A developed simple algorithm for the decision-making on neurovascular bundle preservation does not compromise surgical margins in high risk prostate cancer
Tabata, H1; Hashimoto, K1; Shindo, T1; Kobayashi, K1; Fukuta, F1; Tanaka, T1; Masumori, N1
1: Sapporo medical university, Japan
Objective: Previously, we developed a simple algorithm for the decision-making on neurovascular bundle (NVB) preservation in radical prostatectomy (RP) (Hashimoto K, et al. Jpn J Clin Oncol 2010). Nerve-sparing RP is an important procedure for the recovery of the erectile function after surgery, which leads to the improvement in the quality of life of patients with prostate cancer. In most cases with high risk prostate cancer, however, NVB preservation has not been emphasized to avoid compromising surgical margins. To achieve a good balance between cancer control and functional preservation, we investigated the clinical safety and feasibility of this algorithm in patients with high risk prostate cancer.
Material and Methods: We retrospectively evaluated 31 patients (62 prostate sides) with high risk prostate cancer in NCCN classification who underwent robot-assisted laparoscopic radical prostatectomy (RALP) at our institution between June 2013 and August 2017. We excluded the patients with preoperative androgen deprivation therapy. NVB preservation was performed in only six patients. The algorithm for the decision-making on NVB preservation consisted of four elements, including the clinical T stage, preoperative PSA, Gleason score on biopsy and cores in the apex. All prostate sides were divided into two groups according to this algorithm; the favorable algorithm group and the unfavorable algorithm group. NVB preservation was determined to be impossible, when only fatty tissue exists in between surgical margin at apex and tumor, or when extra-prostatic extension exists on NVB.
Results: The median age was 66 years old. The number of patients with preoperative PSA level 20 ng/ml<, Gleason score 8≦ and clinical T3a< was 1 (3%), 27 (87%) and 5 (16%), respectively. The incidence of extra-prostate extension, seminal vesicle invasion, positive surgical margin was 23%, 3%, and 19%, respectively. Of all the prostates sides, 29 prostate sides (47%) were in the favorable algorithm group. In the favorable algorithm group, extra-prostatic extension on NVB was observed in 7% compared with 33% in the unfavorable algorithm group (p=0.01). No risk of positive surgical margin at the apex was observed in the favorable algorithm group, whereas in the unfavorable algorithm group it was 6% (p=0.18). Overall, In the favorable algorithm group, NVBs of 27 sides (97%) were determined to be preserved safely.
Conclusions: This result suggests that the decision-making on NVB preservation using this algorithm is consistent with margin status even in high risk prostate cancer.
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