Sacral neurostimulation of penile erection: advancing intraoperative neurophysiological monitoring during pelvic surgeries—a narrative review

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Abstract
Demand has increased in recent years to develop and implement strategic approaches for improving functional outcomes following pelvic surgery. Intraoperative neurophysiological monitoring represents one such possible approach for this field. It involves generating neuronal activity within the nerve supply of pelvic organs and structures, conventionally using an external electrical current, and conjunctively recording neuronally mediated functional responses, which then, in real time, guides the surgical dissection in a manner that maximizes nerve preservation. A central aspect of this methodology is the creation of a neuronal stimulus. As such, sacral neurostimulation is proposed, strategically exploiting the neuroregulatory influence of the sacral spinal cord in pelvic physiology. While resembling sacral neuromodulation, a distinct methodology designed for long-term reprogramming of neural circuits, sacral neurostimulation aims to produce more immediate nerve signaling effects. Several technical options in this mode of neurostimulation are described, in which stimulatory electrodes are applied transspinally or peripherally to the neural pathways of the sacral spinal cord. These options can be categorized as surgical, percutaneous, and transcutaneous techniques. Ongoing studies in this field may reveal the most applicable techniques and optimal parameters for inducing erections and other neuronally mediated functional responses in the pelvic region as well. In turn, sacral neurostimulation may contribute toward applying neurophysiological monitoring during pelvic surgeries as a potential advance for improving postoperative functional outcomes. This narrative review serves to present the novelty of sacral neurostimulation for intraoperative induction of penile erection and its possible use in intraoperative neurophysiological monitoring for pelvic surgery.

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