# Nerve-Sparing Robotic-Assisted Radical Prostatectomy Based on the Absence of Prostate Imaging-Reporting and Data System ≥3 or Biopsy Gleason Pattern ≥4 in the Peripheral Zone

## TL;DR

This study shows that nerve-sparing robotic prostate surgery can improve early urinary quality of life without increasing cancer risks for carefully selected patients.

## Contribution

The study introduces selective nerve-sparing criteria based on imaging and biopsy results to optimize outcomes in prostate cancer surgery.

## Key findings

- Nerve-sparing did not increase cancer recurrence or margin positivity rates.
- Urinary quality of life improved significantly in the nerve-sparing group by the third month.
- The RM positivity rate on the nerve-sparing side was 10.8%.

## Abstract

This study evaluates the safety and oncological outcomes of nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) when performed only in patients without Prostate Imaging-Reporting and Data System (PI-RADS) ≥3 lesions or Gleason pattern ≥4 in the peripheral zone (PZ) on biopsy. A retrospective analysis of 208 patients undergoing RARP between August 2017 and December 2022 was conducted, excluding those with preoperative hormonal therapy. After propensity score matching, NS did not increase the positive resection margin (RM) rate or affect PSA recurrence-free survival. Urinary QOL significantly improved in the NS group from the third month postoperatively, although no difference was found in sexual function. The RM positivity rate on the NS side was 10.8%. These findings suggest that selective NS criteria can optimize early urinary QOL without compromising oncological safety.

Background/Objectives: The objective of this study was to evaluate the oncological outcomes and safety of nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) when applied without Prostate Imaging-Reporting and Data System (PI-RADS) ≥3 lesions or Gleason pattern ≥4 on biopsy in the peripheral zone (PZ). Methods: We retrospectively analyzed 208 patients who underwent RARP between August 2017 and December 2022, excluding those who had received preoperative hormonal therapy. After NS status stratification and patient characteristic adjustment using propensity score matching (PSM), positive resection margin (RM) rates and prostate-specific antigen (PSA) recurrence-free survival were compared. Urinary and sexual quality of life (QOL) were assessed using the Expanded Prostate Cancer Index Composite, along with predictive factors associated with positive RM and RM locations in the NS group. Results: NS was performed in 68.6% (n = 129) patients. After PSM, there were no significant differences in RM positivity (p = 0.811) or PSA recurrence-free survival (Log-rank p = 0.79), regardless of NS status. There was no difference in sexual function between groups, but urinary QOL was significantly better in the NS group from the third month onward. In the NS group, RM positivity was 27.9% (n = 36), and diagnostic PSA (odds ratio [OR], 1.110, p = 0.038) and clinical T stage (OR, 1.400, p = 0.038) were predictive factors. The RM positivity rate on the NS side was 10.8%. Conclusions: NS, based on the absence of PI-RADS ≥3 lesions or Gleason pattern ≥4 in PZ, did not increase RM positivity rate and increased early urinary QOL.