An Algorithm to Personalize Nerve Sparing in Men with Unilateral High-Risk Prostate Cancer.

Current guidelines do not provide strong recommendations on the preservation of the neurovascular bundles during RP in case of HR PCa and/or suspicious EPE. We aimed to evaluate when, in case of unilateral HR disease, contralateral NS should be considered or not.

Within a multi-institutional dataset we selected patients with unilateral HR PCa defined as: unilateral EPE and/or SVI on mpMRI or unilateral ISUP 4-5 or PSA ≥20 ng/ml. To evaluate when to perform NS based on the risk of contralateral EPE, we relied on CHAID, a recursive machine learning partitioning algorithm developed to identify risk groups, which was fit to predict the presence of EPE on final pathology, contralaterally to the prostate lobe with HR disease.

705 patients were identified. Contralateral EPE was documented in 87 (12%) patients. The CHAID identified three groups: i) absence of SVI on mpMRI and index lesion's diameter ≤15 mm; ii) index lesion's diameter ≤15 mm and contralateral ISUP 2-3 or index lesion's diameter >15 mm and negative contralateral biopsy or ISUP 1 iii) SVI on mpMRI or index lesion's diameter >15 mm and contralateral biopsy ISUP 2-3. We named those groups as low- intermediate- and high-risk for contralateral EPE. The rate of EPE and PSMs across the groups were: 4.8%, 14%, 26% and 5.6%, 13%, 18%, respectively.

Our study challenges current guidelines by proving that wide bilateral excision in men with unilateral HR disease is not justified. Pending external validation, we propose performing NS and incremental NS in case of contralateral low- and intermediate EPE risk, respectively.

The Journal of urology. 2021 Sep 22 [Epub ahead of print]

Alberto Martini, Timo F W Soeterik, Hester Haverdings, Razvan George Rahota, Enrico Checcucci, Sabrina De Cillis, Thomas Hermanns, Christian Daniel Fankhauser, Luca Afferi, Marco Moschini, Agostino Mattei, Claudia Kesch, Isabel Heidegger, Felix Preisser, Fabio Zattoni, Alessandro Marquis, Giancarlo Marra, Paolo Gontero, Alberto Briganti, Francesco Montorsi, Francesco Porpiglia, Jean Paul Van Basten, Roderick C N Van den Bergh, Harm H E Van Melick, Guillaume Ploussard, Giorgio Gandaglia, Massimo Valerio

Department of Urology, San Raffaele Hospital, Milan, Italy., St. Antonius ziekenhuis, Nieuwegein, The Netherlands., Department of Urology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland., Department of Urology, La Croix du Sud Hospital, Toulouse, France., Department of Urology, San Luigi Hospital, Turin, Italy., Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland., Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland., Department of Urology, University Hospital Essen, Essen, Germany., Department of Urology, Medical University Innsbruck, Innsbruck, Austria., Department of Urology, University Hospital Frankfurt am Main, Frankfurt, Germany., Urology Unit, Academical Medical Centre Hospital, Udine, Italy., Department of Urology, San Giovanni Battista Hospital, University of Turin, Turin, Italy.

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