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

Elin Axén,Rebecka Arnsrud Godtman,Anders Bjartell,Stefan Carlsson,Eva Haglind,Jonas Hugosson,Anna Lantz,Marianne Månsson,Gunnar Steineck,Peter Wiklund,Johan Stranne

doi:10.1016/j.euros.2021.06.005

Abstract

BackgroundReports 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. ObjectiveTo determine whether the degree of NS during radical prostatectomy influences oncological outcomes. Design, setting, and participantsOf 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 analysisData 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 limitationsA 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. ConclusionsA 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 summaryIn 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.

Highlights

My great aunt turned one hundred years old this summer
We found a seven-fold increase in prostate cancer incidence between 1960 and 2016; when accounting for changes in population size and age the difference diminished to a three-fold increase
We have found that a higher degree of preservation of the neurovascular bundles in radical prostatectomy is associated with better postoperative continence, and with higher rates of positive surgical margins; no association with recurrence of prostate cancer was found

Summary

Introduction

My great aunt turned one hundred years old this summer. When she learnt that my thesis was about prostate cancer she asked: ‘Prostate cancer. In 1960, when my great aunt was 39 years old, 1 565 Swedish men were diagnosed with prostate cancer; in 2016, they were 10 474, almost seven times more. We found a seven-fold increase in prostate cancer incidence between 1960 and 2016; when accounting for changes in population size and age the difference diminished to a three-fold increase. An increasing, ageing population is part of the explanation why prostate cancer is common nowadays, at least in Sweden, but what accounts for the remaining increase?

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