High-risk prostate cancer is associated with a higher incidence of extraprostatic disease. This concept has led to an aversion of nerve-sparing (NS) procedures to prevent positive surgical margins as they may increase risk of cancer-recurrence. Due to concerns of anticipated inferior oncological and functional outcomes radical prostatectomy (RP) has not commonly been offered to men with high-risk prostate cancer. Several studies have addressed the impact of NS on urinary continence (UC) and erectile function recovery (EFR). A systematic review and meta-analysis recently published(1) reports NS to be associated to better functional outcomes, while some authors failed to report such association(2,3). However, comparison of functional results in high risk prostate cancer patients is difficult as data on UC and EFR after RP in these patients remains scarce. Little is known about outcomes stratified by degree of NS. Whether NS RP should be attempted in these patients is controversial and remains a matter of debate. The aim of this study was to assess outcomes in high-risk prostate cancer patients following RP.

In a prospective single-centre cohort study, UC, EFR and oncological outcomes of 554 consecutive patients undergoing open RP for high-risk prostate cancer from 1996 to 2017 were evaluated. High-risk was defined as preoperative PSA>20 ng/ml and/or Gleason score ≥8 and/or ≥pT3 and/or pN1. Multivariable logistic-regression analyses were performed to evaluate whether grade of nerve-sparing was a predictor of UC, erectile function recovery and oncological outcomes after RP. Validated International Consultation on Incontinence Questionnaire (ICIQ)-Urinary Incontinence (UI) short forms and International Index of Erectile Function (IIEF)-15 questionnaires were given to patients preoperatively and at 3, 6, 12 and 24 months. UC was defined as complete dryness or occasional loss of no more than a few drops of urine and requiring no more than one safety pad per 24 hours by self-report or by question 3 and 4 of the ICIQ questionnaire. All patients were continent prior to surgery. EFR was defined as the ability to achieve erection sufficient for penetration and maintenance of intercourse by patient self-report or with a score of 3 or more points in question 2 of the IIEF-15-questionnaire with or without erectile aids. Penile rehabilitation with phosphodiesterase type 5 inhibitors three times a week was recommended for all preoperatively potent patients.

Median follow-up of patients was >8 years. At 3, 6, 12 and 24 months, the NS groups had higher proportions of continent patients than the non-NS group. In multivariate analysis any NS was predictive of higher UC compared to patients with no-NSRP at all time points. Furthermore, overall UC rates of our study population at 3, 6, 12 and 24 months (85%, 92%, 94% and 96%) are comparable with the UC rates of patients with low- and intermediate-risk PCa at all time points who underwent RP during the same time period (85%, 91%, 96% and 97%).
Of all patients 86% (478/554) had erections sufficient for penetration preoperatively. EFR rates at 3, 6, 12 and 24 months were higher in the NS groups compared to the non-NS group (Figure 2b). In multivariate analysis any NS was a predictor of better erectile function at all time points. Two years postoperatively, of 175 men who reported erectile recovery, 63 (36%) did not require an erectile aid, 53 (30%) required PDE-5-inhibitors and 59 (34%) required either Alprostadil by use of MUSE (Medicated Urethral System for Erection) or auto-injection therapy. Likewise, patients with bilateral and unilateral NS were less in need of MUSE or auto-injection therapy compared with no NS. Overall EFR-rates of our study population at 3, 6, 12, 24 months (14%, 30%, 44% and 50%) are comparable with EFR rates of patients with low- and intermediate-risk prostate cancer at all time points who underwent RP during the same time period (16%, 34%, 51% and 56%).

NS was significantly associated with higher UC and EFR-rates after RP compared to non-NSRP with an ongoing improvement in all 3 groups during the first two years after RP. In terms of degree of NS, its effect on EFR is more pronounced than on UC at all time points, meaning that wider tumour resection in more advanced tumour stage predominately affected EFR.

Attempted nerve sparing in patients with high-risk prostate cancer is associated with favourable urinary continence and erectile function recovery rates after radical prostatectomy and should therefore be offered in well-selected patients.

Nguyen, L. N., Head, L., Witiuk, K. et al.: The Risks and Benefits of Cavernous Neurovascular Bundle Sparing during Radical Prostatectomy: A Systematic Review and Meta-Analysis. J Urol, 198: 760, 2017.
Marien, T. P., Lepor, H.: Does a nerve-sparing technique or potency affect continence after open radical retropubic prostatectomy? BJU Int, 102: 1581, 2008.
Kundu, S. D., Roehl, K. A., Eggener, S. E. et al.: Potency, continence and complications in 3,477 consecutive radical retropubic prostatectomies. J Urol, 172: 2227, 2004.