Nerve-sparing technique preserves erectile function after RARP

A nerve-sparing technique decreases erectile dysfunction in men undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer in a phase III study.

A year after surgery, patients randomly assigned to the NeuroSAFE technique had significantly better erectile function scores on the International Index of Erectile Function (IIEF-5) scale, averaging 12.7 compared with 9.7 in the standard RARP arm (p<0.0001), reported Dr Greg Shaw from the University College London Hospitals NHS Foundation Trust in London, UK at EAU 2025.

Interestingly, 20 percent of patients in the NeuroSAFE group had an IIEF-5 score of ≥21 on the 25-point scale compared with 14 percent in the standard group. Higher scores indicate better erectile function.

At 12 months, fewer patients treated with the NeuroSAFE technique experienced severe erectile dysfunction (38 percent vs 56 percent with standard RARP), while a greater number of patients reported no or mild erectile dysfunction (39 percent vs 23 percent, respectively). [Lancet Oncol 2025; 26:447-458]

“This is the first randomized controlled trial that demonstrated a benefit to an intervention in terms of erectile function recovery performed during radical prostatectomy,” said Shaw.

Not without risks

RARP is frequently performed for non-metastatic prostate cancer, but it carries a significant risk of postoperative erectile dysfunction and urinary incontinence. Sparing the periprostatic neurovascular bundles during RARP aids in improving postoperative erectile function and facilitating early urinary continence recovery.

Shaw said it is difficult to know the exact extent of prostate cancer and how it relates to the nerves closely approximated to the prostate capsule. “With prostatectomy, we tend to err on the side of oncological control, and many patients who have organ-confined disease with definitive pathology have non-nerve-sparing surgery. We don’t spare nerves when we could have.”

The NeuroSAFE technique enables accurate real-time detection of positive surgical margins during nerve-sparing, increasing the likelihood of successful nerve preservation. However, the impact of this technique on patient outcomes remains uncertain.

In the current trial, researchers sought to assess the effect of NeuroSAFE-guided RARP compared with standard RARP on erectile function and urinary continence. The trial was conducted between January 2019 and December 2022 at five hospitals in the UK.

Eligibility criteria were a diagnosis of non-metastatic prostate cancer suitable for RARP, good erectile function, and no previous prostate cancer treatment.

Included were 407 patients, 381 of whom were randomized to the NeuroSAFE  (n=190) and standard RARP (n=191) groups. About 30 percent of the patients were Black and 5 percent were Asians. More than 90 percent had cancer that was defined as clinically significant.

“Surgery took longer with NeuroSAFE (174 vs 131 mins), but this means an increase in the amount of nerve sparing that we can perform,” Shaw said. Bilateral nerve-sparing was reported in 82.1 percent of patients in the NeuroSAFE group vs 56.4 percent in the standard RARP group.

Regarding the secondary outcome of urinary incontinence, there was an improvement with NeuroSAFE at 3 months; however, it lost statistical significance by 6 months. Interestingly, there was a relatively small difference between the NeuroSAFE and standard arms in prostate-specific antigen persistence (3.8 percent vs. 2.7 percent, respectively) and in biochemical recurrence (5.5 percent vs. 3.7 percent).

The use of adjuvant therapy was, however, four times greater in the NeuroSAFE arm than the standard arm (4.4 percent vs. 1.1 percent). Adverse events (AEs) and serious AEs were similar between the groups.