ED and the Veil of Aphrodite

Dr. Menon gave a presentation at the Pacific Rim Robotics Conference on nerve preservation and the anatomical concept that he has named the veil of Aphrodite. After first reviewing the history of impotence after radical prostatectomy he described the latest modification of his techniques, which he claims further improves the preservation of potency. Originally, of course, radicals were associated with nearly 100% impotence until Dr. Walsh introduced the concept of “nerve sparing”. While Walsh has at times claimed very high rates of preservation, many others felt that preservation in perhaps 50-60% of patients having a nerve sparing represented excellent results. In the introductory remarks to his talk Dr. Menon cited several papers that quoted rates of “normal” erections of only 4-33% after nerve sparing. There is clearly room for improvement.

The veil of Aphrodite is simply the superficial membrane on the anterolateral surface of the prostate, as best I understand it. Dr. Menon feels that this is important because he has identified nerves on the surface of the prostate in that area. To perform a veil of Aphrodite dissection he makes his lateral incision from base to apex much higher on the prostate closer to the midline anteriorly.
To prove that this gave superior outcomes he designed a study that took 76 patients in 2003 who were potent not requiring a PDE-5 inhibitor for erections and who were diagnosed with prostate cancer. They were randomized to two groups, one getting a “classical” VIP and the other getting a veil procedure. Only 48 participated in the complete follow up evaluation. 17% of those receiving a classical VIP were having normal erections without PDE-5, 26% with, and 51% receiving a veil procedure were having normal erections and 86% with.
Several things struck me about the presentation. First was the low rate of potency among the patients getting a VIP which I thought Menon had been promoting as already superior to a standard open prostatectomy. A 17% potency rate is nothing to brag about. Second was that, after describing how the patients were randomized to the two groups, he went on to say that he felt uncomfortable putting patients with higher risk disease by pre-op parameters in the veil group because of concern about getting a positive margin. So he put those in the “classical” group. Unless I misunderstood, that decision made this no longer a randomized controlled study. Third was that, while he has identified nerves on the surface of the prostate, no one knows where they are going or what they are innervate.