Oncological outcomes after attempted nerve sparing radical prostatectomy in patients with high-risk prostate cancer are comparable to standard non-nerve sparing radical prostatectomy: a longitudinal long-term propensity-matched single-centre study.

OBJECTIVE To assess the long-term safety of nerve-sparing radical prostatectomy (NSRP) in men with high-risk prostate cancer (HR-PCa). HR-PCa is associated with higher incidence of extra prostatic disease. This has led to the concept that NS should be avoided to prevent positive surgical margins (PSM) as they may increase risk of disease recurrence. Whether NSRP should be attempted in these patients remains a matter of debate. We aim to compare survival outcomes, disease recurrence the need for additional therapy and peri-operative outcomes of patients undergoing NSRP to those without any NS. MATERIALS AND METHODS We included consecutive patients at a single, academic centre undergoing open RP for HR-PCa, defined as preoperative PSA>20 ng/ml and/or postoperative ISUP-grade group 4 or 5 (i.e. Gleason score ≥ 8) and/or ≥ pT3 and/or pN1 assessing the prostatectomy and lymph node specimen. We calculated a propensity score and used inverse probability of treatment weighting to match baseline characteristics of HR-PCa patients undergoing NSRP to those having non-NSRP. We analyzed oncological outcome as time-to-event and calculated hazard ratios (HR). RESULTS A total of 726 patients were included in this analysis of which 84% (n=609) underwent NSRP. There was no evidence for the PSM being different between the NSRP and non-NSRP groups (47% vs 49%, p=0.64). Likewise, there was no evidence for the need for post-operative radiotherapy being different in men who underwent NSRP from those who did not have nerves spared (HR 0.78, 95%CI 0.53-1.15). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p=0.09) and there was no evidence for the survival being different in men who underwent NSRP to those who had non-NSRP (HR 0.65, 95%CI 0.39-1.08). There was also no evidence for the cancer-specific survival (0.56, 95%CI 0.29-1.11) nor progression-free survival (H) 0.99, 95%CK 0.73-1.34) being different between both groups. CONCLUSION In patients with HR-PCa NSRP can be attempted without compromising long-term oncological outcomes provided a comprehensive assessment of objective (e.g. T-stage) and subjective (e.g. intraoperative appraisal of tissue planes) criteria is conducted