Archived Policies - Surgery


Sural Nerve Graft in Association with Radical Prostatectomy

Number:SUR710.019

Effective Date:08-15-2003

End Date:08-31-2007

Coverage:

Sural nerve graft in association with radical prostatectomy is considered experimental or investigational.

Description:

Erectile dysfunction is a common problem after radical prostatectomy. In particular, spontaneous erections are absent in patients whose extent of prostate cancer requires bilateral resection of the neurovascular bundles as part of the radical prostatectomy procedure. A variety of noninvasive treatments are available, including vacuum constriction devices and intracavernosal injection therapy. However, spontaneous erectile activity is clearly preferred by patients.

Recently, there has been interest in sural nerve grafting to replace cavernous nerves resected at the time of prostatectomy. The sural nerve is considered expendable and has been used extensively in other nerve grafting procedures, such as brachial plexus and peripheral nerve injuries. 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.

Rationale:

Limited data are published regarding the long-term outcomes of sural nerve grafting; the largest study reported is a case series of 12 men with one-year follow-up. All men had clinically localized, but high volume prostate cancer such that bilateral resection of the neurovascular bundles was considered necessary. Prior to surgery all men reported spontaneous erection. Outcomes included assessment of erectile function based on:

  • the International Index of Erectile Function
  • visual assessment
  • assessment by patient partners.

Patients were also encouraged to use a variety of erectile dysfunction treatments, including intracavernosal injections, vacuum constriction devices, or sildenafil citrate, as needed. The results were compared to a group of 12 men who had undergone prostatectomy with bilateral nerve resection, but who declined nerve graft placement. Of the 12 men undergoing nerve graft, 4 (33%) had spontaneous medically unassisted erection sufficient for sexual intercourse. An additional 5 men (42%) reported 40% to 60% spontaneous erections that were insufficient for intercourse. However, 2 of these 5 men were able to have intercourse with associated sildenafil therapy. The remaining 3 patients had minimal or no spontaneous erectile activity and additional sildenafil therapy had no appreciable benefit. Side effects of the sural nerve donor site, which included incisional pain and a sensory deficit along the lateral aspect of the foot, were considered tolerable. The authors note that, based on the time required for nerve regeneration, optimal results may not be evident for 3 years. Some surgeons have performed unilateral sural nerve grafts. However, the outcomes of these procedures have not been reported. In addition, without a controlled study in this population, it will be difficult to isolate the contribution of the sural nerve graft compared to the spontaneous recovery of erectile activity.

In summary, bilateral sural nerve grafting met the treatment goal of unassisted erectile function sufficient for intercourse in 4 (33%) patients. Larger studies with longer outcomes are needed to confirm these preliminary results.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

There are no specific CPT codes describing sural nerve grafting of the cavernous nerves; the CPT codes describing nerve grafts specifically identify the anatomic site and do not include the cavernous nerves. Therefore CPT code 64999 (unlisted procedure, nervous system) may be used to describe the nerve harvest and grafting component of the procedure.

In some cases the nerve harvesting procedure may be performed by a plastic surgeon or a neurosurgeon.  In other cases an urologist may perform both the nerve harvesting, grafting and radical prostatectomy.


Medicare Coverage:

None

References:

  • Kim ED, Nath R, Kadmon D et al. "Bilateral nerve graft during radical retropubic prostatectomy: 1-year followup". J Urol 2001;165:1950-56.
  • BCBSA Medical Policy Reference Manual, "Sural Nerve Graft in Association with Radical Prostatectomy", 11/20/2001, 7.01.81

Policy History:

Archived Document(s):

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