The cavernous nerves (nervi cavernosi) arise from the pelvic plexus (inferior hypogastric plexus) bilaterally at the posterolateral prostate and pass within the neurovascular bundles of Walsh along the posterolateral prostate and then along the membranous urethra to enter the corpora cavernosa of the penis (or clitoris). They carry parasympathetic fibres mediating erection and sympathetic fibres mediating ejaculation.
The cavernous nerves are the critical neural structures for preservation of erectile function in radical prostatectomy. The Walsh nerve-sparing technique identifies and preserves the neurovascular bundles at the posterolateral prostate (in the rectoprostatic fascial plane of Denonvilliers) before urethral division, allowing recovery of erectile function in 50-90% of suitable patients. The nerves cannot be directly visualised with standard lighting; intraoperative near-infrared fluorescence or electrical nerve mapping is used in advanced centres to guide preservation.
Division or thermal injury to the cavernous nerves during radical prostatectomy produces erectile dysfunction in the early post-operative period; nerve-sparing technique preserves the neurovascular bundles along the posterolateral prostate in Denonvilliers plane, with erectile function recovery taking 6-18 months as the neuropraxia resolves, aided by penile rehabilitation with PDE5 inhibitors.
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