Nerve-Sparing Surgery: Who Is It Possible For?
Preserving the nerve bundles responsible for erection during radical prostatectomy — who it is possible for, what it changes and what it does not guarantee.
Last medically reviewed: October 4, 2026 — Assoc. Prof. Dr. Müslüm Ergün
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- Procedure time
- Performed within radical prostatectomy
- Anesthesia
- General anesthesia (same as the main operation)
- Hospital stay
- 2–3 nights
- Stay in Türkiye
- 7–10 days
- Catheter duration
- 7–10 days
- Return to work
- 3–4 weeks
- Flight clearance
- From day 10
About the condition
Two bundles of nerves and vessels responsible for erection run immediately alongside the prostate, on its postero-lateral aspect. These are called the neurovascular bundles. Because they lie so close to the prostate, they can be damaged when it is removed; if they are, erectile function is lost.
Nerve-sparing surgery is the technique of separating these bundles from the prostate and leaving them in place during radical prostatectomy. It is not a separate operation but an approach applied within the main procedure. The high-definition three-dimensional view and millimetric movement of the robotic system make this fine dissection easier.
THE MOST IMPORTANT RULE — ONCOLOGICAL SAFETY COMES FIRST: nerve preservation is not carried out at the cost of removing the cancer completely. If the tumour lies next to a nerve bundle or extends towards it, attempting to preserve the bundle increases the risk of leaving cancer cells behind (a positive surgical margin). In that situation the correct decision is to give up nerve preservation. Sexual function matters; but control of the disease takes priority.
Nerve-sparing is not a yes-or-no choice but a matter of degree. Bilateral full preservation, unilateral preservation and partial preservation are all possible. The surgeon decides which of the fascial layers surrounding the prostate to dissect through; the closer that plane is to the prostate, the more nerve tissue is preserved — but the smaller the oncological safety margin.
The main factors determining the decision are: the location of the tumour on multiparametric MRI and its relationship to the capsule, the biopsy result (ISUP grade and which quadrants are involved), the PSA value, the digital rectal examination finding and your erectile function before surgery. This assessment is made before the operation but can be revised according to the anatomy seen during it.
AN HONEST EXPECTATION: preserving the nerves increases the CHANCE that erectile function returns; it does not GUARANTEE that it will. Other factors also shape the outcome: your age, the quality of your erections before surgery, the presence of diabetes or cardiovascular disease, smoking, and whether preservation could be achieved on one side or both. Recovery takes months and is usually gradual.
Who is it suitable for?
May be suitable
- Patients whose tumour is confined to the prostate (localized)
- Cases in which MRI and biopsy findings show the tumour to be away from the nerve bundles
- Patients whose erectile function before surgery is good or acceptable
- Younger patients — the chance of recovery decreases with age
- Patients who prioritise remaining sexually active and hold realistic expectations about it
May not be suitable
- Cases where the tumour lies next to a nerve bundle or extends beyond the capsule — oncological safety takes priority
- High-risk or advanced disease
- Cases with a clearly palpable tumour on that side at rectal examination
- Patients who already have severe, treatment-resistant erectile dysfunction before surgery — the expected gain is limited
- Patients for whom sexual function is not a priority and who wish to maximise oncological safety
Technology used
- da Vinci robotic system — high-definition 3D vision and millimetric movement
- Definition of the fascial planes (intrafascial, interfascial, extrafascial)
- Limiting the use of heat (cautery) around the nerve bundle
- Planning with pre-operative multiparametric MRI
Surgeon's experience
Verifiable information
- Surgeon's experience
- Assoc. Prof. Dr. Müslüm Ergün121270
Step-by-step journey
- Remote
File assessment
Your multiparametric MRI, biopsy report (ISUP grade and the areas involved) and PSA value are reviewed. Your erectile function before surgery is also asked about; this is critical in setting expectations.
- Day 1–2
Examination and finalising the plan
In-person examination and completion of any missing tests. Whether nerve preservation is planned on one side, both sides or partially is discussed openly with you.
- Day 3
Surgery
Robotic radical prostatectomy is performed. The nerve-sparing decision can be revised according to the anatomy seen during surgery and the relationship of the tissue to the tumour; this is a decision taken in the interest of oncological safety.
- After pathology
Surgical margin assessment
The pathology report shows whether the surgical margin is clear. This result determines both the follow-up plan and, if needed, the decision about additional treatment.
- Month 3–24
Functional follow-up
Erectile function is assessed at regular intervals. Recovery can continue throughout this period; supportive treatments are added if needed.
Method comparison
| Degree | What is done | Who it suits | Expectation |
|---|---|---|---|
| Bilateral full preservation | Both nerve bundles are left in place | If the tumour is away from both bundles | The highest chance of functional return |
| Unilateral preservation | Only the bundle on the tumour-free side is preserved | If the tumour is close to a bundle on one side | There is a chance, but more limited than bilateral |
| Partial preservation | Part of the bundle is preserved | Cases where the tumour shows limited contact | Variable; assessed case by case |
| No preservation | The bundles are removed with the prostate | If the tumour is adjacent to or beyond the capsule | Natural erection is not expected; ED treatments are planned |
This table shows the logic of the decision, not a promise of outcome. Which degree can be applied is determined by MRI, biopsy and the anatomical findings during surgery.
Risks
- Erectile function may not return even when the nerves are preserved — this is the most commonly experienced disappointment
- If nerve preservation is forced, the risk of a positive surgical margin rises; this is why oncological safety always takes priority
- Recovery taking longer than expected (it can extend over 12–24 months)
- Where only unilateral preservation is possible, a more limited result than with bilateral preservation
- The possibility that the plan changes during surgery and preservation is abandoned
Alternatives
- Non-nerve-sparing (extrafascial) radical prostatectomy — where oncological safety is the priority
- Radiotherapy (external beam or brachytherapy)
- Active surveillance — in selected low-risk patients
- Erectile dysfunction treatments after surgery: PDE5 inhibitors, intracavernosal injection, vacuum device
- Penile prosthesis — the final step where other treatments do not give a response
Recovery
Months 0–3
In this period there is usually no erection, or it is very weak; this is expected and does not indicate the final result. Supportive treatments recommended by your physician may be started during this time.
Months 3–6
Partial responses may begin. The return of night-time and morning erections is a positive sign.
Months 6–12
This is the period of most marked recovery. Rigidity sufficient for intercourse with medication support can be achieved in this window.
Months 12–24
Recovery can continue throughout this time. If it is still insufficient at this point, injection therapy, a vacuum device or a penile prosthesis are considered.
Frequently asked questions
Can nerve-sparing surgery be performed in every patient?
No. Whether it is possible depends on the location and extent of the tumour. If the tumour lies next to a nerve bundle or has gone beyond the capsule, trying to preserve the bundle increases the risk of leaving cancer cells behind. In that situation the correct decision is to give up preservation. Oncological safety always comes first.
If the nerves are preserved, will my erections definitely return?
No, there is no guarantee. Nerve preservation increases the chance of return, but the outcome is shaped together by your age, the quality of your erections before surgery, the presence of diabetes or cardiovascular disease, smoking, and whether preservation was possible on one side or both. That is why discussing expectations openly before surgery matters.
How long does recovery take?
It usually takes months and is gradual. Having no erection in the first three months is expected. The most marked recovery is seen between months 6 and 12 and can continue up to month 24. Rather than trying to shorten this period, it is better to maintain follow-up.
What determines the decision?
The location of the tumour on multiparametric MRI and its relationship to the capsule, your biopsy result (ISUP grade and the areas involved), your PSA value, the digital rectal examination finding and your erectile function before surgery. These five pieces of information are assessed together.
Does unilateral preservation help?
Yes, it offers a chance of functional return, though more limited than with bilateral preservation. If the tumour is close to the bundle on one side, giving up that side and preserving the other is a reasonable and frequently used approach.
Can the decision change during surgery?
Yes. The plan is made before the operation, but the anatomy seen during surgery and the relationship of the tissue to the tumour can change it. Such a change is always made in the interest of oncological safety and is explained to you along with the pathology result.
What happens if erections do not return?
A stepwise approach is followed: first oral medication, then intracavernosal injection or a vacuum device if there is no response. If those also fail, a penile prosthesis offers a lasting solution. In other words, erections not returning does not mean there is no solution.
Is nerve preservation related to urinary incontinence?
The nerve bundles are primarily responsible for erection. That said, careful dissection in this area is reported to contribute to the recovery of urinary continence as well. Continence, however, depends mainly on preservation of the sphincter structures.
Is there anything I can do before surgery?
Yes. Stopping smoking, controlling blood sugar and blood pressure and increasing physical activity support vascular health and favour the chance of recovery. The quality of your erections before surgery is one of the strongest predictors of the outcome afterwards.
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This page is for general information only and is not a substitute for medical advice.
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