BlueCross BlueShield of Tennessee Medical Policy Manual

Nerve Graft with Radical Prostatectomy


Nerve grafting at the time of radical prostatectomy has been proposed to reduce the risk of postoperative erectile dysfunction. In particular, spontaneous erections are absent in individuals whose extent of prostate cancer requires bilateral resection of the neurovascular bundles as part of the radical prostatectomy procedure.

The sural nerve is most commonly used as it is considered expendable and has been used extensively in other nerve grafting procedures.  As applied to prostatectomy, a portion of the sural nerve is harvested from one leg and then anastomosed to the divided ends of the cavernous nerve. Reports also indicate the use of other nerves (e.g., genitofemoral nerve) for grafting.

Other grafting techniques, including the use of commercially available nerve allografts (Avance® Nerve Graft) are currently being investigated.




The evidence for nerve grafting in individuals who have radical prostatectomy with resection of neurovascular bundles includes one randomized controlled trial (RCT), cohort studies and case series.  The RCT did not find that unilateral nerve grafting was associated with a statistically significant improvement in potency rates at two years post-surgery.  Cohort studies, limited by lack of randomization and blinding, also did not result in better outcomes with nerve grafting.  The evidence is insufficient to determine the effects of the technology on health outcomes. 


BlueCross BlueShield Association. Evidence Positioning System. (4:2018). Nerve graft with radical prostatectomy (7.01.81). Retrieved June 6, 2018 from (7 articles and/or guidelines reviewed)

Kung, T., Waljee, J., Curtina, C., Wei, J., Montie, J., & Cederna, P. (2015). Interpositional nerve grafting of the prostatic plexus after radical prostatectomy. Plastic & Reconstructive Surgery, 3, e452. (Level 4 evidence)

National Comprehensive Cancer Network. (2019, April). NCCN clinical practice guidelines in oncology (NCCN Guidelines®). Prostate cancer. Retrieved April 29, 2019 from the National Comprehensive Cancer Network.

Siddiqui, K.M., Billia, M., Mazzola, C.R., Alzahrani, A., Brock, G.B., Scilley, C., & Chin, J.L. (2014). Three-year outcomes of recovery of erectile function after open radical prostatectomy with sural nerve grafting. The Journal of Sexual Medicine, 11 (8), 2119-2124. Abstract retrieved August 10, 2016 from PubMed database.

Souza Trindade, J.C., Viterbo, F., Petean Trindade, A., Fávaro, W.J., & Trindade-Filho, J.C.S. (2017). Long-term follow-up of treatment of erectile dysfunction after radical prostatectomy using nerve grafts and end-to-side somatic-autonomic neurorraphy: a new technique. BJU International, 119 (6), 948-954. Abstract retrieved June 6, 2018 from PubMed database.




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