Influence of wide excision of the neurovascular bundle(s) on prognosis in men with clinically localized prostate cancer with established capsular penetration

We analyzed 107 men with clinically localized prostate cancer who had pathologically established capsular penetration in the region of the neurovascular bundles to determine the effect of wide excision of the neurovascular bundle(s) on disease-free survival. In 38 patients established capsular penetration was not suspected clinically and the neurovascular bundle(s) were preserved. In 69 patients established capsular penetration was suspected, and 1 or both neurovascular bundles were excised widely with the prostate. Disease-free survival was defined by an undetectable serum prostate specific antigen (PSA) level postoperatively. Wide excision of the neurovascular bundle(s) resulted in negative surgical margins in 40 of 69 patients (58%) compared to only 17 of 38 (45%) in whom the neurovascular bundle(s) was left intact (p = 0.03). Median interval to disease recurrence, as defined by a measurable serum PSA level, was 22 months in the group in whom neurovascular bundles were preserved versus 33 months in the group undergoing wide excision (p = 0.03). At 39 months, however, 70% of the patients in both groups had detectable PSA levels. Similarly, patients with positive surgical margins had a mean interval to recurrence of 17 months compared to 38 months for the group with negative surgical margins (p = 0.0004). By 43 months, however, 75% of the patients in both groups had a detectable PSA level and the Kaplan-Meier curves had converged. Although wide excision of the neurovascular bundle(s) resulted in negative surgical margins more often with resultant delayed disease progression, most patients with established capsular penetration ultimately failed radical prostatectomy despite wide excision of periprostatic soft tissue. It seems likely, therefore, that many of these patients have occult metastatic disease at operation. Thus, recent enthusiasm for radical prostatectomy in men with locally advanced prostate cancer may not be justified.