Review – Prostate CancerPreservation 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
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
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