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 n eurovascular bundles to determine the effect of wide excision of the n eurovascular bundle(s) on disease-free survival. In 38 patients establ ished capsular penetration was not suspected clinically and the neurov ascular bundle(s) were preserved. In 69 patients established capsular penetration was suspected, and 1 or both neurovascular bundles were ex cised widely with the prostate. Disease-free survival was defined by a n undetectable serum prostate specific antigen (PSA) level postoperati vely. Wide excision of the neurovascular bundle(s) resulted in negativ e surgical margins in 40 of 69 patients (58%) compared to only 17 of 3 8 (45%) in whom the neurovascular bundle(s) was left intact (p = 0.03) . Median interval to disease recurrence, as defined by a measurable se rum PSA level, was 22 months in the group in whom the neurovascular bu ndles were preserved versus 33 months in the group undergoing wide exc ision (p = 0.03). At 39 months, however, 70% of the patients in both g roups had detectable PSA levels. Similarly, patients with positive sur gical 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 dete ctable PSA level and the Kaplan-Meier curves had converged. Although w ide excision of the neurovascular bundle(s) resulted in negative surgi cal margins more often with resultant delayed disease progression, mos t patients with established capsular penetration ultimately failed rad ical prostatectomy despite wide excision of periprostatic soft tissue. It seems likely, therefore, that many of these patients have occult m etastatic, disease at operation. Thus, recent enthusiasm for radical p rostatectomy in men with locally advanced prostate cancer may not be j ustified.