

Males younger than 75 with limited prostate carcinoma with a 10-year life expectancy often get the most benefit from radical prostatectomy. 

Around 75% of patients who undergo nerve sparing surgery have successfully achieved an erection. That’s after taking the prescribed drug treatment. 

This technique uses delicate procedures with the potential for good erectile recovery. That means patients could eventually have a rigid or sufficient erection for penetration. 

One study examined the efficacy of this prostatectomy in 250 patients. The goal was to know whether it would preserve sexual function and urinary continence. 

Overall, 63% of patients preserved their sexual potency. Exactly 98% achieved postoperative continence six months after treatment. 

Of course, to achieve these results, the surgeon must use careful dissection throughout the entire surgery. The surgery spares the neurovascular bundles. These bundles are found in a triangle formed by the prostatic fascia, endopelvic fascia, and Denonvilliers’ fascia. 

Intrafascial dissection between the endopelvic fascia and prostatic fascia enables nerve sparing surgery. It is crucial to locate the prostatic fascia and the rest of the triangle to spare the nerves when performing the procedure. If cancer has extended, then a more extensive procedure may be necessary.

Side Effects 

Every surgery comes with potential adverse reactions. Prostatectomy that spares the nerves is no exception. In most cases, these include:

Urinary incontinence 

Urine leakage or urinary incontinence can happen after treatment. But, this complication can dissipate with time. According to research of 360 patients, recovery of continence was recorded in 74.6% after nnsRP. And 86.4% of patients post nsRP. 

Sterility 

This surgery reduces the odds of impotence. But that doesn’t mean it won’t cause it. Radical prostatectomy severs the connection between the urethra and testicles. 

So, it can trigger retrograde ejaculation. Simply put, the body can’t produce sperm. Although the patient can achieve an orgasm, they won’t ejaculate. 

Lymphedema 

This condition forces fluid to accumulate in the soft tissues and triggers swelling. The condition could result from obstruction, inflammation, or removal of the lymph nodes during the procedure.

Although it happens very rarely, fluid will stack in the genital area or legs if the lymph nodes are taken out. Those affected experience swelling and aches. People can control the swelling after having the lymph nodes removed. But, it can’t cure the condition. 

Reduction in penis length 

Even with such a minimally invasive technique as this one, a large percentage of men experience a reduction in penis length. This side effect can have a significant impact on a person’s sex life and self-esteem. 

Trouble getting an erection 

It can take up to two years after the procedure to get the erections back on track. For better recovery, be sure to consult with a specialist. 

Potential Risks

This is a relatively low-risk treatment. Serious disabilities or death is extremely rare. But, sometimes, patients experience inadvertent nerve damage. 

To reduce the risks of nerve damage and side effects, choose the right prostatectomy surgeon. Ask your healthcare provider to recommend you a prostate surgeon near you. 

Many medical specialists are in practice groups. That means they know plenty of experts in different fields. So, feel free to ask for advice on who will do your prostate surgery.

Probable Complications

Complications rarely happen. Problems that can occur are: 

  • Bleeding 

  • Infection

  • Organ injury 

One study examined the risks of bleeding during laparoscopic radical prostatectomy. Based on the reports, the incidence rates ranged between 1% and 7.6%. While postoperative bleeding complications in endoscopic radical prostatectomy cases occurred in 0.7%. 

Infections can also happen. These infections include complication that requires antibiotic treatment. Other than the standard antibiotic regimen. That includes a wound infection or pneumonia

Germs are the ones that cause the infection. The surgical site develops aches, redness, tenderness, and heals much slower than normal. A doctor can help mitigate these symptoms. 

At other times, nearby organs can be injured during the procedure. For example, an injury to the pelvic nerves can cause constipation, refractory pain, urinary retention, and intimate dysfunction. 

But proper treatments can help mitigate these complications and speed up recovery after the procedure. Be sure to talk to your surgeon if you experience any complications after your surgery. 

Average Healing Time

The hospital stay varies based on the type of surgery you selected. Most patients spend the night in the hospital. The doctors will then suggest you avoid any heavy lifting or strenuous activities for one month or more. 

Even after sparing the nerves, you will need to wait months before knowing if your urinary pathways and erection get back on track. So, take this time to fully recover. 

Conclusion

It can be difficult to choose the right surgery for prostate cancer. A patient with multiple treatment opportunities may jump to the fastest solution without considering the potential side effects. 

Of course, every procedure has its own benefits. But, sparing the nerves can profoundly affect overall health, particularly if the procedure is successful and doesn’t result in unwanted side effects. With it, people have better odds of avoiding problems with erections. 

Explore More

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Sources

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