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Prostate Cancer

Degree of Preservation of the Neurovascular Bundles During Radical Prostatectomy and Urinary Continence 1 Year after Surgery

By: Gunnar Steineck a b lowast , Anders Bjartell c , Jonas Hugosson d , Elin Axén d , Stefan Carlsson e , Johan Stranne d , Anna Wallerstedt e , Josefin Persson c , Ulrica Wilderäng a , Thordis Thorsteinsdottir a f , Ove Gustafsson g , Mikael Lagerkvist h , Thomas Jiborn c , Eva Haglind i and Peter Wiklund e on behalf of the LAPPRO steering committee 1 .

European Urology, Volume 67 Issue 3, March 2015, Pages 559-568

Published online: 01 March 2015

Keywords: Prostate cancer, Radical prostatectomy, Surgical technique, Urinary continence, Anatomy, Neurovascular bundle, Nerve-sparing surgery

Abstract Full Text Full Text PDF (819 KB) Patient Summary

Abstract

Background

Many elderly or impotent men with prostate cancer may not receive a bundle-preserving radical prostatectomy as a result of uncertainty regarding the effect on urinary incontinence.

Objective

We searched for predictors of urinary incontinence 1 yr after surgery among surgical steps during radical prostatectomy.

Design, setting, and participants

More than 100 surgeons in 14 centers prospectively collected data on surgical steps during an open or robot-assisted laparoscopic radical prostatectomy. At 1 yr after surgery, a neutral third-party secretariat collected patient-reported information on urinary incontinence. After excluding men with preoperative urinary incontinence or postoperative irradiation, data were available for 3379 men.

Intervention

Surgical steps during radical prostatectomy, including dissection plane as a measure of the degree of preservation of the two neurovascular bundles.

Outcome measurements and statistical analysis

Urinary incontinence 1 yr after surgery was measured as patient-reported use of pads. In different categories of surgical steps, we calculated the percentage of men changing pads “about once per 24 h” or more often. Relative risks were calculated as percentage ratios between categories.

Results and limitations

A strong association was found between the degree of bundle preservation and urinary incontinence 1 yr after surgery. We set the highest degree of bundle preservation (bilateral intrafascial dissection) as the reference category (relative risk = 1.0). For the men in the remaining six groups, ordered according to the degree of preservation, we obtained the following relative risks (95% confidence interval [CI]): 1.07 (0.63–1.83), 1.19 (0.77–1.85), 1.56 (0.99–2.45), 1.78 (1.13–2.81), 2.27 (1.45–3.53), and 2.37 (1.52–3.69). In the latter group, no preservation of any of the bundles was performed. The pattern was similar for preoperatively impotent men and for elderly men. Limitations of this analysis include the fact that noise influences the relative risks, due to variations between surgeons in the use of undocumented surgical steps of the procedure, variations in surgical experience and in how the surgical steps are reported, as well as variations in the metrics of patient-reported use of pads.

Conclusions

We found that the degree of preservation of the two neurovascular bundles during radical prostatectomy predicts the rate of urinary incontinence 1 yr after the operation. According to our findings, preservation of both neurovascular bundles to avoid urinary incontinence is also meaningful for elderly and impotent men.

Patient summary

We studied the degree of preservation of the two neurovascular bundles during radical prostatectomy and found that the risk of incontinence decreases if the surgeon preserves two bundles instead of one, and if the surgeon preserves some part of a bundle rather than not doing so.

Take Home Message

Sexual inactivity or old age should not be considered a factor in decisions concerning the extent to which the neurovascular bundles are preserved during radical prostatectomy, because the degree of preservation predicts the rate of urinary incontinence in all survivors.

Keywords: Prostate cancer, Radical prostatectomy, Surgical technique, Urinary continence, Anatomy, Neurovascular bundle, Nerve-sparing surgery.

Footnotes

a Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

b Department of Oncology and Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden

c Department of Urology, Skåne University Hospital, Lund University, Lund, Sweden

d Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

e Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden

f Faculty of Nursing, University of Iceland, Reykjavik, Iceland

g Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

h UroClinic, Stockholm, Sweden

i Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

lowast Corresponding author. Clinical Cancer Epidemiology, Sahlgrenska Academy, University of Gothenburg, Box 100, 405 30 Gothenburg, Sweden.

1 Eva Haglind is the PI and Gunnar Steineck the co-PI of LAPPRO.

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