Original article
Clinical—prostate
Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious

https://doi.org/10.1016/j.urolonc.2009.11.023Get rights and content

Abstract

Objective

Given the higher likelihood of extraprostatic extension in high-risk patients, many urologists will sacrifice the neurovascular bundles in such patients in an attempt to decrease the risk of positive surgical margins. In contrast, we frequently perform nerve-sparing in high-risk patients. We analyzed our outcomes in patients with preoperatively high-risk prostate cancer according to the D'Amico risk group classification, and stratified by nerve-sparing status.

Materials and methods

An institutional database of 1,503 robotic-assisted laparoscopic prostatectomies (RALP) was queried for patients presenting with PSA > 20 ng/ml, Gleason 8 or higher on biopsy, or clinical stage T2c or higher. Interfascial nerve-sparing was performed whenever oncologically feasible. Validated questionnaires were used to assess baseline and postoperative functional outcomes.

Results

Adequate follow-up was available in 123 high-risk patients. Mean serum PSA was 10.8. Bilateral, unilateral, and non-nerve-sparing was performed on 58%, 15%, and 27%, respectively. On final histopathology, 42% were organ confined; 55 patients had extraprostatic extension, and 35 had seminal vesicle invasion. Positive surgical margins occurred in 31%: 15% focal and 16% extensive. Favorable pathologic outcomes (organ-confined and negative surgical margins) were observed in 40%. Biochemical recurrence occurred in 20%. Nerve-sparing was associated with more favorable pathologic features, possibly due to selection bias. When controlling for adverse pathologic features, nerve-sparing was not associated with higher rates of positive surgical margins or biochemical recurrence. At a median follow-up of 13 months, 78% were continent and 56% were potent. The “trifecta” of continence, potency, and freedom from recurrence was achieved in 28 patients (23%).

Conclusions

Nerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes at 13-month median follow-up are comparable to those in open surgical series from similar cohorts.

Introduction

Oncologic control is of paramount importance in all patients with prostate cancer, and especially in those with high risk disease. However, the 10-year biochemical-free progression rate is 40% in such patients [1], and the 15-year prostate-cancer specific mortality is 19% [2]. As such, even high-risk patients have a long life expectancy to live with the functional complications of prostatectomy. Given the associations between preservation of the neurovascular bundles and the recovery of erectile function [3] and urinary continence [4], nerve-sparing can significantly improve a man's quality of life following prostatectomy.

Questions have arisen regarding the safety of nerve-sparing in high risk patients, partly due to the lack of haptic feedback on the robotic console. However, there is no standardized approach to select patients for nerve-sparing. Some urologists will widely resect the neurovascular bundles of all high-risk patients in an attempt to reduce the risk of positive surgical margins. Others have developed various criteria to determine preoperatively which patients should undergo nerve-sparing, including preoperative potency, PSA, imaging, location and number of positive biopsy cores, and digital rectal exam findings. These have led to the development of side-specific nerve-preservation nomograms and partial nerve-sparing techniques [5], [6], [7], [8], [9], [10], [11].

In our experience, there are visual clues, enhanced by the improved lighting and magnification of the robotic system, which may be used in selecting patients robotically for nerve-sparing, as these may allow determination of the presence of extraprostatic extension. Poorly defined or sticky dissection planes, bulging of the prostatic capsule, or the appearance of prostate tissue on the preserved neurovascular bundle are all worrisome for the presence of a locally-advanced tumor. Intraoperative frozen section (IFS) can be used in such circumstances to complement the visual inspection. With some exceptions, we have not routinely sacrificed nerves based on preoperative characteristics alone. We have performed bilateral nerve-sparing on most patients, including many high risk patients.

To evaluate the oncologic safety of this approach, as well as to answer the broader question of whether the robot can be used safely to treat high-risk patients, we analyzed our RALP database to evaluate the short-term oncologic and functional outcomes of patients who were preoperatively considered high-risk according to the D'Amico risk group stratification [12]. We then stratified such patients by nerve-sparing status and compared their oncologic and functional outcomes.

Section snippets

Materials and methods

An internal institutional review board approved database was created for all patients undergoing RALP by a single surgeon (DBS). The database was queried for patients undergoing RALP with high-risk features according to the D'Amico risk group stratification until September 2009. All patients with either PSA > 20 ng/ml, biopsy Gleason scores of 8 to 10, or clinical stage T2c or higher were evaluated [12]. Patients with incomplete pathologic data or follow-up of less than 6 weeks after surgery

Results

A total of 1,503 RALPs were performed in the selected time period, 146 (9.7%) of which were in high-risk patients as per the D'Amico risk group stratification. Of these, 23 patients were excluded due to incomplete data or inadequate follow-up, leaving a cohort of 123 patients who constituted the studied population. Of the 123 men, 21 had PSA > 20, 99 had biopsy Gleason sums of 8 or higher, and 12 were clinical stage T2c or higher. Twelve patients had more than 1 high risk factor. Institutional

Discussion

By definition, patients with high preoperative risk prostate cancer by the D'Amico classification are more likely to have non-organ-confined disease [12]. Patients with extraprostatic extension or seminal vesicle invasion are more likely to have tumor at the inked resection margin and are more likely to experience recurrence. As such, high risk patients are often treated more cautiously during prostatectomy than patients with lower risk disease. Various nomograms have been created to predict

Conclusions

Nerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes are comparable to open surgical series from similar cohorts. The use of visual clues by an experienced robotic surgeon to determine the need for nerve-sparing is a safe and efficacious procedure.

References (28)

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