Continence following nerve-sparing radical prostatectomy

Urinary incontinence after radical prostatectomy is a difficult postoperative problem and often is a major consideration in the selection of therapy for clinically localized disease. The occurrence of incontinence is unpredictable and the relationship of incontinence to operative technique is unclear. We compared urinary continence in 68 consecutive patients undergoing radical prostatectomy. In 34 patients nonnerve-sparing radical prostatectomy was performed and in 34 subsequent patients a nerve-sparing operation was done. Patient age, Gleason score and stage of the tumor, and operative time were not significantly different between the groups. In the nonnerve-sparing operated group there were 4 patients (12%) with total and 6 (18%) with stress incontinence requiring absorbent pads, compared to 0 and 2 (6%), respectively, in the nerve-sparing group. The postoperative functional urethral length in the nonnerve-sparing group was 1.9 +/- 0.6 cm. (standard deviation) and in the nerve-sparing group it was 2.3 +/- 0.5 cm., which was significantly different (p less than 0.05). The peak resting urethral pressure of the nonnerve-sparing group was 35.4 +/- 14.2 cm. water and in the nerve-sparing group it was 46.5 +/- 12.3 cm. water, which also was significantly different (p less than 0.05). The study indicates that preservation of the pelvic nerves during radical prostatectomy has a major role in the functional preservation of urinary continence.     

Seminal monolateral nerve-sparing radical prostatectomy in selected patients

INTRODUCTION: In recent years there has been a shift in prostate cancer stage with the majority of patients nowadays being operated with cT1c disease, prostate-specific antigen levels of <10 ng/ml, and a decreased rate of seminal vesicle invasion. Recent data suggest the role of preservation of the seminal vesicle in improving continence and/or potency. We describe our preliminary experience with seminal-sparing, unilateral nerve-sparing retropubic radical prostatectomy. PATIENTS AND METHODS: 21 selected patients with clinically localized prostate cancer underwent seminal unilateral nerve-sparing retropubic radical prostatectomy (seminal-sparing group, SSG). We compared the postoperative continence, erectile function and quality of orgasm results to those obtained in a control group (CG) of 21 patients who underwent unilateral nerve-sparing radical prostatectomy. Sexual function was evaluated preoperatively and 9 months postoperatively with the 5-item International Index of Erectile Function (IIEF-5) questionnaire and with other self-administered questionnaires. The quality of orgasm was evaluated 9 months postoperatively. RESULTS: 1 month postoperatively, 95 and 28% of the patients in the SSG and CG were continent (p<0.001). The median postoperative drop in IIEF-5 score was 5 points in SSG and 14.5 points in CG (p<0.0001). Nine months postoperatively, 90 and 62% of the patients in SSG and CG, respectively (p=0.05), maintained the ability to achieve orgasm. CONCLUSIONS: In our experience seminal-sparing radical prostatectomy showed good feasibility and improved early postoperative urinary continence, erectile function and quality of orgasm, without compromised cancer control.     

Proerectile pharmacological prophylaxis following nerve-sparing radical prostatectomy (NSRP)

The importance of an early pharmacological prophylaxis for erectile function following nerve-sparing radical prostatectomy has been recently stressed by several authors. In spite of that, patient's compliance to erectile rehabilitation protocols seems to be low. The present review is an attempt to define the expected benefits of the currently proposed rehabilitative protocols in terms of cost-efficiency and quality of life. The conclusion is that current scientific evidence in support of an early postoperative use of erectile aids is based mainly on indirect proof of a cavernosal damage that may follow the temporary postoperative 'erectile silence'. Intracavernosal injections or a vacuum device may represent the best first-line treatment option for the first few months from the procedure as their mechanism of action does not require intact neural tissue for erection. Thereafter oral phosphodiesterase 5 inhibitor therapy may be a reasonable choice for those patients who can achieve at least a partial erection. A phosphodiesterase 5 inhibitor may not be effective when spontaneous erections are absent. It is possible, since the rehabilitation of sexual function aims to prevent cavernosal tissue damage by providing oxygenation to the erectile tissue, the choice of a potentially ineffective treatment may jeopardize the results of a reasonable nerve-sparing procedure.     

Clinical experience of nerve-sparing radical prostatectomy

A total of 18 patients underwent nerve-sparing radical prostatectomy for clinical stage B1 or B2 prostatic cancer. An operation was performed according to the modified technique originally described by Walsh and associates. The operative technique involved three steps: 1) accurate ligation of dorsal vein complex, which makes a relatively bloodless field and makes it possible to dissect the lateral pelvic fascia from the prostate; 2) the incision in the lateral pelvic fascia is made anterior to the neurovascular bundle; 3) the lateral pedicle is divided close to the prostate. There were no major intraoperative complications such as rectal perforation or ureteral injury. The mean blood loss was 802 g (340-1600 g) and the average duration of surgery was 173 minutes. Eleven patients had no blood transfusions. Postoperatively, there was a wound infection in one case. Mild bladder neck contracture in one case responded to single dilatation. Sexual function was evaluated in 16 of the patients who have been followed for more than three months and who had not received hormone therapy postoperatively. Of 16 patients 6 (37%) had return of erectile function. Return of erections required 3-15 months (average 9 months). Patients under 70 years old had a higher incidence (80%) of return of erections than those over 70 years old. Four of the 6 patients had tumor involvement confined to the prostate. Initially most patients had significant amounts of stress incontinence. This resolved within the first or second postoperative month. Finally 4 had slight stress urinary incontinence but no patients had total incontinence. The results suggest that nerve-sparing radical prostatectomy is an anatomically safe approach. It can contribute to the quality of life in men at a stage when it is still curable.     

Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy

OBJECTIVES: Based on our recently published anatomic studies, we present the most recent refinement of the endoscopic extraperitoneal radical prostatectomy (EERPE), the intrafascial nerve-sparing EERPE (nsEERPE). METHODS: As part of the intrafascial technique, the dissection plane is directly on the prostatic capsule, freeing the prostate laterally from its thin surrounding fascia that contains small vessels and nerves. The technique enables puboprostatic ligament preservation, leaving intact endopelvic fascia, periprostatic fascia, and neurovascular bundles. The operation was performed in 150 patients with indications for nerve-sparing procedure. RESULTS: The mean operative time was 131 min (range: 50-210 min) and the mean catheterization time was 5.9 d (range: 4-20 d). Twelve months postoperatively, 94.3% of the patients were continent (no need for pads), 4.6% had minimal stress incontinence, and one patient required >2 pads/d. At the 12-mo follow-up, the potency rates (erections sufficient for intercourse with or without the use of phosphodiesterase 5 [PDE5] inhibitors) of the patients who underwent bilateral intrafascial nsEERPE were 89.7% (age: 44-55 yr), 81.1% (age: 56-65 yr), and 61.9% (age: >65 yr). Positive surgical margins in pT2 and pT3 tumors were 4.5% and 29.4%, respectively. CONCLUSIONS: The intrafascial nsEERPE enables the dissection of the prostate with limited trauma to the surrounding fascias and the enclosed neurovascular bundles. We propose that the preserved neurovascular bundles with intrafascial nsEERPE are more viable. The results advocate this proposition.     

Erectile dysfunction following nerve-sparing radical retropubic prostatectomy and its treatment with sildenafil

BACKGROUND: We retrospectively evaluated the erectile function after nerve-sparing radical retropubic prostatectomy (RRP) and the efficacy of sildenafil for erectile dysfunction (ED) following RRP according to the preoperative erectile function. METHODS: We evaluated 48 Japanese patients who underwent nerve-sparing RRP at the Sapporo Medical University School of Medicine, Sapporo, Japan, between January 1996 and December 2001. Erectile function following nerve-sparing RRP was assessed by a simple mailed questionnaire that was constructed for the study. RESULTS: Of the 48 patients, 36 had normal erectile function preoperatively, but for 12, function was not sufficient to penetrate. The overall estimated recovery rates of any degree of erection were 50.6% at 36 months and 94.3% at 60 months. However, that of erection sufficient to penetrate was only 17.7% at 36 months and was only seen in bilateral nerve-sparing patients. Sildenafil was effective in 9 of 13 ED patients (69.2%) in both nerve-sparing groups. When patients were divided according to preoperative erectile function, no difference was found in the efficacy rate between patients with normal function and those with ED. CONCLUSIONS: Even bilateral nerve-sparing RRP can not always guarantee a sufficient erection. However, sildenafil is effective for ED following nerve-sparing RRP regardless of the nerve-sparing procedure or preoperative erectile function. Thus, preoperative function alone, although depending on its severity, may not necessarily be a reason for exclusion from receiving nerve-sparing RRP if patients want to have the operation.     

Indications and contraindications for nerve-sparing radical prostatectomy

Nerve-sparing radical prostatectomy can be performed safely in most men undergoing radical prostatectomy. As is true in many aspects of prostate cancer diagnosis and therapy, the key element is patient selection. With many prostate tumors diagnosed at an earlier stage, the authors have seen a shift toward more favorable pathologic findings at the time of surgery. Concomitant with the success of early detection of prostate cancer is the realization that men are younger at the time of diagnosis and more interested in preserving sexual function. This article has described factors associated with an increased risk for extraprostatic tumor and, subsequently, an increased possibility of postprostatectomy cancer recurrence. Except for the previously mentioned absolute contraindications, none of these factors, by themselves, should be used to exclude a patient from nerve-sparing prostatectomy. Instead, meticulous attention must be given to the surgical dissection. If any doubt remains regarding residual tumor, the surgeon should err on the side of caution and remove the neurovascular bundle. The use of standardized intraoperative frozen-section analysis can help guide these decisions. The patient must be informed before surgery regarding the risks of nerve-sparing surgery, the potency rates of the surgeon, and the possibility that, to ensure adequate cancer control, the nerves may be sacrificed despite any preoperative optimism favoring the potential for their salvage.     

Local steroid application during nerve-sparing radical retropubic prostatectomy

OBJECTIVE: To evaluate the effect on potency rates after surgery of applying local steroids to the neurovascular bundles (NVBs) of the prostate after bilateral nerve-sparing radical retropubic prostatectomy (BNS-RRP). PATIENTS AND METHODS: Sixty potent men undergoing BNS-RRP for clinically localized prostate cancer were prospectively randomized equally into two groups. In group 1, 10 mL of betamethasone cream 0.1% was applied locally to both NVBs, and group 2 had only the usual BNS-RRP with no corticoid cream. Complications and potency were evaluated at 3, 6 and 12 months in all patients and compared between the groups. RESULTS: At 12 months, 57% and 60% of patients were potent in group 1 and 2, respectively; the respective mean International Index of Erectile Function (5-item) scores were 14.76 and 15.43 (P = 0.59). Potency rates at 3, 6 and 12 months were not significantly different between the groups, and the continence rates at 12 months were also similar, with 93% and 90% of patients in groups 1 and 2 being continent, respectively. Ten and five patients in groups 1 and 2, respectively, required a blood transfusion (P = 0.23). There were no fistulae, wound dehiscence or rectal perforations. One patient in group 2 presented 4 months after RRP with a bladder neck contracture. CONCLUSIONS: Local application of betamethasone does not improve or expedite the recovery of erectile function after BNS-RRP, but there were no complications associated with its use.     

Radiographic assessment of the vesicourethral anastomosis directing early decatheterization following nerve-sparing radical retropubic prostatectomy

Early decatheterization directed by postoperative gravity cystography in 55 consecutive radical prostatectomy patients is described. The catheter-free status was 22 per cent by postoperative day 8, 62 per cent by postoperative day 11 and 80 per cent by postoperative day 14. Cystograms performed beginning on postoperative day 7 identified 3 groups of patients and dictated their management: 1) no extravasation resulting in immediate catheter removal (36 patients), 2) moderate extravasation requiring repeat cystography leading to decatheterization by postoperative day 15 (9 patients) and 3) severe extravasation necessitating prolonged catheter drainage (8 patients). A decatheterization protocol is presented.     

Overcoming obstacles: nerve-sparing issues in radical prostatectomy

PURPOSE: To review, compare, and contrast recovery of potency after robot-assisted radical prostatectomy with specific regard to thermal and excisional nerve injury. Our goal was to compare intensity of injury and ability to recover potency in order to stratify risk by injury type. METHODS: We compare potency outcomes in our first 500 consecutive cases of robot-assisted radical prostatectomy. This is a retrospective review of data collected prospectively into an electronic database. Preoperative inclusion criteria were age less than 66 years, International Index of Erectile Function Score of 22-25, and unilateral or bilateral nerve preservation. Potency data were collected via patient-reported validated questionnaires. Potency was defined with two affirmative responses to: "erections hard enough for sexual intercourse" and were they "satisfactory." Results were collated and graphically analyzed so that time-line comparisons of recovery could be evaluated. RESULTS: Time-line curves were generated comparing recovery of sexual function over 2 years after nervesparing techniques using cautery versus cautery-free and unilateral versus bilateral nerve preservation. Use of no cautery improved early return of sexual function 4.7-fold over cautery. Whether using cautery or cautery-free techniques, a doubling of nerve tissue from one nerve to two nerves spared only resulted in a 1.2-fold improvement of potency recovery both early and long-term. CONCLUSIONS: In our experience, avoidance of thermal injury produces nearly a 5-fold improvement in early return of sexual function. Furthermore, thermal injury appears to induce a dense but largely recoverable injury after 2 years. In contrast to common belief, our results demonstrated that preservation of just one nerve will, in the majority of patients, result in similar potency recovery to that with two nerves preserved. Crossover innervation of the one nerve is favored over compensation and hints that techniques that increase nerve volume at the expense of positive surgical margins may need careful introspection.     

Patient-reported sexual function after nerve-sparing radical retropubic prostatectomy

OBJECTIVE: Improved selection criteria have lead to an increasing number of nerve-sparing radical retropubic prostatectomies (RRP) in patients with clinically localised prostate cancer (PCA). Patient questionnaire based outcome analysis on post-operative erectile function after uni- or bilateral nerve-sparing RRP is described. METHODS: Between January 1992 and March 1999, 366 patients (mean age 62.5 years) underwent uni- or bilateral nerve-sparing RRP at our institution. Indication for nerve-sparing procedure was based on the results of a multivariate classification and regression tree analysis (CART). For evaluation of post-operative patient-reported rates of sexual and erectile function non-validated and validated questionnaires (IIEF 5) were administered after a follow-up of 12 months. Data of five operation periods were analysed. RESULTS: The unilateral procedure resulted in rates of 13-29% of erections sufficient for unassisted intercourse. Some degree of tumescence was reported by 37-73% of the remaining patients. Bilateral nerve-sparing procedures were almost exclusively performed in periods 3-5, only four patients of period 2 received the bilateral procedure. Here, rates of erections sufficient for intercourse were 25% (period 2), 61% (period 3), 50% (period 4), and 52% (period 5), respectively. Patients with grades 4 and 5 erections had IIEF scores of 19.2 and 20.2 and patients without rigidity or tumescence had scores of 5.7 and 7.0 after uni- and bilateral nerve-sparing procedure, respectively. Patients <60 years of age had better erections than those > or =60 (unilateral: 19% versus 13%, bilateral 45% versus 38%). CONCLUSION: Compared to a unilateral nerve-sparing procedure, the bilateral nerve-sparing technique revealed much better results inasmuch as about 50% of the patients reported recovery of erections sufficient for sexual intercourse without use of sexual aids.