Surgery in MotionNeurovascular Structure-adjacent Frozen-section Examination (NeuroSAFE) Increases Nerve-sparing Frequency and Reduces Positive Surgical Margins in Open and Robot-assisted Laparoscopic Radical Prostatectomy: Experience After 11 069 Consecutive Patients
Introduction
Due to considerably improved postoperative potency and measurable effects on continence [1], [2], radical prostatectomy (RP) should be performed using a nerve-sparing (NS) technique as long as the oncologic outcome is not compromised [3]. However, NS is always a balancing act between the ambition to preserve as much quality of life as possible and the risk of compromising cancer control by leaving residual tumor behind in the preserved neurovascular tissue.
Intraoperative frozen-section (IFS) analysis of the whole neurovascular tissue-adjacent circumference enables a rapid but comprehensive histologic surgical margin (SM) assessment, allowing the surgeon to intraoperatively demonstrate the oncologic safety of an NS procedure. The clinical impact of IFS-guided NS during RP is controversial. The main points of criticism are that IFS is time and resource consuming, has low sensitivity and specificity, and has potentially conflicting oncologic results [4], [5], [6]. In our study, we assessed the clinical value of a complete neurovascular structure-adjacent frozen-section examination (NeuroSAFE) approach in a consecutive cohort of 11 069 RP patients.
Section snippets
Patient population
Data from 11 231 consecutive patients who underwent RP in our institution between January 2002 and June 2011 were analyzed. All procedures were performed by 12 surgeons according to our institutional surgical standard. All data were collected prospectively into an institutional review board-approved database. One hundred sixty-two patients were excluded due to neoadjuvant hormonal treatment (n = 124) or prior radiation therapy (n = 38). RP was performed using an open retropubic approach (n = 10 427)
Description of patient population
Clinicopathologic data are detailed in Table 2. Overall, 5392 RPs (48.7%) were navigated by NeuroSAFE. The standard tumor parameters were significantly worse in the NeuroSAFE group compared to non-NeuroSAFE patients, revealing a considerable selection bias. Adjustment for those confounding biases by propensity score–based matching resulted in a cohort of 2567 matched pairs. Of these, 161 (3%) and 17 (0.2%) of the NeuroSAFE, and 239 (4.2%) and 41 (0.7%) of the non-NeuroSAFE patients received an
Discussion
NeuroSAFE enables real-time histologic monitoring of the oncologic safety of a NS procedure. Our study demonstrates that patients undergoing NeuroSAFE-guided RP can significantly benefit from increased NS frequencies and decreased PSM rates without compromising oncologic outcome.
A particular feature of prostate cancer surgery is that >50% of the prostate surface is closely surrounded by functional neurovascular tissue [16]. The area of NS is prone to PSMs, which can be induced by ECE or
Conclusions
NeuroSAFE is an oncologically safe concept allowing intraoperative monitoring of patients in whom NS can be appropriately performed. A systematic application of this approach results in a significant increase of NS and significant reduction of PSMs in RP. Moreover, patients with a PSM could be converted to a prognostically more favorable NSM state by secondary resection of the ipsilateral neurovascular tissue.
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These authors contributed equally to this work and therefore share first authorship.