Articles

Platinum Priority – Prostate Cancer
Editorial by Declan G. Murphy and Anthony J. Costello on pp. 445–447 of this issue

Effect of a Risk-stratified Grade of Nerve-sparing Technique on Early Return of Continence After Robot-assisted Laparoscopic Radical Prostatectomy

By: Abhishek Srivastava a , Sameer Chopra a , Anthony Pham a , Prasanna Sooriakumaran a , Matthieu Durand a , Bilal Chughtai a , Siobhan Gruschow a , Alexandra Peyser a , Niyati Harneja a , Robert Leung a , Richard Lee a , Michael Herman a , Brian Robinson b , Maria Shevchuk b and Ashutosh Tewari a lowast

European Urology, Volume 63 Issue 1, March 2013, Pages 438-444

Published online: 01 March 2013

Keywords: Prostate cancer, Continence, Nerve-sparing, Robotic-assisted laparoscopic prostatectomy

Abstract Full Text Full Text PDF (603 KB)

Abstract

Background

The impact of nerve sparing (NS) on urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP) has yet to be defined.

Objective

To evaluate the effect of a risk-stratified grade of NS technique on early return of urinary continence.

Design, setting, and participants

Data were collected from 1546 patients who underwent RALP by a single surgeon at a tertiary care center from December 2008 to October 2011. Patients were categorized preoperatively by a risk-stratified approach into risk grades 1–4, with risk grade 1 patients more likely to receive NS grade 1 or complete hammock preservation. This categorization was also conducted for risk grades 2–4, with grade 4 patients receiving a non-NS procedure.

Intervention

Risk-stratified grading of NS RALP.

Outcome measurements and statistical analysis

Univariate and multivariate analysis identified predictors of early return of urinary continence, defined as no pad use at ≤12 wk postoperatively.

Results and limitations

Early return of continence was achieved by 791 of 1417 men (55.8%); of those, 199 of 277 (71.8%) were in NS grade 1, 440 of 805 (54.7%) were in NS grade 2, 132 of 289 (45.7%) were in NS grade 3, and 20 of 46 (43.5%) were in NS grade 4 (p < 0.001). On multivariate analysis, better NS grade was a significant independent predictor of early return of urinary continence when NS grade 1 was the reference variable compared with NS grade 2 (p < 0.001; odds ratio [OR]: 0.46), NS grade 3 (p < 0.001; OR: 0.35), and NS grade 4 (p = 0.001; OR: 0.29). Lower preoperative International Prostate Symptom Score (p = 0.001; OR: 0.97) and higher preoperative Sexual Health Inventory for Men score (p = 0.002; OR: 1.03) were indicative of early return of urinary continence. Positive surgical margin rates were 7.2% (20 of 277) of grade 1 cases, 7.6% (61 of 805) of grade 2 cases, 7.6% (22 of 289) of grade 3 cases, and 17.4% (8 of 46) of grade 4 cases (p = 0.111). Extraprostatic extension occurred in 6.1% (17 of 277) of NS grade 1 cases, 17.5% (141 of 805) of NS grade 2 cases, 42.5% (123 of 289) of NS grade 3 cases, and 63% (29 of 46) of NS grade 4 cases (p < 0.001). Some limitations of the study are that the study was not randomized, grading of NS was subjective, and possible selection bias existed.

Conclusions

Our study reports a correlation between risk-stratified grade of NS technique and early return of urinary continence as patients with a lower grade (higher degree) of NS achieved an early return of urinary continence without compromising oncologic safety.

Take Home Message

Nerve sparing is important for the return of urinary continence, especially within 12 wk. The degree of nerve sparing can be determined by a risk-stratified approach that can optimize early continence recovery without compromising oncologic safety.

Keywords: Prostate cancer, Continence, Nerve-sparing, Robotic-assisted laparoscopic prostatectomy.

Footnotes

a LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA

b Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, NY, USA

lowast Corresponding author. LeFrak Institute of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, 525 East 68th Street, Starr 900, New York, NY 10065, USA. Tel. +1 212 746 5634; Fax: +1 212 746 9842.

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