Prostate MRI vascular markers and erectile function after nerve‐sparing prostatectomy

Abstract Objectives To determine whether preoperative multiparametric magnetic resonance imaging (mpMRI)‐derived vascular markers are associated with baseline and postoperative erectile function (EF) and change in EF in men undergoing bilateral nerve‐sparing robot‐assisted radical prostatectomy (RARP). Patients and Methods A secondary retrospective imaging analysis was undertaken using prospectively collected cohort data. Men undergoing bilateral nerve‐sparing RARP with a preoperative International Index of Erectile Function—erectile function domain score (IIEF‐6) and preoperative mpMRI incorporating dynamic contrast‐enhanced sequences were included. MRI‐detected accessory pudendal artery (APA), prostate enhancement ratio (PER) and corporal enhancement ratio (CER) were assessed by two expert uro‐radiologists. Associations with EF outcomes were examined using correlation analyses and univariable and multivariable linear regression. Results Seventy‐one patients (mean age 60 years) met inclusion criteria; APA was identified in 31 (43.6%). APA presence was associated with higher baseline IIEF‐6 scores (mean 24.1 vs. 20.0, p = 0.043). Baseline IIEF‐6 demonstrated moderate negative correlation with PER ( ρ = −0.30, p = 0.014) and moderate positive correlation with CER ( ρ = 0.30, p = 0.018). On multivariable analysis, APA presence ( β = 5.20, p = 0.019), PER ( β = −0.049, p = 0.017) and CER ( β = 0.040, p = 0.049) independently predicted baseline EF. Increasing age independently predicted lower baseline IIEF‐6 ( β = −0.34, p = 0.017), while higher body mass index correlated with poorer 24‐month IIEF‐6 scores ( ρ = −0.27, p = 0.046). Bilateral intrafascial/intra‐interfascial nerve‐sparing techniques were associated with superior 24‐month EF outcomes (mean 16.8 vs. 10.5, p = 0.028). No MRI‐derived marker predicted 24‐month EF or EF change. Conclusion Preoperative mpMRI‐derived vascular markers, particularly APA identification, independently correlate with baseline EF in men undergoing BNS RARP, supporting a contributory vascular component in post‐prostatectomy ED. Prospective studies are warranted to determine whether intraoperative vascular preservation strategies, guided by preoperative MRI vascular mapping, influence functional recovery and can be integrated into surgical planning pathways.