title: Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious.
abstract: OBJECTIVE
  Given the higher likelihood of extraprostatic extension in high-risk patients, many urologists will sacrifice the neurovascular bundles in such patients in an attempt to decrease the risk of positive surgical margins. In contrast, we frequently perform nerve-sparing in high-risk patients. We analyzed our outcomes in patients with preoperatively high-risk prostate cancer according to the D'Amico risk group classification, and stratified by nerve-sparing status.
  
  
  METHODS
  An institutional database of 1,503 robotic-assisted laparoscopic prostatectomies (RALP) was queried for patients presenting with PSA > 20 ng/ml, Gleason 8 or higher on biopsy, or clinical stage T2c or higher. Interfascial nerve-sparing was performed whenever oncologically feasible. Validated questionnaires were used to assess baseline and postoperative functional outcomes.
  
  
  RESULTS
  Adequate follow-up was available in 123 high-risk patients. Mean serum PSA was 10.8. Bilateral, unilateral, and non-nerve-sparing was performed on 58%, 15%, and 27%, respectively. On final histopathology, 42% were organ confined; 55 patients had extraprostatic extension, and 35 had seminal vesicle invasion. Positive surgical margins occurred in 31%: 15% focal and 16% extensive. Favorable pathologic outcomes (organ-confined and negative surgical margins) were observed in 40%. Biochemical recurrence occurred in 20%. Nerve-sparing was associated with more favorable pathologic features, possibly due to selection bias. When controlling for adverse pathologic features, nerve-sparing was not associated with higher rates of positive surgical margins or biochemical recurrence. At a median follow-up of 13 months, 78% were continent and 56% were potent. The "trifecta" of continence, potency, and freedom from recurrence was achieved in 28 patients (23%).
  
  
  CONCLUSIONS
  Nerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes at 13-month median follow-up are comparable to those in open surgical series from similar cohorts.
authors.affiliation: Department of Urology, Division of Robotics and Minimally Invasive Surgery, The Mount Sinai Medical Center, New York, NY 10022, USA.
authors.forename: Hugh J
authors.initials: HJ
authors.lastname: Lavery
authors.forename: Fatima
authors.initials: F
authors.lastname: Nabizada-Pace
authors.forename: John R
authors.initials: JR
authors.lastname: Carlucci
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Brajtbord
authors.forename: David B
authors.initials: DB
authors.lastname: Samadi
mesh_terms: D006801:Humans; D008297:Male; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000517:prevention & control*; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D012307:Risk Factors; D012371:Robotics / Q000379:methods*