Emerging role of the neurovascular structure-adjacent frozen-section examination technique in robot-assisted radical prostatectomy amidst the diversification of treatment strategies for localized prostate cancer

Recently, the age-standardized incidence of prostate cancer has been increasing owing to rising populations and aging (1). Moreover, advances in screening and treatment have contributed to a decline in age-standardized mortality rates (1). Therefore, treatment strategies for localized prostate cancer have been shifting toward personalization and less invasive approaches.

This study evaluated robot-assisted radical prostatectomy (RARP) using the neurovascular structure-adjacent frozen-section examination (NeuroSAFE) technique in patients with localized prostate cancer who had no previous treatment and preserved preoperative sexual function (2). Innervation of the prostate arises from autonomic and somatic fibers originating in the T11–L2 and S2–S4 segments. The autonomic component diverges in a spray-like configuration to the neurovascular bundle, proximal plate, and ancillary pathways (3). This technique prioritizes initial bilateral posterolateral dissection along the intrafascial plane to preserve the neurovascular bundles, regardless of preoperative surgical planning recommendations. Intraoperative frozen section analysis of the resected prostate was used to guide additional resection of periprostatic tissue adjacent to the neurovascular bundles if: (I) positive surgical margins in ≥2 frozen sections on the same side, (II) presence of Gleason pattern ≥4 at the inked surface, or (III) Gleason pattern 3 >2 mm at the inked surface in a single section (2). Consequently, a median follow-up of 12.3 months revealed improved patient-reported International Index of Erectile Function-5 scores and earlier recovery of urinary continence (at three months postoperatively) (2). Notably, patients who are not eligible for bilateral nerve-sparing procedures using the standard technique demonstrated a more marked improvement in erectile function (2). These findings suggest that the NeuroSAFE technique represents a promising strategy for functional preservation in RARP.

However, this study did not address cancer control outcomes, optimal patient selection criteria for NeuroSAFE-guided RARP, or associated healthcare costs. Confocal laser microscopy has been reported as one of the emerging microscopic digital imaging techniques for intraoperative margin assessment during radical prostatectomy (4). A comparison of oncological outcomes with these approaches would be of particular interest. Recent advances in diagnostic imaging and biopsy techniques have improved the localization of prostate cancer and assessment of its aggressiveness, leading to increased adoption of active surveillance (5) and growing interest in focal therapy (6). Focal therapy has shown favorable mid- to long-term outcomes (7-9) and encouraging results in pair-matched comparisons with radical prostatectomy (10), suggesting its viability for localized disease.

In this evolving landscape of minimally invasive treatments, the clinical positioning of NeuroSAFE-assisted RARP warrants further consideration. Radical prostatectomy, involving complete gland removal, may remain crucial for patients with more diffusely distributed tumors or higher-grade disease. For such cases, establishing clear preoperative selection criteria based on imaging and histopathology, and demonstrating long-term outcomes regarding oncologic control and functional preservation are essential.

As treatment strategies for localized prostate cancer diversify, the NeuroSAFE-assisted RARP presents a viable minimally invasive option. Future research should explore patient selection criteria, comparative outcomes with image-guided RARP (11,12), and cost-effectiveness.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article has undergone external peer review.

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-545/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-545/coif). The author has no conflicts of interest to declare.

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