Nerve sparing in high-risk robotic prostatectomy was not linked to worse early cancer outcomes

Design

Retrospective single-centre cohort

Population

1,385 men having robotic prostatectomy; 262 with 2 or more STAMPEDE high-risk features

Primary outcome

Positive margins, 12-month biochemical recurrence and continence

Effect

High-risk margins 21.3% NS vs 23.2% non-NS (P = .72); BCR 6.7% vs 5.4%

A retrospective single-centre cohort in BJU International (30 September 2026) reviewed 1,385 robotic radical prostatectomies in 2021 and 2022 performed within a structured, patient-specific surgical planning pathway, and compared nerve-sparing with non-nerve-sparing surgery by number of STAMPEDE high-risk features.

Among 262 men with two or more high-risk features, 57% had some nerve sparing. Positive margins (21.3% vs 23.2%) and biochemical recurrence at 12 months (6.7% vs 5.4%) did not differ. Pad-free continence at 3 and 12 months was similar, but men who had nerve sparing used fewer pads at 12 months.

The surgeons chose whom to nerve-spare using imaging and planning, so the men who had it probably had less extensive disease on the relevant side. Follow-up is one year. This supports careful, image-guided nerve sparing in selected high-risk men, not as a default.

• Consider side-specific nerve sparing in selected high-risk men when MRI and biopsy mapping allow.
• Discuss the margin risk and the continence trade-off with each patient.
• Use a structured planning process that maps disease side by side before deciding.
• Counsel that longer-term cancer control after nerve sparing in high-risk disease is not yet known.

Why it matters

It challenges the reflex to abandon nerve sparing whenever disease is labelled high risk.

Don't overread it

Surgeons selected whom to nerve-spare, and follow-up is one year; this cannot show nerve sparing is oncologically safe in all high-risk men.

The statistics, in plain English

Margin rates of 21% and 23% with P = 0.72 mean no detectable difference, but with 262 men the study could miss a modest one. The fewer-pads finding is a secondary result and may reflect differences in who was chosen for nerve sparing.

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