Die nerverhaltende radikale retropubische Prostatektomie Ergebnisse nach Patientenbefragung

Improved selection criteria have led to an increasing number of nerve-sparing radical retropubic prostatectomies (RRP) in patients with clinically localized prostate cancer. The results based on patient questionnaires regarding postoperative erectile function are described. Between January 1992 and March 1999, 366 patients (mean age: 62.5 years) underwent uni- or bilateral nerve-sparing RRP at our institution. For evaluation of postoperative patient-reported rates of sexual and erectile function, a questionnaire was used after a follow-up of at least 12 months. Data of five operation periods were analyzed. The results of the unilateral procedure for the five operation periods revealed consistent rates of 13-29% for erections sufficient for intercourse. Bilateral nerve-sparing procedures were almost exclusively performed in periods 3 to 5; only four patients from period 2 underwent the bilateral procedure. The rates of intercourse-sufficient erections were 25% (period 2), 61% (period 3), 50% (period 4), and 52% (period 5), respectively. The results of the unilateral procedure were disappointing. However, the bilateral nerve-sparing method achieved much better results inasmuch as about 50% of the patients reported recovery of erections sufficient for sexual intercourse.     

Erektionsstatus nach nervenerhaltender radikaler Prostatektomie

The time lapse before recovery of erectile function after nerve-sparing radical prostatectomy is still under debate. Several pathophysiologies are postulated for postoperative erectile function rehabilitation. In prospective studies we measured nocturnal penile tumescence (NPTR) in the acute phase during the first night after catheter removal subsequent to nerve-sparing radical prostatectomy to assess the neuronal organic erectile integrity.Eighteen sexually active patients suffering from local prostate cancer underwent bilateral and unilateral nerve-sparing retropubic radical prostatectomy. All patients completed an IIEF-5 questionnaire concerning erectile function preoperatively. The transurethral catheter was removed 14 days after surgery, and nocturnal penile tumescence was measured with an erectometer (Rigi-Scan) in each patient during the following night. None of these patients received any comedication interacting with erectile function.The preoperative IIEF score was >18 in all patients. After catheter removal, 17 of 18 patients (95%) had nocturnal penile radial rigidity >70% that persisted for >10 min during one night. In a control of four patients without a nerve-sparing procedure, no nocturnal erections were recorded.The measurement of NPTR in the acute phase after nerve-sparing radical prostatectomy showed retained erectile function even during the "first" night after catheter removal. Our findings are important for an appropriate choice of pharmacotherapy for optimal recovery of erectile function. In cases of early penile erections, the cavernous nerve had been well preserved during surgery providing good neuronal integrity, and PDE-5 inhibitors can support organic rehabilitation of the corpus cavernosum. In the absence of early penile erections, the neuronal integrity of the cavernous nerve is presumed to be impaired. In this case, additional injection therapy should be chosen to support recovery of spontaneous erectile function.     

Penile vascular evaluation and sexual function before and after radical retropubic prostatectomy: 5-year follow-up

Sexual dysfunction is common after surgery for prostate cancer. The aetiology of changes in sexual potency after radical prostatectomy is probably multifactorial, including neurogenic, vascular and psychosexual factors. A prospective study was designed to investigate haemodynamic and psychosexual changes before and after radical retropubic prostatectomy (RRP) for organ-confined prostate cancer. Penile haemodynamic evaluation and an assessment of sexual excitement were performed preoperatively and 3 months after RRP by colour Doppler ultrasonography (CDU) with visual erotic stimulation combined with a single intracavernous injection of a mixture of papaverine/phentolamine. Questionnaires on sexual function [International Index of Erectile Function (IIEF)], general health and quality of life were sent to the patients preoperative, 3 months and 5 years after operation. Forty-eight men participated in the study. Mean age was 62.6 years (range 55-69). CDU did not show any significant reduction in mean peak systolic flow velocity and mean resistance index. From the men who preoperatively had normal arterial inflow 18% developed arteriogenic insufficiency. Some form of veno-occlusive insufficiency and low resistance indices were already present in the majority of normal potent men preoperatively. Surgical technique did not influence penile arterial blood flow after the operation. Three months and 5 years postoperatively, there was a highly significant reduction in erectile function, intercourse satisfaction, overall satisfaction, orgasmic function and sexual desire. However, with respect to the outcome at 3 months there was a significant improvement of orgasmic function 5 years after operation, especially after a bilateral nerve sparing procedure. Erections sufficient for vaginal penetration (questions 3 and 4 of the IIEF, score >or=8) improved from 2% to 11% 3 months and 5 years after RRP respectively. Total IIEF score was significantly better after a bilateral nerve-sparing procedure compared with non-nerve sparing. No structural vascular changes were observed 3 months after operation. Vascular factors appear to be less important in the aetiology of ED after RRP. There seems to be a trend of a better improvement of sexual function over time, especially orgasmic function, in patients with bilateral nerve-sparing surgery.     

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.     

Nocturnal tumescence: a parameter for postoperative erectile integrity after nerve sparing radical prostatectomy

PURPOSE: The exact process and time required for rehabilitation of erectile function after nerve sparing prostatectomy remain unclear to date. Different theories of the pathophysiology of postoperative erectile dysfunction are currently being discussed. In a prospective study we performed recordings of nocturnal penile tumescence and rigidity during the acute phase after nerve sparing radical prostatectomy, ie in the first night after removal of the catheter, to assess the organic penile integrity. MATERIALS AND METHODS: In 27 patients with local prostate carcinoma who had been sexually active before the intervention, we performed unilateral or bilateral nerve sparing radical prostatectomy. Preoperative sexual function of all patients was evaluated by the International Index of Erectile Function-5 questionnaire. On the day of catheter removal (postoperative day 7 to 14) an NPTR recording was performed on the following night with an erectometer (RigiScan). RESULTS: All patients had a preoperative IIEF score greater than 18. After removal of the catheter 25 of 27 patients (93%) showed 1 to 5 nocturnal rigidity increases by greater than 70% for at least 10 minutes. In a control group of 4 patients who underwent radical prostatectomy without nerve sparing, no nocturnal erections were recorded. CONCLUSIONS: NPTR recording during the acute phase after nerve sparing radical prostatectomy showed residual erectile function as early as the first night after catheter removal. These results are significant for selecting adequate pharmacological treatment for optimal therapy and rehabilitation of satisfactory erections and sexual function. In cases of early nocturnal tumescence, application of a PDE5 inhibitor can support successive organ rehabilitation. However, if tumescence does not occur, penile injection therapy is recommended.     

Efficacy of unilateral nerve sparing in radical perineal prostatectomy

AIM: We determine the efficacy of unilateral nerve-sparing radical perineal prostatectomy in preserving the sexual function. PATIENTS AND METHODS: Ninety-two patients with histologically confirmed unilateral prostate cancer were scheduled for contralateral nerve preservation. The perioperative morbidity was assessed using the patients' chart reviews. Postoperative health-related quality of life, urinary continence, and potency were evaluated prospectively with questionnaires provided before surgery and then after 6, 12, and 24 months. RESULTS: Unilateral nerve preservation was performed in 88 of the 92 patients. Due to extensive scarring or prostatic size, the procedure was terminated as regular radical prostatectomy in 4 other patients. The perioperative complication rate was low and of minor significance, except in 1 patient who experienced a significant myoglobulinuria due to a prolonged procedure. Blood transfusions were necessary in 5 (5.4%) patients. Ureteral reimplantation was performed in 1 patient because of ureteral stricture. Positive surgical margins were present in 12 (18%) of 67 pT2 patients and in 8 (35%) of 23 pT3 patients. A proportion of 48% (15/31) of the patients followed for more than 24 months and who had a good erectile function prior to surgery reported unassisted sexual intercourse. However, only 4 of these patients were completely satisfied with all aspects of sexual performance, as asked in a short version of the International Index of Erectile Function questionnaire. CONCLUSIONS: Unilateral nerve-sparing radical perineal prostatectomy is technically feasible and yields excellent results in terms of potency preservation for prostates <60 ml. However, the quality of erections is decreased, even in patients with erections sufficient for intercourse. Hence, appropriate sexual counseling in conjunction with medical therapy should be offered to all patients.     

Recovery of sexual function after nerve-sparing radical prostatectomy or cystectomy

BACKGROUND: The recovery of sexual function (erectile function and frequency of sexual intercourse) over time after nerve-sparing radical prostatectomy or cystoprostatectomy was evaluated. METHODS: Forty-nine consecutive patients with clinically localized prostate cancer and muscle-invasive bladder cancer were treated with radical prostatectomy and radical cystoprostatectomy with a nerve-sparing procedure. Erectile function was evaluated by the circumferential change of the penis during nocturnal penile tumescence (NPT value) with an erectometer before and after surgery. Erectile function and the frequency of sexual intercourse were also evaluated with a self-administered questionnaire before and after surgery. Multivariate analysis by Cox's proportional hazards model was used to evaluate the factor(s) that affected the recovery of erectile function and sexual intercourse. RESULTS: The recovery rates of erectile function were 49% at 3 years and 79% at 5 years. For recovery of sexual intercourse the rates were 36% at 3 years and 57% at 5 years. Multivariate analysis revealed that the preoperative NPT value was the only independent factor which significantly affected the recovery of erectile function. The age at surgery was a significant factor for recovery of sexual intercourse. CONCLUSION: Nerve-sparing operations can often, but not always, provide preservation or recovery of erectile function for patients who receive radical prostatectomy or cystoprostatectomy. Recovery of erectile function depends upon the preoperative NPT value and recovery of sexual intercourse depends upon the age of the patient.     

Impact of penile rehabilitation with low-dose vardenafil on recovery of erectile function in Japanese men following nerve-sparing radical prostatectomy

Erectile dysfunction （ED） is a major complication after radical prostatectomy （RP）; however, debatecontinues regarding the efficacy of penile rehabilitation in the recovery of the postoperative erectile function （EF）. This study includeda total of 103 consecutive sexually active Japanese men with localized prostate cancer undergoing nerve-sparing RP, and analyzed the postoperative EF, focusing on the significance of penile rehabilitation. In this series, 24 and 79 patients underwent bilateral and unilateral nerve-sparing RPs, respectively, and 10 or 20 mg of vardenafil was administered to 35 patients at least once weekly, who agreed to undergo penile rehabilitation. Twelve months after RP, 48 （46.6%） of the 103 patients were judged to have recovered EF sufficient for sexual intercourse without any assistance. The proportion of patients who recovered EF in those undergoing penile rehabilitation （60.0%） was significantly greater than that in those without penile rehabilitation （38.2%）. Of several parameters examined, the preoperative International Index of Erectile Function-5 （IIEF-5） score and nerve-sparing procedure were significantly associated with the postoperative EF recovery rates in patients with and without management by penile rehabilitation, respectively. Furthermore, univariate analysis identified the preoperative IIEF-5 score, nerve-sparing procedure and penile rehabilitation as significant predictors of EF recovery, among which the preoperative IIEF-5 score and nerve-sparing procedure appeared to be independently associated with EF recovery. Considering these findings, despite the lack of independent significance, penile rehabilitation with low-dose vardenafil could exert a beneficial effect on EF recovery in Japanese men following nerve-sparing RP.     

Sexual function before and after radical retropubic prostatectomy: A systematic review of prognostic indicators for a successful outcome

OBJECTIVES: Erectile dysfunction is common after surgery for prostate cancer. Potency rates after radical retropubic prostatectomy (RRP) vary widely among different studies. Since the introduction of the nerve-sparing technique potency rates have increased. Erectile function recovery rates for selected groups of patients are high. However, studies from community practices have shown less favourable outcomes after RP. METHODS: We have performed a systematic review of the literature concerning sexual function after RRP and focused on prognostic indicators for a successful sexual outcome. RESULTS: Most important prognostic factors for the return of potency after RRP are preservation of the neurovascular bundles, age of the patient and sexual function before the operation. Neurogenic and vasculogenic factors seem to play an important role in the aetiology of the erectile dysfunction after surgery. The role of preserving the accessory pudendal artery is not certain, although some investigators found significant hemodynamic changes after sacrificing the accessory pudendal artery. Colour Doppler ultrasound studies in combination with intracavernous injection of vasoactive drugs or after PDE-5 inhibitors administration has shown to be a reliable test for vascular factors. CONCLUSIONS: After bilateral nerve-sparing RRP sexual potency is preserved in 31-86% of sexually active men with organ-confined disease. The aetiology of impotence following RRP is multifactorial, but neurogenic factors seem to play a major role. Vascular factors may be of importance in selective cases. Colour Doppler ultrasound appears to be the most reliable, non-invasive diagnostic test for erectile dysfunction after RRP in patients who do not respond to pharmacotherapy.     

Role of sildenafil citrate in treatment of erectile dysfunction after radical retropubic prostatectomy

BACKGROUND: Sildenafil citrate was introduced as a treatment for erectile dysfunction in April 1998 in the United States and has been available since March 1999 in Japan. In this article, we assess the efficacy of sildenafil in the treatment of erectile dysfunction in Japanese men after radical retropubic prostatectomy for localized prostate cancer. METHODS: Of 106 men who underwent radical retropubic prostatectomy between January 1994 and March 2000, 43 were prescribed sildenafil at their request after radical retropubic prostatectomy. Medication was initiated at 25 mg, and if this was ineffective, the dose was increased to 50 mg. Of the patients, 18 underwent bilateral and 21 unilateral nerve sparing (NS) procedures, while in 4 patients, a non-NS procedure was performed. These patients were interviewed using a questionnaire about their response to sildenafil and using the 5-item International Index of Erectile Function (IIEF-5) questionnaire. RESULTS: Thirty-three of the 43 patients were eligible for evaluation of the efficacy of sildenafil and 27 completed the IIEF-5 questionnaires. Sildenafil at 50 mg had a better effect on sexual function than 25 mg in most Japanese patients. Of the 16 patients who underwent bilateral NS procedures, 10 (62.5%) had improved ability for intercourse and 3 (18.8%) had improved erections. Of the 13 patients who underwent unilateral NS procedures, 7 (53.8%) had improved ability for intercourse and 4 (30.8%) had improved erections. None of the 4 patients who underwent non-NS procedures had a positive response. Of 24 patients with positive response to sildenafil, 3 (12.5%) did not have to take sildenafil after receiving it because they did not require it for intercourse. Mean IIEF-5 score increased from 4.3 to 11.4 (P < 0.0001). Patient age, time since surgery, PSA and pathological stage did not have statistically significant effects on outcome. The most commonly cited adverse effect was headache (21%). CONCLUSION: Sildenafil is equally effective for erectile dysfunction in Japanese patients who have undergone bilateral and unilateral NS procedures, and aids recovery of natural erectile function after radical retropubic prostatectomy. However, non-NS procedure patients had no response to sildenafil. This study suggested that sildenafil is well tolerated and should be initially used for treatment of Japanese men with erectile dysfunction after radical retropubic prostatectomy.     

Papaverine testing of impotent patients following nerve-sparing radical prostatectomy

To investigate the etiology of impotence following nerve-sparing radical retropubic prostatectomy we performed papaverine testing on 23 patients who did not regain erections sufficient for vaginal penetration. Intervals from surgery to testing ranged from 3 to 30 months, with an average of 9 months. All patients achieved some degree of tumescence. In response to intracavernous papaverine injection only 1 patient (5 per cent) obtained an erection equivalent to the preoperative state. Of 18 patients who were fully potent preoperatively 8 (44 per cent) achieved an erection less than normal but judged to be sufficient for intercourse by the examining physician. Twelve patients, including 2 who were not fully potent preoperatively, had erections of poor quality insufficient for vaginal penetration. The results suggest that in most of these patients postoperative erectile dysfunction is predominantly vasculogenic in origin. Thus, factors other than injury to the neurovascular bundles may be responsible for postoperative impotence.     

Utility of Rigiscan and papaverine in diagnosis of erectile impotence

The Rigiscan machine was used to measure nocturnal penile tumescence and rigidity in 41 men referred for evaluation of erectile impotence. In 6 patients, the Rigiscan was compared with the Tumistore and Snap-Gauge bands. Two patients achieved significant tumescence as measured by Tumistore, and 3 had significant tumescence as indicated by the breaking of two or three of the Snap-Gauge bands. None of these men achieved sufficient rigidity for intercourse as measured by the Rigiscan. Fourteen patients with organic impotence received intracorporeal injections of papaverine and were then monitored by Rigiscan. Six of the 14 were noted to have a Peyronie plaque. Of the remaining 8, 6 of these men achieved lasting erections sufficient for intercourse. The other 2 had erections that lasted ten minutes and were considered to have venous leak impotence. All patients with Peyronie disease had tumescence after papaverine injection, but in 5 the penis became rigid only at the base. Complications of papaverine injection were uncommon and minor. The Rigiscan and papaverine are useful in the diagnosis and management of erectile impotency.     

Factors affecting erectile function after radical retropubic prostatectomy: results from 1620 consecutive patients

OBJECTIVE

To report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function.

PATIENTS AND METHODS

From January 1992 to October 2006, one surgeon performed RRP with a nerve‐sparing technique where feasible. Men with erectile dysfunction before surgery, salvage RRPs, those not having a nerve‐sparing procedure, neoadjuvant or adjuvant therapy within 6 months of RRP and a follow‐up of <6 months were excluded from the analyses. Erectile function was evaluated by the surgeon when possible or by an annual questionnaire. Potency was defined as erectile function sufficient for intercourse with or without a phosphodiesterase‐5 inhibitor.

RESULTS

Of 619 men who had a bilateral and of 178 who had a unilateral nerve‐sparing RRP, 72% and 53%, respectively, were potent. When stratifying by age groups (≤49, 50–59, 60–69 and ≥70 years) potency rates were 86%, 76%, 58% and 37%, respectively. Potency was more common after bilateral than unilateral nerve‐sparing RRP in all age groups (P < 0.001). Age, bilateral nerve‐sparing (odds ratio 2.9) and surgeon experience were associated with potency in a multivariate analysis.

CONCLUSION

Careful patient selection and meticulous surgical technique are essential to achieve the right balance between cancer control and morbidity. The patient’s age, nerve‐sparing RRP and the surgeon’s experience were the significant predictors of return of potency after RRP.     

Interposition of sural nerve restores function of cavernous nerves resected during radical prostatectomy

PURPOSE: The permanent loss of erectile function when both neurovascular bundles are widely resected at radical prostatectomy as well as the successful use of autologous nerve grafts in reconstructive surgery led us to perform bilateral nerve grafts in an effort to restore erectile function in potent patients treated for prostate cancer who underwent radical retropubic prostatectomy and resection of both neurovascular bundles. MATERIALS AND METHODS: Radical retropubic prostatectomy with deliberate resection of both neurovascular bundles was recommended for high grade, locally extensive prostate cancer in 9 select, sexually active men who reported normal erectile function. After the prostate was removed but before vesicourethral anastomosis an autologous sural nerve graft was interposed between the divided ends of the cavernous nerves bilaterally. Erectile function was monitored by patient interview, questionnaire and nocturnal penile tumescence testing after the operation. RESULTS: Four to 5 months postoperatively patients noticed slowly improving spontaneous erections, as manifested by mild tumescence regularly every several hours. Nocturnal penile tumescence testing with the RigiScan device at 4 to 6 months in 2 cases revealed erections that approached minimal criteria for normalcy. Approximately 14 months after surgery a rigid erection sufficient for penetration and intercourse developed in 1 patient. He described this event as "an erection of substance-hard, not just fluffy." CONCLUSIONS: We have developed a technique using sural nerve grafts to restore continuity of the cavernous nerves, which are resected during radical prostatectomy. The early return of spontaneous partial erections in our patients suggests that interposition nerve grafts may enhance the recovery of erectile function when the neurovascular bundles are resected.     

Efficacy and safety of fixed-dose oral sildenafil in the treatment of sexual dysfunction in depressed patients with idiopathic Parkinson's disease

OBJECTIVE AND METHODS: The efficacy and safety of oral Sildenafil, a potent inhibitor of phosphodiesterase type 5, were evaluated in depressed men with idiopathic Parkinson's disease and erectile dysfunction. Thirty-three men were enrolled in a 4-month prospective, open-label, fixed-dose study, and received 50mg of Sildenafil in the home setting approximately 1 hour before sexual activity, not more than once daily. Efficacy was determined by responses to question 3 (ability to achieve an erection) and question 4 (ability to maintain an erection) of the 15-item International Index of Erectile Function (IIEF). Other measures of efficacy included the five sexual function domains of IIEF, a global efficacy question, the Beck Depression Inventory (BDI) and the Hamilton Depression Rating Scale-21 (HDRS-21). RESULTS: At the end of the study, improved erections were reported by 84.8% of patients. Sildenafil significantly increased patients' ability to achieve and maintain erections. Significant improvements were also observed in the IIEF domains for erectile function, orgasmic function, intercourse satisfaction and overall sexual satisfaction. BDI and HDRS scores improved from baseline to the end of the study. A clear improvement of depressive symptoms was observed in 75% of patients. Sildenafil was well tolerated in all the patients. CONCLUSIONS: Treatment with oral Sildenafil improves erectile function and, indirectly, depressive symptoms in patients with idiopathic Parkinson's disease stages 1-3, and is well tolerated.     

Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function

To assess the efficacy of vacuum constriction devices (VCD) following radical prostatectomy (RP) and determine whether early use of VCD facilitates early sexual activity and potentially earlier return of erectile function. This prospective study consisted of 109 patients who underwent nerve-sparing (NS) or non-nerve-sparing (NNS) RP between August 1999 and October 2001 and developed erectile dysfunction following surgery. The patients were randomized to VCD use daily for 9 months (Group 1, N=74) or observation without any erectogenic treatment (Group 2, N=35). Treatment efficacy was analyzed by responses to the Sexual Health Inventory of Men (SHIM) (abridged 5-item International Index of Erectile Function (IIEF-5)), which were stratified by the NS status. Patient outcome regarding compliance, change in penile length, return of natural erection, and ability for vaginal intercourse were also assessed. The mean patient age was 58.2 years, and the minimum follow-up was 9 months. Use of VCD began at an average of 3.9 weeks after RP. In Group 1, 80% (60/74) successfully used their VCD with a constriction ring for vaginal intercourse at a frequency of twice/week with an overall spousal satisfaction rate of 55% (33/60). In all, 19 of these 60 patients (32%) reported return of natural erections at 9 months, with 10/60 (17%) having erections sufficient for vaginal intercourse. The abridged IIEF-5 score significantly increased after VCD use in both the NS and NNS groups. After a mean use of 3 months, 14/74 (18%) discontinued treatment. In Group 2, 37% (13/35) of patients regained spontaneous erections at a minimum follow-up of 9 months after surgery. However, only four of these patients (29%) had erections sufficient for successful vaginal intercourse and rest of patients (71%) sought adjuvant treatment. Of the 60 successful users, 14 (23%) reported a decrease in penile length and circumference at 9 months (range, 4-8 months) compared to 12/14 (85%) among the nonresponders. However, in control group 22/35 reported decrease in penile length and circumference. Early use of VCD following RP facilitates early sexual intercourse, early patient/spousal sexual satisfaction, and potentially an earlier return of natural erections sufficient for vaginal penetration.     

Significance of erection hardness score as a diagnostic tool to assess erectile function recovery in Japanese men after robot-assisted radical prostatectomy

The objective of this study was to characterize time-dependent recovery of erectile function in Japanese patients following robot-assisted radical prostatectomy (RARP) using the erection hardness score (EHS). This study prospectively included 170 Japanese patients with localized prostate cancer (PC) undergoing RARP without neoadjuvant hormonal therapy. The erectile function of each patient was assessed based on the International Index of Erectile Function-5 (IIEF-5) and EHS at the baseline and on every visit to an outpatient clinic after RARP. In this series, potency was defined as the ability to have an erection sufficient for intercourse, corresponding to EHS ≥3, while patients with EHS ≥2 were regarded as those with erectile function. Of these 170 patients, 20 and 75 underwent bilateral and unilateral nerve-sparing procedures, respectively; however, non-nerve-sparing procedures were performed in the remaining 75. A proportional increase in the IIEF-5 score according to EHS was noted at 24 months after RARP. At 6, 12 and 24 months after RARP, the recovery rates of erectile function were 11.9, 21.7 and 35.8 %, respectively, while those of potency were 3.8, 9.8 and 13.7 %, respectively. Of several factors examined, the age, preoperative IIEF-5 score and nerve-sparing procedure were identified as independent predictors of erectile function recovery. These findings suggest that favorable erectile function recovery could not be achieved in Japanese PC patients even after the introduction of RARP; therefore, it might be preferable for such a cohort to use EHS rather than IIEF-5 as an assessment tool for the postoperative recovery of erectile function.     

Treatment of erectile dysfunction after radical prostatectomy with sildenafil citrate (Viagra)

Objectives. To determine whether the response to the new oral medication, sildenafil citrate (Viagra), was influenced by the presence or absence of the neurovascular bundles, as recent reports on its success did not specify the efficacy of the drug in patients with erectile dysfunction after radical prostatectomy.Methods. Baseline and follow-up data from 28 healthy patients presenting with erectile dysfunction after radical prostatectomy were obtained. Patients receiving any neoadjuvant/adjuvant hormones or adjuvant radiation therapy were excluded. Patients reported what their erectile status was before surgery, before sildenafil therapy, and after using a minimum of four doses of sildenafil. Both the patients and their spouses were interviewed using the Cleveland Clinic post-prostatectomy questionnaire, which includes questions about response to therapy, duration of intercourse, spousal satisfaction, side effects, and related topics. The patients were compared on the basis of the type of surgical procedure they had undergone—nerve sparing or non-nerve sparing. A positive response to sildenafil was defined as erection sufficient for vaginal penetration.Results. Of the 15 patients who had bilateral nerve-sparing procedures, 12 (80%) had a positive response to sildenafil, with a mean duration of 6.92 minutes of vaginal intercourse. These 12 patients also reported a spousal satisfaction rate of 80%. All 12 of the responders had a positive response within the first three doses, and 10 of the 12 responded with the first or second dose. None of the 3 patients who had undergone a unilateral nerve-sparing procedure responded, nor did any of the 10 patients who had undergone a non-nerve-sparing procedure. The two most common side effects of the drug were transient headaches (39%) and abnormal color vision (11%). No patients discontinued the medication because of side effects.Conclusions. Successful treatment of erectile dysfunction in a patient after prostatectomy with sildenafil citrate may depend on the presence of bilateral neurovascular bundles. No patient who had undergone a non-nerve-sparing procedure responded. Whether patients who undergo unilateral nerve-sparing procedures will respond to sildenafil is still unclear because of the small number of patients in our study. These findings should encourage urologists to continue to perform and perfect the nerve-sparing approach. The ability to restore potency with an oral medication after radical prostatectomy will impact our discussion with the patient on the surgical morbidity of radical prostatectomy.     

Urinary continence and erectile function: a prospective evaluation of functional results after radical laparoscopic prostatectomy

OBJECTIVES: To evaluate prospectively functional results (urinary continence and erectile function) after laparoscopic radical prostatectomy. METHODS: From 1998 to 2001, 235 patients underwent laparoscopic radical prostatectomy for localized prostate cancer. All of them completed a confidential, self-administered questionnaire regarding urinary continence and erectile function before, and 1, 3, 6, and 12 months after surgery. Results were analyzed separately for day and night for urinary continence and status of neurovascular bundles as well as age for erectile function. RESULTS: To date, 100 consecutive patients have completed all questionnaires. Diurnal and nocturnal urinary continence have increased to 90% and 97% one year after surgery. Overall, 49.3% of the 77 patients, who were potent preoperatively, and did not receive any form of adjuvant therapy, had erections sufficient for intercourse one year after surgery. Potency rates were 38.4%, 53.8% and 58.8% after no, unilateral, and bilateral nerve bundle preservation, respectively. For younger patients (<60 years) with unilateral and bilateral neurovascular bundle preservation, potency rates were 75% and 83.3%, respectively. CONCLUSION: One year after laparoscopic radical prostatectomy, urinary continence rate is 90% during the day and 97% during the night. Overall potency rates after bilateral preservation of neurovascular bundles are 58.8% and 83.8% for the subgroup of younger patients (<60 years).     

Erectile function after non-nerve-sparing radical prostatectomy: fact or fiction?

OBJECTIVE: To evaluate the potency in patients after radical perineal prostatectomy with wide excision of both neurovascular bundles. MATERIAL AND METHODS: In this prospective study, a quality-of-life questionnaire was completed by 128 patients at the preoperative stage, and 6 and 12 months postoperatively. Ten questions concerning the patient's sexuality were included on the pre- and both postoperative questionnaires. In addition, 6 patients who recorded some erectile function were sent a separate questionnaire containing eight more detailed questions. RESULTS: Preoperatively, 74/128 (57.8%) patients reported erections sufficient for sexual intercourse, and of these 74, 6 (8.1%) described having spontaneous erections 1 year postoperatively. These spontaneous erections occurred 1-5 times per week. The reply to the separate mailing made clear that the reported erections were insufficient for intercourse. CONCLUSIONS: Patients undergoing standardized radical prostatectomy with wide excision of the neurovascular bundle have a very small chance of spontaneous erections sufficient for intercourse postoperatively.