<p><strong> </strong><strong>In patients electing radical prostatectomy, nerve-sparing, when oncologically appropriate, should be performed. <em>(Moderate Recommendation; Evidence Level: Grade B)</em></strong></p>
Discussion
Discussion
<p>Preservation of the neurovascular bundles during radical prostatectomy has consistently been associated with a lower likelihood of postoperative erectile dysfunction, has variously but favorably been associated with improved urinary continence after surgery, and has not been found to significantly compromise the rates of positive surgical margins or biochemical recurrence.<sup>178-181</sup> The Panel does acknowledge, however, that the systematic review did not identify RCTs of nerve-sparing versus non-nerve sparing radical prostatectomy. The Panel also recognizes the balance between nerve preservation and optimizing cancer control. Indeed, the decision to perform nerve-sparing is frequently multifactorial, and may include PSA, DRE, biopsy findings (grade, tumor volume, and location), MRI findings, as well as the patient’s baseline erectile function and stated prioritization of sexual function. The Panel further asserts that MRI should not be used in isolation to determine nerve-sparing, as the ability of MRI to predict extracapsular extension, particularly when microscopic, is suboptimal.<sup>182</sup> Importantly, the Panel notes that nerve-sparing does not necessarily entail an “all or none” decision, and both partial nerve preservation and unilateral nerve-sparing may be utilized.</p>