A 68-year-old man has a PSA of 12 ng/mL. MRI prostate shows a PIRADS 5 lesion in the left peripheral zone. Targeted biopsy confirms Gleason score 4+4=8 (Grade Group 4) prostate cancer. Bone scan and CT show no metastases. After discussion of options, he opts for radical prostatectomy (RP). Which nerve-sparing approach offers the best combination of oncological clearance and functional outcome for this high-risk localised disease?
- A Bilateral nerve-sparing RP to maximise erectile function preservation
- B Nerve-sparing is contraindicated in all Grade Group ≥3 disease
- C Unilateral non-nerve-sparing RP on the right (contralateral) side only
- D Non-nerve-sparing (wide excision) RP on the side of the lesion with contralateral nerve-sparing ✓
Explanation
In high-risk localised prostate cancer (Gleason 4+4, PIRADS 5 on one side), oncological safety requires non-nerve-sparing (wide local excision) on the ipsilateral (tumour-bearing) side to avoid positive surgical margins, while nerve-sparing on the contralateral side is appropriate if there is no imaging/biopsy evidence of contralateral disease. Bilateral nerve-sparing in high-risk unilateral disease risks positive margins and local recurrence. Nerve-sparing is not absolutely contraindicated for Grade Group ≥3 if carefully selected based on lesion laterality and absence of extracapsular extension on MRI.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.