Urologic Oncology: Seminars and Original Investigations 33 (2015) 18.e1–18.e6
Original article
The association between nerve sparing and a positive surgical margin
during radical prostatectomy
Mark A. Preston, M.D.a, Rodney H. Breau, M.D.b,c, Andrea G. Lantz, M.D.d,
Christopher Morash, M.D.b, Ronald G. Gerridzen, M.D.b, Steve Doucette, Ph.D.e,
Ranjeeta Mallick, Ph.D.c, James A. Eastham, M.D.f, Ilias Cagiannos, M.D., F.R.C.S.C.b,*
b
a
Department of Urology, Brigham and Women’s Hospital, Boston, MA
Department of Surgery, The Ottawa Hospital, General Campus, University of Ottawa, Ottawa, Ontario, Canada
c
Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
d
Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
e
Research Methods Unit, Capital Health Authority, Halifax, Nova Scotia, Canada
f
Department of Urology, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, NY
Received 20 June 2014; received in revised form 5 September 2014; accepted 7 September 2014
Abstract
Purpose: A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the
effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would
increase rates of pT2 positive margins.
Methods: We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering
Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive
SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostatespecific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model.
Results: Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP.
Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a
positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive
margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] ¼ 1.52, 95% CI: 0.97–2.39)
after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated
increase in risk of positive margin after adjustment for other variables (RR ¼ 0.96, 95% CI: 0.80–1.16). Prostate incision into tumor
(pT2R1) was significantly more likely in patients treated with robotic surgery (RR ¼ 1.76, 95% CI: 1.25–2.48) than in those with open
surgery. There was no difference between laparoscopic and open RP (RR ¼ 0.86, 95% CI: 0.65–1.12).
Conclusions: Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease
during RP. r 2014 Elsevier Inc. All rights reserved.
Keywords: Prostate; Carcinoma; Prostatectomy; Nerves
1. Introduction
Radical prostatectomy (RP) is a well-established treatment for men with clinically localized prostate cancer. The
* Corresponding author. Tel.: þ1-613-7-614-500; fax: þ1-613-7-615305.
E-mail address: [email protected] (I. Cagiannos).
http://dx.doi.org/10.1016/j.urolonc.2014.09.006
1078-1439/r 2014 Elsevier Inc. All rights reserved.
goals of this procedure are to achieve oncologic control
while preserving urinary continence and erectile function, if
possible. A nerve-sparing RP preserves the neurovascular
bundles adjacent to the posterior-lateral prostate. It is
associated with maintenance of erectile function and urinary
continence [1–4]. However, a concern with nerve-sparing
RP is that the closer dissection plane results in a higher risk
of positive surgical margins (SMs). Previous studies
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M.A. Preston et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 18.e1–18.e6
evaluating the relationship between nerve sparing and
positive SMs have produced conflicting results, possibly
owing to small sample size, incomplete information about
potential confounders, lack of pathologic tumor stage
stratification, or being performed in a noncontemporary
era [5–11].
Positive SMs can occur in patients who have extraprostatic disease (pT3) and in patients with organ-confined
(pT2) disease [12]. Prostate incision into organ-confined
tumor can occur when the plane of surgical dissection is
carried into the prostate. Pathologically, it is defined as
tumor extension to the inked margin in the same plane
where benign prostatic acini also extend to the inked margin
[13,14]. Prostate incision into tumor (pT2R1) during RP
increases the risk of biochemical recurrence and may
decrease cancer-specific survival [14,15]. A positive SM
has important implications for adjuvant treatment and is
possibly an indication of poor surgical quality [16–18].
Our objective was to evaluate the effect of nerve sparing
on risk of positive margins in patients with pT2- and pT3category disease using a large multisurgeon prospective
cohort of contemporary RP patients. We hypothesized that
the close prostate dissection required for neurovascular
bundle preservation would increase the risk of positive SMs.
2. Materials and methods
2.1. Patient selection
After receiving institutional review board approval, we
evaluated a historical cohort of 9,915 consecutive RP
patients treated at The Ottawa Hospital (n = 866) or
Memorial Sloan-Kettering Cancer Center (MSKCC, n =
9,049) between 2000 and 2010 for clinically localized
prostate adenocarcinoma. Patients who received preoperative androgen deprivation, who underwent preoperative
prostate radiation therapy, who were operated on before
2000, or who had incomplete data were excluded. Data
were combined to enhance generalizability through inclusion of a broader range of surgeons and settings.
2.3. Pathologic technique
Dedicated genitourinary pathologists reviewed all pathology specimens at both centers. Intact RP specimens were
fixed in formalin, inked to determine SMs in the fresh state,
serially sectioned, and entirely submitted for histologic
examination. The inked apical margin was assessed via
the perpendicular coned technique. The most apical 3-mm
portion of the gland is sectioned and further segmented
radially in a conelike fashion and embedded. Finally, the
remaining bulk of the gland is sectioned from apex to base
at approximately 3-mm intervals and entirely submitted.
Pathologists assessed prostate specimens for grade, category, SM status, and the presence of extraprostatic extension. A positive SM was consistently defined as tumor
extending to the inked surface of the prostatectomy specimen. Prostate incision into tumor (pT2R1) was defined as
tumor at the inked margin in the same plane where benign
prostatic acini are at the inked margin. The location and
extent of prostate incision into tumor was not available.
2.4. Statistical analysis
Descriptive statistics were used to characterize the study
subjects. The primary outcome was the presence of a
positive SM on the prostatectomy specimen. This was
evaluated a priori in the overall cohort and in categorystratified cohorts (pT2 and pT3). The association between
nerve sparing and a positive margin was assessed using
univariable and multivariable logistic regression analyses.
Adjustments for prostate-specific antigen (PSA; continuous), pathologic Gleason sum (categorical o7, 7, and 47),
pathologic category ( pT2 and pT3; only in the overall
model), RP modality (categorical open, pure laparoscopic,
and robotic-assisted laparoscopic), year of prostatectomy
(continuous), and location (The Ottawa Hospital or
MSKCC) were made in the multivariable model. The tests
were 2-sided with P o 0.05 considered statistically significant. Confidence intervals are 95% when reported. Statistical analyses were conducted using SAS v9.2 (SAS
Institute Inc, Cary, NC).
2.2. Surgical technique
3. Results
All patients underwent a RP performed by 1 of 19
surgeons at MSKCC or by 1 of 3 surgeons at the Ottawa
Hospital. The approach was not standardized and procedures were performed by open, laparoscopic, or robotic
technique. Patients underwent nerve resection, unilateral
nerve sparing, or bilateral nerve sparing. The decision to
spare or resect nerves was at the discretion of the surgeon
and patient based on preoperative sexual function and
extent of disease. No information was available on intrafascial or interfascial periprostatic dissection. Furthermore,
no information was available for the extent of “wide
dissection” during non–nerve-sparing procedures.
Patients who received preoperative androgen deprivation
(n = 369), who underwent preoperative prostate radiation
therapy (n = 5), who were operated on before 2000
(n = 178), or who had incomplete data on nerve sparing
(n = 2,621), pathologic category (n = 298), preoperative
PSA (n = 238), or surgical modality (n = 86) were
excluded, leaving 6,120 patients included in the analysis.
Of the eligible patients, most had clinical T1c-category
(3,814/5,872, 65.0%) and Gleason 6 disease on biopsy
(3,086/5,877, 52.5%). Detailed patient and disease characteristics are presented in Table 1. Patients underwent open
M.A. Preston et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 18.e1–18.e6
Table 1
Demographics and disease characteristics
Bilateral
18.e3
Table 2
Margin status by nerve sparing performed stratified by pathologic category
Nerve sparing
Unilateral
Resection
Mean age, y (SD)
Mean PSA, ng/ml (SD)
(n ¼ 5,429)
59.2 ⫾ 7.1
6.3 ⫾ 5.8
(n ¼ 441)
60.6 ⫾ 6.9
8.3 ⫾ 8.5
(n ¼ 250)
62.3 ⫾ 7.5
9.4 ⫾ 10.2
Clinical categorya (%)
T1
T2
T3
3,559 (68.3)
1,571 (30.1)
83 (1.59)
159 (37.7)
204 (48.3)
59 (14.0)
96 (40.5)
105 (44.3)
36 (15.2)
Pathologic category (%)
T2
T3
3,927 (72.3)
1,502 (27.7)
175 (39.7)
266 (60.3)
97 (38.8)
153 (61.2)
Biopsy Gleason sum (%)
0–6
7
47
2,928 (56.2)
1,957 (37.5)
329 (6.3)
94 (22.1)
221 (51.9)
111 (26.1)
64 (27.0)
99 (41.8)
74 (31.2)
RP Gleason sum (%)
0–6
7
47
1,846 (34.2)
3,274 (60.6)
286 (5.3)
46 (10.5)
303 (69.2)
89 (20.3)
44 (17.8)
141 (57.1)
62 (25.1)
RP year (%)
2000–2005
2006–2010
2,709 (49.9)
2,720 (50.1)
227 (51.5)
214 (48.5)
143 (57.2)
107 (42.8)
Surgical modality (%)
Open
Laparoscopic
Robotic
3,491 (64.3)
1,392 (25.6)
556 (10.1)
304 (68.9)
102 (23.1)
35 (7.9)
163 (65.2)
72 (28.8)
15 (6.0)
Nerve sparing
Bilateral
Unilateral
Resection Total
Pathologic category T2
Negative margins (%) 3,582 (91.2) 163 (93.1) 91 (93.8) 3,836 (91.4)
Positive margins (%) 345 (8.8)
12 (6.9)
6 (6.2)
363 (8.6)
Total
4,199
Pathologic category T3
Negative margins (%) 1,128 (75.1) 210 (79.0) 98 (64.1) 1,436 (74.8)
Positive margins (%) 374 (24.9) 56 (21.1) 55 (36.0) 485 (25.2)
Total
1,921
Note: Bold indicates those with a positive surgical margin for emphasis.
(3,958/6,120, 64.7%), laparoscopic (1,566/6,120, 25.6%),
or robotic (596/6,120, 9.7%) RP. Bilateral nerve sparing,
unilateral nerve sparing, and nerve resection were performed in 5,429 (88.7%), 441 (7.2%), and 250 (4.1%) of
6,120 patients, respectively.
patients who underwent bilateral nerve sparing were more
likely to have prostate incision into tumor (RR ¼ 1.33,
95% CI: 0.84–2.10) than those with nerve resection were
(Table 4). After adjusting for available potential confounders (PSA level, RP Gleason sum, RP modality, RP year, and
institution) patients with bilateral nerve sparing remained
more likely to have a positive SM (RR ¼ 1.52; 95% CI:
0.97–2.39; P ¼ 0.069) than those who had nerve resection
(Table 4).
Prostate incision into tumor (pT2R1) occurred in approximately 4.6% (72/1,566) of laparoscopic cases, 6.1% (242/
3,958) of open cases, and 8.2% (49/596) of robotic cases.
Prostate incision into tumor was significantly more likely to
occur in patients treated with robotic surgery (RR ¼ 1.76;
95% CI: 1.25–2.48; P ¼ 0.001) vs. those with open
surgery. There was no difference between those undergoing
laparoscopic and open RP (RR ¼ 0.86; 95% CI: 0.65–
1.12; P ¼ 0.266). The risk of prostate incision into tumor
has decreased over time (RR ¼ 0.93 per y; 95% CI: 0.90–
0.97; P ¼ 0.001). Preoperative PSA level and pathologic
Gleason score were significantly associated with prostate
incision into tumor (Table 4).
3.1. Overall cohort
3.3. Pathologic pT3-category cohort
In the overall analysis, bilateral nerve sparing was
associated with a reduced risk of positive margin on
univariable analysis (relative risk [RR] ¼ 0.71, 95% CI:
0.60–0.84) (Table 2). However, after adjusting for confounders including pathologic category, there was no
significantly altered risk of positive margin (RR ¼ 1.06;
95% CI: 0.89–1.26; P ¼ 0.526) (Table 3). Preoperative
PSA level, RP Gleason sum Z7, pathologic category, RP
year, location (Ottawa vs. MSKCC), and modality (robotic
vs. open) were significantly associated with the risk of a
positive SM (Table 3).
Among patients with pT3-category tumors, bilateral
nerve sparing was not associated with a significantly altered
risk of a positive SM on univariable analysis (RR ¼ 0.94,
95% CI: 0.78–1.13) or multivariable analysis after adjusting
for available potential confounders (RR ¼ 0.96; 95% CI:
0.80–1.16; P ¼ 0.698). Preoperative PSA, RP year, and
location (Ottawa vs. MSKCC) were significantly associated
with risk of a positive SM (Table 5).
3.2. Pathologic pT2-category cohort
The benefits of nerve-sparing RP on erectile function and
urinary continence have been shown in multiple observational
studies [1–4]. However, our study reveals that patients with
organ-confined cancer (pT2) who undergo a nerve-sparing RP
SD ¼ standard deviation.
a
Clinical category present in 96% (5,872/6,120) of patients.
Among patients with organ-confined tumors (pT2), 5.9%
(363/6,120) had a positive SM. In univariable analysis,
4. Discussion
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M.A. Preston et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 18.e1–18.e6
Table 3
Relative risk of positive margin on univariable and multivariable analysis
Univariable
Nerve resection (unilateral or bilateral)
Bilateral nerve spare
Preoperative PSA
RP Gleason sum (Z7 vs. o7)
Pathologic category T2 vs. T3
RP year
Laparoscopic RP vs. open RP
Robotic RP vs. open RP
Ottawa vs. MSKCC
Multivariable
RR
95% CI
RR
95% CI
P value
Ref.
0.71
–
–
–
–
–
–
–
–
0.60–0.84
–
–
–
–
–
–
–
Ref.
1.06
1.02
1.39
0.39
0.95
0.87
1.40
1.47
–
0.89–1.26
1.01–1.02
1.16–1.67
0.34–0.45
0.92–0.97
0.74–1.02
1.12–1.74
1.09–1.98
–
0.526
o0.0001
0.0003
o0.0001
o0.0001
0.084
0.003
0.012
are at an increased risk (RR = 1.52, 95% CI: 0.97–2.39) of a
positive SM compared with patients undergoing either
unilateral or bilateral nerve resection. Although not statistically significant (P = 0.069), the lower bound of the
confidence interval bordering 1.0 suggests an increased risk
of a positive margin in patients with pT2-category disease
who undergo nerve-sparing RP. The point estimate increases
from univariable to multivariable analysis (RR = 1.33 to RR =
1.52) suggesting that significance might be attained with a
larger sample size or if additional variables such as tumor
volume or margin length were included in the model.
In this study, the overall risk of a prostate incision into
tumor (pT2R1) was low (5.9%), and within the range of
other reported studies (1.3–33%) [13,19–24]. Prostate
incision into tumor (pT2R1) has been shown to have a
detrimental effect on biochemical recurrence-free survival
and potentially, cancer-specific survival [13,14,19–21,
25,26]. In a prior analysis, we found that patients with
pT2R1 had a higher risk of PSA recurrence (recurrence-free
survival = 0.77, CI: 0.72– 0.83) compared with those with
pT2R0 (recurrence-free survival = 0.94, CI: 0.93–0.95) and
those with completely resected, extraprostatic disease
(recurrence-free survival = 0.86, CI: 0.84–0.87) [14]. In
addition to worse cancer outcomes, positive SMs may result
in adjuvant or salvage radiotherapy [16–18]. This additional
local therapy, while possibly beneficial from an oncologic
perspective, has adverse effects on sexual, urinary, and
bowel function [16–18].
The pathologic category pT3 analysis found no association
between nerve sparing and risk of positive SM (RR = 0.96;
95% CI: 0.80–1.16; P = 0.698). Preoperative PSA, year of
surgery, and institution were also significantly associated with
positive SM among patients with pT3-category disease.
Unfortunately, we did not have information on the extent of
extraprostatic extension, tumor volume, or extent of positive
margin. All of these factors could be important considerations
when interpreting these results. It is likely that patients with
pT3 disease who underwent nerve resection had more
extensive tumor than those who underwent a nerve-sparing
procedure. The effect of this potential selection bias is
unknown, but may underestimate the beneficial effects of
wide dissection for patients with pT3-category tumors.
These results do not suggest that nerve-sparing RP should
not be performed. In fact, nerve sparing should be performed,
and encouraged, in men with acceptable risk of extraprostatic
extension and good sexual function [27]. However, these
results do have implications on operative planning for
patients with poor preoperative erectile function where
unilateral/bilateral nerve resection or interfascial dissection
may be most appropriate. Individual surgeon experience and
surgical technique likely affect risk of positive SMs and
should also be taken into consideration [28–30].
Table 4
Relative risk of positive margin on univariable and multivariable analysis among only patients with pathologic category T2 (i.e., risk of pT2R1)
Univariable
Nerve resection (unilateral or bilateral)
Bilateral nerve spare
Preoperative PSA
RP Gleason sum (Z7 vs. o7)
RP year
Laparoscopic RP vs. open RP
Robotic RP vs. open RP
Ottawa vs. MSKCC
Multivariable
RR
95% CI
RR
95% CI
P value
Ref.
1.33
–
–
–
–
–
–
–
0.84–2.10
–
–
–
–
–
–
Ref.
1.52
1.02
1.72
0.93
0.86
1.76
1.34
–
0.97–2.39
1.00–1.03
1.38–2.14
0.90–0.97
0.65–1.12
1.25–2.48
0.83–2.16
–
0.069
0.026
o0.0001
0.001
0.266
0.001
0.230
M.A. Preston et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 18.e1–18.e6
18.e5
Table 5
Relative risk of positive margin on univariable and multivariable analysis among only patients with pathologic category T3
Univariable
Nerve resection (unilateral or bilateral)
Bilateral nerve spare
Preoperative PSA
RP Gleason sum (Z7 vs. o7)
RP year
Laparoscopic RP vs. open RP
Robotic RP vs. open RP
Ottawa vs. MSKCC
Multivariable
RR
95% CI
RR
95% CI
P value
Ref.
0.94
–
–
–
–
–
–
–
0.78–1.13
–
–
–
–
–
–
Ref.
0.96
1.02
0.88
0.96
0.87
1.15
1.66
–
0.80–1.16
1.01–1.02
0.68–1.14
0.93–0.99
0.71–1.06
0.86–1.54
1.16–2.39
–
0.698
o0.0001
0.330
0.010
0.164
0.332
0.006
Previous studies have also observed an association
between nerve sparing and risk of positive SM [7,10].
Although Palisaar et al. [7] found a pT2 positive margin rate
of 10.6% and no overall association between nerve-sparing
procedures (bilateral and unilateral sparing vs. nerve
resection) and PSA failure, they did note a significant
5-fold increase in positive margins at the lateral aspect of
the prostate in patients with organ-confined cancer who
underwent a nerve-sparing procedure compared with those
who underwent a non–nerve-sparing procedure (26/843
[3%] vs. 4/669 [0.6%]; P ¼ 0.001). The comparison group
for the non–nerve-sparing procedure came predominantly
from an older cohort (1992–1995) before PSA screening
was commonly performed and, subsequently, had more
advanced disease.
Other studies have not have not found nerve sparing to be
an independent predictor of positive SMs [6–8,11,12]. Most
of these studies were performed before 2000, were performed
by a single surgeon, were not stratified by category (pT2 vs.
pT3), or had a sample size fewer than 1,000 men. The largest
study, performed by Ward et al. [6], found that in patients
who were operated on between 1990 and 2000, the risk of
positive SMs in patients undergoing a nerve-sparing procedure was 0.86 (95% CI: 0.76–0.97, P ¼ 0.012) when
compared with those undergoing resection after incorporating
age, clinical stage, biopsy grade, year of surgery, and PSA
level in the analysis. The finding that nerve sparing prevented
positive SMs seems to suggest the presence of an unmeasured
confounder such as tumor volume. An alternative theory is
that nerve sparing improves periprostatic anatomic dissection,
thereby resulting in fewer positive margins.
In the present study, surgical modality was associated
with risk of positive SM. Prostate incision into tumor was
significantly more likely in patients treated with robotic
surgery (RR ¼ 1.76; 95% CI: 1.25–2.48; P ¼ 0.001) vs.
those treated with open surgery. There was no difference
between patients undergoing laparoscopic and open RP (RR ¼
0.86; 95% CI: 0.65–1.12; P ¼ 0.266). Williams et al. [30]
reported a similar finding in their study comparing open
radical retropubic prostatectomy with robotic-assisted laparoscopic prostatectomy, each performed by a single surgeon. They found that men undergoing robotic-assisted
laparoscopic prostatectomy were significantly more likely to
have a positive margin (adjusted odds ratio ¼ 1.9; 95% CI:
1.2–3.1; P ¼ 0.0095) when compared with those treated
with radical retropubic prostatectomy. Whether this difference is because of the learning curve associated with the
robotic procedure or potentially secondary to the benefit of
magnification and improved optics of robotics leading to
more intrafascial dissection is unclear.
Other factors found to be associated with positive SMs
were institution and year of surgery. A positive SM was
significantly associated with RP performed for pT3-category
disease in Ottawa vs. MSKCC (RR ¼ 1.66, 95% CI: 1.16–
2.39). This may be because of the varied techniques or
extent of wide local excision. Prostate incision into tumor
(pT2R1) was less likely to occur in more recent years (RR ¼
0.93, 95% CI: 0.90–0.97). This may be the result of decreased
tumor volume owing to PSA screening and the associated
stage migration or to individual surgeons gaining expertise
with additional cases performed.
The strengths of our study include the large sample size,
pathologic category-stratified analysis, and multiinstitutional nature incorporating many (22) surgeons at
varied levels of experience. Furthermore, the inclusion of
patients treated by open, laparoscopic, and robotic
approaches is a unique feature and emphasizes the generalizability of our results.
Our study is limited because it is a historical cohort and
is susceptible to bias and unadjusted confounding. There is
clear patient selection bias in that surgeons and patients are
more likely to choose a non–nerve-sparing procedure for
larger or more extensive tumors. Furthermore, we were
unable to adjust for the likely confounding effects of
prostate volume, tumor volume, extent of extraprostatic
extension, and periprostatic fascial dissection technique
(intrafascial/interfascial). The clinical implications of a
positive margin are also limited owing to the lack of
information about margin size and location. This study
took place in academic institutions and thus the results may
not be directly transferable to nonacademic hospitals.
However, given that rates of 30% have been reported in
population-based studies with pT2R1 (with no significant
difference between community and teaching hospitals), it is
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M.A. Preston et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 18.e1–18.e6
probable that the association between nerve sparing and
positive SMs exists similarly in both academic and nonacademic centers [24].
Clinical nomograms for estimating the extent of disease,
consideration of pre-existing erectile function, and use of
prostate magnetic resonance imaging in cases with higher risk
features may help patients and surgeons balance the benefits
and risks of nerve-sparing RP. Future prospective studies and
possibly a randomized trial of nerve sparing for patients with
higher-risk disease may clarify the effect of nerve preservation
on cancer-related and functional outcomes.
5. Conclusion
Bilateral nerve sparing during RP is associated with
increased risk of positive SMs in patients with pathologic
organ-confined prostate cancer. These data highlight the
challenges of balancing oncologic and functional outcomes
in RP in addition to the learning curve associated with
technologic advancement.
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