The Evolution of Nerve-Sparing Radical Prostatectomy: Mechanisms of Injury, Economic Impact, and the Potential Value of Intraoperative Nerve Visualization

Background/Objectives: Iatrogenic nerve injury is a significant challenge in urologic surgery, with radical prostatectomy posing a high risk due to complex pelvic neural anatomy. Despite advances in robotic-assisted and nerve-sparing techniques, postoperative urinary incontinence and erectile dysfunction remain prevalent, adversely affecting patients’ quality of life and imposing substantial healthcare costs. Methods: A narrative review was conducted using PubMed, MEDLINE, and the Cochrane Library (searches through February 2026) for studies on radical prostatectomy epidemiology, mechanisms of nerve injury, functional outcomes, and economic burden. Emerging intraoperative fluorescence imaging technologies, surgical strategies to mitigate iatrogenic nerve injuries, and the financial costs of post-prostatectomy complications were assessed. Results: Robotic-assisted radical prostatectomy now accounts for >80% of procedures in the United States, and has been associated in observational studies with improved early recovery of erectile function compared with open and laparoscopic approaches. However, the lack of real-time nerve visualization remains a limiting factor. Recent milestones (January 2026) include the Food and Drug Administration Investigational New Drug clearance for the nerve-specific fluorophore LGW16-03 (NerveTrace), which enables real-time identification of sub-millimeter nerve branches, and the 510(k) premarket clearance of Dendrite imaging (November 2025). Conclusions: Enhanced intraoperative nerve discrimination via molecularly targeted imaging has the potential to reduce iatrogenic complications and improve long-term functional and economic outcomes in prostate cancer surgery, although these benefits have yet to be demonstrated in prospective clinical and health-economic studies.