前列腺癌根治术后勃起功能障碍的相关问题

前列腺癌根治术后的勃起功能障碍一直是困扰泌尿外科医师的难题,并严重影响患者的生活质量.术中海绵体神经的损伤是造成术后勃起功能障碍的主要原因.随着保留神经血管束或重建海绵体神经的前列腺癌根治术的开展及腹腔镜技术、机器人辅助腹腔镜技术与治疗药物的应用,前列腺癌根治术后勃起功能障碍的发生率已逐渐下降.本文拟就前列腺癌根治术后勃起功能障碍的相关问题进行讨论,以促进前列腺癌根治术后勃起功能障碍防治措施的推广应用.     

The failure of a nerve sparing template to improve urinary continence after radical prostatectomy: attention to study design

PurposeTo accurately assess the relationship between nerve sparing radical prostatectomy and urinary continence using an anonymous validated survey in men undergoing surgical treatment for prostate cancer.Materials and methodsFrom September 1999 to February 2006, men undergoing radical prostatectomy (RP) by one surgeon were given the UCLA Prostate Cancer Index to complete preop, and then annually thereafter to 2 years. We have 285 men who have completed the pre-op and year 1 and /or year 2 surveys. Continence was defined as requiring “no pads” on the survey. Analysis was based on attempted nerve sparing status of the surgery; none, unilateral, or bilateral. Subgroup analysis was then performed on successful nerve sparing surgery, defined as men responding they have an erection “firm enough for intercourse.”ResultsOverall continence rates were 81% at year 1 and 87% at year 2. Attempted nerve sparing surgery, or successful nerve sparing surgery, did not result in better rates of continence than non-nerve sparing surgery.ConclusionsUsing a validated survey with anonymous data collection, we found no improvement in continence, defined as pad-free, with attempted or successful nerve sparing RP. Based on our study, the goal of improving urinary outcomes should not be used as a justification for a nerve sparing template at radical prostatectomy.     

Intra- and peri-operative outcomes comparing radical retropubic and laparoscopic radical prostatectomy: results from a prospective, randomised, single-surgeon study

OBJECTIVES: To prospectively compare intra- and peri-operative outcomes of open radical retropubic prostatectomy (RRP) and laparoscopic prostatectomy (LRP) by a single surgeon. PATIENTS AND METHODS: One-hundred-twenty, consecutive, age-matched patients diagnosed with clinically localized prostate cancer were eligible for surgery. Sixty patients underwent RRP and 60, LRP. Intra- and peri-operative parameters, pathologic findings and early complications were recorded. A validated visual analogue scale was used to assess pain in the recovery room, 3 h after the operation and on post-operative days 1, 2 and 3. A cystogram was performed on post-operative day 5. RESULTS: Operating time was significantly shorter in the RRP group versus the LRP group (mean+/-SD, 170+/-34. 2 vs 235+/-49.9 min, p<0.001). Blood loss was significantly less in the LRP group versus the RRP group (mean+/-SD, 853.3+/-485 vs 257.3+/-177 ml, p<0.001), but no patient in either group underwent early re-intervention for bleeding. The RRP group showed a trend for higher use of analgesia. A watertight anastomosis was shown at cystourethrography and the catheter removed in 86% and 66% of LRP and RRP patients, respectively. The overall percentage of post-operative complications and positive margins were comparable. CONCLUSION: Laparoscopic prostatectomy is an attractive alternative to open prostatectomy, offering the advantages of reduced blood loss and safe early catheter removal. Furthermore, the laparoscopic procedure proved to be safe oncologically. Long-term follow-up is required to compare functional results in terms of continence and potency.     

Erectile dysfunction and sexual health after radical prostatectomy: impact of sexual motivation

The life expectancy of patients with localized prostate cancer at treatment initiation has increased, and post-treatment quality of life has become a key issue. The aim of this study is to assess the impact of Radical prostatectomy (RP) on patients' sexual health and satisfaction according to sexual motivation using a self-administered questionnaire completed by two groups of RP patients, with high or lower levels of sexual motivation. A total of 63 consecutive patients were included (mean age, 63.9 years), of whom 74.6% were being treated for erectile dysfunction (ED). After RP, patients reported lower sexual desire (52.4%), reduced intercourse frequency (79.4%), anorgasmia (39.7%), less satisfying orgasm (38.1%), climacturia (25.4%), greater distress (68.3%) and/or lower partner satisfaction (56.5%). Among the most sexually motivated patients, 76.0% reported loss of masculine identity, 52% loss of self-esteem and 36.0% anxiety about performance. These rates were lower among less motivated patients (52.6, 28.9, and 18.4%, respectively). Mean overall satisfaction score was 4.8 ± 2.9. The score was significantly lowered in motivated than less motivated patients (3.4 vs 5.8) (P = 0.001). In conclusion, RP adversely affected erectile and orgasmic functions but also sexual desire, self-esteem and masculinity. The more motivated patients experienced greater distress and were less satisfied.     

The effect of erectile dysfunction on the quality of life of men after radical prostatectomy

OBJECTIVE: To report on the first use of a quality-of-life (QoL) measure specific for erectile dysfunction (ED), the 'ED effect on QoL' (ED-EQoL), to assess the effect of ED on QoL after radical prostatectomy (RP). PATIENTS AND METHODS: We retrospectively identified 89 patients who had undergone RP at one institution. Each was sent the ED-EQoL and a second questionnaire asking whether they had been counselled before RP about possible ED afterward. RESULTS: The response rate was 91% and the median time since RP 92 months; 76% of those who were potent before RP were impotent afterward. The overall results showed that the QoL of 72% of patients was moderately or severely affected. For each question, on average a third of the patients reported that their QoL was affected either 'quite a lot' or 'a great deal'. CONCLUSIONS: This study shows that ED after RP has a profound effect on QoL; it is therefore important when assessing ED to use an ED-specific QoL questionnaire such as the ED-EQoL to measure the psychosocial effect of ED, in addition to using an instrument such as the International Index of Erectile Function to measure the functional aspects of ED.     

The impact of preoperative erectile dysfunction on survival after radical prostatectomy

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

PURPOSE

Erectile dysfunction (ED) and cardiovascular disease (CVD) share etiology and pathophysiology. The underlying pathology for preoperative ED may adversely affect survival following radical prostatectomy (RP). We examined the association between preoperative ED and survival following RP.

MATERIALS AND METHODS

Between 1983 and 2000, a single surgeon performed RP on 2511 men, with preoperative ED (ED group, n= 231, 9.2%) or without ED (No ED group, n= 2280, 90.8%). We retrospectively analysed their CVD‐specific survival (CVDSS), prostate cancer‐specific survival (PCSS), non‐PCSS (NPCSS) and overall survival (OS) from time of surgery.

RESULTS

With median follow‐up of 13 years after RP, 449 men (18%) died (140 from prostate cancer, 309 from other causes). Kaplan–Meier analyses demonstrated significant differences in CVDSS (P < 0.001), NPCSS (P < 0.001) and OS (P < 0.001), but not in PCSS (P= 0.12), between the ED group vs No ED group. In univariate proportional hazards analyses, preoperative ED was associated with a significant decrease in OS, hazard ratio (HR), 1.71 (95% CI, 1.34–2.23), P < 0.001. However, in multivariable analyses, the association of ED with survival became non‐significant (HR, 1.25 (95% CI, 0.97–1.66), P= 0.111) after adjusting for other prognostic factors, such as age, preoperative prostate‐specific antigen (PSA) level, Gleason score, pathologic stage, body mass index and Charlson Comorbidity Index.

CONCLUSIONS

Preoperative ED is associated with decreased overall survival and survival from causes other than prostate cancer following RP. However, preoperative ED was not an independent predictor of overall survival after adjusting for other predictors of survival. Urologists should carefully assess pretreatment ED status to enhance appropriate treatment recommendation for men with prostate cancer.     

The impact of prostatectomy and brachytherapy in patients with localized prostate cancer

PURPOSE: to compare urinary incontinence and erectile dysfunction symptoms reflecting quality of life and the willingness to undergo treatment again in patients treated by radical retropubic prostatectomy and low dose radiation (LDR) brachytherapy. MATERIALS AND METHODS: from July 1992 to November 2001, 158 patients with clinical localized prostate cancer were treated by radical retropubic prostatectomy with or without nerve sparring or LDR brachytherapy. To all the 158 patients we mailed a self-reporting questionnaire with 5 questions to access sexual function, 4 questions for urinary continence, and 2 for the satisfaction with the treatment and willingness to undergo treatment again. Patients had no form of adjuvant radiation therapy, or neoadjuvant or adjuvant androgen suppression therapy. A total of 56 patients (43%), 34 of the prostatectomy and 22 patients of the brachytherapy group answered the questionnaire. Questionnaire results were independently analyzed by someone else not involved with patients' treatment. RESULTS: patients self-reported some degree of erectile dysfunction in 84.8% (p = 0.01) in the group treated by prostatectomy and 23.07% (p = 0.86) in the brachytherapy group. Urinary incontinence occurred in 17.6% in the group treated by prostatectomy (p = 0.01) and in 9.5% (p = 0.52) in the brachytherapy group. Urinary incontinence and impotence significantly affected treatment satisfaction. However, considering satisfaction with the treatment and willingness to undergo treatment again, 88.2% of patients would elect surgery again and 95.5% brachytherapy again.     

From QOL to QALYs: Comparing nononcologic outcomes in prostate cancer survivors across treatments

Objective

We aim to highlight the progression from the early definition of nononcologic outcomes in prostate cancer (PC) to measurement and use of preferences to ensure appropriate treatment decisions in men with localized disease.

The association of age with perioperative morbidity and mortality among men undergoing radical prostatectomy

Introduction

Older age is considered a relative contraindication to radical prostatectomy (RP). However, data are limited regarding the impact of age on perioperative outcomes following RP. We examined the association of age with perioperative outcomes following RP to inform risk-stratification and management.

Recovery of health related quality of life after radical prostatectomy in Japanese men: A longitudinal study

BACKGROUND: We performed a longitudinal survey of health related quality of life (HRQOL) after radical retropubic prostatectomy (RP) in Japanese men with localized prostate cancer. METHODS: The present study started with self-reported HRQOL assessments provided by 72 patients who received only RP. The RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index were administered before and 3, 6 and 12 months after RP. RESULTS: Patients who underwent RP showed problems in some domains of general HRQOL, but these problems diminished over time. Urinary function declined substantially at 3 months and continued to recover at 6 and 12 months, but scored lower than the baseline. Urinary bother at 3 months had a significant decrease, but at six months it turned out to be the same as the baseline. The data of sexual function and bother showed a substantially lower score after RP. The sexual bother score of the younger men was significantly worse than that of the older men. Those who underwent nerve sparing procedures experienced significantly better recovery of urinary and sexual functions than the non-nerve sparing group. CONCLUSION: Despite reports of problems with sexuality and urinary continence, general HRQOL was mostly unaffected by RP after 6 months. Although there was a substantial decrease in urinary function, recovery from urinary bother was rapid. Deterioration of the sexual domain was remarkable throughout the postoperative period. Therefore, careful attention should be given to preoperative counseling, especially for younger patients.     

Positive margins after laparoscopic radical prostatectomy: a prospective study of 100 cases performed by 4 different surgeons

OBJECTIVE: Laparoscopic radical prostatectomy (LRP) has been refined by experienced surgeons into a competitive treatment alternative for localized prostate cancer. Less is known, however, about the outcomes of "learning curve" cases from newly trained surgeons. We prospectively studied 100 cases of LRP performed by 2 senior and 2 junior surgeons and addressed the rates of positive margins-an important early endpoint of oncologic efficacy. METHODS: 100 consecutive cases of LRP were performed by two senior (n=62) and two junior surgeons (n=38) by a 5-port transperitoneal route. Whole-mount step-section prostate specimens were examined by Stanford protocol. RESULTS: Positive margins occured in 25% of cases: 18% for pT2a (2/11), 18% for pT2b (11/61), 45% for pT3a (10/22), and 50% for pT3b (2/4) (p=0.002 pT2 vs. pT3). By surgeon experience, the rates were 19% (12/62) for senior and 34% (13/38) for junior (p=0.04). However, in a multiple logistic regression analysis, only pathologic stage (p=0.083) and Gleason sum (p=0.0133) reached statistical significance, while surgeon experience did not (p=0.0992). CONCLUSION: Positive margin rates after laparoscopic radical prostatectomy are significantly influenced by pathologic stage and Gleason score, and are within the range reported from open series. The higher positive margin rate from junior surgeons, although not statistically significant, suggests the need for further study and continued mentoring during surgery and/or video review of cases to improve oncologic results.     

Early postoperative pelvic-floor biofeedback improves erectile function in men undergoing radical prostatectomy: a prospective, randomized, controlled trial

Erectile dysfunction (ED) and urinary incontinence are common complications following radical prostatectomy (RP). Although pelvic-floor biofeedback training (PFBT) may improve urinary continence following RP, its effects on the recovery of potency are unknown. Fifty-two patients selected for RP were prospectively randomized for a treatment group (n=26) receiving PFBT once a week for 3 months and home exercises or a control group (n=26), in which patients received verbal instructions to contract the pelvic floor. Erectile function (EF) was evaluated with the International Index of Erectile Function-5 (IIEF-5) before surgery and 1, 3, 6 and 12 months postoperatively. Patients were considered potent when they had a total IIEF-5 score >20. Continence status was assessed and defined as the use of no pads. Groups were comparable in terms of age, body mass index, diabetes, pathological tumor stage and neurovascular bundle preservation. A significant reduction in IIEF-5 scores was observed after surgery in both groups. In the treatment group, 8 (47.1%) patients recovered potency 12 months postoperatively, as opposed to 2 (12.5%) in the control group (P=0.032). The absolute risk reduction was 34.6% (95% confidence interval (CI): 3.8-64%) and the number needed to treat was 3 (95% CI: 1.5-17.2). A strong association between recovery of potency and urinary continence was observed, with continent patients having a 5.4 higher chance of being potent (P=0.04). Early PFBT appears to have a significant impact on the recovery of EF after RP. Urinary continence status was a good indicator of EF recovery, with continent patients having a higher chance of being potent.     

Comparison of health-related quality-of-life outcomes for African-American and Caucasian-American men after radical prostatectomy

Study Type – Therapy (outcomes) Level of Evidence 2c What's known on the subject? and What does the study add? In addition to a higher prevalence and biological aggressiveness of prostate cancer, African‐Americans tend towards narrower pelvises than Caucasians resulting in a potentially more difficult surgical dissection doing radical prostatectomy and increased positive surgical margins. In this study, there was no difference in urinary or sexual HRQL or overall satisfaction between African‐Americans and Caucasians 2 years after radical prostatectomy, suggesting that the potential technical challenges of a narrower pelvis do not translate into poorer outcomes for African‐Americans.

OBJECTIVE

• ? To determine if any differences exist in postoperative health‐related quality‐of‐life (HRQL) outcomes, e.g. erectile function and continence, after radical prostatectomy (RP) in African‐American (AA) vs Caucasian‐American (CA) men.

PATIENTS AND METHODS

• ? Between October 2000 and July 2008, 1338 CA and 56 AA men underwent open RP by a single surgeon and signed informed consent to participate in a prospective longitudinal outcomes study.
• ? The American Urological Association Symptom Score (AUA‐SS) and University of California, Los Angeles, Prostate Cancer Index (UCLA‐PCI) and a global assessment of satisfaction were self‐administered at baseline and after RP 24 months.
• ? Urinary, sexual, and satisfaction outcomes were compared at 24 months.

RESULTS

• ? AA men had significantly higher rates of hypertension and diabetes.
• ? There were no other significant baseline differences in age, co‐morbidities, body mass index, phosphodiesterase type 5 inhibitor use, preoperative prostate‐specific antigen level, AUA‐SS, and UCLA‐PCI scores.
• ? There were no differences in the percentage of men undergoing nerve‐sparing procedures, estimated blood loss, transfusion rates, or complication rates between the groups.
• ? At 24 months after RP the mean UCLA‐PCI urinary and sexual function and bother scores and global satisfaction scores were similar between the groups.

CONCLUSION

• ? AA and CA men experience no significant differences in urinary and sexual HRQL or overall satisfaction after open RP when performed by a single experienced surgeon.

     

Psychological impact of erectile dysfunction: validation of a new health related quality of life measure for patients with erectile dysfunction

PURPOSE: Male erectile dysfunction has a substantial impact on health related quality of life. We examined the psychometric properties of 2 new scales created to measure the psychological impact of erectile dysfunction. MATERIALS AND METHODS: Patients enrolled in a long-term study of men with erectile dysfunction completed clinical and health related quality of life information at baseline and at 3 followup points. The questionnaire incorporated a number of standard scales of psychosocial characteristics as well as questions developed from comments made during focus groups of men with erectile dysfunction and of their female partners. Principal components analysis was used to identify underlying constructs in response to the new questions. RESULTS: A total of 168 men completed the baseline quality of life questionnaire. The principal components analysis of the psychological impact of erectile dysfunction questions resulted in 2 new scales. Reliability was good with an internal consistency reliability of 0.91 for scale 1 and 0.72 for scale 2. Test-retest reliability was 0.76 and 0.66, respectively. Men reporting a greater psychological impact of erectile dysfunction also reported greater impairment in functional status, lower sexual self-efficacy, greater depression and anxiety at the last intercourse. Each new scale significantly differentiated men with mild/moderate versus severe erectile dysfunction. CONCLUSIONS: We developed 2 new scales to measure the psychological impact of erectile dysfunction and they showed good reliability and validity. These new scales, named the Psychological Impact of Erectile Dysfunction instrument, comprehensively capture the psychological effect of erectile dysfunction on health related quality of life, which is not adequately assessed by existing patient centered measures of erectile function.     

Detailed analysis of patient-reported lower urinary tract symptoms and effect on quality of life after robotic radical prostatectomy

Objective

To prospectively evaluate short- to medium-term patient-reported lower urinary tract symptoms (LUTS) and their effect on health-related quality of life (HRQoL) using validated questionnaires in a large cohort of patients following robotic-assisted radical prostatectomy (RARP) for prostate cancer.

A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes

Context

The optimal management strategy for men with newly diagnosed clinically localized prostate cancer remains a matter of debate. Numerous series have reported cancer control and quality-of-life (QoL) outcomes following treatment with radical prostatectomy (RP).

Objective

Critically review published oncologic and functional outcomes after RP, and evaluate factors associated with these outcome measures.

Evidence acquisition

A review of the literature was performed using the Medline and Web of Sciences databases. Relevant reports published between 1980 and 2011 identified using the keywords prostate cancer, radical prostatectomy, prostate-specific antigen, biochemical recurrence, incontinence, and erectile dysfunction were reviewed and summarized.

Evidence synthesis

Cancer control rates following RP largely depend on the definition of treatment efficacy. While up to 40% of men have been reported to experience postoperative biochemical recurrence on long-term follow-up, death from prostate cancer has been noted in <10% of men at 15 yr after surgery in contemporary series. For men with high-risk disease, surgery affords pathologic staging, thereby facilitating the selective application of secondary therapies, and has been associated with decreased mortality risk versus radiation in retrospective series. Reported functional outcomes after surgery, particularly urinary continence and erectile dysfunction, have varied greatly to date. These assessments have been limited by nonstandardized reporting methodology. The use of robot-assisted radical prostatectomy has increased in recent years, and while follow-up is thus far short, available data do not suggest the superiority of either approach in terms of functional or oncologic outcomes.

Conclusions

RP is associated with excellent long-term cancer control. Continued efforts to conduct prospective assessments of postoperative functional outcomes are necessary using validated QoL instruments. The importance of surgical approach will also require further study, incorporating comparative oncologic, functional, and economic data.     

Demonstration of erectile management techniques to men scheduled for radical prostatectomy reduces long-term regret: a comparative cohort study

Study Type – Outcomes (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Patients with localized prostate cancer face a bewildering number of treatment choices. Modern technology and innovation in treatment techniques have seen patient expectations rise exponentially, leading to an increase in regret of treatment choice. This study has shown that the demonstration of erectile function techniques helps inform decision‐making and reduce long‐term regret of treatment choice in localized prostate cancer.

OBJECTIVE

? To determine whether preoperative demonstrations of intracavernosal and vacuum therapies for erectile dysfunction (ED) influence the decision of treatment choice, reducing long‐term regret.

PATIENTS AND METHODS

? In all, 82 consecutive men with localized prostate cancer, scheduled for radical prostatectomy and reporting an International Index of Erectile Function score of >21, were prospectively enrolled at a single cancer centre. ? Following standard preoperative counselling, half of the men were invited to attend a further consultation for intracavernosal and vacuum therapy demonstrations. ? All patients were evaluated pretreatment and then 3 monthly using the five‐point International Index of Erectile Function score and the 14‐item Hospital Anxiety and Depression scale. ? At 12 months treatment choice changes were recorded and patients were assessed for treatment choice regret using Clark’s validated two‐item regret questionnaire. Statistical analysis was performed using the Mann–Whitney and Fisher’s exact tests. Results were compared with a control population of 41 men who did not undergo additional ED counselling.

RESULTS

? In all, 8/41 men (19%) changed their treatment choice, opting for brachytherapy rather than radical prostatectomy. ? Only 1/41 in the control population changed their decision before surgery. ? At 1 year, one patient (2%) in the intervention group expressed regret at his treatment choice (radical prostatectomy) compared with eight (20%) in the control group (P= 0.03, two‐sided Fisher’s exact test); ED was identified as the major cause of this regret.

CONCLUSION

? Preoperative demonstrations of ED therapies can optimize decision making in prostate cancer and help reduce long‐term regret.     

Quality of life after radical prostatectomy in Japanese men: A 5-Year follow up study

Objectives:   To measure health-related quality of life (HRQOL) after radical prostatectomy (RP) in Japanese men with localized prostate cancer.
Methods:   A total of 154 patients who underwent RP were included in this 5-year longitudinal survey. The Short Form 36-Item Health Survey, the University of California, Los Angeles, Prostate Cancer Index and the International Prostate Symptom Score questionnaires were administered at diagnosis and nine times afterwards.
Results:   Patients undergoing RP showed problems in some physical domains of general HRQOL, but these problems diminished over time. Mental health and social functions significantly improved during the follow-up period. The urinary function substantially declined at 3 months and continued to recover gradually but never returned to baseline. Most patients (95%) recovered to their baseline urinary bother score within 60 months. The overall mean total International Prostate Symptom Score progressively improved with time. On the other hand, at 60 months after RP, only 34% of subjects had fully returned to baseline sexual function. By 5 years postoperatively, 78% of the men had reached baseline sexual bother and the mean recovery time was 8.6 months. Adverse effects of RP on sexual function and bother were mitigated by bilateral nerve-sparing procedures up to 5 years after the operation.
Conclusions:   Despite reported problems with sexuality and urinary continence, general HRQOL was mostly unaffected by RP after 6 months in our survey with functional outcomes remaining relatively stable in the majority of patients.     

Quality of life after radical prostatectomy in elderly men

Objectives:   To evaluate the impact of radical prostatectomy (RP) on health-related quality of life (HRQOL) in elderly men with prostate cancer.
Methods:   Between January 2002 and December 2006, a total of 205 elderly men (≥70 years) undergoing RP participated in our longitudinal outcome study. Patients completed general (Short Form 36) and disease-specific (University of California, Los Angeles Prostate Cancer Index) HRQOL questionnaires. A t-test was used to compare each HRQOL score after RP with the baseline scores and Cox proportional hazard models to characterize the recovery trends.
Results:   Patients undergoing RP showed physical problems, which diminished over time. Several emotional domains significantly improved during the follow-up period. By 2 years postoperatively, 57% and 81% of subjects had fully returned to baseline urinary function and bother, respectively. Mean recovery time to baseline urinary function and bother was 8.3 months and 4.7 months, respectively. When incontinence was defined as 'no pad', 82% of patients reported continence. Whereas only 25% of patients returned to the baseline sexual function level, 83% had reached baseline sexual bother. Among those returning to their own baseline scores, the mean recovery time was 10.9 months for sexual function and 5.3 months for sexual bother.
Conclusions:   Selected elderly patients can achieve satisfactory functional outcomes after RP. These outcomes should be considered when decisions about treatment are made.