Nerve-sparing approach during radical prostatectomy is strongly associated with the rate of postoperative urinary continence recovery



I read with real interest the article by Suardi et al [1] about a large, single-centre series of open radical prostatectomies (RPs). The authors showed that the bilateral nerve-sparing (NS) technique is associated with a higher rate of urinary continence (UC) recovery compared with the non-NS procedure, and should be offered more widely when surgically and oncologically feasible. However, I have some points to debate.

The authors do not report whether the high-risk patients were treated with adjuvant therapy, either radiotherapy or hormonal suppression, both of which significantly affect continence [2]. The long-term follow-up of this study probably might reveal disease relapse, requiring some treatment in a subgroup of patients. This consequence could be argued from the rate of UC in the high-risk group because this rate is the only one not changing at years 1 and 2 (54.7% vs 56.2%, respectively). This result might reflect possible clinical events or therapeutic manipulations that occurred during follow-up.

It is unclear how many patients, of 1249, received pelvic floor rehabilitation for UC recovery. A bias could have been introduced because most patients were at low-risk and had undergone NS-RP. This population suggests a high percentage of oncologically successful patients, with motivation to start a rehabilitation programme.

This study, depicting UC recovery at 1 and 2 years, is focused mainly on the prospective probability of UC after NS-RP. However, even if based on preoperative characteristics (age, risk group, Charlson comorbidity index) and operative characteristics (NS vs non-NS), the authors do not report the probability of immediate UC after surgery (i.e., at catheter removal or at first postoperative week). Evaluating the above-mentioned data with the outcome
of immediate UC could confer on this interesting study a comprehensive view of postoperative UC after open RP. In addition, this information may be relevant for both the patient and the surgeon.