Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
J Urol. 2017 Oct;198(4):760-769. doi: 10.1016/j.juro.2017.02.3344. Epub 2017 Mar 9.
We summarize published data on associations between cavernous neurovascular bundle preservation (nerve sparing) during prostatectomy and positive surgical margins, erectile function, urinary function and other patient reported outcomes.
A systematic literature search of MEDLINE®, Embase® and Cochrane Reviews databases was performed for interventional or observational studies published between 2000 and 2014. English language articles that compared clinical outcomes of patients undergoing nerve sparing and nonnerve sparing radical prostatectomy were included. Meta-analyses were performed to calculate pooled relative risk estimates for positive surgical margins, erectile dysfunction and urinary incontinence in nerve sparing and nonnerve sparing groups. Sensitivity analyses compared outcomes among unilateral and bilateral nerve sparing vs nonnerve sparing groups.
Of the 1,883 articles identified, 124 studies (73,448 patients) were included in the analysis. Nerve sparing did not increase the risk of positive surgical margins in patients with pT2 (RR 0.92, 95% CI 0.75-1.13) or pT3 disease (RR 0.83, 95% CI 0.71-0.96), potentially due to appropriate patient selection. The risk of incontinence was lower in nerve sparing cases (RR 0.75, 95% CI 0.65-0.85 and RR 0.61, 95% CI 0.44-0.84) at 3 and 12 months, respectively. The relative risk of erectile dysfunction with nerve sparing was 0.77 (95% CI 0.70-0.85) at 3 months and 0.53 (95% CI 0.39-0.71) at 12 months. Subgroup analyses of unilateral and bilateral nerve sparing approaches demonstrated similar results.
Among cohort studies nerve sparing was not associated with worse cancer outcomes. Nerve sparing is associated with better urinary and erectile function. These results should be interpreted with caution given the potential for selection bias and unadjusted confounding factors.
我们总结了发表的关于前列腺切除术时海绵体神经血管束保护（神经保留）与阳性手术切缘、勃起功能、尿功能和其他患者报告结果之间关系的文献。
对 2000 年至 2014 年期间发表的干预性或观察性研究进行了 MEDLINE、Embase 和 Cochrane 综述数据库的系统文献检索。纳入了比较行神经保留和非神经保留根治性前列腺切除术患者临床结局的英文文章。对神经保留和非神经保留组的阳性手术切缘、勃起功能障碍和尿失禁的汇总相对风险估计值进行了荟萃分析。敏感性分析比较了单侧和双侧神经保留与非神经保留组之间的结局。
在 1883 篇文章中，有 124 项研究（73448 例患者）纳入分析。在 pT2（RR 0.92，95%CI 0.75-1.13）或 pT3 疾病（RR 0.83，95%CI 0.71-0.96）患者中，神经保留并未增加阳性手术切缘的风险，这可能是由于患者选择适当。神经保留组在 3 个月和 12 个月时的尿失禁风险较低（RR 0.75，95%CI 0.65-0.85 和 RR 0.61，95%CI 0.44-0.84）。神经保留与勃起功能障碍的相对风险为 3 个月时为 0.77（95%CI 0.70-0.85），12 个月时为 0.53（95%CI 0.39-0.71）。单侧和双侧神经保留方法的亚组分析显示了相似的结果。
在队列研究中，神经保留与癌症结局恶化无关。神经保留与更好的尿和勃起功能有关。考虑到选择偏倚和未调整的混杂因素，这些结果应谨慎解释。
