Quantitative and qualitative analysis of the recovery of potency after radical prostatectomy: effect of unilateral vs bilateral nerve sparing

OBJECTIVES

To analyse the impact of a ≈50% reduction of cavernous nervous tissue on the qualitative and quantitative recovery of sexual function after unilateral (UNS) and bilateral (BNS) nerve‐sparing robotic radical prostatectomy (RALP), by evaluating these differences in two groups treated with cautery and a cautery‐free technique (CFT).

PATIENTS AND METHODS

UNS was defined as wide‐excision of one neurovascular bundle (NVB). Only men aged ≤65 years with preoperative International Index of Erectile Function (IIEF‐5) scores of ≥22 were included. The cautery group comprised 42 men (of case numbers 1–125) undergoing RALP with cautery, and the CFT group (62 men of cases 151–350) had a cautery‐free technique along the NVB. Data were collected prospectively using validated self‐administered questionnaires. Potency was defined as two affirmative answers to: do you have erections ‘adequate for vaginal penetration?’ and ‘Are they satisfactory?’. Patient‐reported IIEF‐5 scores and quality of erections (i.e. an estimate of erection as 0%, 25%, 50%, 75% or 100% of preoperative fullness) were obtained after surgery.

RESULTS

In the cautery group, doubling the nerve volume increased potency by 1.36 times (UNS 50% vs BNS 68%). The results were similar in the CFT group as doubling nerve tissue increased potency by 1.15 times (UNS 80% and BNS 93%). At 24 months, comparing IIEF‐5 scores, there was no difference between UNS and BNS for the cautery group, at 19.6 (95% confidence interval 15.7–23.5) vs 18.9 (16.6–21.0), or the CFT group, at 22.0 (20.2–23.8) vs 21.0 (19.8–22.1).

CONCLUSIONS

Doubling the nerve volume only increased potency by 1.15–1.36 times for both the CFT and cautery groups. Furthermore, the quality of erections and IIEF‐5 scores did not vary appreciably with doubling of nerve tissue.     

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.     

Outcomes after robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy （RALRP） using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.     

Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Bilateral nerve‐sparing radical prostatectomy still represents an issue for urologists as the indications to perform it depend oft from the personal clinical experience. Moreover, until now data concerning bilateral and unilateral laparoscopic nerve‐sparing radical prostatectomy have been limited. This study states that bilateral laparoscopic intrafascial nerve‐sparing technique results in superior functional outcomes when compared with unilateral nsLRP and it suggests to prefer a bilateral nerve‐sparing technique in younger patients with low‐risk, organ‐confined prostate cancer.

OBJECTIVE

To evaluate the surgical and functional outcomes in bilateral and unilateral nerve‐sparing laparoscopic radical prostatectomy (nsLRP).

PATIENTS AND METHODS

Between January 2005 and May 2009, 457 nsLRP were performed at our clinic. In all, 250 patients underwent a bilateral nsLRP and 207 patients underwent an unilateral nsLRP. One surgeon performed all the operations. All patients presented at biopsy a localized prostate cancer. Demographic data and perioperative and postoperative measurements and outcomes were compared.

RESULTS

The operative times for bilateral nsLRP and unilateral nsLRP were 165 ± 45 min and 130 ± 25 min, respectively. The mean intra‐operative blood loss was 450 ± 300 mL and 270 ± 160 mL in the bilateral and unilateral nsLRP groups with a transfusion rate of 3% and 1%, respectively (P= 0.013). Conversion to open surgery was never deemed necessary. Postoperatively, the mean Gleason Score after nsLRP and distribution of tumour stages was similar in the two groups, and the frequency of positive margins in both groups did not present any statistically significant difference. At 12 months, a complete continence was reported in 97% of patients who underwent a bilateral nsLRP and in 88% of patients of the unilateral nsLRP group. At that time, 69% in the bilateral nsLRP and 43% in the unilateral nsLRP groups reported the ability to engage in sexual intercourse.

CONCLUSION

The bilateral laparoscopic intrafascial nerve‐sparing technique results in superior functional outcomes with regard to urinary continence and sexual potency, when compared with unilateral nsLRP, reporting similar oncological outcomes.     

Athermal early retrograde release of the neurovascular bundle during nerve-sparing robotic-assisted laparoscopic radical prostatectomy

While cancer control is the primary objective of radical prostatectomy, maintenance of sexual function is a priority for the majority of men presenting with prostate cancer. Preservation of the neurovascular bundles is the challenging and critical step of radical prostatectomy with regards to maintenance of potency. The objective of this study is to describe the surgical steps of our hybrid technique: athermal early retrograde release of the neurovascular bundle during nerve-sparing robotic-assisted laparoscopic radical prostatectomy. This technique involves releasing the neurovascular bundle in a retrograde direction from the apex toward the base of the prostate, during an antegrade prostatectomy. It is a hybrid of the traditional open and the laparoscopic approaches to nerve sparing. With this approach we are able to clearly delineate the path of the bundle and avoid inadvertently injuring it when controlling the prostatic pedicle. Our hybrid nerve-sparing technique combines aspects of the traditional open anatomical approach with those of the laparoscopic antegrade approach. The benefits of robotic technology allow a retrograde neurovascular bundle dissection to be performed during an antegrade radical prostatectomy. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Laparoscopic vs open retropubic intrafascial nerve‐sparing radical prostatectomy: surgical and functional outcomes in 300 patients

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

OBJECTIVE

To evaluate the surgical and functional outcomes in nerve‐sparing laparoscopic radical prostatectomy (nsLRP) and retropubic nsRP (nsRRP).

PATIENTS AND METHODS

Between January 2005 and November 2007, 150 nsLRP and 150 nsRRP were performed at our clinic. Demographic data, variables before and after surgery, and outcomes, were compared.

RESULTS

The operative duration was 165 min for nsLRP and 120 min for nsRRP. Although the nsLRP group had a lower frequency of positive margins, the difference was not statistically significant. At 1 year after surgery, complete continence was reported in 97% of patients who had nsLRP and in 91% who had nsRRP (P= 0.03). At that time, 66% of patients in the nsLRP and 51% in the nsRRP group reported being able to engage in sexual intercourse (P < 0.05). There were no statistical differences in surgical trauma in both groups.

CONCLUSION

Our study showed that nsLRP performed by expert surgeons results in better functional outcomes for continence and potency than for nsRRP. There was no significant difference between the surgical techniques in surgical trauma.     

Predicting erectile function outcome in men after radical prostatectomy for prostate cancer

What's known on the subject? and What does the study add? Over the last decade, the surgical treatment of prostate cancer has evolved towards minimal access surgery, particularly via a robot‐assisted technique. However, there is still debate regarding the true benefit for patients with respect to a functional outcome such as erectile function. The present prediction model provides a reliable estimation of the likelihood of regaining erectile function after prostatectomy.

OBJECTIVE

• ? To identify the reported rates of potency after prostatectomy in the recent literature for men without preoperative erectile dysfunction (ED) and to develop a statistical model for predicting the expected potency after prostatectomy.

MATERIALS AND METHODS

• ? A Medline search was conducted with the keywords ‘potency’ and ‘prostatectomy’ from 2003 to 2009.
• ? In total, 33 studies in the English language reporting pre‐ and postoperative erectile function were identified.
• ? Data from studies reporting outcome after open, laparoscopic and robot‐assisted prostatectomy were analyzed separately.
• ? Only data obtained from potent men before surgery were included in the analysis.

RESULTS

• ? In potent men before surgery, the main predictors of post‐treatment erectile function are age and time after treatment.
• ? The cumulative range of potency rates at 48 months for all ages (45–75 years) was 49–74% for open, 58–74% for laparoscopic and 60–100% for robotic prostatectomy.
• ? The predicted outcome differs by type of operation and patient age.

CONCLUSIONS

• ? Men aged <60 years have a significant likelihood of regaining erectile function after radical prostatectomy.
• ? The reported statistical model provides a reliable estimation of erectile function outcome after prostatectomy for men with localized prostate cancer and intact erectile function.

     

Age-stratified outcomes after robotic-assisted laparoscopic radical prostatectomy

We sought to evaluate post-operative return of urinary and sexual function in men undergoing robotic-assisted laparoscopic radical prostatectomy (RLRP). Prospective assessment of urinary continence and sexual function was performed in patients undergoing RLRP. Subjective assessment involved the use of the validated RAND-36 Item Health Survey/UCLA Prostate Cancer Index questionnaire. Questionnaires were completed pre-operatively and at 1, 3, 6 and 12 months post-operatively. Subset analyses were performed to assess the effect of age on functional outcomes. A total of 338 consecutive patients underwent RLRP between February 2003 and August 2005. Included patients for evaluation comprised of 21, 129, and 150 patients, aged <50, 50–59, and ≥60 years old, respectively. Kaplan–Meier curve analysis demonstrated that younger men (<60 years) achieved subjective continence significantly earlier than older age group (≥60 years) (P = 0.02). Continence rates, however, equalized among all age groups at 1 year follow-up. Younger men (<50 years) also demonstrated a quicker and greater return of sexual function (P = 0.01), which persisted through assessment at 1 year post-operatively. Our results suggest that younger men may have an earlier return of continence and potency when compared to men > 60 years. Despite this finding, continence outcomes appear to be equal among age groups after 1 year of follow-up. Moreover, men < 60 years continue to report superior potency outcomes compared to men > 60 years at 1 year post-operatively. Such findings are valuable in counseling patients undergoing RLRP.     

Trends in radical prostatectomy

The surgical treatment of prostate cancer ideally removes the entire cancer, avoids excessive blood loss or serious perioperative complications, and results in complete recovery of continence and potency. To achieve this, the surgeon must excise sufficient periprostatic tissue to cure the cancer while preserving the cavernosal nerves required for erectile function and the neuromusculature required for normal urinary and bowel function. Here we will examine recent trends in radical prostatectomy, focusing on surgical technique.     

The impact of nerve sparing on incidence and location of positive surgical margins in radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Nerve sparing radical prostatectomy has been associated with increased risk of positive surgical margins due to the close anatomical relationship of the neurovascular bundle to the posterolateral aspect of the prostatic fascia. Our study of 945 men who underwent radical prostatectomy be one experienced surgeon found no increased risk of positive surgical margins, whether the cancer was organ confined or extracapsular extension was present.

OBJECTIVE

• ? To examine whether nerve‐sparing surgery (NSS) is a risk factor for positive surgical margins (PSMs) in patients with either organ‐confined prostate cancer or extracapsular extension (ECE).

PATIENTS AND METHODS

• ? Clinicopathological outcome data on 945 consecutive patients treated with radical prostatectomy (RP) were prospectively collected.
• ? All patients underwent RP (bilateral, unilateral or non‐NSS) by one surgeon between 2002 and 2007.
• ? Risk of PSMs and their locations with respect to NSS was determined by multivariate logistic regression analysis adjusting for preoperative risk factors for PSMs within pT2, pT3a and pT3b tumours.

RESULTS

• ? Overall a PSM was identified in 19.6% of patients in an unscreened population with mean prostate‐specific antigen (PSA) level of 8.1 ng/mL.
• ? There was no significant difference in rates of PSMs between NSS groups on multivariate analysis (P= 0.147).
• ? There was no significant difference in pT2 (P= 0.880), pT3a (P= 0.175) or pT3b (P= 0.354) tumours.
• ? The only significant predictor of PSMs was preoperative PSA level (risk ratio 1.289, P= 0.006).
• ? There was no significant difference in the location of PSMs except for the pT3a group, where the patients that had bilateral NSS were at higher risk of a posterolateral PSM (P= 0.028).

CONCLUSIONS

• ? With appropriate selection of patients, NSS does not increase the risk of PSMs, whether the cancer is organ confined or ECE is present.
• ? The adverse impact of the NSS procedure in the hands of an experienced surgeon is minimal and is a realistic compromise to obtain the increase in health‐related quality of life offered by NSS.

     

Transperitoneal robotic-assisted laparoscopic radical prostatectomy and inguinal herniorrhaphy

Patients undergoing radical prostatectomy are at increased risk of development of post-operative inguinal hernias (IH). We present the largest series of transperitoneal combined robotic-assisted laparoscopic prostatectomy (RALP) and IH. After IRB approval, data from patients undergoing RALP at two centers were prospectively entered into a database and analyzed. IH were repaired robotically via a transperitoneal route with mesh. Between June 2002 and May 2007, 837 RALPs were performed, 80 of which included combined IH repair (9.6%), by two surgeons, T.A. and D.S. Forty-two patients (52.5%) had IH on pre-operative exam. Twenty-four hernias were left, 32 right, and 24 bilateral. Twenty-two patients had prior ipsilateral or contralateral herniorrhaphy. After dissection of the hernia sac, a swatch of flat Marlex mesh (n = 22), a polypropylene mesh plug (n = 19), an Ultrapro hernia system (n = 7), a Proceed coated mesh (n = 19), a 3D-Max (n = 37), a combination of both umbrella and flat mesh (n = 3), or suture alone (n = 2) was used. Inguinal herniorrhaphy added approximately 15 min of operative time in all cases. There was one hernia recurrence over an average follow-up period of 12.5 months (0.2–52 months). There was one complication attributable to IH repair—a urine leak which was attributed to anastomotic stretch due to reperitonealization. Urological surgeons should perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical inguinal hernias. Inguinal herniorrhaphy at the time of RALP is safe and should be routinely performed.     

Progression after radical prostatectomy for men in their thirties compared to older men

OBJECTIVE

To assess the biochemical outcome after radical prostatectomy (RP) specifically for men aged 30–39 years, as previous studies suggest that prostate cancer in young men might be more aggressive.

PATIENTS AND METHODS

From a large (15 899) database of RPs (1975–2007) we identified 42 men aged 30–39, 893 aged 40–49, 4085 aged 50–59, 3766 aged 60–69, and 182 men aged ≥70 years old. The clinical characteristics and treatment outcomes were compared between men aged 30–39 years and older men.

RESULTS

Among the men in their thirties, 81% had organ‐confined disease in the RP specimen, vs 62% of men aged ≥40 years. At a mean follow‐up of 5 years, there was biochemical progression in 4.8% of men in their thirties and 16.1% of men age ≥40 years (P = 0.055). The corresponding 5‐year biochemical progression‐free survival estimates were 95% for men in their thirties and 83% for men aged ≥40 years (P = 0.045). On multivariate analysis, increasing age was a significant independent predictor of biochemical progression.

CONCLUSION

Contrary to earlier reports, in the present study men in their thirties did not have more aggressive disease. Instead, they had more favourable pathological features and progression‐free survival rates than their older counterparts. After controlling for other prognostic variables on multivariate analysis, being in the fourth decade was independently associated with a lower risk of biochemical progression. These results suggest that early aggressive treatment for these patients with a long life‐expectancy is associated with favourable long‐term biochemical outcomes.     

Urinary continence recovery after radical prostatectomy – anatomical/reconstructive and nerve‐sparing techniques to improve outcomes

In an editorial board‐moderated debate format, two experts in prostate cancer surgery are challenged with presenting the key strategies in radical prostatectomy that improve urinary functional outcomes. Dr Bernardo Rocco was tasked with arguing the facts that support the anatomical preservation and reconstruction steps that improve urinary continence. Drs Christian Pavlovich and Sasha Druskin were tasked with arguing the facts supporting neurovascular bundle and high anterior release surgical planes that improve urinary continence. Associate Editor John Davis moderates the debate, and outlines the current status of validated patient questionnaires that can be used to evaluate urinary continence, and recent work that allows measuring what constitutes a ‘clinically significant’ difference that either or both of these surgical techniques could influence. A review of raw data from a publication from Dr Pavlovich's team demonstrates how clinically relevant differences in patient‐reported outcomes can be correlated to technique. A visual atlas is presented from both presenting teams, and Dr Davis demonstrates further reproducibility of technique. A linked video on this concept is available as a supplementary file.     

Heparin prophylaxis and the risk of venous thromboembolism after robotic-assisted laparoscopic prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? The incidence of deep venous thrombosis (DVT) in major urological surgery has decreased over time with the introduction of pharmacological prophylaxis, early mobilization, and the use of sequential mechanical compression devices. We examined the value of heparin prophylaxis in robotic assisted laparoscopic prostatectomy (RALP), where the risk of DVT is already low. The rate of thromboemolic events within 30 days was 0.6% in this series. Heparin did not influence estimated blood loss, haematrocrit change, or length of stay. The incidence of thromboembolism is low after RALP, which may obviate the use of heparin prophylaxis. However, its use appears to be safe and does not affect surgical outcomes.

OBJECTIVE

? The incidence of venous thromboembolism (VTE) after robotic‐assisted laparoscopic prostatectomy (RALP) in patients receiving perioperative heparin prophylaxis was compared with those who did not receive such prophylaxis.

MATERIALS AND METHODS

? Between July 2007 to February 2010, a total of 307 RALPs were performed at our institution by two surgeons. A total of 187 patients operated on by surgeon 1 received perioperative heparin prophylaxis, whereas 120 patients operated on by surgeon 2 did not receive any. ? All demographic, clinical and pathological data were prospectively recorded, whereas the incidence of venous thromboembolism within 30 days of the operation was retrospectively reviewed. Evaluation for potential VTE was based on clinical symptoms.

RESULTS

? Cohorts were comparable with respect to PSA, clinical stage, preoperative Gleason score, body mass index, smoking status, pathological stage, path Gleason score and margin status. A total of two thromboemoblic events occurred (0.6%) within 30 days of surgery (one in each arm of the study). ? Heparin prophylaxis did not influence estimated blood loss (P= 0.076) or haematocrit change from preoperative levels (P= 0.378). Length of stay was comparable between the two groups (1.4 vs 1.3 days; P= 0.159).

CONCLUSION

? The incidence of thromboembolism is low after RALP, which may obviate the need for heparin prophylaxis. However, its use is safe and does not impact surgical outcomes. Larger series are needed to confirm the results obtained in the present study.     

Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Thus far, no institution has investigated the impact of the most commonly used surgical techniques – open, laparoscopic and robotic radical prostatectomy – on biochemical outcome. However, recent data from large meta‐analysis suggest that the impact of the chosen surgical technique on biochemical outcome is minimal and statistically not relevant. We are the first to apply the method of propensity score matching in the urology literature to compare three different surgical techniques. This method is intended to simulate a randomized trial which is unlikely to be undertaken for radical prostatectomies. We confirmed previous data that the surgical technique does not seem to have an impact on biochemical outcome following radical prostatectomy.

OBJECTIVE

? To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot‐assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes.

PATIENTS AND METHODS

? A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate‐specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. ? Pathological and biochemical outcomes of the three cohorts were examined.

RESULTS

? Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). ? In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. ? Kaplan–Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups.

CONCLUSIONS

? RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence‐free survival between groups. ? Further prospective studies are warranted to determine whether any particular technique is superior with regard to long‐term clinical outcomes.     

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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