Gentle nerve surgery: Do patients choose self-
The vast majority of patients make a rational decision when it comes to conserving the erection nerves in a prostate cancer operation, provided they are fully informed.
At the prostate along run two neurovascular bundles, mostly rear side (see the prostate anatomy ). They also contain nerve fibers for the erection are important (stiffening member).Therefore, trying to get at a prostate cancer operation possible one or both bundles. After such a nerve-sparing radical prostatectomy (NS-RPE), therefore the risk is erectile dysfunction(impaired limb stiffening) is lower, as is the risk of urinary incontinence (involuntary loss of urine).
However, prostate cancer is often in the region of the bundle and penetrates the prostatic capsule, preferably in places where blood vessels and nerves of the beams passing through them. Therefore, the risk increases that the tumor is incompletely removed, if one leaves the bundle, especially in locally advanced prostate cancer.
Reasons for the study and implementation
Currently, there are no generally accepted criteria for nerve-sparing radical prostatectomy (NS-RPE). In addition, the desire to preserve sexual function in those affected is most pronounced differently: for some it is crucial even at high risk for capsule out, for others, it is complete tumor removal has absolute priority. The extent to which the patient is involved in the decision, is also very different: they choose the doctor or the patient alone, or both together (engl. shared decision making). In the latter case, the patient satisfaction with the outcome is greatest, even with an unfavorable outcome.
For the first time a study has now been carried out, in which the patient could actively decide on the nerve sparing at a RPE with. Examines this was especially concerned if after a reasonable education can make a sensible decision or whether this best left to the physician.
Were included in the study 150 men who underwent in 2008 a robotic-assisted radical prostatectomy (RA-RPE). In addition to the general conversation before surgery they received a standardized education. These included, among other things, the method of nerve sparing, the capsule-border growth of prostate cancer, the possibilities of resuming sexual activity after surgery in those who previously had no erectile dysfunction, as well as the necessary adjuvant (subsequent) irradiation with incomplete removal of the tumor, also as a result of nerve sparing.
The individual risk for a capsule-border spread of the tumor was determined from a nomogram (special table) and low (<20%), moderate (20-50%) and high (> 50%) is divided. Thereafter, each patient decided for or against the nerve sparing. The operation was then carried out as desired, provided that no massive capsule exceedance was discovered.
Results and assessment
Compared to men without nerve sparing surgery men were slightly younger and not so often already affected with nerve-sparing surgery an average of erectile dysfunction, while at her tumor presented after surgery less often than locally advanced or removed as incomplete out (see Table 1 ). The higher the risk had been assessed for a capsule-border spread of the tumor, the more likely the men decided against a nerve sparing during radical prostatectomy (see Table 2).
Table 1: Data on patients who had undergone radical prostatectomy with or without nerve sparing (NS).
| Patients after radical prostatectomy | with NS | without NS |
| Average age | 59 years | 65.5 years |
| Previous erectile dysfunction | 30% (30/100) | 64% (23/36) |
| Locally advanced tumors (pT3-4) | 14% (15/109) | 59% (24/41) |
| Incomplete tumor removal (R +) | 13% (14/109) | 27% (11/41) |
Table 2: decision for or against a nerve sparing (NS) in radical prostatectomy depending on the risk for a capsule-border spread of the tumor before surgery.
| Decision for radical prostatectomy | with NS | without NS |
| Each spread risk | 73% (109) | 27% (41) |
| At low risk spreading (<20%) | 88% (81) | 12% (11) |
| Under moderate spread risk (20-50%) | 59% (22) | 41% (15) |
| At high propagation risk (> 50%) | 25% (6) | 75% (15) |
| With a very high spread risk (> 70%) | 0% (0) | 100% (41) |
Overall, the results were comparable with other studies. The decision was strongly dependent on the risk of capsule exceeded, at low and medium risk, the age of the person concerned and his sexual function before surgery played a major role, at high contrast, the desire for complete tumor removal. Only a few patients chose the "unreasonable" alternative. Vast majority, however, in their case, "reasonable", which confirmed the findings after surgery
Weaknesses in their study, the authors, are the lack of a control group, in which the decision was made by the physician, and that patient satisfaction has not been studied with their choice.In addition, despite standardized education is not ruled out that the doctor has unconsciously influenced the patient.
Conclusion of the authors
Decide to leave patients on the nerve sparing during radical prostatectomy, is a new and sensible strategy. It does not mean that increasingly concerned opt for a nerve-protecting procedures that have a high risk for a capsule exceeding the tumor. After appropriate consultation, the study participants met a sensible decision. They generally preferred the complete removal of the tumor at high risk for capsule exceeded and the preservation of sexual function at low. The security shown here could encourage other doctors to their patients an enhanced role in the decision about surgery.
Source
Lavery, HJ, et al.: Active patient decision making Regarding nerve sparing radical prostatectomy falling on: A novel approach. J Urol 2011; 186: 487-493, DOI: 10.1016/j.juro.2011.03.136
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