The article this month in the Journal of Endourology by Kim associates presents evidence for the potential role of anti-inflammatory intervention to reduce injury and or accelerate recovery of cavernosal nerve function. Surgeons and patients alike have long recognized that following robotic radical prostatectomy recovery of sexual function essentially always takes months to years. Clearly understanding the physiology of why it takes "2 years" is the key to understanding either how to prevent injury or help accelerate recovery. In 1943, the neurosurgeon HJ Seddon described the mechanisms for peripheral nerve injury and recovery.(Seddon HJ Brain 1943;66:237) When simplified to its most basic components he demonstrated three levels of injury: neurotmesis or permanent due to transection/resection, axonotmesis or intermediate (months to years) where the myelin sheath is preserved but the axon is injured requiring regeneration, and neurapraxia or transient(days to weeks) similar to a concussion. So based on Seddon's findings a surgeon can physically preserve the cavernosal nerve but due to injury such as thermal or traction the axon is injured presumably near the prostatic vascular pedicle requiring degeneration of the axon and regeneration explaining the axonotmetic injury. The potential to prevent injury or improve recovery logically introduces a role for anti-inflammatory interventions. The present study sheds reasonably compelling evidence for a role for an anti-inflammatory intervention. Usually retrospective non-randomized consecutive experiences are fatally flawed because of the confounding effect of "learning curve". What is unique is the Control group is introduced after the agent eliminating this confounder. The fact that a benefit is seen in my opinion warrants and supports publication and additionally further study with a multi-centered randomized controlled trial. However, the remaining unknown confounder of individual surgeon skill demands that each individual surgeon must have randomization of the agent in order to adjust for this confounder.
Journal of endourology / Endourological Society. 2016 May 18 [Epub ahead of print]
Tom Ahlering
UCI , 101 City Drive, Bldg 26 Rte 81 , Orange, United States , 92868 ; .