Does Preservation of the Neurovascular Bundle During Radical
Radical prostatectomy (RP) can adversely affect erectile function. Surgical techniques that aim to preserve the neurovascular bundle (NVB) can minimize the risk of postoperative impotence, but it has been suggested that these nerve-sparing (NS) procedures increase the likelihood of positive surgical margins (SMs), thereby compromising oncologic control.

To determine whether NS-RP increases the risk of positive SMs and biochemical recurrence in men with prostate cancer compared with wide excision (WE).

This was a retrospective analysis of men who underwent RP at the Mayo Clinic between 1990 and 2000. Those who received neoadjuvant hormonal or radiation therapy and men with proven/suspected metastasis were excluded. Postoperatively, serum PSA was measured at regular intervals to detect biochemical recurrence (PSA ≥ 0.4 ng/ml).

All patients were considered candidates for NS-RP, which was performed according to the same basic protocol. The decision to proceed to WE was made intraoperatively, on the basis of in situ findings and frozen section analysis of SMs. Permanent tissue sections were analyzed postoperatively.

Rates of positive SMs and biochemical recurrence in men treated with NS-RP, compared with those in whom WE-RP was performed.

NS-RPs and WE-RPs were performed in 3,741 (median age 62 years) and 3,527 (median age 67 years) men, respectively, by 21 surgeons. Follow-up was for a median of 6.4 years. The proportion of patients undergoing NS-RPs increased during the study period (from 44% to 64%). Men who underwent an NS procedure were generally younger, with lower preoperative PSA, clinical stage, and biopsy grade, and a higher rate of preoperative potency.

The incidence of positive SMs decreased during the study period (from 42% to 29%). Positive SMs were detected in 38% of all patients, most commonly in the apical margin (21%). Positive SM rate was significantly higher in the WE-RP group compared with NS-RP patients (42% vs 34%, P < 0.001), and in men who underwent unilateral compared with bilateral NVB preservation (40% vs 33%, P 0.001).

After adjustment for biopsy grade, clinical stage, preoperative PSA level, age, and surgical year and technique, NS-RP did not significantly increase the likelihood of positive SMs (ODDS RATIO [OR] 0.86, 95% CI 0.76-0.97, P = 0.012), even in patients with extraprostatic extension (OR 0.89, 95% CI 0.79-1.01, P = 0.073).

Five- and 10-year postoperative biochemical disease-free rates ±SE were 74 ± 1% and 61 ± 1% in WE-RP patients, and 79 ± 1% and 66 ± 1% in NS-RP patients, respectively. After adjustment for clinical and pathologic features, NS-RP did not significantly increase the risk of biochemical recurrence (HAZARD RATIO [HR] 0.98, 95% CI 0.88-1.08, P = 0.64).

NVB preservation during RP does not increase the risk of positive SMs or biochemical recurrence, and should be attempted in men with organ-confined disease.