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BJU Int. 2018 Dec 21. doi: 10.1111/bju.14655. [Epub ahead of print]

An updated approach to incremental nerve sparing for robot-assisted radical prostatectomy.

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Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.



To update the algorithm for performing incremental nerve sparing (NS) using our multiparametric magnetic resonance imaging (mpMRI)-based nomogram.


We applied the coefficients of the nomogram to the observations extracted from our population of patients who underwent robot-assisted radical prostatectomy between February 2014 and October 2015 and who received preoperative mpMRI. The information considered were PSA level, highest side-specific biopsy Gleason grade group, highest ipsilateral percentage core involvement with the highest Gleason grade group, and extracapsular extension (ECE) on mpMRI. The nomogram-derived probability [P (%)], after internal validation, was used as the independent variable on a classification tree to identify the most significant thresholds for ECE prediction. Incremental NS was performed as follows: Grade 1 NS: intrafascial dissection between the peri-prostatic veins and the pseudocapsule of the prostate; Grade 2 NS: inter-fascial dissection along the peri-venous plane; Grade 3 NS: inter-fascial dissection through the outer compartment of the lateral prostatic fascia; Grade 4 NS: extrafascial dissection.


Data from 561 patients were considered, and 829 prostatic lobes with biopsy-documented tumour were analysed. Overall, 142 lobes presented ECE that was focal in 27 (19%) cases. The classification tree identified four risk categories. In the low- [P (%) ≤10], intermediate- [P (%) 10-21], high [P (%) 21-73] and very-high-risk [P(%) >73] groups, the ECE rates were 3.3%, 16%, 61.6% and 90%, respectively. Amongst those, ECE was focal in 41.7%, 31.7%, 7.9% and 0%, respectively.


We suggest that Grade 1 NS (intrafascial) should be performed in the low-risk group. The inter-fascial approach, namely grades 2 and 3 NS, should be performed in the intermediate- and high-risk categories, respectively. Grade 4 NS (extrafascial) should be performed in the very-high-risk group. The current algorithm yields a better accuracy than the previous one; however, prospective validation is warranted.


#PCSM; #ProstateCancer; #RARP; extracapsular extension; multiparametric MRI; nerve sparing


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