PROPOSAL OF A METHOD TO ASSESS AND REPORT THE EXTENT OF RESIDUAL NERVE TISSUE PRESENT ON RADICAL PROSTATECTOMY SPECIMENS

Objective: Use of nerve sparing (NS) prostatectomy in highrisk prostate cancer (HRCaP) is controversial, due to the higher incidence of extraprostatic extension of tumor. However we believe that in a subset of HRCaP, with clinically localized disease, favourable biopsy characteristics and disease which is macroscopically feasible for resection that it is possible to perform a NS-RALP without compromising oncological safety. We analyzed our outcomes in preoperative high-risk patients according to D’Amico risk stratification and nerve preservation. Materials and Methods: An institutional review board (IRB) approved, prospective robot assisted radical prostatectomy (RARP) database was analyzed retrospectively. Of 1,720 patients who underwent RARP, 147 patients had a PSA >20, Gleason 8 or more and clinical stage T2c–T4. Bilateral full nerve sparing (BNS) and partial nerve sparing (PNS) was performed when oncologically feasible. Biochemical Recurrence (BCR) was defined as >0.2 ng/ml; Continence as the use of ‘no pads’; potency as the ability to achieve and maintain satisfactory erections firm enough for sexual intercourse for more than 50% of the times, with or without the use of PDE 5 inhibitors. Results: The mean follow-up (± SD) was 19 months (6.9). Mean serum psa was 8.5 ± 7.32. Bilateral, partial and nonnerve sparing was done in 22.1%, 40% and 37.9% respectively. Histopathological evaluation showed 52.1% of tumors to be organ confined. Extraprostatic extension was present in 24.3% and overall positive surgical margins (PSM) were present in 21.4% of which pT2 PSM rate was 5.4%. Overall BCR rate was 16.4% and ranged from 22.9% in NNS, 12.54% in PNS and 12.9% BNS. This difference was not significant. The overall potency rates were 66.1% for PNS and 87.1% for BNS. Overall continence rates were for both PNS and BNS were above 90%. The trifecta was achieved in 60% of PNS and 71% of BNS. Conclusion: Nerve sparing in RARP is feasible without compromising oncological safety in selected preoperatively high-risk patients. The short term outcomes are comparable to open series with similar cohorts. Surgeon experience and precise preoperative characterization tumor is essential to identify the subset of patients in whom nerve sparing is feasible.