Current results and patient selection for nerve-sparing radical retropubic prostatectomy

The anatomical radical retropubic prostatectomy currently may be performed with low morbidity and mortality. The nerve-sparing aspect of the anatomical radical retropubic prostatectomy has allowed preservation of potency in the majority of men with localized prostate cancer. Overall potency rates of up to 71% may be achieved without compromising the complete eradication of cancer. Prostate cancer control with nerve-sparing surgery is similar to that reported for the standard radical retropubic prostatectomy. Inaccurate clinical staging of prostate cancer and the inability to determine tumor involvement of the neurovascular bundle have made it difficult to decide with certainty preoperatively which patients should undergo preservation versus wide excision of the neurovascular bundle. Some of the controversies that may determine utility of nerve-sparing radical prostatectomy include the impact of prostate cancer capsular penetration and positive surgical margins on tumor progression and patient survival. The selection of the ideal patient who has clinically localized prostate cancer for nerve-sparing radical prostatectomy has been improved by using as guidelines such preoperative factors as serum prostate-specific antigen tumor grade and the presence of perineural invasion on biopsy, and by using tumor location and volume to help predict true pathological stage. Other preoperative studies including transrectal ultrasound, computed tomography, and magnetic resonance imaging are generally not helpful.