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NeuroSAFE

Despite hard-earned successes in screening, diagnosis and management, prostate cancer remains a persistent and pervasive clinical affliction. The epidemiological impact of prostate cancer is illustrated by it being the most common non-cutaneous cancer affecting American men, with an estimated 233,000 new cases with subsequent mortality in 29,480 patients in the United States in 2014(Siegel, Ma, Zou, & Jemal, n.d.). The advent of prostate-specific antigen (PSA) screening as well as the expansion in the therapeutic armamentarium over the years has however shifted the clinical burden from mortality to morbidity. The disease process is habitually indolent and prostate cancer exhibits excellent survival rates with 98.9% of diagnosed patients surviving for 5 years. In 2011 there were approximately 2,707,821 men living with prostate cancer in the United States (SEER Stat Fact Sheets: Prostate Cancer), highlighting the significance of quality-of-life considerations in the disease management. Of the available modalities, radical prostatectomy (RP) is considered the standard treatment option and a rapid diffusion over the past decade has led to robot-assisted laparoscopic radical prostatectomy (RALP) commanding the lion's share, making it the surgery-of-choice in prostatic carcinoma(Box & Ahlering, 2008; Stitzenberg, Wong, Nielsen, Egleston, & Uzzo, 2012). However the extant adverse effects of urinary incontinence and impotence exhort continuing search for better techniques to afford the patient the highest possible health-related quality-of-life (HRQoL) following surgery.

One of the primary factors benefitting functional outcomes following RP is preservation of the prostatic neurovascular bundle (NVB) (Budaus et al., 2009; Eastham et al., 1996) but cancer control being the foremost guiding principle in any therapeutic strategy, tumour eradication and nerve sparing (NS) become a delicate juggling act for the clinician. In recent years, research elucidating the intricate anatomy of the prostatic neurovascular bundle and pre-operative risk stratification of patients has enhanced the oncological safety of NS procedures. Evolution of intra-operative frozen section (IFS) analysis in the form of Neurovascular Structure-adjacent Frozen-section Examination or NeuroSAFE has the potential to further augment these gains. Research on prostatic NVB anatomy has come a long way since the description of corpus cavernosal nerve supply by Walsh and Donker in 1982[1] and our group has previously described that unlike a thread entering a bead at a distinct singular point, the prostatic NVB enmeshes the gland in an intricate trizonal hammock of nerves[2]. In the same study we also explicated a detailed surgical technique of the aforementioned neural hammock sparing along with a comprehensive pre-operative EPE risk stratification of patients in 4 instead of 2 groups, enabling us to transform the previously binary decision of NS vs. No NS to an incremental one. This ensures that, within limits of oncological safety, all our patients receive a measure of nerve sparing. The risk stratification algorithm has been since modified by our group to predict EPE risk with greater accuracy and the results will be published in another paper (?) The complex network of nerves that envelope the prostate gland, increase the opportunities of nerve rescue for a surgeon, however the sites of oncological surveillance increase concomitantly. It is herein that real-time analysis of the entire neurovascular tissue adjacent circumference would safeguard the maximum number of nerves while achieving comprehensive histological surgical margins. Initially demonstrated primarily in open RPs [3], the NeuroSAFE approach has yet to see widespread acceptance by the RALP community despite exposition of a tailored, time-neutral approach for the Da Vinci robotic system by the original authors[4]. Continuing our tradition of relentlessly working toward achievement of the highest HRQoL for our patients, we have included the NeuroSAFE technique in our package in addition to our athermal, traction-free, risk stratified, graded nerve sparing approach which is now the standard of care at our institute.



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