Long-term function and oncologic outcomes following nerve spare or wide resection during radical prostatectomy

Nerve sparing during radical prostatectomy (RP) is associated with improved postoperative erectile function and urinary continence but may increase the risk of positive surgical margins. This study sought to compare the long-term outcomes of patients treated with nerve spare (NS) compared to wide resection (WR).

A historical cohort of consecutive patients was reviewed. A standardized surgical approach of lobe-specific NS or WR was performed. The primary outcome was treatment failure, defined as prostate-specific antigen (PSA) recurrence (PSA ≥0.2 ng/mL) or receipt of postoperative radiation. Secondary outcomes included time to metastases, urinary continence, and erectile function.

Of 193 consecutive patients, 123 (63%) received bilateral NS, 36 (19%) received unilateral NS, and 34 (18%) bilateral WR. Patients undergoing any NS had lower preoperative PSA, tumor stage, and grade group compared to WR patients (all p<0.05). Adjusting for these variables, the risk of treatment failure (PSA ≥2 ng/mL or postoperative radiation) was increased in patients who underwent NS compared to WR (hazard ratio [HR] 2.46, 95% confidence interval [CI] 1.25-4.83). Urinary continence recovered more quickly after NS, but by 24 months post-RP, this difference was not statistically significant (bilateral NS: risk ratio [RR] 1.10, 95% CI 0.95-1.30; unilateral NS: RR 1.01, 95% CI 0.82-1.24). Postoperative erectile function was better in patients receiving unilateral or bilateral NS (unilateral: 21%, bilateral: 59%, WR: 0%).

NS during RP was associated with higher risk of treatment failure, but better functional outcomes compared to WR. These results indicate that NS presents a tradeoff of outcomes that must be matched to individual patient's values and preferences.