Editorial Comment to Impact of nerve sparing in robot‐assisted radical prostatectomy on the risk of positive surgical margin and biochemical recurrence

Abstract

Postoperative complications of radical prostatectomy include urinary incontinence (UI) and erectile dysfunction (ED). Nerve sparing (NS) techniques developed to relieve ED can reduce postoperative ED and UI. 1 However, NS techniques may result in more positive surgical margins (PSMs) because the dissection is close to the prostate, and the indication is often determined after evaluating prostate cancer grade and localization. 2 Although some studies have reported that NS techniques do not affect PSM and biochemical recurrence (BCR), 1 others have reported an increase in PSM. 3 Komori et al. reviewed 814 cases of robot-assisted radical prostatectomy with respect to NS and cancer control. 4 A multivariate analysis adjusted for several factors that affected cancer control concluded that bilateral NS techniques increased PSM more than non-NS ones, and unilateral NS techniques increased PSM on the NS side with an increased BCR risk. 4 The indication for NS may contribute to the increased PSM and BCR. In this study, the indications for NS were T stage ≤T2 with evaluations, including digital rectal examination and magnetic resonance imaging (MRI), and International Society of Urological Pathology grade group ≤3. A comparison of clinical and pathological stages showed that the number of cases with T stage ≥T3 increased with pathological stage from 9.2% to 32.2% in all cases, from 3.9% to 26.3% in unilateral NS, and from 0% to 14.4% in bilateral NS. 4 Staging in preoperative evaluation cannot predict the pathological stage accurately. In the study, the number and sites of positive biopsies, cancer occupancy on biopsy, and prostate imaging reporting and data system evaluation on MRI were not considered when determining the indication for NS, which could have increased PSM on the side of NS. 2,4 Although NS is beneficial 1 and should be performed when possible, its possible adverse effects on cancer control should be considered. 3,4 Prostate cancer location should be determined using all possible modalities, including prostate needle biopsy and MRI findings, to determine the appropriate indication for NS and reduce PSM and BCR rates. 2