title: Degree of preservation of the neurovascular bundles during radical prostatectomy and urinary continence 1 year after surgery.
abstract: BACKGROUND
  Many elderly or impotent men with prostate cancer may not receive a bundle-preserving radical prostatectomy as a result of uncertainty regarding the effect on urinary incontinence.
  
  
  OBJECTIVE
  We searched for predictors of urinary incontinence 1 yr after surgery among surgical steps during radical prostatectomy.
  
  
  METHODS
  More than 100 surgeons in 14 centers prospectively collected data on surgical steps during an open or robot-assisted laparoscopic radical prostatectomy. At 1 yr after surgery, a neutral third-party secretariat collected patient-reported information on urinary incontinence. After excluding men with preoperative urinary incontinence or postoperative irradiation, data were available for 3379 men.
  
  
  METHODS
  Surgical steps during radical prostatectomy, including dissection plane as a measure of the degree of preservation of the two neurovascular bundles.
  
  
  METHODS
  Urinary incontinence 1 yr after surgery was measured as patient-reported use of pads. In different categories of surgical steps, we calculated the percentage of men changing pads "about once per 24 h" or more often. Relative risks were calculated as percentage ratios between categories.
  
  
  CONCLUSIONS
  A strong association was found between the degree of bundle preservation and urinary incontinence 1 yr after surgery. We set the highest degree of bundle preservation (bilateral intrafascial dissection) as the reference category (relative risk = 1.0). For the men in the remaining six groups, ordered according to the degree of preservation, we obtained the following relative risks (95% confidence interval [CI]): 1.07 (0.63-1.83), 1.19 (0.77-1.85), 1.56 (0.99-2.45), 1.78 (1.13-2.81), 2.27 (1.45-3.53), and 2.37 (1.52-3.69). In the latter group, no preservation of any of the bundles was performed. The pattern was similar for preoperatively impotent men and for elderly men. Limitations of this analysis include the fact that noise influences the relative risks, due to variations between surgeons in the use of undocumented surgical steps of the procedure, variations in surgical experience and in how the surgical steps are reported, as well as variations in the metrics of patient-reported use of pads.
  
  
  CONCLUSIONS
  We found that the degree of preservation of the two neurovascular bundles during radical prostatectomy predicts the rate of urinary incontinence 1 yr after the operation. According to our findings, preservation of both neurovascular bundles to avoid urinary incontinence is also meaningful for elderly and impotent men.
  
  
  RESULTS
  We studied the degree of preservation of the two neurovascular bundles during radical prostatectomy and found that the risk of incontinence decreases if the surgeon preserves two bundles instead of one, and if the surgeon preserves some part of a bundle rather than not doing so.
authors.affiliation: Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Oncology and Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden. Electronic address: Gunnar.Steineck@gu.se.
authors.forename: Gunnar
authors.initials: G
authors.lastname: Steineck
authors.affiliation: Department of Urology, Skåne University Hospital, Lund University, Lund, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Bjartell
authors.affiliation: Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
authors.forename: Jonas
authors.initials: J
authors.lastname: Hugosson
authors.affiliation: Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
authors.forename: Elin
authors.initials: E
authors.lastname: Axén
authors.affiliation: Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Carlsson
authors.affiliation: Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
authors.forename: Johan
authors.initials: J
authors.lastname: Stranne
authors.affiliation: Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Wallerstedt
authors.affiliation: Department of Urology, Skåne University Hospital, Lund University, Lund, Sweden.
authors.forename: Josefin
authors.initials: J
authors.lastname: Persson
authors.affiliation: Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
authors.forename: Ulrica
authors.initials: U
authors.lastname: Wilderäng
authors.affiliation: Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Faculty of Nursing, University of Iceland, Reykjavik, Iceland.
authors.forename: Thordis
authors.initials: T
authors.lastname: Thorsteinsdottir
authors.affiliation: Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ove
authors.initials: O
authors.lastname: Gustafsson
authors.affiliation: UroClinic, Stockholm, Sweden.
authors.forename: Mikael
authors.initials: M
authors.lastname: Lagerkvist
authors.affiliation: Department of Urology, Skåne University Hospital, Lund University, Lund, Sweden.
authors.forename: Thomas
authors.initials: T
authors.lastname: Jiborn
authors.affiliation: Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
authors.forename: Eva
authors.initials: E
authors.lastname: Haglind
authors.affiliation: Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Peter
authors.initials: P
authors.lastname: Wiklund
mesh_terms: D000328:Adult; D000368:Aged; D001341:Autonomic Nervous System / Q000503:physiopathology / Q000601:surgery*; D004210:Dissection / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D016496:Incontinence Pads; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D013548:Sweden; D013997:Time Factors; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000294:innervation*; D014549:Urinary Incontinence / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*
keywords: Anatomy; Nerve-sparing surgery; Neurovascular bundle; Prostate cancer; Radical prostatectomy; Surgical technique; Urinary continence