Better clinical outcomes with intrafascial nerve-sparing radical prostatectomy
Patients who underwent intrafascial nerve-sparing radical prostatectomy (NSRP) had better functional (ie, urinary continence and erectile function) and oncologic outcomes (ie, cancer control) compared with those who had interfascial NSRP, according to a meta-analysis.
Six studies comprising 1,663 men were included in the analysis. Of these, 916 and 747 had intrafascial and interfascial NSRP, respectively, which were carried out employing laparoscopic, robot-assisted, or open retropubic techniques. [Sci Rep 2017;doi:10.1038/s41598-017-11878-7]
The intrafascial method outdid the interfascial approach in terms of urinary continence at 6 months (risk ratio [RR], 1.18, 95 percent confidence interval [CI], 1.08–1.30; p=0.0002) and 36 months (RR, 1.13, 95 percent CI, 1.02–1.25; p=0.02).
The researchers pointed out that the lack of significant difference in urinary continence at 12 months might have been due to the variety of techniques used or could be a ‘spurious result’.
In terms of erectile function, better potency outcomes were observed at 6 months (RR, 1.49, 95 percent CI, 1.01–2.18; p=0.04) and 12 months (RR, 1.40, 95 percent CI, 1.24–1.57; p<0.00001) with the intrafascial vs interfascial approach.
The researchers acknowledged that the differences in functional outcomes could be attributed to the minimal periprostatic tissue damage with intrafascial NSRP which, in turn, provides better urinary control as more nerves are spared. [Eur Urol 2015;68:692-704]
The lower overall positive surgical margin with the intrafascial vs interfascial approach (RR, 0.64, 95 percent CI, 0.48–0.86; p=0.003) was considered an important finding as cancer control remains the ‘most important goal of RP’, according to the researchers.
With regards to perioperative parameters, transfusion rates were similar in both intrafascial and interfascial approaches (RR, 0.50; p=0.57). Operative time ranged from 60 to 169.41 minutes, mean blood loss from 87 to 200 mL, mean duration of catheterization from 5 to 11.09 days, and mean hospital stay was 8 days.
Overall, intrafascial NSRP had better functional and oncologic outcomes compared with interfascial NSRP irrespective of the surgical technique, said the researchers. However, despite the incremental security margin offered by the different dissection planes, [BJU Int 2011;108:984-992; Eur Urol 2012;61:796-802; Eur Urol 2016;70:301-11] the choice should be tailored according to the level of disease severity and biopsy and imaging results, they said. [Eur Urol 2015;68:692-704]
Moreover, the limited patient selection could have affected the findings, hence the need for more trials to shed light on the safety and effectiveness of both approaches, noted the researchers. Future studies could also support data regarding the effect of both approaches on functional outcomes, given issues such as postoperative impotence and urinary incontinence which may affect patients’ quality of life. [Urol Oncol 2015;33:e211-208; Eur Urol 2013;63;445-447; Eur Urol 2012;62:405-417]