Anatomical aspects of the neurovascular bundle in prostate surgery

Over recent years, widespread prostate-specific antigen screening has resulted in a downwards stage migration of prostate cancer in developed nations, with most patients being diagnosed nowadays at a younger age with early organ-confined disease (Schröder et al., N Engl J Med 360:1320-8, 2009; Jemal et al., CA Cancer J Clin 59:225-49, 2009; Quinn and Babb, BJU Int 90:162-73, 2002). Radical prostatectomy has a proven survival benefit over conservative treatment (Bill-Axelson et al., N Engl J Med 352:1977-84, 2005; Tewari et al., J Urol 171:1513-9, 2004), and thus is the gold standard for the management of clinically localized prostate cancer. Hence, with more patients undergoing surgery, minimizing functional loss is of utmost importance. However, despite recent advances in surgical technique and technologies, return of erectile function sufficient for sexual intercourse at 1 year after surgery varies from 15 to 87%, respectively, in contemporary series of radical prostatectomy (Zippe et al., Int J Impot Res 18:1-18, 2006; Berryhill et al., Urology 72:15-23, 2008; Ficarra et al., Eur Urol 55:1037-63, 2009). For younger men, postprostatectomy erectile dysfunction (PPED) significantly affects their sense of masculinity and their daily interactions with women (Penson et al., J Clin Oncol 21:1147-54, 2003; Kirschner-Hermanns and Jakse, Crit Rev Oncol Hematol 43:141-51, 2002). Patient age, clinical and pathological stage of cancer, preoperative potency status, and aggressiveness of nerve-sparing are the most significant factors for recovery of potency after surgery (Quinlan et al., J Urol 145:998-1002, 1991; Rabbani et al., J Urol 164:1929-34, 2000; Dubbelman et al., Eur Urol 50:711-20, 2006). Surgeon experience and surgical volume, penile ischemia and subsequent fibrosis, and veno-occlusive disease are also important for successful return of sexual function following surgery (McCullough, Asian J Androl 10:61-74, 2008; Bianco et al., J Sex Med 1:33, 2004).