Cistoprostatectomía radical con preservación neurovascular para el tratamiento del cáncer vesical. Relación con la disfunción eréctil: revisión de la literatura científica

Radical cystectomy (RC) with bilateral pelvic lymph node dissection and urinary diversion remains the gold standard extirpative treatment for high risk non-invasive bladder cancer and muscleinvasive carcinoma. The endpoints after this operation have been historically focused on cure, urethral recurrence and continence. Functional outcomes in radical cystectomy patients were not considered until the middle eighties, thus the evaluation of these patients was mainly based on oncologic outcomes. In a classic approach, the neurovascular bundles are usually excised en bloc or damaged with bladder removal. Recent interest in quality-of-life issues has stimulated the evolution of ileal orthotopic bladder substitution. This technical advance has provided the momentum for assessing other quality-of-life issues after RC. Upon the introduction of orthotopic intestinal neobladders into urological practice and the description of the technique that allowed the preservation of cavernous neurovascular bundles, the drawbacks of cutaneous ostomies and sexual dysfunction were both mitigated, but they could not be totally avoided. The role of nerve-sparing surgery to attain these goals is still a matter of intense debate. At present, there is some evidence of a positive impact on erectile function and urinary continence after ileal orthotopic bladder substitution and, it has been shown that oncologic outcome are not compromised by a nerve sparing technique in carefully selected patients; in particular, the rate of local recurrence is not increased. Based on these previous considerations, there should be a role for nerve sparing cystectomy. In the present issue this surgical technique is described in step by step fashion as well as the anatomical and functional aspects essential for its comprehension. The current evidence-based literature related to postoperative erectile function outcomes with this procedure is also discussed.