Preoperative erectile function is an independent predictor for decision to spare cavernous nerves during radical prostatectomy

Introduction: Cavernous nerve sparing (NS) is critical for recovery of erectile function (EF) as well as erectile tissue preservation following radical prostatectomy (RP). Clinical experience suggests that surgeons may opt for non-NS RP in patients with impaired baseline EF. Aim: This study was performed to define if baseline EF is an independent predictor of NS status during RP. Methods: A total of 2,323 mean (mean age 59±7 years) who underwent RP at a tertiary referral academic medical center were retrospectively evaluated. Patients who underwent preoperative radiation therapy or androgen deprivation treatment were excluded. Main Outcome Measures: Preoperative parameters evaluated included biopsy pathological characteristics, prostate-specific antigen (PSA) level, patient age, and EF. Baseline EF was graded on a validated five-point patient reported scale. NSS was graded intraoperatively by the surgeon, using a four-point NS score assigned to each nerve where 1=fully preserved, 2=partially preserved, 3=minimally preserved, and 4=resected. NS surgery was defined as NSS of 1 or 2 on both sides, and nerve resection surgery was defined as NSS of 3 or greater on both sides. Results: On univariate analysis, factors related to nerve resection surgery included (all P<0.01): increasing age (r=0.16), Gleason score (r=0.19), EF score (r=0.21), percentage biopsy cores positive (r=0.11), higher preoperative PSA (relative risk [RR] 1.72, 95% confidence interval [CI] 1.23-2.40), and clinical stage ≥T2 (RR 2.17, 95% CI 1.68-2.78). On multivariable analysis, factors independently predicting for non-NS surgery included (all P<0.01): baseline EF (odds ratio [OR] 1.50, 95% CI 1.33-1.68), biopsy Gleason sum (OR 1.95, 95% CI 1.65-2.36), clinical T stage ≥T2 (OR 1.59, 95% CI 1.15-2.20), patient age (OR 1.07, 95% CI 1.04-1.09), and percentage of biopsy cores positive (OR 1.01, 95% CI 1.00-1.02). Conclusions: While unfavorable clinical and prostate biopsy characteristics predict less NS, we have shown that poorer baseline EF also independently predicts for nerve resection RP. For every point increase in EF score (that is, worsening EF) the odds of not receiving NS during surgery increase by a factor of 1.5. Although NS is not associated with worse cancer outcomes in appropriately selected patients, failure to spare nerves is associated with poor post-operative EF, urinary continence, and increased severity of cavernous venous leak. Patient anxiety related to cancer diagnosis and impending treatment may lead to falsely-worsened apparent EF when recent erections are assessed during a pre-operative planning visit. For these reasons prostatectomists should consider NS based solely on factors other than patient's baseline EF, even when it is impaired. 2013 International Society for Sexual Medicine.