Department of Urology, University Hospitals Leuven, Leuven, Belgium.
Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
Eur Urol Focus. 2022 May;8(3):690-700. doi: 10.1016/j.euf.2021.05.009. Epub 2021 Jun 17.
Surgical techniques aimed at preserving the neurovascular bundles during radical prostatectomy (RP) have been proposed to improve functional outcomes. However, it remains unclear if nerve-sparing (NS) surgery adversely affects oncological metrics.
To explore the oncological safety of NS versus non-NS (NNS) surgery and to identify factors affecting the oncological outcomes of NS surgery.
Relevant databases were searched for English language articles published between January 1, 1990 and May 8, 2020. Comparative studies for patients with nonmetastatic prostate cancer (PCa) treated with primary RP were included. NS and NNS techniques were compared. The main outcomes were side-specific positive surgical margins (ssPSM) and biochemical recurrence (BCR). Risk of bias (RoB) and confounding assessments were performed.
Out of 1573 articles identified, 18 studies recruiting a total of 21 654 patients were included. The overall RoB and confounding were high across all domains. The most common selection criteria for NS RP identified were characteristic of low-risk disease, including low core-biopsy involvement. Seven studies evaluated the link with ssPSM and showed an increase in ssPSM after adjustment for side-specific confounders, with the relative risk for NS RP ranging from 1.50 to 1.53. Thirteen papers assessing BCR showed no difference in outcomes with at least 12 mo of follow-up. Lack of data prevented any subgroup analysis for potentially important variables. The definitions of NS were heterogeneous and poorly described in most studies.
Current data revealed an association between NS surgery and an increase in the risk of ssPSM. This did not translate into a negative impact on BCR, although follow-up was short and many men harbored low-risk PCa. There are significant knowledge gaps in terms of how various patient, disease, and surgical factors affect outcomes. Adequately powered and well-designed prospective trials and cohort studies accounting for these issues with long-term follow-up are recommended.
Neurovascular bundles (NVBs) are structures containing nerves and blood vessels. The NVBs close to the prostate are responsible for erections. We reviewed the literature to determine if a technique to preserve the NVBs during removal of the prostate causes worse cancer outcomes. We found that NVB preservation was poorly defined but, if applied, was associated with a higher risk of cancer at the margins of the tissue removed, even in patients with low-risk prostate cancer. The long-term importance of this finding for patients is unclear. More data are needed to provide recommendations.
旨在保留根治性前列腺切除术（RP）期间的神经血管束的手术技术已被提出以改善功能结果。然而，神经保留（NS）手术是否会不利地影响肿瘤学指标仍不清楚。
探讨 NS 与非 NS（NNS）手术的肿瘤学安全性，并确定影响 NS 手术肿瘤学结果的因素。
搜索了 1990 年 1 月 1 日至 2020 年 5 月 8 日期间发表的英文文献，纳入了接受原发 RP 治疗的非转移性前列腺癌（PCa）患者的比较研究。比较了 NS 和 NNS 技术。主要结果是特定侧阳性手术边缘（ssPSM）和生化复发（BCR）。进行了偏倚风险（RoB）和混杂因素评估。
从 1573 篇文章中筛选出 18 项研究，共纳入 21654 例患者。所有领域的总体 RoB 和混杂因素都很高。NS RP 最常见的选择标准是具有低危疾病特征，包括低核心活检受累。有 7 项研究评估了与 ssPSM 的关系，并在调整了特定侧的混杂因素后显示出 NS RP 后 ssPSM 增加，NS RP 的相对风险范围为 1.50 至 1.53。13 篇评估 BCR 的论文显示，在至少 12 个月的随访中，结果没有差异。由于潜在的重要变量缺乏数据，无法进行任何亚组分析。NS 的定义在大多数研究中是异质的，描述得很差。
目前的数据显示，NS 手术后 ssPSM 的风险增加与 NS 手术之间存在关联。尽管随访时间短，且许多男性患有低危 PCa，但这并未转化为 BCR 的负面影响。在各种患者、疾病和手术因素如何影响结果方面存在重大知识空白。建议进行适当的、有影响力的、设计良好的前瞻性试验和队列研究，并进行长期随访以解决这些问题。
神经血管束（NVBs）是包含神经和血管的结构。靠近前列腺的 NVBs 负责勃起。我们回顾了文献，以确定在切除前列腺时保留 NVB 是否会导致更差的癌症结果。我们发现 NVB 保存的定义很差，但如果应用，即使在低危前列腺癌患者中，也与组织切除边缘的癌症风险增加相关。这一发现对患者的长期重要性尚不清楚。需要更多的数据来提供建议。
