Degree of Preservation of Neurovascular Bundles in Radical Prostatectomy and Recurrence of Prostate Cancer

BACKGROUND: Reports on possible benefits for continence with nerve-sparing (NS) radical prostatectomy have expanded the indications beyond preservation of erectile function. It is unclear whether NS surgery affects oncological outcomes. OBJECTIVE: To determine whether the degree of NS during radical prostatectomy influences oncological outcomes. DESIGN SETTING AND PARTICIPANTS: Of 4003 patients enrolled in a prospective, controlled trial comparing open and robotic radical prostatectomy during 2008-2011, we evaluated 2401 patients who received robotic radical prostatectomy at seven Swedish centres. Patients were followed for 8 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Data for recurrence and positive surgical margin status were assessed using validated patient questionnaires, patient interviews, and clinical record forms before and at 3, 12, and 24 mo and 6 and 8 yr after surgery. Cox and logistic regressions were used to model the effect on recurrence and positive surgical margins (PSM), respectively. RESULTS AND LIMITATIONS: A total of 481 men had PSM and 467 experienced recurrence during follow-up. Median follow-up for men without recurrence was 6.6 yr. There were no statistically significant differences in recurrence rate between degrees of NS. The PSM rate was significantly higher with a higher degree of NS: interfascial NS, odds ratio (OR) 2.32 (95% confidence interval CI 1.69-3.16); intrafascial NS, OR 3.23 (95% CI 2.17-4.80). Recurrence rates were higher for patients with pT2 disease and PSM (hazard ratio HR 3.32, 95% CI 2.43-4.53) than for patients with pT3 disease without PSM (HR 2.08, 95% CI 1.66-2.62). The lack of central review of pathological specimens is a limitation. CONCLUSIONS: A higher degree of NS significantly increased the risk of PSM but did not significantly increase the risk of cancer recurrence. Combined with the known functional benefits of NS surgery, these results underscore the need to identify an individualised balance. PATIENT SUMMARY: In this report we looked at the effect of a nerve-sparing approach during removal of the prostate on cancer outcomes for patients having robot-assisted surgery at seven Swedish hospitals. We found that a high degree of nerve-sparing increased the rate of cancer positivity at the margins of surgical specimens and that positive surgical margins increased the risk of recurrence of prostate cancer.