Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n= 158) underwent non-NSRP and 39% (n= 516) and 50% (n= 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). 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 difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39–1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29–1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.
神经保留术是一种旨在优化根治性前列腺切除术功能预后的外科技术。然而，由于存在手术切缘阳性的风险可能增加癌症复发概率，该技术通常不推荐用于高危病例。过去二十年间，观点逐渐转变，认为在严格筛选的病例中，神经保留术可能成为肿瘤学上安全且能获得更佳功能预后的选择。因此，本研究旨在比较高危前列腺癌患者接受根治性前列腺切除术时，采用神经保留术的功能预后与肿瘤学安全性。本研究共纳入1340例患者，其中12%（158例）接受非神经保留根治性前列腺切除术，39%（516例）和50%（666例）分别接受单侧及双侧神经保留根治性前列腺切除术。我们计算了倾向评分并采用逆概率处理加权法，以平衡接受非神经保留术与单侧/双侧神经保留术的前列腺癌患者基线特征。神经保留术显著改善了功能预后：经逆概率处理加权校正后，非神经保留术组仅3%患者在24个月时达到完全勃起功能恢复（无需辅助），22%实现勃起功能恢复（需辅助），87%达到尿控。单侧神经保留术提高了所有功能指标的恢复概率（比值比分别为1.1和1.2），双侧神经保留术改善程度略高（比值比1.1-1.4）。神经保留术未影响任何复发风险（风险比0.99，95%置信区间0.73-1.34，p=0.09），接受神经保留术患者的生存期亦无差异（风险比0.65，95%置信区间0.39-1.08）。癌症特异性生存率同样无统计学差异（风险比0.56，95%置信区间0.29-1.11）。本研究表明，神经保留根治性前列腺切除术能显著改善功能预后，且经严格筛选的高危前列腺癌患者接受该手术不会影响长期肿瘤学结局。
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