Enhancing nerve sparing in robotic prostate surgery: the impact of NeuroSAFE on fascia preservation score

Background: Robot-assisted radical prostatectomy (RARP) has become the standard surgical procedure for localized prostate cancer (PCa). Nerve sparing with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) has been associated with improved functional outcomes while maintaining oncological outcomes. This study investigates the impact of NeuroSAFE on nerve sparing during RARP, using the fascia preservation (FP) score. This score (range 0–6 per side) reflects the extent of preserved fascia at twelve circumferential positions; higher scores indicate greater nerve preservation. Methods: A single-center retrospective cohort study was conducted between January 2022 and December 2024, including 100 PCa patients selected for RARP. A preoperative surgical plan was created, including an estimated FP score using NeuroSAFE. Patients subsequently underwent prostatectomy with NeuroSAFE. The actual FP score was determined perioperatively. Postoperatively, four urologists retrospectively estimated FP scores assuming prostatectomy had been performed without NeuroSAFE. Actual and estimated scores were compared. Interobserver agreement among urologists was assessed using the intraclass correlation coefficient. Results: RARP with NeuroSAFE resulted in statistically significantly higher FP scores on both sides compared to the estimated FP scores without NeuroSAFE (P<0.001). The median FP score was 5 per side (full nerve sparing) with NeuroSAFE versus 4 (partial nerve sparing) without. Interobserver agreement among urologists was moderate for single measurements and high for average measurements. Conclusions: NeuroSAFE enables greater nerve sparing during RARP, as estimated by four expert urologists. Although functional outcomes were not assessed in this cohort, previous randomized evidence has demonstrated an association between greater nerve sparing and improved erectile function.