Abstract
Purpose
To investigate the effects and associated factors of extended pelvic lymph node dissection (ePLND) on urinary control (UC) and sexual function recovery following bilateral nerve-sparing radical prostatectomy.
Methods
From June 2016 to December 2023, our institution treated and followed 341 patients who underwent bilateral nerve-sparing RP for over a year. These patients were divided into two groups: ePLND (n = 185) and no PLND (n = 246). To minimize potential biases, 1:1 propensity score matching (PSM) was utilized to compare functional outcomes, and complications between the groups.
Results
After adjusting for propensity scores, a total of 240 patients (120 in each group) were included for further analysis. There was no significant difference between the two groups (p > 0.05) in terms of complete UC (0 pad) at 3, 6, and 12 months postoperatively. Regarding sexual function recovery, 21.7% of patients in the ePLND group and 35.9% in the no PLND group returned to the preoperative level (p = 0.015). The proportion of patients with the International Index of Erectile Function (IIEF)-5 score ≥ 17 was 5.8% and 18.2%, respectively (p = 0.003). Multivariate analysis further identified preoperative IIEF-5 score (p = 0.004), high-risk group (p = 0.042), and super extended pelvic lymph node dissection (s-ePLND) (p = 0.036) as independent factors associated with sexual function recovery. The complications occurred in 9.2% of patients in the ePLND group and 4.2% in the no PLND group (p = 0.121).
Conclusions
ePLND does not affect the recovery of postoperative UC or increase the incidence of complications, but it significantly impairs the recovery of sexual function. Independent factors associated with sexual function recovery include the preoperative IIEF-5 score, high-risk group, and s-ePLND.
Keywords: Prostate cancer, Prostatectomy, Pelvic lymph node dissection, Sexual function, Urinary incontinence, Scoring methods
Introduction
Radical prostatectomy (RP) is the primary treatment for most localized prostate cancers in men, conferring a life expectancy of more than 10 years [1]. Long-term postoperative outcomes are typically assessed using the trifecta criteria, which include oncologic control, sexual function, and urinary continence [2, 3]. In rectal cancer surgery, pelvic lymph node dissection (PLND) has been shown to affect erectile and urinary control (UC) function in men [4, 5]. It is, therefore, speculated that PLND may increase the risk of pelvic plexus injury, particularly during lymphatic dissection in the internal iliac region. As this region lies close to the pelvic plexus [6, 7], which plays a central role in regulating erectile function and UC in men, the potential for nerve damage warrants further investigation [8]. To date, the benefits of PLND in patients undergoing RP remain widely debated [8–11]. Some researchers believe that PLND does not affect the recovery of urinary continence or erectile function [8, 9], while others argue that both PLND and the extent of dissection may negatively impact UC and sexual function [10, 11]. Since 2004, our research group has conducted studies on zoned super extended pelvic lymph node dissection (s-ePLND) in RP patients and proposed that dissection of the internal iliac region is essential [12]. More recently, we conducted autopsy studies on partitioned s-ePLND and found that the anatomical location and extent of dissection were closely related to both the number of lymph nodes retrieved and the pelvic nerve plexus [13]. Herein, we retrospectively analyzed 341 patients with localized prostate cancer (ePLND: n = 185, no PLND: n = 246) who underwent bilateral nerve-sparing RP. Propensity score matching (PSM) was applied to reduce or eliminate selection bias between groups. The aim was to evaluate the impact of ePLND on postoperative UC and sexual function, identify related influencing factors, and provide clinical evidence to guide the decision on whether ePLND should be performed in RP patients.
Materials and methods
Inclusion and exclusion criteria
The inclusion criteria were as follows: ① patients who underwent bilateral nerve-sparing RP via open or laparoscopic surgery and ② follow-up duration of more than 1 year. Meanwhile, the exclusion criteria included the following: ①patients who underwent unilateral nerve-sparing RP; ② patients with incomplete clinical information; ③ follow-up duration of less than 1 year; and ④ patients who received androgen deprivation therapy (ADT) before or after surgery.
Patient characteristics and PSM
From January 2016 to December 2023, a total of 889 patients underwent nerve-sparing RP at Jinhua Hospital, affiliated with Zhejiang University Hospital (193 patients with unilateral nerve preservation and 696 patients with bilateral nerve preservation). Whether this group can undergo nerve-sparing radical surgery is determined according to the discussion and recommendation of multidisciplinary experts (urology, pathology, medical imaging, ultrasound diagnosis and treatment, radiotherapy and endocrinology departments, etc.) in our hospital and whether it meets the indications standard for nerve preservation [14]. Among the 696 patients with bilateral nerve preservation, 22 had incomplete clinical information, 107 were followed up for less than 1 year, and 136 received ADT before or after surgery (37 neoadjuvant and 99 immediate adjuvant treatment). As a result, 458 patients were excluded from the study cohort, while 431 patients were included in the study. Based on whether extended pelvic lymph node dissection (ePLND) was performed, the patients were grouped according to the D'Amico risk classification of tumors based on the 2002 TNM staging system [15, 16]. High-risk and intermediate-risk patients [15, 17] with a lymph node metastasis rate exceeding 5% underwent ePLND (n = 185), while low-risk and intermediate-risk patients with a lymph node metastasis rate of less than 5% did not undergo PLND (n = 246). In addition, PSM was performed based on other factors (The basis for this group to undergo ePLND was based on the D’Amico risk classification. When we performed PSM, the three factors of the D’Amico risk classification were not included in the score matching) to reduce or eliminate selection bias between groups. The study protocol was approved by the Ethics Committee of Jinhua Hospital (ethics number: 2021-ethics-187).
A multivariable logistic regression model was used to calculate the propensity score for each patient, including variables, such as age, body mass index(BMI), comorbidities (hypertension, diabetes, and heart disease), prostate volume, American Society of Anesthesiologists (ASA) score, surgical approach (open or laparoscopic), intraoperative bleeding, operation time, adjuvant radiotherapy, preoperative International Index of Erectile Function (IIEF)−5score, and follow-up duration. The matching ratio for propensity scores was 1:1, with a matching tolerance of 0.02 between the two groups.
Surgical methods
Open surgery employed the classic method [18, 19] for nerve-sparing, while laparoscopy used the interfascial/intrafascial method for nerve-sparing [20, 21] There are four types of PLND [17, 22]: (1) limited PLND (lPLND), involving the obturator nodes; (2) standard PLND (sPLND), involving the obturator and external iliac nodes; (3) extended PLND (ePLND), involving the obturator, external, and internal iliac nodes; and (4) super-extended PLND (s-ePLND), involving ePLND plus the common iliac and presacral nodes (Fig. 1). Herein, all patients underwent ePLND, with 77 patients receiving s-ePLND [12].
Fig. 1.
Schematic illustration of the range of ePLND and s-ePLND
Follow-up and study endpoints
Functional assessment included UC, sexual function, and complications. A trained team of physicians and nurses conducted follow-ups for all patients. The follow-up method involved direct inquiries during hospital visits or telephone follow-up. Patients were asked about the number of routine urinary pads used daily to assess UC function. The assessment was conducted at 3, 6, and 12 month post-surgery, with a follow-up window of 1 week before or after the specified timepoints. Urinary function recovery assessment [23] was categorized as follows: use of at least one pad per day was considered as incontinence, while complete UC (no pads, dry) was considered as recovery of UC. For sexual function, the endpoint was defined as the best sexual performance, equivalent to preoperative levels (the primary endpoint of this study) or an IIEF-5 score ≥ 17 [9, 24–26], observed at any time. Preoperative questions about sexual function included topics on fertility, sexual activities (such as masturbation, foreplay, and intercourse), and erectile dysfunction. Postoperatively, at 6 months, questions focused on sexual activity and erectile function, comparing them to preoperative levels, and were recorded accordingly [23]. Complications were recorded using the Clavien–Dindo classification [27].
Statistical analysis
PSM and statistical analysis were performed using SPSS (version 27.0, IBM). All baseline factors affecting the study endpoints were analyzed. Continuous variables were analyzed using either the t test or the Mann–Whitney U test, while categorical variables were analyzed using the χ2 test and Fisher's exact test. A post-match logistic regression model was established to explore the relevant factors affecting postoperative sexual function based on all relevant variables prior to matching. A p value of < 0.05 was considered statistically significant.
Results
Clinical and pathological characteristics
There were 185 patients in the ePLND group before PSM, including 77 patients with s-ePLND and 246 patients in the no PNLD group. Statistical differences were observed in factors, such as ASA score, surgical approach (open/laparoscopy), operation time, adjuvant radiotherapy (yes/no), and follow-up time (p < 0.001). After PSM, a total of 240 patients were successfully matched (120 in each group), with all 12 factors showing no significant differences (p > 0.05) (Table 1). Whether PLND surgery was performed was determined based on the EAU Prostate Cancer Guidelines, using the D'Amico Risk Assessment Classification [15, 16]. Therefore, the three factors used in the D'Amico Risk Assessment (PSA, clinical staging, and Gleason score) were not included in the matching process. Significant differences in these three factors were observed before and after PSM in both groups (p < 0.001) (Table 2).
Table 1.
Clinical factors characteristics for matching
| Variables[Mean ± SD, or n (%)] | Before propensity score matching | After propensity score matching | ||||
|---|---|---|---|---|---|---|
| ePLND (n = 185) | No PLND (n = 246) | p value | ePLND (n = 120) | No PLND (n = 120) | p value | |
| Age (years) | 68.36 ± 5.81 | 68.05 ± 6.51 | 0.616 | 68.22 ± 6.02 | 68.01 ± 6.62 | 0.791 |
| BMI (kg/m2) | 22.93 ± 3.20 | 22.83 ± 2.65 | 0.711 | 22.90 ± 3.10 | 22.94 ± 2.71 | 0.927 |
| Associated comorbidities | 0.849 | 0.377 | ||||
| Hypertension | 48 (25.9) | 60 (24.4) | 31 (25.8) | 20 (16.7) | ||
| Diabetes | 18(9.7) | 19 (7.7) | 11 (9.2) | 11 (9.2) | ||
| Heart disease | 9(4.9) | 13 (5.3) | 6 (5.0) | 7 (5.8) | ||
| Prostate volume (mL) | 39.91 ± 17.85 | 39.38 ± 16.96 | 0.752 | 40.13 ± 18.38 | 40.70 ± 18.47 | 0.811 |
| ASA physical status | < 0.001 | 0.327 | ||||
| ≤ 2 | 137 (74.1) | 239 (97.2) | 109 (90.8) | 113 (94.2) | ||
| > 3 | 48 (25.9) | 7 (2.8) | 11(9.2) | 7(5.8) | ||
| Surgical approach | < 0.001 | 0.512 | ||||
| Laparoscopic surgery | 137 (74.1) | 213 (86.6) | 95 (79.2) | 99 (82.5) | ||
| Open surgery | 48 (25.9) | 33 (13.4) | 25 (20.8) | 21 (17.5) | ||
| Estimated blood loss(mL) | 271.46 ± 174.72 | 266.12 ± 169.81 | 0.750 | 281.21 ± 165.27 | 280.79 ± 177.02 | 0.985 |
| Operation time(min) | 211.50 ± 44.86 | 189.19 ± 49.45 | < 0.001 | 204.54 ± 40.04 | 205.13 ± 50.45 | 0.921 |
| Adjuvant radiotherapy | 42 (22.7) | 13 (5.3) | < 0.001 | 10(8.30) | 11(9.20) | 0.819 |
| Preoperative IIEF-5 score | 15.99 ± 6.26 | 15.93 ± 6.89 | 0.923 | 15.76 ± 6.25 | 15.62 ± 6.82 | 0.867 |
| Preoperative IIEF-5 score ≥ 17 | 84 (45.4) | 125 (50.8) | 0.266 | 55 (45.8) | 57 (47.5) | 0.796 |
| Follow-up time [M(IQR),months] | 38(28- 57) | 33(21–47) | < 0.001** | 37(26.5- 54) | 40 (31.5–55) | 0.132** |
ePLND extended pelvic lymph node dissection, no PLND no pelvic lymph node dissection, BMI body mass index, ASA American Society of Anesthesiologists, IIEF-5 Index of Erectile Function-5, M median, IQR interquartile range. ** Mann–Whitney U test
Table 2.
D'Amico classification factors characteristics not matched
| Variables[Mean ± SD, or n (%)] | Before propensity score matching | After propensity score matching | ||||
|---|---|---|---|---|---|---|
| ePLND (n = 185) | No PLND (n = 246) | p value | ePLND (n = 120) | No PLND (n = 120) | p value | |
| PSA (ng/mL) | 24.66 ± 15.34 | 9.23 ± 4.49 | < 0.001 | 27.33 ± 16.37 | 8.96 ± 4.67 | < 0.001 |
| PSA risk stratification (ng/mL) | < 0.001* | < 0.001* | ||||
| < 10 | 38 (20.5) | 151 (61.4) | 18 (15.0) | 78 (65.0) | ||
| 10–20 | 34 (18.4) | 94 (38.2) | 22 (18.3) | 41 (34.2) | ||
| > 20 | 113 (61.1) | 1 (0.4) | 80 (66.7) | 1 (0.8) | ||
| Gleason score | < 0.001* | < 0.001* | ||||
| 6 | 53 (28.6) | 106 (43.1) | 39 (32.5) | 63 (52.5) | ||
| 7 | 93 (50.3) | 140 (56.9) | 72 (60.0) | 57 (47.5) | ||
| ≥ 8 | 39 (21.1) | 0 (0.00) | 9 (7.50) | 0 (0.00) | ||
| Clinical T staging | 0.001* | < 0.001* | ||||
| ≤ cT2a | 82 (44.3) | 155 (63.0) | 62 (51.7) | 68 (56.7) | ||
| cT2b | 26 (14.1) | 91 (37.0) | 11 (9.2) | 52 (43.3) | ||
| ≥ cT2c | 77 (41.6) | 0 (0.00) | 47 (39.2) | 0 (0.00) | ||
ePLND extended pelvic lymph node dissection, no PLND no pelvic lymph node dissection, PSA prostate-specific antigen*Fisher's exact test
UC and sexual function
All patients in both the ePLND and no PLND groups were followed up for more than 12 months after surgery. The rates of daily complete UC (0 pads) at 3, 6, and 12 months after surgery were 60.8%, 86.7%, and 94.2% in the ePLND group, and 62.5%, 86.7%, and 95.0% in the no PLND group, respectively (p = 0.791, 1.000, and 0.776). The rates of complete UC at night (0 pads) were 45.0%, 75.8%, and 87.5% in the ePLND group, and 54.2%, 76.7%, and 88.3% in the no PLND group, respectively (p = 0.156, 0.879, and 0.743). The two groups were comparable in terms of postoperative UC function recovery (p > 0.05) (Table 3).
Table 3.
Urination control function recovery of the two groups after matching
| Variables[Mean ± SD, n (%)] | ePLND (n = 120) | No PLND (n = 120) | p value |
|---|---|---|---|
| Complete daytime UC rate | |||
| 3 months | 73 (60.8) | 75 (62.5) | 0.791 |
| 6 months | 104 (86.7) | 104 (86.7) | 1.000 |
| 12 months | 113 (94.2) | 114 (95.0) | 0.776 |
| Nocturnal complete UC rate | |||
| 3 months | 54 (45.0) | 65 (54.2) | 0.156 |
| 6 months | 91 (75.8) | 92 (76.7) | 0.879 |
| 12 months | 105 (87.5) | 106 (88.3) | 0.843 |
ePLND extended pelvic lymph node dissection, no PLND no pelvic lymph node dissection
Patients in both the ePLND and no PLND groups had normal fertility function preoperatively and were instructed to preserve sexual function as much as possible. The preoperative IIEF-5 scores were comparable between the groups (p = 0.867), and the percentage of patients with IIEF-5 scores ≥ 17 was 45.8% in the ePLND group and 47.5% in the no PLND group (p = 0.796). The median follow-up periods for the two groups were 37 and 40 months, respectively. Postoperatively, the percentage of patients who subjectively felt their sexual function had returned to preoperative levels was 21.7% in the ePLND group and 35.9% in the no PLND group (p = 0.015). Postoperative IIEF-5 scores (p < 0.001) and the percentage of patients with IIEF-5 scores ≥ 17 were 5.8% in the ePLND group and 18.3% in the no PLND group (p = 0.003). Significant statistical differences were observed between the two groups (p < 0.05) (Table 4).
Table 4.
Sexual functional recovery of the two groups after matching
| Variables [Mean ± SD, n (%)] | ePLND (n = 120) | No PLND (n = 120) | p value |
|---|---|---|---|
| Subjective perception of sexual function recovery to preoperative level | 26 (21.7) | 43(35.9) | 0.015 |
| Postoperative IIEF-5 score | 9.57 ± 4.14 | 11.50 ± 4.46 | < 0.001 |
| Postoperative IIEF-5 score ≥ 17 | 7 (5.80) | 22 (18.3) | 0.003 |
ePLND extended pelvic lymph node dissection, no PLND no pelvic lymph node dissection, IIEF-5 Index of Erectile Function-5
Next, a matching logistic regression model was established to analyze the relevant factors based on all variables. Univariate analysis showed that age (p < 0.001), PSA (p = 0.003), D'Amico risk classification (all risk groups) (p = 0.022), preoperative IIEF-5 score (p = 0.028), and s-ePLND (yes/no) (p = 0.043) were significant factors. Multivariate analysis further identified preoperative IIEF-5 score (p = 0.004), high-risk group in D'Amico risk classification (p = 0.042), and s-ePLND (yes/no) (p = 0.036) as independent factors (Table 5).
Table 5.
Univariate and multivariate analyses of Sexual functional restored after matching
| Variables | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| OR (95% CI) | p value | OR (95% CI) | p value | |
| Age (years) | 0.856 (0.814–0.901) | < 0.001 | 0.940 (0.871–1.013) | 0.105 |
| PSA (ng/mL) | 0.964 (0.940–0.988) | 0.003 | 1.008 (0.983–1.034) | 0.521 |
| Preoperative IIEF-5 score | 1.196(1.130–1.266) | < 0.001 | 1.111(1.034–1.194) | 0.004 |
| D'Amico risk classification (n, %) | 0.022 | 0.117 | ||
| Low risk | 1 | 1 | ||
| Intermediate risk | 2.795(1.233–6.336) | 0.014 | 1.572 (0.556–4.446) | 0.394 |
| High risk | 2.081 (1.097–3.945) | 0.025 | 2.290 (1.029–5.093) | 0.042 |
| s-ePLND (yes/no) | 2.240 (1.025–4.891) | 0.043 | 2.413 (1.057–5.508) | 0.036 |
ePLND extended pelvic lymph node dissection, no PLND no pelvic lymph node dissection, PSA prostate-specific antigen, IIEF-5 Index of Erectile Function-5, s-ePLND super extended pelvic lymph node dissection
Complications
There were no reports of treatment-related death in either group. The total complication rates, based on the Clavien–Dindo classification, were 9.2% (11/120) in the ePLND group and 4.2% (5/120) in the no PLND group (p = 0.121). The postoperative complication rates were 7.5% (9/120) and 4.2% (5/120), respectively (p = 0.271). In the ePLND group, there were 2 cases of intraoperative venous injury, 6 cases of postoperative lymphatic fistula/lymphocyst, and 3 cases of pulmonary embolism. In the no PLND group, there were no intraoperative complications, but 1 case of postoperative anastomotic urinary fistula and bladder neck obstruction, as well as 3 cases of venous thrombosis/pulmonary embolism, were reported. Importantly, all complications were successfully treated and resolved.
Discussion
PLND is a crucial surgical step in RP for patients with intermediate to high-risk prostate cancer. It not only improves prognosis by clearing micrometastatic lymph nodes [28], but also enables accurate clinical staging to guide postoperative treatment [12, 22]. Nonetheless, the impact of PLND on UC and sexual function after RP surgery remains controversial [8–11]. Despite this, most scholars and guidelines recommend ePLND for high-risk and intermediate-risk patients with a lymph node metastasis probability exceeding 5% [1, 15, 17, 29]. With advancements in robotic equipment and surgical technology, more and more intermediate-to-high-risk patients are being recommended for RP [30, 31]. Therefore, it is highly relevant to clarify the impact of ePLND on UC, sexual function, and surgical complications in patients undergoing RP. The present study treated 431 patients who underwent bilateral nerve-preserving RP. Importantly, our results indicated that compared with the no PLND group, ePLND surgery did not affect the recovery of UC function or the incidence of surgical complications, but it significantly impacted the recovery of sexual function.
Gandaglia et al. [8] followed 396 patients who underwent bilateral nerve-preserving RP for more than 2 years. They found no significant differences between the ePLND and no PLND groups in UC recovery (90% vs. 90.2%, p = 0.845) or erectile function recovery (46.6% vs. 49.7%, p = 0.33). However, in that study, the decision to perform ePLND was made subjectively by the surgeon, which differs significantly from the D'Amico risk classification used in this study, which is based on established guidelines. Moreover, the study did not include an analysis of anatomical regions, such as the internal iliac area, which may have introduced substantial bias in the results. Ken Lee et al. [10] evaluated postoperative UC (defined as not using or using only a safety pad daily) in 349 patients undergoing robot-assisted RP. It is believed that the higher rate of postoperative (1 month) urinary incontinence and worsened urinary symptoms may be due to the removal of part of the sympathetic innervation during ePLND. We believe that in terms of UC function, there is currently no universally accepted definition in the literature. Different studies have used various assessment tools, including questionnaires, urodynamic studies, and pad tests. Some defined UC as using up to one pad per day or night, while others relied solely on subjective patient reports without consistent criteria. The present study utilized a widely recognized questionnaire to assess complete UC and voiding patterns [23], defining complete UC as dry and using zero pads. There was no difference between the ePLND group and the no PLND group at 3, 6, and 12 months after surgery, indicating that ePLND had no impact on the recovery of UC. Regarding sexual function, this study is the first to report the effect of the anatomical areas of ePLND, on sexual function. Furthermore, we used an IIEF-5 score ≥ 17 as the criterion for determining erectile dysfunction, as this score was designed to simply and effectively identify the presence of erectile dysfunction [25]. The recovery of erectile function was 5.8% in the ePLND group and 18.3% in the no PLND group (p = 0.003). Subjectively, 21.7% of patients in the ePLND group and 35.9% in the no PLND group reported that their sexual function had returned to preoperative levels (p = 0.015). These findings show significant differences between the two groups and are consistent with previous studies [11, 26]. In contrast, the recovery rate of erectile function was considerably lower than that reported in other studies. This may be due to two factors. First, the IIEF-5 score is subjective and can be influenced by cultural background, regional differences, and patients’ understanding of specific terms, which may lead to discrepancies between perceived and actual erectile function. Second, Among the patients in this group, most of them came from rural areas and had a relatively low level of education; In our country, the older generation of elderly people (over 60 years) is very conservative in their thinking about "sex culture" and is unwilling or ashamed to talk about sexual life issues, let alone express the true situation of sexual life frankly, resulting in a low ratio of IIEF-5 score ≥ 17. In this study, during the follow-up to assess sexual function, we incorporated the assessment of 'subjective recovery of sexual function to preoperative levels,' which includes evaluation of sexual activity status (masturbation, foreplay, and sexual intercourse), and erectile function [23]. We strongly believe that this approach helps provide a more comprehensive and objective evaluation of postoperative sexual function recovery.
The previous literature has reported preoperative erectile function, baseline IIEF-5 score, tumor stage, surgical approach, and patient age as independent predictors affecting sexual function recovery [8, 9, 32]. In this study, multivariate analysis identified preoperative IIEF-5 score, high-risk group, and s-ePLND as independent factors. Of the above three factors, s-ePLND is the only associated with PLND surgery. s-ePLND, including the internal iliac, common iliac and presacral areas, etc. These areas are close to the neural fibers of the pelvic plexus [8, 13], which is mainly responsible for potency and continence in men [8]. Pelvic plexus (also called hypogastric plexus). It consists of ganglia and nerve fibers, which gather to form nerve plate 4–5 cm in diameter. The plexus spreads to both sides between the side wall of the pelvis and such organs as the rectum, vesicles, prostate, and the back part of the bladder [7]. It arises from three different sources: the inferior mesenteric nerve from the superior hypogastric plexus, the sacral splanchnic from the sacral sympathetic trunk (chiefly the S2 ganglion), and the pelvic splanchnic nerves, mainly branches from the third and fourth lumbar. The fourth ventral branch of the sacral spinal nerves, which forms the parasympathetic cavernous nerve [6]. These nerve branches provide autonomic innervation to the pelvis; therefore, based on the above anatomy, s-ePLND for these sympathetic and parasymp fibers injury would result in urologic and sexual dysfunction. The area and extent of the dissection of the PLND are increasing the risk of sexual dysfunction. In addition, we have previously found that: the presaeral region should be the key to be checked, while regular dissection in common iliac region is not necessary [12]. It is apparent that the presaeral and common iliac regions should be selectively removed in patients who require pelvic lymph node dissection according to operative conditions. In addition, the surgical method (open/laparoscopic) and patient age were not found to be independent factors in this group, which may be due to the small number of open surgery cases and the low proportion of patients whose sexual function recovered to the preoperative level after surgery, resulting in no correlation during the multivariable analysis.
The complication rates in the ePLND and no PLND groups in this study were 9.2% and 4.2%. Complications of ePLND were similar to those reported (7.3%) by Castro et al. [33], and there was no difference between the two groups. ePLND would not significantly increase postoperative complications. However, attention should be paid to the complication of presacral venous plexus injury and bleeding during presacral area dissection.
The issue of oncological status may influence the extent of nerve preservation. Our group’s nerve-sparing technique was determined according to the discussion recommendations of the multidisciplinary experts in our hospital and our published indications for nerve preservation (the conclusion was that nerve preservation indications were a positive needle number of unilateral puncture < 1/3, and no capsule invasion on MRI could be implemented [14]).This surgical indication was concluded based on the criteria of “distance ≥ 2 mm between the cancer focus and the nerve-vascular bundle (NVB) in the pathological macro slice” [14], and it is applicable to any technique of nerve preservation currently in widespread use. Therefore, there is no need to pay special attention to the influence of the tumor status (such as intermediate–high-risk classification) on the degree of nerve preservation in patients who meet the above indications for nerve preservation. Meanwhile, nerve-sparing surgery was all performed by an experienced surgeon (attending physician), and for cases with postoperative positive surgical margins, adjuvant radiotherapy and endocrine therapy and other salvage treatments were performed to further reduce the impact of factors, such as different surgeons, tumor status, and so on, on the degree of nerve preservation.
Limitations
Nevertheless, this study has several limitations that should be acknowledged. First, this was a retrospective and exploratory analysis, which inevitably introduces potential biases in case selection and data collection. Although the study included only patients who underwent bilateral nerve-preserving RP and used PSM to reduce selection bias between groups, randomized controlled trials remain the gold standard for establishing causality. Second, while this study enrolled more patients than previous reports, expanding the sample to include a broader patient population would enhance the generalizability of the findings and support future randomized trials. Third, our findings stem from a larger clinical medical center with an experienced surgeon performing the operations. Therefore, the results may not be generalizable to other hospitals. Fourth, this study did not address the oncologic outcomes of the cohorts, an issue that continues to be debated [29]. We will strengthen our follow-up efforts to address this deficiency as soon as possible. Finally, these findings still require further validation in clinical practice to provide robust and objective evidence for the future application of ePLND, and future need of multi-center or prospective studies to validate the current findings.
Conclusion
Although ePLND does not significantly affect the recovery of postoperative UC or the incidence of complications in patients undergoing bilateral nerve-preserving RP, it has a significant impact on sexual function recovery postoperatively. Independent factors associated with sexual function recovery include the preoperative IIEF-5 score, high-risk group, and the performance of s-ePLND. Dissection of the presacral and iliac regions should be selectively performed according to the intraoperative situation.
Acknowledgements
Not applicable.
Author contributions
Zaisheng Zhu: Study design,completed PLND surgery and project development. Yiyi Zhu: Article writing. Hongqi Shi & Penfei Zhou: Data collection and data analysis. Yadong Xue & Quanqi Liu: data analysis and statistical analysis All authors reviewed the manuscript. All authors read and approved the final manuscript.
Funding
This work was supported by grants from the Zhejiang Provincial Medical and Health Program Project (2022KY1332) and the Zhejiang Jinhua City Major Science and Technology Research Program (Social Development Category) (2021-3-022).
Data availability
The datasets generated and analyzed during the current study are not publicly available as consent was not obtained from all patients to publish this data. However, they are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Medical Ethics Committee of Jinhua Hospital, The Affiliated Hospital of Zhejiang University Medical School (approval number: 2021-187). All patients provided informed consent. All methods were carried out in compliance with the relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are not publicly available as consent was not obtained from all patients to publish this data. However, they are available from the corresponding author upon reasonable request.