V410: Tips for Preserving Pudendal Nerve Innervation to the Male Urinary Sphincter during Pelvic Surgery
VideoIntroduction and Objectives
The urinary rhabdosphincter is innervated by branches of the pudendal nerve, but the anatomic course of these nerves is underappreciated. We provide tips on how to identify and preserve these “continence nerves” during pelvic surgery.
Video clips from 7 robotic-assisted radical prostatectomies show keys to successful preservation of pudendal nerve branches to the urinary sphincter: 1) close inspection of the lateral surface of the prostate after opening the endopelvic fascia 2) nerve mobilization outside the layers of periprostatic fascia, prior to potency-nerve sparing 3) identification of associated “worm-like” vasculature and 4) contralateral traction on the lateral surface of the prostate. Because the continence nerves are lateral to the cavernous nerves, a potency-nerve sparing procedure will often result in preservation these “continence nerves”, without formal mobilization. However, the techniques demonstrated in this video are particularly important when the potency nerves are to be widely excised.
Prospective identification of the continence nerves began with case 87 of our robotic prostatectomy program. Of the 89 subsequent cases through March 2012, the continence nerve(s) were identified and preserved in 50 (56%). Kaplan-Meier analysis showed no difference in the time to recovery of continence, regardless of whether or not the continence nerve(s) had been identified (log rank test, p=0.90).
We demonstrate techniques to preserve pudendal nerve innervation responsible for urinary continence. Preservation of these branches may be particularly valuable when the potency nerves are to be widely excised.