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.     

Penile rehabilitation after radical prostatectomy: patients’ attitude and feasibility in China

Objective

To investigate the behavior of Chinese erectile dysfunction (ED) patients after radical prostatectomy (RP) who were offered the penile rehabilitation and to assess their attitude and feasibility of rehabilitation after RP in China.

Materials and methods

Comprehensive medical and sexual histories of 187 evaluable PCa patients for RP were obtained together with their attitude towards penile rehabilitation. The rehabilitation data was compared between patients who accepted this treatment or not. The successful intercourse rate six months after treatment was also compared among three rehabilitation interventions, including phosphodiesterase type 5 inhibitor (PDE-5i), vacuum erection device (VED) and combination of both.

Results

141 (75.4%) patients reported being sexually active in the six months before RP.122 (65.2%) patients wished to preserve sexual activity and 80 (42.8%) had interest in penile rehabilitation after RP. Penile rehabilitation rate was 30.5%. The patients with younger age (P<0.001), higher IIEF-5 score preoperatively (P=0.03) and no adjuvant therapy post-RP (P=0.01) were more acceptable for rehabilitation. Main reasons for refusal of rehabilitation included lack of sexual interest followed by high cost of treatment. The successful intercourse rate was not significantly different among three rehabilitation interventions (P=0.32).

Conclusions

Less than one-third of Chinese RP patients accepted penile rehabilitation postoperatively. Patients’ attitude towards rehabilitation was conservative because of many reasons from traditional Chinese culture, doctors and patients themselves. Penile rehabilitation was feasible and effective in Chinese RP patients.     

Prospective comparison of scar-related satisfaction and quality of life after laparoscopic versus open radical prostatectomy: no differences from patients’ point of view

Objectives

To evaluate and compare scar-related satisfaction in patients treated with open (ORP) versus laparoscopic radical prostatectomy (LRP).

Patients and method

We prospectively included all patients treated with ORP and LRP in our department between March and June 2010. Scar-related outcomes were collected at 1 and 3 months postoperatively. Three months after surgery, all patients filled up a questionnaire concerning their scar-related symptoms, scar self-consciousness and satisfaction. These variables were statistically compared between the two groups.

Results

A total of 101 patients were included for analysis. Of them, 48, 49 and 4 were treated with LRP, ORP and LRP converted to ORP, respectively. Age distribution was not statistically different between groups. Postoperatively, 5 patients experienced skin infection on their scar site, 2 in the ORP and 3 in the LRP group. The most frequently reported symptom was scar itching, that was more frequent after LRP, although difference was not significant (33 vs. 19 %, p = 0.2). According to patient scar-related consciousness, satisfaction and impact on quality of life, no differences were reported between groups. Impact on quality of life was insignificant in 27 (55 %) versus 21 (44 %) patients after ORP and LRP, respectively (p = 0.3).

Conclusion

With an overall low impact on satisfaction and quality of life, scars gendered by LRP and ORP were not different from patients’ point of view. In patients undergoing radical prostatectomy, the cosmetic aspect of scars does not seem to be a concern.     

Predictors for immediate recovery of continence following Retzius-sparing robot-assisted radical prostatectomy: a case–control study

International Urology and Nephrology - We evaluated urinary continence in a series of consecutive patients who underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) to identify...     

Recovery of sexual function after nerve-sparing radical retropubic prostatectomy: is cavernous nitric oxide level a prognostic index?

The preservation of NANC nerve fibers (producing nitric oxide, NO) is necessary for erection recovery after retropubic radical prostatectomy (RRP). Yet, it is impossible to establish when and if a patient will recover erections; therefore, we investigate the prognostic value of cavernous blood NO levels on this parameter. Nerve-sparing RRP was performed on 14 patients for localized prostate cancer. We evaluated all patients 3 months after surgery by IIEF score: no patients had erections. A cavernous blood sample was also taken to determine NO levels (as nitrite). Patients were evaluated again 18 months after surgery. In six cases, erectile function was compromised, whereas in seven cases, potency was restored. Statistical analysis showed a relationship between nitrite levels in cavernous blood 3 months after surgery and the recovery or erectile function at 18 months. We propose that cavernous NO blood levels are a prognostic index of erection recovery.     

Validation of “patient-reported outcomes via online questionnaire” as a urinary continence assessment and quality improvement tool following radical prostatectomy

BackgroundSecuring reliable data on functional outcomes following radical prostatectomy (RP) is paramount to patient follow-up and management.ObjectiveTo validate an email-based patient-reported outcomes tracking system in assessing pad-free continence rates and time-to continence recovery following RP.Patients and Methods483 men undergoing RP by a single surgeon from November 2013 to March 2019 were prospectively assigned to 1 of 3 tracking systems: 1) a preaddressed paper packet containing a pad-free card and daily urinary pad log, (N = 249); 2) an automated email questionnaire, (N = 234) or 3) both (N = 51). Patients tracked electronically received electronic Research Electronic Data Capture surveys 30 days after catheter removal, with up to 3 reminders sent automatically if no response was received within 2 days. Response rates and continence rates were compared in group 1 vs. group 2 via student t-tests; time-to pad-free status was assessed for concordance among men in group 3 via linear regression.ResultsThirty-day response rates in group 1 (paper) vs. group 2 (electronic) were 80.7% (201/249) and 94.0% (220/234), (P < 0.0001); pad-free rates were 64.2% (129/201) and 64.1% (141/220), (P = 0.9847), respectively. Similarly, 1-year response rates in group 1 and 2 were 87.6% (218/249) vs. 94.0% (220/234), (P = 0.0146); pad-free rates were 91.7% (200/218) vs. 96.4% (212/220), (P = 0.0411), respectively.In group 3, time to pad-free continence recovery assessed via Patient Reported Outcomes via Online Questionnaire (PROVOQ) was highly concordant in 89.6% (43/48) of patients ± 5 days (Figure 1, R² = 0.9893). No significant bias was found for subsequent reporting in either group.ConclusionThe use of automated email survey questionnaires via PROVOQ for the assessment of patient-reported post-RP continence recovery facilitates increased response rates, timeliness of response, and accuracy. PROVOQ significantly reduce the labor of tracking continence outcomes, improve quality improvement efforts, and enables surgeons to more clearly differentiates risk of long-term incontinence.     

Penile shortening after radical prostatectomy and Peyronie’s surgery

Penile shortening following radical prostatectomy and straightening procedures for Peyronie’s disease can be a devastating and unwelcome side effect of these operations. The majority of men undergoing radical prostatectomy for prostate cancer have a measured loss of penile length, which also can occur in men with Peyronie’s disease and may be exacerbated by surgery. Recent studies have investigated the mechanisms resulting in penile shortening, and various treatments have emerged to prevent and treat postoperative penile shortening. This article reviews the recent literature on penile length loss after radical prostatectomy and following correction of penile deformity for Peyronie’s disease.     

A centralized comparison of radical perineal and retropubic prostatectomy specimens: is there a difference according to the surgical approach?

PURPOSE: We performed a central review of pathology specimens from radical perineal and radical retropubic prostatectomies performed by a single surgeon. We determined whether differences exist in the 2 approaches in regard to the ability to obtain adequate surgical margins around the tumor and adequate extracapsular tissue around the prostate, and avoid inadvertent capsular incision. MATERIALS AND METHODS: The review included whole mount prostates from 60 patients who underwent radical retropubic prostatectomy and 40 who underwent radical perineal prostatectomy. The pathologist (N. S. G.) was blinded to the surgical approach. All prostatectomies were consecutive and performed by the same surgeon (H. J. K.). To ensure consistency of the pathological measurements patients were excluded from analysis if they had undergone preoperative androgen ablation or a nerve sparing procedure, leaving 45 retropubic and 27 perineal prostatectomy specimens for further evaluation. Pertinent clinical parameters were assessed and a detailed pathological analysis of each specimen was performed. RESULTS: In the retropubic and perineal groups 78% of the tumors were organ confined (stage pT2) with extracapsular extension (stage pT3) in the majority of the remaining patients. There was no significant difference in the positive margin rate for the retropubic and perineal procedures (16% and 22%, p = 0.53) or for Gleason 6 and 7 tumors only in the 2 groups (10% and 17%, respectively, p = 0.47). The capsular incision rate was 4% in each group. The distance of the tumor from the posterolateral margins and the amount of extracapsular tissue excised were equivalent in each group. Subgroups of patients with a prostate of less than 50 gm. and containing only low grade, low stage neoplasms were also analyzed. Subgroup analysis showed no difference in any variable. CONCLUSIONS: Radical perineal prostatectomy is comparable to radical retropubic prostatectomy for obtaining adequate surgical margins, avoiding inadvertent capsular incisions and excising adequate extracapsular tissue around tumor foci. Additional patient accrual and prostate specific antigen followup would further help validate the similar efficacy of the 2 surgical approaches as treatment for prostate cancer.     

Is robotically assisted laparoscopic radical prostatectomy less invasive than retropubic radical prostatectomy? Results from a prospective,unrandomized, comparative study

OBJECTIVES

To evaluate whether robotically assisted laparoscopic prostatectomy (RALP) is less invasive than radical retropubic prostatectomy (RRP), as experimental studies suggest that the acute phase reaction is proportional to surgery‐induced tissue damage.

PATIENTS AND METHODS

Between May and November 2006, all patients undergoing RRP or RALP in our department were prospectively assessed. Blood samples were collected 24 h before (T0), during surgery (T1), at the end of anaesthesia (T2), and 12 (T3) and 24 h after surgery (T4), and assayed for interleukin(IL)‐6 and IL‐1α, C‐reactive protein (CRP), and lactate. The Mann‐Whitney U‐, Student’s t‐ and Friedman tests were used to compare continuous variables, and the Pearson chi‐square and Fisher test for categorical variables, with a two‐sided P < 0.05 considered to indicate significance.

RESULTS

In all, 35 and 26 patients were assessed for RALP and RRP, respectively; the median (interquartile range) age was 62 (56–68) and 68.5 (59.2–71.2) years, respectively (P < 0.009). Baseline levels (T0) of IL‐1, IL‐6, CRP and lactate were comparable in both arms. IL‐6, CRP and lactates levels increased during both kinds of surgery. The mean IL‐6 and CPR values were higher for RRP at T1 (P = 0.01 and 0.001), T2 (P = 0.001 and <0.001), T3 (P = 0.002 and <0.001) and T4 (P < 0.001 and 0.02), respectively. Lactate was higher for RRP at T2 (P = 0.001), T3 (P = 0.001) and T4 (P = 0.004), although remaining within the normal ranges. IL‐1α did not change at the different sample times.

CONCLUSIONS

This study showed for the first time that RALP induces lower tissue trauma than RRP.     

Accurate control of the superficial and deep dorsal veins during radical retropubic prostatectomy: the Münster clamp technique

OBJECTIVE: To better control the superficial and deep dorsal veins during radical retropubic prostatectomy and, thus, to reduce blood loss. PATIENTS AND METHODS: A surgical technique is described which introduces a modified Babcock clamp to fully encompass all tissue above the prostatic capsule. In a prospective protocol, 30 consecutive patients (median age 64.5, range 57-76 years) were randomly assigned to either the standard technique or the Münster clamp method. Blood loss was estimated for the entire phase from teasing away the periprostatic fat until the apex had been mobilized. RESULTS: Median hemorrhage was 950 (range 300-2,100) ml for the standard technique and 800 (range 200-1,750) ml for the clamp procedure (Wilcoxon rank sum test, p = 0.17). CONCLUSIONS: The Münster clamp technique can reduce hemorrhage during radical retropubic prostatectomy. This method is easy to apply and is also suitable for cystoprostatectomy.     

Can leakage at the vesico‐urethral anastomosis be predicted after radical retropubic prostatectomy?

OBJECTIVES: To determine if low-risk patients can be identified in whom cystography is unnecessary to assess the integrity of the vesico-urethral anastomosis after radical retropubic prostatectomy (RRP), and thus who can have early catheter removal. PATIENTS AND METHODS: In all, 275 RRPs by one surgeon were analysed retrospectively; the surgical technique, blood loss and comorbidity were recorded. Cystograms were taken 8 days after RRP to assess vesico-urethral integrity before catheter removal. RESULTS: Of the 275 patients, 75% and 89% had cystography before 8 and 10 days after RRP, respectively; 71% of patients had no leak on cystography and were catheter-free at 8 days. Eighty-four leaks were identified, of which 25 (9.6%) were moderate or large. Previous transurethral prostatectomy, ischaemic heart disease, blood loss, mucosal eversion and preservation of the prostatic urethra were significant risk factors for developing a leak and were used to create a nomogram to assess the relative risk of leakage. However, none of the variables assessed, either alone or combined, could be used to predict which leaks were clinically significant. CONCLUSIONS: Leakage cannot be reliably predicted at the vesico-urethral anastomosis. Cystograms are necessary to identify clinically significant leaks at 8 days and should be taken if early catheter removal is being considered.