Preservation of Neurovascular Bundles in High-risk Prostate Cancer Patients: Long-term Oncological Outcomes from Two High-volume Tertiary Centers.

Background and objective: Preservation of neurovascular bundles (NVBs) in prostate cancer (PCa) patients undergoing radical prostatectomy (RP) has been associated with better functional outcomes. The aim of this study is to investigate the oncological impact of NVB preservation in patients with high-risk PCa.

Methods: D'Amico high-risk PCa patients who underwent RP between 2002 and 2022 at two high-volume referral centers were included in the study analysis. Patients who underwent neoadjuvant and adjuvant therapy as well as those with evidence of M1 or pT4 disease were excluded. Propensity score and inverse probability of treatment weighting were used to account for a selection bias in treatment allocation. A time-to-event analysis was performed to assess the effect of NVB preservation on biochemical (BCR) and clinical (CR) recurrences.

Key findings and limitations: Overall, 1551 high-risk PCa patients were included in the analysis (56.8% and 43.2% underwent preservation of NVBs vs no NVBs). After applying the inverse probability of treatment weighting, at 120 mo after RP, BCR- and CR-free survival rates were 27.1% versus 27.5% and 58.9% versus 58.4% for the preservation of NVBs versus no NVBs, respectively. In the models adjusted for pathological characteristics, age, and prostate-specific antigen density, NVB preservation was not associated with a significantly higher risk of BCR (adjusted hazard ratio [aHR]: 0.79, 95% confidence interval [CI]: 0.56-1.11, p = 0.2) and CR (aHR: 0.78, 95% CI: 0.45-1.32, p = 0.4), compared with no NVB preservation. In the subgroup analysis of pathological International Society of Urological Pathology grade 4-5 and/or pT stage 3a-3b patients, NVB preservation did not make oncological outcomes worse at both univariable and multivariable cox analyses.

Conclusions and clinical implications: NVB preservation might have a limited effect on the risk of BCR and CR compared with no preservation. Nerve-sparing surgery may be attempted in selected high-risk PCa patients without compromising long-term oncological outcome.