Impact of cautery versus cautery-free preservation of neurovascular bundles on early return of potency

PURPOSE: To update our short-term potency outcomes from a cautery-free (CFT) versus bipolar cautery technique to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (RLP). PATIENTS AND METHODS: Previously, we reported on 3-month potency outcomes in 23 men, which we now extend to 51 men. All men met three criteria: age <66 years, Sexual Health Inventory in Men (SHIM-5) score of 22 to 25, and either unilateral or bilateral NVB preservation at LRP. Group 1 (N = 51), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. The average age and preoperative SHIM scores were similar for the two groups. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. All men were asked to estimate the fullness of erections compared with baseline (preoperative). RESULTS: The average age and preoperative SHIM scores were similar for both groups. The rate of potency at 3 months was 47% (24/51) in group 1 versus just 8.3% (3/36) in group 2 (P < 0.001). Additionally, only 9 of 25 CFT patients (36%) reported zero fullness compared with 15 of 22 patients (68%) in the bipolar cauterytreated group (P = 0.03). CONCLUSIONS: With expanded experience, there was no change in 3-month return of sexual function (47%) compared with our initial publication. This result further supports the importance of avoiding cautery when controlling the vascular pedicle and dissecting the NVB.     

Recovery of erectile function after radical prostatectomy is quantitatively related to the response to intraoperative cavernous nerve stimulation

OBJECTIVE

To correlate the results of intraoperative cavernous nerve stimulation (CaNS) at radical prostatectomy (RP), with preoperative erectile function (EF) and to determine the significance of the results of stimulation after RP in predicting the recovery of EF.

PATIENTS AND METHODS

The study included 183 potent men who had not received neoadjuvant therapy, and who had RP without nerve grafting, with intraoperative CaNS, between July 1998 and April 2002. Follow‐up International Index of Erectile Function (IIEF) questionnaires were returned at a median (range) of 25 (1–51) months. Age, preoperative EF, neurovascular bundle (NVB) status, pathological stage and CaNS results were evaluated as independent predictors of the recovery of EF, as assessed by the IIEF, using Cox proportional hazards analysis.

RESULTS

CaNS strength before RP correlated with the level of preoperative potency (P = 0.023). CaNS strength after RP correlated with that before RP (P < 0.001) and the degree of NVB preservation (P = 0.007). Only age and maximum percentage change in penile girth after RP were significant independent predictors of the recovery of EF. For each 1‐year increase in age, men were 4%, 6% and 5% less likely to achieve erections, defined as an IIEF EF domain score of ≥17, ≥22 and ≥26, respectively. For each 1% increase in maximum percentage change in penile girth after RP with CaNS, men were 26% (95% confidence interval 7–48%), 22% (0–49%), and 47% (17–83%) more likely to achieve erections, with an IIEF EF score of ≥17, ≥22 and ≥26, respectively. There was a significant false‐negative rate, with 15% of patients with a minimal CaNS response normalizing their EF score and 35% recovering scores of ≥22.

CONCLUSIONS

While CaNS results after RP correlated strongly with the degree of NVB preservation, the degree of penile girth change, rather than degree of surgeon‐documented NVB preservation, was independently predictive of the recovery of EF.     

Rapid communication: early potency outcomes with cautery-free neurovascular bundle preservation with robotic laparoscopic radical prostatectomy

PURPOSE: To report short-term potency outcomes with a cautery-free technique (CFT) to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS: All men were <66 years of age and had a Sexual Health Inventory in Men (SHIM) score of 22 to 25. They underwent unilateral or bilateral dissections. Group 1 (N = 23), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. RESULTS: At 3 months, 10 patients (43%) in the CFT group reported potency versus just 3 (8.3%) in the bipolar-cautery group (P = 0.003). Additionally, only 2 (18%) of those having CFT reported zero penile fullness compared with 15 (68%) in the bipolar-cautery group (P = 0.01). CONCLUSIONS: The technique of controlling the vascular pedicle of the prostate and dissecting the NVB without cautery produced significant improvement in potency outcomes at just 3 months.     

Recovery of erectile function after nerve-sparing radical prostatectomy: improvement with nightly low-dose sildenafil

OBJECTIVE

To evaluate the effect of low‐dose sildenafil for rehabilitating erectile function after nerve‐sparing radical prostatectomy (NSRP), as the delay to recovery of erectile function after NSRP remains under debate.

PATIENTS AND METHODS

Forty‐three sexually active patients had a NSRP; at 7–14 days after surgery they had a Rigiscan® (Dacomed Corporation, Minneapolis, MN, USA) measurement of nocturnal penile tumescence and rigidity (NPTR). To support the recovery of spontaneous erectile function, 23 patients with preserved nocturnal erections received sildenafil 25 mg/day at night. A control group of 18 patients were then followed but had no phosphodiesterase‐5 inhibitors. The International Index of Erectile Function (IIEF)‐5 questionnaire was completed 6, 12, 24, 36 and 52 weeks after NSRP.

RESULTS

Of the 43 patients, 41 (95%) had one to five erections during the first night after catheter removal. In the group using daily sildenafil the mean IIEF‐5 score decreased from 20.8 before NSRP to 3.6, 3.8, 5.9, 9.6 and 14.1 at 6, 12, 24, 36 and 52 weeks after NSRP, respectively. In the control group the respective scores were 21.2, decreasing to 2.4, 3.8, 5.3, 6.4 and 9.3. There was a significant difference in IIEF‐5 score and time to recovery of erectile function between the groups (P < 0.001), with potency rates of 86% vs 66%.

CONCLUSION

The measurement of NPTR after NSRP showed erectile function even the ‘first’ night after catheter removal. In cases of early penile erection, daily low‐dose sildenafil leads to a significant improvement in the recovery of erectile function.     

Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Orgasm has a major influence on patients’ satisfaction with the overall sexual experience, and alternations in orgasm are associated with significant reductions in emotional and physical satisfaction, which in turn may lead to sexual avoidance behaviour, disharmonious relationships and relationship breakdowns. Studies have found a reduction in orgasmic function after retropublic radical prostatectomy. While open radical prostatectomy inevitably damages some pelvic neuronal circuitry, which will thus impact on orgasmic responses, there is a paucity of data investigating the effect on robotic assisted radical prostatectomy on this. To our knowledge this study represents the largest analysis of orgasmic function in the robotic prostatectomy literature, and therefore would be of value to surgeons in counseling candidates for RALP about orgasmic outcomes. In our series, young men (age ≤60 years) and those who underwent bilateral nerve sparing approaches had a better recovery of their premorbid orgasmic function when compared to older men or men with no nerve sparing.

OBJECTIVE

• ? To investigate orgasmic outcomes in patients undergoing robotic‐assisted laparoscopic radical prostatectomy (RALP) and the effects of age and nerve sparing on these outcomes.

PATIENTS AND METHODS

• ? Between January 2005 and June 2007, 708 patients underwent RALP at our institution.
• ? We analysed postoperative potency and orgasmic outcomes in the 408 men, of the 708, who were potent, able to achieve orgasm preoperatively and available for follow‐up.

RESULTS

• ? Of men aged ≤60 years, 88.4% (198/224) were able to achieve orgasm postoperatively in comparison to 82.6% (152/184) of older men (P < 0.001).
• ? Of patients who received bilateral nerve sparing (BNS) during surgery, 273/301 (90.7%) were able to achieve orgasm postoperatively compared with 46/56 (82.1%) patients who received unilateral nerve sparing and 31/51 (60.8%) men who received non‐nerve‐sparing surgery (P < 0.001).
• ? In men ≤60 years who also underwent BNS, decreased sensation of orgasm was present in 3.2% of men, and postoperative orgasmic rates were significantly better than men ≤60 years who underwent unilateral or no nerve sparing (92.9% vs 83.3% vs 65.4%, respectively; P < 0.001).
• ? Potency rates were also significantly higher in men ≤60 years and in those who underwent BNS.

CONCLUSIONS

• ? Age and nerve sparing influence recovery of orgasm and erectile function after RALP.
• ? Men ≤60 years old and those who undergo BNS are most likely to maintain normal sexual function.

     

Comparison of outcomes between pure laparoscopic vs robot-assisted laparoscopic radical prostatectomy: a study of comparative effectiveness based upon validated quality of life outcomes

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Few studies exist comparing functional outcomes between RALP and LRP using validated questionnaires. This single surgeon study utilizes data from the EPIC questionnaire that was collected prospectively to compare urinary and sexual function after prostatectomy. In this comparison, return of post‐prostatectomy continence was similar between groups while RALP patients demonstrated earlier return of sexual function.

OBJECTIVE

• ? To compare perioperative, oncological and functional outcomes of laparoscopic radical prostatectomy (LRP) and robot‐assisted laparoscopic radical prostatectomy (RALP) with emphasis on health‐related quality of life (HRQOL) data as few studies exist.

PATIENTS AND METHODS

• ? Patients underwent RALP or LRP by a single, fellowship trained surgeon with a standard clinical care pathway.
• ? HRQOL data using the Expanded Prostate Cancer Index Composite (EPIC) were collected at 0, 3, 6 and 12 months after 175 consecutive LRP and 174 RALP procedures.
• ? Urinary and sexual function outcomes were compared using two methods: (1) EPIC summary/subscale analyses described as percent return to baseline function and (2) traditional single‐question analysis.

RESULTS

• ? The two groups were statistically similar with respect to demographics, clinical stage, perioperative outcomes, stage‐specific surgical margin rates, and baseline urinary and sexual function scores.
• ? There was no statistical difference in postoperative urinary function between RALP and LRP using EPIC or single‐question analyses at 3, 6 and 12 months.
• ? EPIC questionnaire data showed a greater return to baseline sexual function over time (mixed model analysis) in RALP than in LRP patients who had a bilateral nerve sparing procedure (Sexual Summary Score, P= 0.005; Sexual Function and Bother Subscales, P= 0.007).
• ? Using EPIC, RALP patients receiving a bilateral nerve sparing procedure showed improved percent return to baseline potency at 3 and 6 months (P < 0.025) compared with LRP patients, but had similar outcomes at 12 months (73.7% vs 66.2%, P= 0.3).
• ? Single‐question analysis suggested improved potency after RALP compared with LRP, with a greater percentage of RALP patients reporting successful sexual intercourse in the past 4 weeks (87.5% vs 66.7% at 12 months, P= 0.06).

CONCLUSIONS

• ? When comparing surgical techniques, RALP and LRP groups showed statistically similar postoperative urinary function outcomes.
• ? RALP patients had an earlier return of sexual function when compared with LRP patients after a bilateral nerve sparing procedure.

     

Curtain dissection of the lateral prostatic fascia and potency after laparoscopic radical prostatectomy: a veil of mystery

OBJECTIVE

To assess the effect on potency recovery of incorporating a high incision of the lateral prostatic fascia (LPF) or curtain dissection (CD) into our technique of laparoscopic nerve‐sparing radical prostatectomy (LNSRP).

PATIENTS AND METHODS

In all, 137 bilateral neurovascular bundle (NVB) preserving LNSRPs were performed, incorporating curtain dissection (CD) of the LPF. Potency was assessed at 1, 3, 6 and 12 months using validated questionnaires and compared with a control group (CG) of standard NVB preservation.

RESULTS

There were no conversions to open surgery in either group. The median operative duration in the CD group and the CG was 178 min and 174 min (P = 0.04), blood loss was 300 mL and 200 mL (P = 0.01), and the positive margin rate was 16.1% and 24.1% (P = 0.04), respectively. At a mean follow‐up of 5.8 months in the CD group and 28.2 months in the CG, potency rates were 21.1% and 8.8% at 1 month (P = 0.01), and 68.4% and 67.2% at 12 months (P = 1.00), respectively.

CONCLUSION

The potency rate was significantly higher in the CD group at 1 month than in the CG, thereafter the rates were similar between the groups. We think that the merit of this technique is in improved visualization of the basal prostatic contour during antegrade NVB dissection, rather than preserving important nerve fibres. This may explain the lower basal positive margin rate in the CD group of 0% vs 5.8% in the CG (P = 0.007).     

Laparoscopic versus robot-assisted bilateral nerve-sparing radical prostatectomy: comparison of pentafecta rates for a single surgeon

Background

This study aimed to compare the pentafecta rates between laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RALP) and to identify prognostic factors predicting the pentafecta for each technique.

Methods

This prospective comparative study enrolled 248 consecutive male patients 70 years of age or younger with clinically localized prostate cancer [PCa: age ≤70 years, prostate-specific antigen (PSA) ≤10 ng/ml, biopsy Gleason score ≤7] who were fully continent, potent, and candidates for bilateral nerve-sparing (BNS) LRP or RALP. The pentafecta rates between LRP and RALP were compared. A logistic regression model was created to evaluate independent factors for achieving pentafecta.

Results

In the final analysis, 91 LRP and 136 RALP patients were evaluated. The median follow-up period was 21 months for the 91 LRP patients and 18 months for the 136 RALP patients (p = 0.07). Of the 227 patients, 87 reached pentafecta [25 LRP patients (27.5 %) vs 62 RALP patients (45.6 %), p = 0.006]. Of the 140 patients who failed pentafecta, 90 (64.3 %) missed a single parameter, and the difference between the groups was significant (80 % LRP vs 53.3 % RALP, p = 0.007). Lower age, lower pathologic stage, and RALP are significantly associated with pentafecta as independent factors. For the pT3 disease, the two techniques did not differ significantly.

Conclusions

Patients submitted to BNS RP have low possibilities of achieving pentafecta. Use of the robotic platform by a single surgeon significantly enhances the possibility of achieving pentafecta independently of age and pathologic stage. Potency was the most difficult outcome to reach after surgery, and it was the main factor leading to pentafecta failure. LRP and RALP provide equivalent pentafecta rates for the pT3 disease and similar “tetrafecta” outcomes when potency recovery is not included among the postoperative expectations of the patient.     

The timing of penile rehabilitation after bilateral nerve‐sparing radical prostatectomy affects the recovery of erectile function

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To define if erectile function (EF) outcomes were better in men with early institution of penile rehabilitation after radical prostatectomy (RP), as one of the mechanisms by which patients fail to recover EF after RP is collagenization of corporal smooth muscle with subsequent venous leak development, and rehabilitation is aimed at preventing these structural alterations.

PATIENTS AND METHODS

The study population comprised patients who: (i) had clinically organ‐confined prostate cancer; (ii) had fully functional erections, corroborated by the partner; (iii) had bilateral nerve‐sparing RP; and (iv) committed to pharmacological penile rehabilitation. Patients completed the International Index of Erectile Function (IIEF) serially after RP. Patients were instructed to obtain three erections/week using initially sildenafil, and if unsuccessful, then intracavernous injections. Patients were subdivided into those starting rehabilitation at <6 months after RP (early) and those starting at ≥6 months after RP (delayed).

RESULTS

There were 48 patients in the early group and 36 in the delayed group; patients in both groups were matched for age, comorbidity status and baseline EF. The mean duration after RP at the time of starting penile rehabilitation was 2 and 7 months in the early and delayed groups, respectively (P < 0.01). At 2 years after surgery there was a highly statistically significant difference in IIEF EF domain score between the early and delayed groups (22 vs 16, P < 0.001). There were also statistically significant differences between the groups in the percentage of men at 2 years after RP who had unassisted functional erections and sildenafil‐assisted functional erections (58% vs 30%, P < 0.01; 86% vs 45%, P < 0.01, respectively).

CONCLUSIONS

These data suggest that delaying the start of penile rehabilitation after RP is associated with poorer outcomes for EF.     

Early intervention with phosphodiesterase‐5 inhibitors after prostate brachytherapy improves subsequent erectile function

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To examine the early use of phosphodiesterase‐5 inhibitor (PDE‐5i; sildenafil citrate) in preventing subsequent erectile dysfunction (ED) after (monotherapy) prostate brachytherapy (PB, an accepted option for Gleason 6 or low‐volume Gleason 7 prostate cancer), as PB is currently being offered more frequently in younger patients, and ED can be a side‐effect often within the first 12 months after treatment.

PATIENTS AND METHODS

We examined a single‐surgeon series of 69 patients who had been treated with PB from 2002 to 2005. All patients had a follow‐up of ≥1 year; prospectively, and patients had baseline, 6‐ and 12‐month assessments using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF)‐6 scores. The 69 patients were divided into early treatment with PDE‐5i (31) and not treated with PDE‐5i (38), and their SHIM and IIEF‐6 scores were compared at baseline, 6 and 12 months. Daily sildenafil (25–50 mg) was given immediately after PB for 12 months. Overall, for the entire group, the mean prostate‐specific antigen (PSA) level was 6.8 ng/mL; 78% had Gleason 6 cancer and 20% had Gleason 7 (3 + 4) cancer. The mean age in the early PDE‐5i group was 64.8 years, and was 66.0 years in the no‐PDE‐5i group. The mean radiation dose in the early PDE‐5i group was 50.2 Gy, and 43.9 Gy in the other group (P= 0.08).

RESULTS

In the no‐PDE‐5i group, the mean baseline SHIM score of 17.1 decreased rapidly to 9.1 at 6 months (P= 0.01) and stayed at 9.3 at 12 months (P= 0.01). In the early PDE‐5i group, the mean baseline SHIM score of 21.8 decreased slightly to 17.6 at 6 months (P= 0.2), and was maintained at 17.9 at 12 months (P= 0.2). Using the Wilcoxon rank‐sum test, the 6‐ and 12‐month SHIM scores in the two groups (P < 0.001). The IIEF‐6 questionnaire confirmed the SHIM analysis.

CONCLUSIONS

After PB patients had a significant decline in SHIM/IIEF‐6 scores at 6 and 12 months. Our results indicate a 50% decrease in the quality of their erections. This provides an opportunity to initiate early intervention with PDE‐5i or perhaps vacuum constriction devices or intraurethral alprostadil. In this study, the early use of PDE‐5i after PB maintained erectile function at both 6 and 12 months.     

Does a nerve‐sparing technique or potency affect continence after open radical retropubic prostatectomy?

OBJECTIVE

To characterize the effect of preserving the neurovascular bundle (NVB) and of potency on urinary continence after open radical retropubic prostatectomy (ORRP).

PATIENTS AND METHODS

Between October 2000 to September 2005, 1110 consecutive continent men had ORRP by one surgeon. The University of California Los Angeles Prostate Cancer Index was self‐administered at baseline and 3, 6, 12, and 24 months after ORRP. Men were considered continent if they responded that they had total urinary control or had occasional urinary leakage. Men were considered potent if they engaged in sexual intercourse with or without the use of phosphodiesterase inhibitors at least once in the month before or after ORRP. Of the 1110 men, 728 (66%) were potent and continent at baseline. Men undergoing adjuvant hormonal therapy, radiation therapy or chemotherapy were excluded. The potency status was evaluated in 610 men at 24 months after ORRP, and the number of NVBs preserved was recorded at the time of ORRP.

RESULTS

Of men who were potent at baseline and had bilateral vs unilateral nerve sparing, 96% and 99% were continent at 24 months, respectively (P = 0.50). Of the men who were potent and impotent at 24 months, 98% and 96% were continent at 24 months, respectively (P = 0.25). Continence did not depend on whether men regained potency or whether they had a bilateral or a unilateral nerve‐sparing procedure.

CONCLUSION

Our observation that only 60% of men undergoing bilateral nerve‐sparing ORRP regain potency suggests that the NVBs are often inadvertently injured, despite efforts to preserve them. We feel that potency status is the best indicator of the true extent of NVB preservation. That men undergoing bilateral vs unilateral nerve‐sparing procedures, and that potent vs impotent men at 24 months have similar continence rates, provides compelling evidence that nerve‐sparing is not associated with better continence. Based on these findings, NVBs should not be preserved in men with baseline erectile dysfunction, with the expectation of improving continence.     

A prospective,non‐randomized trial comparing robot‐assisted laparoscopic and retropubic radical prostatectomy in one European institution

OBJECTIVE

To compare the functional results of two contemporary series of patients with clinically localized prostate cancer treated by robot‐assisted laparoscopic prostatectomy (RALP) or retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

This was a non‐randomized prospective comparative study of all patients undergoing RALP or RRP for clinically localized prostate cancer at our institution from February 2006 to April 2007.

RESULTS

We enrolled 105 patients in the RRP and 103 in the RALP group; the two groups were comparable for all clinical and pathological variables, except median age. For RRP and RALP the respective median operative duration was 135 and 185 min (P < 0.001), the intraoperative blood loss 500 and 300 mL (P < 0.001) and postoperative transfusion rates 14% and 1.9% (P < 0.01). There were complications in 9.7% and 10.4% of the patients (P = 0.854) after RRP and RALP, respectively; the positive surgical margin rates in pT2 cancers were 12.2% and 11.7% (P = 0.70). For urinary continence, 41% of patients having RRP and 68.9% of those having RALP were continent at catheter removal (P < 0.001). The 12‐month continence rates were 88% after RRP and 97% after RALP (P = 0.01), with the mean time to continence being 75 and 25 days (P < 0.001), respectively. At the 12‐month follow‐up, 20 of 41 patients having bilateral nerve‐sparing RRP (49%) and 52 of 64 having bilateral nerve‐sparing RALP (81%) (P < 0.001) had recovery of erectile function.

CONCLUSIONS

RALP offers better results than RRP in terms of urinary continence and erectile function recovery, with similar positive surgical margin rates.     

Erectile haemodynamic status after radical prostatectomy correlates with erectile functional outcome

OBJECTIVE

To define haemodynamic changes after radical retropubic prostatectomy (RP) and the predictive value of these for the outcome of erectile function (EF), as although there are predictors of the recovery of EF, penile vascular changes might also affect the recovery of EF.

PATIENTS AND METHODS

Prospective data were analysed from men who had RP followed by duplex penile Doppler ultrasonography (DUS) within 6 months of RP. All men had functional erections before RP, based on self‐report and partner corroboration, and all completed the International Index of Erectile Function (IIEF) questionnaire serially after RP. The EF, based on IIEF scores, was then correlated with the penile DUS results.

RESULTS

In all, the study included 111 patients; 32 (29%) had normal erectile haemodynamics after RP, while 79 (71%) had abnormal haemodynamics. Twelve patients (11%) had a venous leak. There were no differences in mean patient age or comorbidity profile between those with and without haemodynamic changes. Comparing those with normal and abnormal haemodynamics, the mean IIEF EF domain scores were 25 and 17 (P = 0.025), the percentages of erectile rigidity at 18 months was 66% vs 35% (P = 0.013), the percentage of patients with normal EF domain scores was 28% vs 6% (P < 0.01), the percentage of patients with functional erections permitting sexual intercourse unassisted by pharmacological agents was 47% vs 22% (P = 0.018), and the percentage of patients responding to sildenafil citrate, as defined by vaginal penetration, was 72% vs 43% (P = 0.03), respectively.

CONCLUSIONS

The results of this prospective study indicate that a patient’s penile vascular status is correlated with their EF after RP.     

Incidence of bladder neck contracture after robot‐assisted laparoscopic and open radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To evaluate the incidence and risk factors for bladder neck contracture (BNC) in men treated with robot‐assisted laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (ORP), as BNC is a well‐described complication of ORP and may be partially attributable to technique.

PATIENTS AND METHODS

The University of California San Francisco Urologic Oncology Database was queried for patients undergoing RALP or ORP from 2002 to 2008. Patient demographics, prostate cancer‐specific information, surgical data, and follow‐up were collected. For each surgical approach, multivariate Cox proportional hazards regression was performed to evaluate associations of demographics and clinical characteristics with BNC. Time to BNC after RP was evaluated using life table and Kaplan–Meier methods.

RESULTS

From 2002 to 2008, 988 patients underwent RP as primary treatment and had at least 12 months of follow‐up. Of these men, 695 underwent ORP and 293 underwent RALP. The mean (sd ) age was 59.3 (6.80) years and 91% of men were Caucasian. D’Amico risk groups at diagnosis were low (38%), intermediate (38%), and high (24%). The BNC incidence was 2.2% (22 cases) overall, 1.4% (four) for RALP, and 2.6% (18) for ORP (P= 0.12). Patients with BNC were diagnosed a median (range) of 4.7 (1–15) months after surgery. At 18 months after surgery, the BNC‐free rate was 97% for ORP and 99% for RALP (log‐rank P= 0.13). The most common presenting complaint was slow stream, followed by urinary retention. In Cox proportional hazards regression analysis, earlier year of surgery, older age at diagnosis and higher PSA level at diagnosis were significantly associated with BNC among ORP patients. In the RALP group, none of the covariates were associated with BNC.

CONCLUSIONS

The overall incidence of BNC was low in both RALP and ORP groups. Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group.     

Predictors of prolonged operative time during robot‐assisted laparoscopic radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Robotic prostatectomy has now become the most common surgical approach in the United States for patients with prostate cancer. There is a significant learning curve for this procedure and this paper attempts to help understand what factors will make the operative times longer. Very little to date has been written on this topic.

OBJECTIVE

To determine risk factors for prolonged operative time (OT) during robot‐assisted laparoscopic radical prostatectomy (RALP). Being able to predict prolonged OT is of pivotal importance both to the physician for patient counseling and to the hospital management.

PATIENTS AND METHODS

Retrospective review of patient records undergoing RALP between 2003 and 2009 at a tertiary academic center with a structured teaching program. The following variables were recorded: age, race, body‐mass index (BMI), previous abdominal surgery (yes/no), nerve‐sparing technique (yes/no), lymph nodes dissection (yes/no), pathological stage (organ‐confined versus non), cumulative surgical experience with RALP (expressed as number of years since introduction of RALP at our center), prostate weight and OT calculated skin‐to‐skin by the anesthesiologists. Prolonged OT was defined as the upper quintile (20%) according to the distribution. Multivariate regression model was generated to assess potential predictors of prolonged OT.

RESULTS

A total of 523 records were retrieved. Caucasians accounted for 77.8% of the cohort. Median age was 60.3 years (interquartile range, IQR, 55.0–64.6 years), median BMI 28.1 (25.8–30.7 kg/m²), prostate weight 46.0 g (37.0–57.8 g). Eighty‐six (16.4%) patients had previous abdominal surgery, lymph nodes dissection was performed in 341 (65.2%) and nerve‐sparing technique was done in 310 (59.3%) cases. Median OT was 175 min (IQR 146–220 min). Prolonged OT was set at >230 min, thereby 105 (20.1%) records were classified as such. On multivariate analysis, cumulative surgical experience with RALP (P < 0.001), nerve sparing (P= 0.023) and prostate weight (P < 0.001) were independent predictors of prolonged OT.

CONCLUSIONS

Larger prostates are associated with longer OT and this effect is maintained independently of cumulative robotic experience that represents another independent factor in determining OT.     

Erectile dysfunction is predictive of all-cause mortality in patients with prostate cancer treated with permanent interstitial brachytherapy

Study Type – Prognosis (individual cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Cardiovascular disease is a leading cause of death in prostate cancer patients. Pretreatment ED is a surrogate for vascular pathology. Aggressive treatment of medical co‐morbidity in prostate cancer patients may positively impact overall survival.

OBJECTIVE

• ? To evaluate the relationship between pre‐treatment erectile function and all‐cause mortality in patients with prostate cancer treated with brachytherapy.

PATIENTS AND METHODS

• ? In all, 1279 consecutive patients with clinically localized prostate cancer and pre‐implant erectile function assessed by the International Index of Erectile Function‐6 (IIEF‐6) underwent brachytherapy.
• ? Potency was defined as an IIEF‐6 score of ≥13 without pharmacological or mechanical support.
• ? Patients were stratified into IIEF‐6‐score cohorts (≤12, 13–23 and 24–30).
• ? The median follow‐up was 5.0 years.

RESULTS

• ? The 8‐year overall survival (OS) of the study population was 85.1%.
• ? The 8‐year OS for IIEF‐6scores ≤12, 13–23 and 24–30 were 78.0%, 92.8% and 91.4%, respectively (P < 0.001).
• ? Cardiovascular events accounted for a significant portion of deaths in each IIEF‐6 group.
• ? When combined with other risk factors for cardiovascular disease, an IIEF‐6 score of ≤12 had an additive effect on all‐cause mortality (IIEF‐6 score of ≤12 and less than two comorbidities vs two or more comorbidities were 18.2% and 32.1%).

CONCLUSIONS

• ? A pre‐implant IIEF‐6score of ≤12 was associated with a higher incidence of all‐cause mortality.
• ? Pre‐treatment erectile dysfunction is a surrogate for underlying vascular pathology, probably explaining the lower OS in this subset of patients.
• ? Aggressive treatment of medical co‐morbidity is warranted to impactOS.

     

Neurovascular bundle size measured on 3.0-T magnetic resonance imaging is associated with the recovery of erectile function after robot-assisted radical prostatectomy

Background and objective

Erectile dysfunction is one of the complications occurring after radical prostatectomy (RP), and recovery of erectile function is quantitatively related to the preservation of the neurovascular bundles (NVB).We evaluated the significance of NVB area on functional outcomes after RP.

Peripheral neuropathy: an underdiagnosed cause of erectile dysfunction

OBJECTIVES

? To assess the prevalence of peripheral neuropathy in patients with erectile dysfunction (ED). ? To evaluate the reliability of clinical tests such as the five‐item version of the International Index of Erectile Function (IIEF‐5) and the Neuropathy Symptom Score (NSS) classification system in predicting the concurrence of peripheral neuropathy.

PATIENTS AND METHODS

? We studied 90 patients who were consecutively recruited from the Department of Andrology of the Central Hospital of Asturias. ? Anamnesis included questions about risk factors related to ED. ? The severity of ED was classified according to IIEF‐5 scores and symptoms of peripheral neuropathy were assessed using the NSS. ? Neurophysiological tests included electromyography, nerve conduction studies, evoked potentials from pudendal and tibial nerves as well as bulbocavernosus reflex. ? Small fibre function was assessed using quantitative sensory tests and sympathetic skin response. Statistical analysis was performed using the SPSS‐11 program.

RESULTS

? Patients with more severe symptoms of peripheral neuropathy showed lower (worse) IIEF‐5 scores (P= 0.015) and required more aggressive therapies (P < 0.001). ? Neurophysiological exploration confirmed neurological pathology in 68.9% of patients, of whom 7.8% had myelopathy and 61.1% peripheral neuropathy. ? Polyneuropathy was found in 37.8% of the patients, of whom 8.9% had pure small fibre polyneuropathy, and pudendal neuropathy was diagnosed in 14.4%. ? No association between neurophysiological diagnosis and IIEF‐5 score was detected, but a statistical association was found between neuropathy and NSS scores.

CONCLUSIONS

? Up to now, the impact of peripheral neuropathy in the pathogenesis of ED has been underestimated. The combination of anamnesis and an ad hoc neurophysiological protocol showed its high prevalence and provided a more accurate prognosis. ? In future, clinical practice should optimize the assessment of pelvic small fibre function.     

The impact of cavernosal nerve preservation on continence after robotic radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Continence after radical prostatectomy (RP) has been linked to surgical techniques including careful dissection of the neurovascular bundles, bladder neck preservation, sparing of the puboprostatic ligaments and reconstruction of the posterior urethral plate or total reconstruction of the vesico‐urethral junction. Several authors have reported that men undergoing bilateral nerve‐sparing have quicker and better recovery of continence than men undergoing partial or non‐nerve‐sparing procedures. Others have reported that preoperative variables have a greater effect than technique on postoperative return to continence. We examine the association between baseline characteristics (age, International Index of Erectile Function [IIEF‐5] score, American Urological Association symptom score, body mass index [BMI], clinical T stage, Gleason score, and prostate‐specific antigen level), nerve‐sparing status, learning curve and overall continence at 1, 3 and 12 months after robotic RP. In addition, nerve‐sparing status was physically verified by comparing the amount of extraprostatic tissue seen on the wide excision side and nerve‐sparing side for unilateral nerve‐sparing procedures. After multivariate analysis, age, IIEF‐5 and BMI were found to affect continence in a statistically significant fashion, while nerve‐sparing status did not significantly affect continence.

OBJECTIVE

? To evaluate associations between baseline characteristics, nerve‐sparing (NS) status and return of continence, as a relationship may exist between return to continence and preservation of the neurovascular bundles for potency during radical prostatectomy (RP).

PATIENTS AND METHODS

? The study included 592 consecutive robotic RPs completed between 2002 and 2007. ? All data were entered prospectively into an electronic database. ? Continence data (defined as zero pads) was collected using self‐administered validated questionnaires. ? Baseline characteristics (age, International Index of Erectile Function [IIEF‐5] score, American Urological Association symptom score, body mass index [BMI], clinical T‐stage, Gleason score, and prostate‐specific antigen level), NS status and learning curve were retrospectively evaluated for association with overall continence at 1, 3 and 12 months after RP using univariate and multivariable methods. ? Any patient taking preoperative phosphodiesterase inhibitors was excluded from the postoperative analysis.

RESULTS

? Complete data were available for 537 of 592 patients (91%). ? Continence rates at 12 months after RP were 89.2%, 88.9% and 84.8% for bilateral NS, unilateral NS and non‐NS respectively (P= 0.56). ? In multivariable analysis age, IIEF‐5 score and BMI were significant independent predictors of continence. ? CavernosalNS status did not significantly affect continence after adjusting for other co‐variables.

CONCLUSION

? After careful multivariable analysis of baseline characteristics age, IIEF‐5 score and BMI affected continence in a statistically significant fashion. This suggests that baseline factors and not the physical preservation of the cavernosal nerves predict overall return to continence.     

Comparison of lymph node yield in robot‐assisted laparoscopic prostatectomy with that in open radical retropubic prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

? To investigate both the feasibility and the adequacy of pelvic lymph node dissection (PLND) during robot‐assisted laparoscopic prostatectomy (RALP) by comparing lymph node yields obtained during RALP with those obtained during traditional open retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

? We retrospectively reviewed 1047 patients who underwent radical prostatectomy between 2001 and 2009. ? In all, 626 patients underwent RALP while 421 patients had traditional open RRP. All patients undergoing bilateral PLND were included in our analysis. ? Lymph node yields and lymph node involvement for each surgical approach were calculated and examined. ? PLND‐related complications were analysed.

RESULTS

? Of the 1047 patients, 816 patients underwent bilateral PLND of whom 473 underwent RALP, while 343 underwent RRP. The mean lymph node yields for the RALP cohort (7.1, interquartile range 4–10) was significantly higher (P < 0.001) than for the RRP cohort (6.0, interquartile range 3–8). ? The percentage of patients with nodal involvement was 1.1 for RALP and 2.3 for RRP (P= 0.167). ? Mean age, preoperative PSA values, and pre‐ and postoperative Gleason scores were similar between the two cohorts. ? PLND‐related complications were similar between both cohorts.

CONCLUSIONS

? In patients undergoing RALP, PLND is feasible and provides lymph node yields comparable with those of the standard open approach. ? PLND should be strongly considered in all radical prostatectomy patients when clinically indicated, regardless of surgical technique.