Comparing Nerve Sparing and Retzius treatments, or basic RARP ?

Your side effects (ED, incontinence) will be a function of the skill of your surgeon. That alone would get me to find one that specialized in nerve sparing and the Retzius procedure. Nerve sparing is always best efforts, depending on the extent of your cancer. To wait 6 months that should be for the best surgeon available. Otherwise, should be looking for another surgeon to treat you.

What kind of insurance do you have? Are you in a country that has those waits for treatment or some very bad Medicare HMO? If the later, you might want to change. The statistics show that treatment outcomes at 10 years are the same for RT and RP so changing treatment is an option. However, you should not have to do that and that would be if all else failed if I had decided on RP as my treatment of choice.

Each form of prostate cancer treatments comes with its own risk profile (as you’re obviously aware). (Even focal therapies have risk profiles.) The success rates comparing surgery with external radiation are statistically equivalent so, the decision comes down to the side/after-effects that you’re prepared to deal with.

Regarding specialty surgeries:
> if you want to reduce the risk of ED, look into nerve-sparing surgery (and a center that specializes with that).
> if you want to reduce the risk of incontinence, look into retzius-sparing surgery (and a center that specializes with that).

As with any treatment, you’re going to have to prioritize the quality-of-life factors that are most important to you, and then go with the treatment that most closely aligns with those personal priorities.

As for the term “nerve-sparing” that can mean many things. With RP nerve sparing surgery you might have, what % of the two nerve bundles will be spared - 100%/0%? 75%/25%? 50%/50%; 25%/25%? Some other %/%? That can impact how long recovery takes (if at all).

(When I asked my urologist that question, his response was “We won’t know that until we get in there.” That wasn’t good enough for me so, at 65y/o I went with 28 sessions of proton radiation. (They say that with most guys by the time they’re 75y-80y have some type of urinary issues anyway; so, if it does eventually happen after radiation, it’s the same profile that would’ve happened anyway.) But, so far, 5-1/3 years later (at 71y/o) quality-of-life is unchanged.

It is important to note that nerve sparing can be done with both surgical techniques but Retzius sparing cannot be done with the standard RALP that most surgeons perform. Also as brianjarvis commented nerve sparing percentages can vary considerably. That depends where your tumors are in relation to the nerve bundles on each side and the need for margin removal. I have commented previously on how patient’s hear in their consultation that the surgeon is going to do nerve sparing and they believe that puts them in the clear. The surgeon from your MRI and biopsy already has an idea how much nerve sparing he can do prior to surgery, so ask him what percentage’s he anticipates.

Now for Retzius sparing, again different from nerve sparing, cannot be done by typical surgeon performing a RALP. It actually now has it’s own acronym within the medical field as it has gained wider surgical availability as more surgeons become trained due to it’s advantages. It is RS-RALP.

The significance of Retzius sparing is the non cutting of the Puboprostatic ligament tethering the bladder. This is going to substantially improve more immediate continence. This procedure has a longer learning curve for surgeons so you definitely want an experienced surgeon in this technique not a newbie. There are also two surgical techniques related to the Retzius space done by surgeons trained in one of those two techniques to improve continence. One is called the Anterior approach, referred to as a Hood’s technique to protect the Retzius space ( different from Retzius sparing) and the other Posterior approach which is actually the only one referred to as Retzius sparing surgery to completely avoid the space. The surgeon comes in behind and underneath the bladder. The posterior approach the surgeon actually looks at your anatomy in reverse.

I had Retzius sparing. The anterior approach gets called the anterior fascia sparing while Retzius sparing is called Retzius sparing. It is again something to be cognizant of the differences, but in both those approaches the Puboprostatic ligament is not cut to improve contingence.

Since you are a 3+4 without other aggressive issues, SBRT radiation could be all you need.

Yes, you can wait for that nerve sparing and Retzius Sparing surgery, Since a 3+4 grows very slowly, that amount of time shouldn’t make a difference. If you’re really worried about it, starting on ADT would prevent your cancer from spreading and growing while you wait the months to have surgery.

I'm no expert in which surgical approach is best. But, I did go to the experts at Northwestern (whose team co-authored the highly-regarded prostate cancer book, "Dr. Patrick Walsh's Guide to Surviving Prostate Cancer."

My surgeon used the anterior pelvic fascial sparing approach to robotic radical prostatectomy (also referred to as the “hood technique”). I knew there was also the posterior approach, but what made me comfortable in not searching out a surgeon with the posterior approach is that a five year study had shown the anterior approach was effective at both minimizing incontinence as well as CANCER control.

Meaning, "The review’s central conclusion is that preserving the anterior peri-prostatic anatomy improves early urinary continence after RARP, and that the most carefully studied anterior-approach variant — the “hood” technique — achieves this without compromising cancer control."

I like the idea of going with solid data for decision making and cancer control was definitely my primary goal while also minimizing continence issues. Hoping that they get all the data on the posterior approach as well.

This article is a good review on the approaches:
https://ernesturology.com/blog/blog-anterior-pelvic-fascial-sparing.html

@jim18 Thanks Jim. I live in Ontario Canada and health insurance is all through the government. Good news is my RARP surgeon yesterday agreed to see me next week to help answer more of my questions. I will ask him about an earlier surgery date, and if he will perform Retzius. He mentioned sparing 2/5 and 3/5 of the nerves - Hmm, I am hoping for a better outcome than that. Key for me is to not let enough time pass and then the cancer gets out of the prostate shell.

@brianjarvis Thanks Brian, your response is a good one with the idea that SBRT is an option that minimizes QOL. My RO said he would do 5 sessions over 12 days, and if there is recurrence, he would then to Brachytherapy. Anywhere I read about the treatment path suggested has been stated as a very good treatment path…I have another meeting with my RARP surgeon next week to answer questions have…

@fritzo Thanks for your response. Have you had the treatment already?

Yes sir! I am five months post surgery.

The really good news is that my post-surgery pathology was as the doctor said, "as good as it gets." What that means is that my cancer was contained to the prostate and they were able to remove all of it. For other people, the cancer may have escaped to the walls of the prostate or into other tissues, so results of the surgery will vary. The docs caught mine not so early that I could avoid treatment, but early enough that it hadn't spread.

Mine was also nerve sparing, which does appear to have worked in my case. Am I back 100 percent at five months? Nope, but my response has been very positive from fairly early on.

Everyone is different. I chose surgery because I wanted to leave the most options for treatment if there was recurrence. I explored radiation, and they did a Decipher test, but my score just crossed from intermediate to aggressive, so I would have had to have hormone therapy with radiation. Didn't want that, so that sealed the deal for surgery.

But, I just had lunch with a buddy who I did not know had prostate cancer. He got radiation 10 years ago and he is still undetectable.

Decisions are hard....but just decide what feels right for you based on all your homework. You are doing all the right things.

@fritzo Great story Fritz, Your result is exactly what I am looking for. I will push my RARP surgeon to focus more on nerve sparing. He said he would do a, “high lift” approach. Meaning that he would go in, elevate the nerve bundles from the sides upward, then remove the prostate. He did say that a 30-50% chance for me for erections without enhancements. This is lower than what I was hoping but still something. Maybe I will chime back in with you after I meet him again next Thursday to ask more questions. I wonder how far off my situation ends up relative to, “as good as it gets”… How old were you on surgery date? I am 68 and 3+4, with no IDC or EPE at this point. My concern is waiting until 8 months post biopsy to have the surgery as I don’t want it to progress. Thanks for connecting