Elsevier

European Urology

Volume 68, Issue 4, October 2015, Pages 692-704
European Urology

Review – Prostate Cancer
Preservation of the Neurovascular Bundles Is Associated with Improved Time to Continence After Radical Prostatectomy But Not Long-term Continence Rates: Results of a Systematic Review and Meta-analysis

https://doi.org/10.1016/j.eururo.2014.10.020Get rights and content

Abstract

Context

The aetiology of urinary incontinence following radical prostatectomy (RP) is incompletely understood. In particular, it is unclear whether there is a relationship between neurovascular bundle (NVB) sparing and post-RP urinary continence.

Objective

To review systematically the association of NVB sparing in RP with postoperative urinary continence outcomes and synthesise the results in a meta-analysis.

Evidence acquisition

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. PubMed, Medline, and Cochrane Central Register of Controlled Trials were searched (December 2013), yielding 3413 unique records. A total of 27 longitudinal cohort studies were selected for inclusion. Studies were evaluated using a predefined criteria adapted from the Cochrane Tool to Assess Risk of Bias in Cohort Studies.

Evidence synthesis

Data from 13 749 participants in 27 studies were synthesised in a meta-analysis. An assessment of the study methodology revealed a high risk of bias due to differences in baseline characteristics, outcome assessment, and the likely presence of unreported confounding factors such as meticulous apical dissection. Meta-analysis demonstrated that nerve sparing (NS) compared with non–nerve sparing (NNS) resulted in improved early urinary continence rates up to 6 mo postoperatively. Beyond this time, no significant difference was observed. This effect was seen most clearly for bilateral NS compared with NNS. A sensitivity analysis of prospective cohort studies revealed consistent results.

Conclusions

This analysis demonstrates an association between NS and improved urinary continence outcomes up to 6 mo postoperatively. NS in men with poor preoperative erectile function should be considered in the context of oncologic risk stratification because it may improve time to continence recovery. The underlying cause of the relationship between NS and continence is unknown. It may represent preservation of the intrapelvic somatic nerves supplying the rhabdosphincter or the influence of other confounding factors. Future research should be directed towards improving understanding of the anatomy of urinary continence and the pathophysiology of post-RP incontinence.

Patient summary

We found that avoiding damage to the nerves around the prostate improves urinary continence in the first 6 mo after surgery. After this time, there is no difference in continence between men who had these nerves removed and those who had them saved. This finding could be due to a true effect of saving these nerves or to a number of other factors affecting the research.

Introduction

For most men with localised prostate cancer (PCa), radical prostatectomy (RP) provides excellent oncologic outcomes [1]. The trifecta of optimal outcomes following RP includes preservation of continence and potency in addition to oncologic control [2] but is only achieved by 62–70% of patients in centres of excellence [2], [3]. Despite improvements in surgical technique, urinary incontinence and erectile dysfunction, in particular, significantly affect quality of life (QoL) in many men. Reported 12-mo potency rates following robot-assisted RP are highly variable, ranging from 54% to 90% [4]. Post-RP incontinence also remains a devastating problem for many men. On average, 16% of men are incontinent at 12 mo (using a no-pad definition) [5]. Post-RP incontinence is associated with a decreased QoL [6] that may manifest as a preoccupation with leakage avoidance and/or location of bathrooms, and feeling dirty, helpless, and embarrassed [7].

Since Walsh and Donker's description of the pelvic course of the cavernous nerves [8] and the subsequent development of the NS RP, postoperative potency outcomes have improved dramatically. Whether or not there is also an association between sparing the neurovascular bundle (NVB) and urinary continence outcomes is a controversial but important clinical question that previous systematic reviews have not addressed. If sparing the NVB has a true effect on postoperative urinary continence, then preservation of continence should be an independent indication for nerve sparing (NS). This question is particularly contentious because there is no clear anatomic basis for such a relationship [9]. The classical view is that nerve supply to the external striated rhabdosphincter comes from the somatic pudendal nerve [10], [11], [12], [13], which takes its course caudal to the levator ani and therefore should be protected from operative injury and not influenced by NVB sparing. However, some authors have posited the existence of an intrapelvic somatic supply to the rhabdosphincter [14], [15], [16].

The primary objective of this study was to conduct a systematic review and meta-analysis to evaluate if in men having RP, sparing the NVB is associated with postoperative urinary continence outcomes. The secondary objective was to assess if NS is associated with the timing of urinary continence return postoperatively.

Section snippets

Evidence acquisition

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement [17]. A study protocol was written a priori (Supplement 1) defining the search strategy (based on the patient, problem, or population; intervention; comparison, control, or comparator; and outcomes [PICO] framework), study eligibility criteria, data collection, and a synthesis process.

Study selection and characteristics

Figure 1 shows the PRISMA flowchart of this systematic review. Our search yielded 3412 unique records. After exclusion of non-English studies, 621 potentially relevant full-text articles were evaluated.

Ultimately, 27 studies (total: 13 749 participants) were included for quantitative synthesis (Table 1) [18], [19], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51]. This included 12 prospective and

Conclusions

This meta-analysis demonstrates an association between NS and improved urinary continence rates in the first 6 mo postoperatively. This association is most consistently seen in BNS and is no longer evident at 12–24 mo. NS in men with preoperative erectile dysfunction should be considered on an individual basis because it may improve early continence.

We hypothesise that this relationship may be due to preservation of intrapelvic nerves supplying the rhabdosphincter and/or the effect of

References (62)

  • S. Namiki et al.

    Impact of unilateral sural nerve graft on recovery of potency and continence following radical prostatectomy: 3-year longitudinal study

    J Urol

    (2007)
  • T.J. Bradford et al.

    Is residual neurovascular tissue on prostatectomy specimens associated with surgeon intent at nerve-sparing and postoperative quality of life measures?

    Urol Oncol

    (2010)
  • L. Budaus et al.

    Current technique of open intrafascial nerve-sparing retropubic prostatectomy

    Eur Urol

    (2009)
  • F.C. Burkhard et al.

    Nerve sparing open radical retropubic prostatectomy--does it have an impact on urinary continence?

    J Urol

    (2006)
  • B.L. Dalkin et al.

    Health related quality of life outcomes after radical prostatectomy: attention to study design and the patient-based importance of single-surgeon studies

    Urol Oncol

    (2006)
  • N. Koehler et al.

    Early continence in patients with localized prostate cancer. A comparison between open retropubic (RRPE) and endoscopic extraperitoneal radical prostatectomy (EERPE)

    Urol Oncol

    (2012)
  • K.C. Nandipati et al.

    Nerve-sparing surgery significantly affects long-term continence after radical prostatectomy

    Urology

    (2007)
  • G. Novara et al.

    Evaluating urinary continence and preoperative predictors of urinary continence after robot assisted laparoscopic radical prostatectomy

    J Urol

    (2010)
  • P.D. O’Donnell et al.

    Continence following nerve-sparing radical prostatectomy

    J Urol

    (1989)
  • A. Srivastava et al.

    Effect of a risk-stratified grade of nerve-sparing technique on early return of continence after robot-assisted laparoscopic radical prostatectomy

    Eur Urol

    (2013)
  • D.T. Tzou et al.

    The failure of a nerve sparing template to improve urinary continence after radical prostatectomy: attention to study design

    Urol Oncol

    (2009)
  • P. McCulloch et al.

    No surgical innovation without evaluation: the IDEAL recommendations

    Lancet

    (2009)
  • M.M. Koraitim

    The male urethral sphincter complex revisited: an anatomical concept and its physiological correlate

    J Urol

    (2008)
  • R. Chao et al.

    Incontinence after radical prostatectomy: detrusor or sphincter causes

    J Urol

    (1995)
  • M.A. Ficazzola et al.

    The etiology of post-radical prostatectomy incontinence and correlation of symptoms with urodynamic findings

    J Urol

    (1998)
  • A. Groutz et al.

    The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study

    J Urol

    (2000)
  • A. Centemero et al.

    Preoperative pelvic floor muscle exercise for early continence after radical prostatectomy: a randomised controlled study

    Eur Urol

    (2010)
  • J. Walz et al.

    A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy

    Eur Urol

    (2010)
  • P.C. Walsh et al.

    Efficacy of first-generation Cavermap to verify location and function of cavernous nerves during radical prostatectomy: a multi-institutional evaluation by experienced surgeons

    Urology

    (2001)
  • P. Sooriakumaran et al.

    Comparative effectiveness of radical prostatectomy and radiotherapy in prostate cancer: observational study of mortality outcomes

    BMJ

    (2014)
  • D.C. Miller et al.

    Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy

    J Clin Oncol

    (2005)
  • Cited by (142)

    • The NeuroSAFE frozen section technique during radical prostatectomy – Implementation and optimization of technical aspects in a routine pathology workflow

      2023, Pathology Research and Practice
      Citation Excerpt :

      Anatomically, however, this technique increases the risk of incomplete tumor resection and thus inadvertently creating a so-called positive surgical margin (PSM). In order to minimize the risk of a PSM at the side of the nerve bundle sparing, histological intraoperative frozen sections (IFS) was introduced and has been shown to be of functional benefit for patients without deterioration in oncological outcome [3,4,18]. However, the IFS procedure is time-, labor- and staff-intensive for the pathology department and often results in a relevant prolongation of the surgical procedure.

    View all citing articles on Scopus
    View full text