Preserving Neurovascular Bundles Preserves the Mind: Cognitive, Functional, and Quality-of-Life Outcomes of Nerve-Sparing Radical Prostatectomy.

Abstract

Introduction: Radical prostatectomy (RP) is a standard curative treatment for localized Prostate cancer (PCa), but may negatively affect health-related quality of life (HRQoL) through urinary incontinence, erectile dysfunction, psychological distress, cognitive decline. Neurovascular bundle (NVB)-sparing techniques aim to preserve functional outcomes; however, their effects on neurocognitive performance remain unclear.

Purpose: This study evaluated the impact of bilateral NVB-sparing RP on cognitive function, psychological status, HRQoL, and biochemical recurrence in patients with PCa.

Methods: This retrospective study included 100 Caucasian patients who underwent laparoscopic RP between 2017 and 2022, either with bilateral intrafascial NVB preservation or without NVB sparing, according to European Association of Urology criteria. All surgeries were performed by high-volume surgeons with experience exceeding 250 RPs each. Cognitive function was assessed using a standardized computer-based test. Psychological and functional status was evaluated with the HADS Scale, ICIQ-UI SF and IIEF5 scale. HRQoL was measured with the EORTC QLQ-C30 and PR25 questionnaires. Serum prostate-specific antigen (PSA) and testosterone levels were analyzed.

Results: Patients undergoing NVB-sparing RP demonstrated faster reaction times and better visual working memory compared with the non-NVB-sparing group. Postoperative erectile function, urinary continence, and testosterone levels were significantly superior following NVB preservation. HRQoL outcomes favored NVB-sparing RP, including higher global health status, physical, emotional, and cognitive functioning, and reduced fatigue. Anxiety and depression scores were lower but did not reach statistical significance. Lower postoperative PSA and absence of biochemical recurrence were associated with better verbal memory and executive functioning. No significant differences in BCR rates were observed between groups.

Conclusion: Bilateral NVB-sparing RP preserves urinary and sexual function while supporting cognitive performance and psychosocial well-being, resulting in improved HRQoL without increasing the risk of BCR. These findings confirm the oncological safety of NVB-sparing RP and support the inclusion of neurocognitive and quality-of-life outcomes in surgical decision-making for patients with prostate cancer.