End-to-side Somatic-to-autonomic Nerve Grafting to Restore Erectile Function and Improve Quality of Life After Radical Prostatectomy

Eur Urol. 2019 Aug;76(2):189-196. doi: 10.1016/j.eururo.2019.03.036. Epub 2019 Apr 5.


Background: Radical prostatectomy (RP) is recommended for the treatment of men with clinically localised prostate cancer. However, RP is associated with a high incidence of erectile dysfunction (ED), which can impact the quality of life (QoL) significantly.

Objective: To evaluate the effectiveness of end-to-side nerve grafting surgery to restore erectile function and improve sexual QoL in men with ED after RP.

Design, setting, and participants: A retrospective review of a single-centre experience of nerve grafting in men with ED following RP was performed. Seventeen men had surgery between March 2015 and October 2017 in Melbourne, Australia, which fulfilled study inclusion and exclusion criteria.

Intervention: Microsurgical bilateral end-to-side nerve grafts from a selective fascicular neurotomy of the femoral nerve to the penile corpora cavernosa.

Outcome measurements and statistical analysis: Results were serially measured utilising the International Index of Erectile Function (IIEF-5) and the sexual domain of Expanded Prostate Cancer Index Composite (EPIC-26). The proportion and 95% confidence interval (CI) of men recovering sexual function following nerve grafting were determined.

Results and limitations: All patients had ED following their RP. Median age at nerve grafting was 64yr (interquartile range [IQR] 60-66yr). Median time between nerve- and non-nerve-sparing RP, and nerve grafting was 2.4 (IQR 2.1-3.1) and 2.2 (IQR 1.7-5.1)yr, respectively. Median follow-up was 18 (IQR 15-24) mo. At 12mo after nerve grafting, 71% (95% CI 44-90%) of patients had erectile function recovery sufficient for satisfactory sexual intercourse, and 94% (95% CI 71-99%) and 82% (95% CI 57-96%) had clinically significant improvements in sexual function and reduced bother, respectively. There were two minor wound infections. Limitations include the retrospective study design.

Conclusions: End-to-side nerve grafting restored erectile function in 71% of men with ED following RP, supporting previous findings. Of the men, 94% had clinically relevant improvements in sexual QoL. We recommend multicentre implementation of post-RP nerve grafting into clinical practice with appropriate data collection to confirm its efficacy and feasibility.

Patient summary: We provide confirmatory evidence that end-to-side nerve grafting surgery restored erectile function and improved sexual quality of life in, respectively, 71% and 94% of men with erectile dysfunction following radical prostatectomy.

Keywords: End-to-side nerve grafting; Erectile dysfunction; Erectile function; Radical prostatectomy; Sexual quality of life.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Autonomic Pathways / surgery*
  • Coitus
  • Erectile Dysfunction / etiology
  • Erectile Dysfunction / physiopathology
  • Erectile Dysfunction / surgery*
  • Femoral Nerve / surgery*
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Penile Erection
  • Penis / innervation
  • Prostatectomy / adverse effects*
  • Quality of Life*
  • Recovery of Function
  • Retrospective Studies
  • Severity of Illness Index
  • Sural Nerve / transplantation*
  • Transplantation, Autologous / methods