Descending Nerve-Sparing Radical Prostatectomy – Results and Consequences

Abstract

Nerve-sparing radical prostatectomy is the ther­apy of choice in selected prostate cancer patients. In an internal quality control including a questionnaire, our nerve-sparing radical prostatectomies have been analysed for oncological and functional results as well as patient satisfaction. 171 consecutive nerve sparing radical prostatectomies have been analysed, 123 bilateral, 48 unilateral. The median follow-up was 26 (2–56) months. The operations were performed by 5 surgeons. In 27 % the T-category and in 12 % the Gleason score had been understaged preoperatively, 9 % had positive margins and in 4 % lymph nodes were positive. 99 % of the patients stated that they would again prefer the operation as treatment of first choice. 95 % were satisfied with their postoperative situation. 53 % of the patients had erections sufficient for sexual intercourse following the bilateral, 25 % following the unilateral nerve-sparing procedure. The time until recurrence of erections was 1 month in 42 %, 6 months in 90 % and 12 months in 100 % of the potent men. 90 % of all patients within the observation period are fully continent, 10 % of the patients need more than 1 pad. The intersurgeon varia­bility is 77–98 % for continence and 25–60 % for potency. Patient satisfaction, oncological and functional results are good. The understaging rate suggests the necessity for better patient ­selection including re-biopsy and reference histology. 27 % would have been undertreated by brachytherapy as alternative treatment. Intensive surgeon teaching is mandatory.

Key words

nerve-sparing radical prostatectomy - patient satisfaction - potency - continence - influence of surgeon

References

• 1 Bannowsky A, Schulze H, van der Horst C et al. Nocturnal tumescence: a parameter for postoperative erectile integrity after nerve sparing radical prostatectomy.  J Urol. 2006;  175 2214-2217
• 2 Bianco Jr F J, Scardino P T, Eastham J A. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”).  Urology. 2005;  66 83-94
• 3 Bill-Axelson A, Homberg L, Ruutu M Scandinavian prostate cancer group study No. 4 et al.,. Radical prostatectomy versus watchful waiting in early prostate cancer.  NEJM. 2005;  352 1977-1984
• 4 Burkhard F C, Kessler T M, Fleischmann A et al. Nerve sparing open radical retropubic prostatectomy-does it have an impact on urinary continence?.  J Urol. 2006;  176 189-195
• 5 Burnett A L. Erectile dysfunction following radical prostatectomy.  JAMA. 2005;  293 2648-2653
• 6 Catalona W J, Carvalhal G F, Mager D E et al. Potency, continence an complication rates in 1870 consecutive radical retropubic prostatectomies.  J Urol. 1999;  162 433
• 7 Catalona W J, Ramos C G, Carvalhal G F. Contemporary results of anatomic radical prostatectomy.  CA Cancer J Clin. 1999;  49 282
• 8 Han M, Partin A W, Chan D Y et al. An evaluation of the decreasing incidence of positive surgical margins in al large retropubic prostatectomy series.  J Urol. 2004;  171 23
• 9 Han M, Partin A W, Pound C R et al. Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience.  Urol Clin North Am. 2001;  28 555-565
• 10 Heidenreich A, Aus G, Abbou C C et al. Guidelines on Prostate Cancer.  Eur Association of Urol. 2005;  48 546-551
• 11 Hull G W, Rabbani F, Abbas F et al. Cancer control with radical prostatectomy alone in 1000 consecutive patients.  J Urol. 2002;  167 (2 Pt 1) 528-534
• 12 Jacobsen N EB, Moore K, Estey E et al. Open versus laparoscopic radical prostatectomy: a prospective comparison of postoperative urinary incontinence rates.  J Urol. 2007;  177 615-619
• 13 Michl U HG, Friedrich M G, Graefen M et al. Prediction of postoperative sexual function after nerve sparing radical retropubic prostatectomy.  J Urol. 2006;  176 227-231
• 14 Noldus J, Michl U, Graefen M et al. Patient-reported sexual function after nerve-sparing radical retropubic prostatectomy.  Eur Urol. 2002;  42 118
• 15 Ponholzer A, Brössner C, Struhal G et al. Lower urinary tract symptoms, urinary incontinence, sexual function and quality of life after radical prostatectomy and external beam radiation therapy: real life experience in Austria.  World J Urol. 2006;  24 325-330
• 16 van Poppel H, Goethuys H, Callewaert P et al. Radical prostatectomy can provide cure for well selected clinical stage T3 prostate cancer.  Eur Urol. 2000;  38 372-379
• 17 Rosen R C, Cappelleri J C, Smith M D et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction.  Int J Impot Res. 1999;  11 319
• 18 Swindle P, Eastham J A, Ohori M et al. Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens.  J Urol. 2005;  174 903-907
• 19 Ward J F, Slezak J M, Blute M L et al. Radical prostatectomy for clinically advanced (cT3) prostate cancer since the advent of prostate-specific antigen testing: 15-year outcome.  BJU Int. 2005;  95 751-756
• 20 Wieder J A, Soloway M S. Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer.  J Urol. 1998;  160 299
• 21 Wirth M P, Hakenberg O W, Fröhner M. Therapie des lokalen fort­ge­schrittenen Prostatakarzinoms.  Urologe. 2005;  44 1295-1302