Surgery Insight: optimizing open nerve-sparing radical prostatectomy techniques for improved outcomes

Men with prostate cancer have a variety of treatment choices available, including expectant management with deferred treatment, brachytherapy, external-beam radiation therapy, or both of the latter options--with or without hormonal therapy, cryotherapy, and radical prostatectomy (RP). Physicians have long endeavored to guide patients through these choices on the basis of the health threat posed by the cancer, the potential effectiveness and complications associated with treatment, and the patient's life expectancy. As early detection programs now identify cancers much earlier in their natural history, individual patients have a longer life expectancy than in the past. The patient and physician must, therefore, weigh the potential benefit of the selected treatment with the risk of early or delayed complications that would detract from the patient's quality of life. Optimally, when a surgical approach is used to treat prostate cancer, the operation removes the cancer completely with negative surgical margins, avoids excessive blood loss or serious perioperative complications, and culminates in complete recovery of continence and potency. To achieve this, the surgeon must treat sufficient periprostatic tissue to achieve cure while preserving the cavernosal nerves required for erectile function and the neuromusculature required for normal urinary and bowel function. Evidence suggests that the small details of how a surgery is performed have a major impact on the outcome of RP. Here the role of surgical techniques in determining oncologic and quality of life outcomes after RP, focusing on open RP, are presented.