Nerve-sparing radical prostatectomy: evaluation of results after 250 patients

Abstract

To examine the efficacy of nerve-sparing radical retropubic prostatectomy in preserving sexual potency and urinary continence, and in providing complete tumor excision we analyzed the records of the first 250 consecutive patients with clinical stage A or B prostate cancer treated since this operation was adopted at our institution. Over-all, sexual potency was preserved in 71 of 112 patients (63%) who underwent bilateral nerve-sparing prostatectomy and 13 of 33 (39%) who underwent a unilateral nerve-sparing procedure with a minimum of 6 months of followup. Preservation of potency correlated with patient age (p equals 0.0035, chi-square) and was significantly (p less than 0.001, chi-square) higher in patients with pathologically organ-confined tumors (72%) than in those with pathologically extracapsular tumors (51%). Of 192 patients followed for at least 6 months 188 (98%) achieved urinary continence postoperatively. Over-all, apparent complete tumor excision as defined by organ-confined tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels was achieved in 14 preoperatively potent patients (42%) who underwent a unilateral and 67 (59%) who underwent a bilateral nerve-sparing procedure. Completeness of tumor excision correlated with tumor stage. In approximately 45% of the patients incomplete tumor excision was owing to seminal vesicle and/or lymph node involvement or positive bladder neck margins that could not be attributed to the nerve-sparing modification. However, improper application of the nerve-sparing technique may have contributed in the others. We were unable to detect microscopic penetration of the capsule or distinguish between gross extracapsular tumor extension and periprostatic fibrosis at operation. We conclude that with proper application of nerve-sparing radical retropubic prostatectomy, potency can be preserved in the majority of patients without compromising the adequacy of tumor excision. The completeness of tumor excision appears to be determined primarily by the extent of the tumor. Therefore, patient selection is important. Patients with focal, well differentiated tumors are ideal candidates for a nerve-sparing procedure, while those with high volume, poorly differentiated tumors may be at a higher risk for positive surgical margins. The benefits of wide excision of the neurovascular bundles remain to be demonstrated formally.