(039) A Game-Changer: Allograft-Assisted Cavernous Nerve Reconstruction During Radical Prostatectomy

Introduction Despite the evolution of radical prostatectomy (RP) techniques, postoperative erectile dysfunction (ED) and urinary incontinence remain prevalent. These outcomes are especially burdensome in younger patients with long-term survivorship. When direct nerve-sparing is not oncologically feasible, reconstructive strategies should be employed. While autologous sural nerve grafting was previously employed by the authors for cavernous nerve (CN) reconstruction, it was ultimately abandoned due to donor site morbidity, variable outcomes, and increased operative time. Objective This study describes a novel surgical technique using nerve allograft (NA) -- a biological scaffold that has already demonstrated clinical efficacy in nerve repair across the human body -- to reconstruct CNs during RP. Methods A retrospective, comparative study was conducted to evaluate the functional and oncologic outcomes of 10 patients who underwent bilateral CN reconstruction using NA, vs. 11 patients who underwent bilateral nerve sparing RP. All procedures were performed between 2009 and 2016 by a single dual-fellowship trained surgeon. Allografts (Avance® Nerve Graft; Axogen Inc.) were used to bridge CN defects created during oncologically indicated nerve resection. Anterograde dissection from pelvic plexus to seminal vesicles was employed to optimize visualization and avoid thermal injury. Standard postoperative rehabilitation included phosphodiesterase inhibitors and mechanical adjuncts. Results There was no statistical difference observed in post-operative SHIM scores, time to achieving erection, time to achieving continence (≤ 1 pad per day), or 5-year PSA scores between the two groups (Table 1). Age at surgery, prostate size, tumor size, and pre-operative PSA scores were comparable. Conclusions When nerve-sparing techniques are not oncologically feasible, allografting enables CN reconstruction without secondary donor site morbidity and allows tension-free, biologically scaffolded repair. This proposed technique and clinical evaluation demonstrates surgical feasibility, preserves erectile and urinary function in complex non-nerve sparing cases, and offers an off-the-shelf solution when direct nerve-sparing is not possible. This data supports that radical prostatectomy without reconstruction should not be defensible. Disclosure No