Does nerve-sparing status impact surgical margin location for recurrence of prostate cancer after prostate surgery?

This article looked at the impact of nerve-sparing (NS) surgery on positive surgical margin (PSM) location and the recurrence of tumors in patients following radical prostatectomy (RP; prostate removal surgery). The authors found that having NS surgery on both sides of the prostate increased the risk of PSM and was associated with a higher rate of tumor recurrence. 

Prostate cancer (PC) is the second most frequent tumor found in men. RP is one of the surgical procedures used to treat PC. It has been shown to be more effective than a ‘watchful waiting’ in men with PC. RP involves the complete removal of the prostate gland and surrounding tissues. This can often be curative. 

A PSM indicates that cancer cells are still present in the surrounding tissues following the removal of the tumor. PSM is associated with a higher risk of tumor recurrence. One of the goals of RP should be having negative surgical margins.

NS surgery has been used to avoid complications such as erectile dysfunction and urinary incontinence following RP. However, the impact of NS surgery on PSM and recurrence in men undergoing RP is still unknown. 

The authors reviewed data from 726 patients with PC undergoing RP. RP was done either by open surgery, laparoscopic (keyhole surgery), or robotic surgery. 214 patients had bilateral NS surgery (BNS; the nerves were spared on both sides of the prostate). 217 patients had unilateral NS (UNS; the nerves were spared on only one side of the prostate). The remaining patients did not have NS surgery. 

Overall, NS surgery was associated with a 2.29 times higher risk of having PSM compared to the non-NS group. Having BNS was associated with a 3.04 times higher risk of PSM compared to no NS surgery. 

Overall, 5.8% of the patients had a recurrence after an average of 43.5 months. There was no difference in recurrence rates between patients who had PSM and those with negative margins. PSM in patients with a lower tumor stage (T2) was associated with a higher risk of recurrence. However, in those with a higher tumor stage (T3 or higher), PSM were not associated with recurrence. 

The most common location for PSM was the anterior-apex (AA; where the urethra exits the prostate to the penis) of the prostate. Having PSM in other parts as the AA in the part where the nerves were not spared in patients with UNS was associated with a 2.56 times higher risk of recurrence. 

The authors found that avoiding a PSM on other parts of the prostate than the AA where the nerves were not spared in patients having UNS was important in maintaining a recurrence-free survival.

This trial included different techniques of RP which may have an impact on the study results. Also, the study was based on medical records from a Japanese database.