High Anterior Release of the Levator Fascia Improves Sexual Function Following Open Radical Retropubic Prostatectomy

Purpose: Recent anatomical studies have shown that branches of the cavernous nerves running adjacent to the prostate at the apex travel more anteriorly than previously recognized. Outcomes of robot assisted radical prostatectomy suggest improved postoperative sexual outcomes following high anterior release of the levator fascia. We prospectively evaluated the effect of high anterior release on oncological and sexual function outcomes following open radical retropubic prostatectomy. Materials and Methods: A total of 167 patients with clinically localized prostate cancer with a preoperative Sexual Health Inventory for Men score of greater than 21 underwent radical retropubic prostatectomy with bilateral nerve sparing and selective high anterior release, as performed by a single surgeon. Data on postoperative sexual function were collected by an independent third party. Sexual function outcomes at 12 months were defined as 1) a Sexual Health Inventory for Men score of 16 or greater and/or a satisfaction score of 4 or greater and 2) a Sexual Health Inventory for Men score of 22 or greater. Results: Because unilateral high anterior release was equivalent to bilateral high anterior release for both definitions (p >0.3), they were combined into 1 group for analyses. Patients undergoing high anterior release were more likely to achieve a Sexual Health Inventory for Men score of 16 or greater and/or a satisfaction score of 4 (93% vs 77%, p = 0.007), and a Sexual Health Inventory for Men score of 22 or greater (70% vs 54%, p = 0.07) at 1 year. Return to baseline (a Sexual Health Inventory for Men score of 22 or greater) was even higher among patients receiving high anterior release who were more sexually active (greater than 1 attempt per week) preoperatively (78% vs 52%, p <0.05). The improved outcomes in potency achieved with high anterior release did not increase the likelihood of a positive surgical margin. Conclusions: Unilateral or bilateral high anterior release of the levator fascia in open radical retropubic prostatectomy provides excellent oncological results and is associated with improved postoperative sexual function.