Bilateral Nerve-sparing Procedure Research Articles

Comparative evaluation of continence and potency after radical prostatectomy: Robotic vs. laparoscopic approaches, validating LAP-01 trial

BackgroundMinimally invasive techniques have demonstrated several advantages over the open approach. In the field of prostate cancer, the LAP-01 trial demonstrated the superiority of robotic-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) when comparing continence at 3-month after surgery, with no statistically significant differences at 6 and 12 months of follow-up. ObjectivesExternally validate the LAP-01 study and compare functional outcomes between the two minimally invasive approaches. Material and methodsThis retrospective study, conducted by a single surgeon (MRB), utilized data from a prospectively collected database, which included patients who underwent both RARP or LRP. Data regarding baseline characteristics, continence (assessed through the 24-h Pad test and ICIQ questionnaire) and potency were collected at multiple time points: 1 and 6 weeks after catheter removal, 3-, 6-, and 12-months post-surgery. ResultsThe study encompasses 601 patients, 455 who underwent LRP and 146 RARP. The median age at diagnosis was 64 for LRP and 62 for RARP, while the median PSA levels at diagnosis were 6.7 ng/mL for LRP and 6.5 ng/mL for RARP. Bilateral nerve-sparing procedures were performed in 34.07 % of LRP cases and 51.37 % of RARP cases.RARP exhibited a significant advantage over LRP both in continence and potency. Continence rates at 3-, 6- and 9-month after radical prostatectomy (RP) were 36.43 %, 61.86 % and 79.87 % for LRP, compared to 50.98 %, 69.87 % and 91.69 % for RARP. Potency rates at the same intervals were 0.90 %, 3.16 % and 6.39 % for LRP, and 6.19 %, 9.16 % and 18.96 % for RARP. These rates were more pronounced in patients with bilateral nerve-sparing. ConclusionOur study demonstrates that RARP results in significantly better continence recovery and superior potency outcomes throughout the entire follow-up period compared to LRP, even at the beginning of the robotic approach learning curve.

The effects of social distancing and self-isolation on functional outcomes after radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic.

Background:This study is aimed to analyze the effect of social distancing on functional outcomes (potency, continence recovery, and quality of life) on patients undergoing open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) during the COVID-19 pandemic.Materials and methods:We retrospectively assessed functional outcomes of 55 consecutive patients who underwent radical prostatectomy during the COVID-19 pandemic (group A: 12 ORP and 15 RARP) and compared these data with patients from the previous year (group B: 13 ORP and 15 RARP). Propensity-score matching was performed to analyze variables associated with potency, continence recovery and compared between the groups at 1 and 3months.Results:Patients from group A were less interested in postsurgical rehabilitation compared to those from group B (95.7% vs. 56.2%, p = 0.042). Continence recovery among group B patients also tended to be higher for RARP (p = 0.06) and ORP (p = 0.08) at 1 month, although statistical significance was not reached. The cumulative continence recovery at 3 months among group B patients was higher and statistically significantly advantageous for RARP (p = 0.00) and ORP (p < 0.01). Potency rates among younger group B patients following bilateral nerve-sparing procedures were statistically significantly advantageous for RARP (p = 0.026) and ORP (p = 0.011).Conclusions:Our results highlight the large impact of the COVID-19 pandemic on functional outcomes following radical prostatectomy. Future design and planning of home-based models for improved post-operative care should consider this evidence.

Adherence and barriers to penile rehabilitation over 2\u2009years following radical prostatectomy

BackgroundA variety of penile rehabilitation (PR) therapies are available to improve post-prostatectomy erectile dysfunction (ED) with mixed results. It is uncertain how adherent men are to PR therapies. The aim of this study is to determine adherence to and identify barriers to PR treatment.MethodsA longitudinal cross-sectional approach was used in men who underwent radical prostatectomy over 2 years. Men were instructed to take a PDE5 inhibitor (PDE5i) three times per week, and if required, utilize a vacuum constriction device (VCD) daily. Outcomes were measured by multiple validated questionnaires. In addition, penile stretched length, side effects, compliance to PR regimen & barriers to participation were documented.ResultsSeventy-seven patients were enrolled, however only 49 completed evaluation at 3 or more timepoints and were included in analysis. This cohort was an average age of 58.1 years (±7.7), had robotic laparoscopic radical prostatectomy (91.7%), and had bilateral nerve sparing procedures (95.8%). Majority (62.5%) reported normal SHIM pre-operatively, however 79% used PDE5i. Erectile function as measured by IIEF and Erection Hardness Rating were negatively affected post-operatively, with gradual improvement in parameters throughout the 24 month follow up. Of the participants who had normal pre-op SHIM, only 23.1 and 28.6% regained baseline function at 1 and 2 years, respectively. Orgasm was significantly diminished immediately post-operatively, however, at the end of the study period only 37% of men reported diminished climax and no men reported absent orgasm. Adherence to penile rehabilitation therapies declined overtime. Men took oral PDE5i on average 2.3 times weekly at 12 and 24 months (p < 0.001). Men used the VCD 2.3–3.9 days a week, which declined overtime (p = 0.014).ConclusionsImprovement in erectile and orgasm parameters was observed over time, but most men did not return to baseline function. Despite comprehensive instructions and a frequent follow up schedule, PDE5i and VCD adherence was poor. High attrition rates were noted with only 55.8% of men remaining at 12 months and 45% of men completing 24 months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.

Does The Learning Curve Affect the Surgical, Functional, and Oncologic Outcomes in Bilateral Nerve-Sparing Robot Assisted Laparoscopic Prostatectomy?

IntroductionNowadays, the expectations for functional prostatectomy outcomes are quite high. Robot-assisted laparoscopic radical prostatectomy (RALRP) has become an increasingly common treatment option for men with localized prostate cancer. In this study, we aimed to present the results of our bilateral nerve-sparing RALRP procedure and to evaluate the effects of the learning curve (LC) on perioperative data, early oncologic, and functional outcomes.MethodsThe records of 132 RALRP cases performed between January 2016 and March 2019 by a single surgeon experienced in open and laparoscopic radical prostatectomy were evaluated retrospectively. Results of 91 cases with the bilateral nerve-sparing technique were analyzed. The learning curve was determined using the moving average method. LC analysis using the moving average method showed that the LC stabilized between cases 40 and 50. So, patients were divided into two groups: group 1 consisted of the first 45 cases, while group 2 consisted of 46-91st cases. The groups were compared in terms of surgical, functional, and oncologic outcomes.ResultsThe mean duration of surgery was significantly reduced in the second group (250 vs 235 min, p <0.002). However, there was no statistically significant difference between the groups in terms of hemoglobin decrease, hospitalization and catheterization time, and intraoperative and postoperative complication rates. The rates of pT2 cancers’ positive surgical margins (PSMs) were 32.4% and 19.4%, respectively. The recovery rate of continence in all the patients was 90.1% at 12 months. The potency ratios were calculated as 33.8% at 12 months. There was no statistically significant difference between the groups in terms of potency and continence rates at 3 months and 12 months, postoperatively.ConclusionFor surgeons experienced in retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) surgeries, RALRP is a safe and feasible surgical procedure for both oncological and functional outcomes even during the learning curve.

Extraperitoneal robot-assisted radical prostatectomy: a high-volume surgical center experience.

Herein we report our high-volume single center experience with extraperitoneal robot-assisted radical prostatectomy (eRARP) in patients with prostate cancer (PCa). A retrospective chart review of our prospectively maintained institutional PCa database was performed to analyze eRARP cases done between April 2009 and March 2016. Nerve-sparing technique was applied in accordance with Tewari. Baseline characteristics, surgical outcomes, continence and erectile function were assessed by descriptive statistics. Of 1354 patients, 61% had intermediate-risk disease. Mean total operative duration was 146±44 min (median 140 minutes; interquartile range 120-160 minutes). In 91.7% of case no complication was recorded. Gleason Score on final pathology was mostly 6 (43.3%) or 7 (3+4) (32.3%). The pathological T stage was mostly pT2c (53.8%). Patients who had a bilateral nerve sparing procedure showed the best functional results, with 81.2% continence rate at 1 month, and 65% reported recovery of erectile function at 3 months postoperation. eRARP is a safe, reproducible, and effective procedure for the surgical treatment of prostate cancer. Superior functional outcome can be achieved when a bilateral intrafascial nerve-sparing approach can be performed.

Clinical outcomes and costs of robotic surgery in prostate cancer: a multiinstitutional study in Korea.

BackgroundThis study compared the surgical, functional, and oncologic outcomes of robot-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and retropubic radical prostatectomy (RRP) in Korean men.MethodsThe study population included 864 patients who underwent radical prostatectomy for prostate cancer in the departments of urology of five tertiary hospitals between 2010 and 2011. RALP, LRP, and RRP perioperative, oncological, and functional outcomes as well as complications were assessed. Medical cost data were analyzed for 682 of 864 patients.ResultsNo significant differences were found among the three groups regarding the length of stay, biochemical recurrence, complications, and metastasis. The RALP group had a significantly higher rate of pelvic lymph node dissection (64.6% vs. 35.3% or 53.3%, P value <0.0001) and bilateral nerve-sparing procedures (15.7% vs. 10.0% or 8.9%, P value <0.0001) and less blood loss (median 250 mL vs. 300 mL or 700 mL, P value <0.0001) than the LRP and RRP groups. The 12-month continence recovery rate was higher in the RALP group (92.1%) than in the LRP (86.5%) and RRP (84.4%) groups (P value <0.0001). Medical costs for RALP were approximately twofold to threefold higher than those for LRP or RRP.ConclusionsOur findings suggest that surgical and functional outcomes are better with robot-assisted surgery than with laparoscopic or open surgery in terms of estimated blood loss and urinary continence; however, no differences were found among groups in terms of biochemical recurrence and the rate of complications.

Does topical hemostatic agent (Floseal®) have a long-term adverse effect on erectile function recovery after nerve-sparing robot-assisted radical prostatectomy?

To investigate the long-term effects of Floseal® on erectile function recovery (EFR) after nerve-sparing robot-assisted radical prostatectomy (RALP). We prospectively collected results of the self-administered International Index Erectile Function Questionnaire 1-5 and 15 (IIEF 1-5 and 15) of 532 consecutive patients who underwent RALP for prostate cancer in our institution between October 2007 and December 2015. Patients were divided into two groups according to Floseal® application after prostatectomy. They were enrolled according to the following criteria: (a) bilateral nerve-sparing procedure; (b) preoperative IIEF≥17; adherence to our erectile rehabilitation protocol; (c) 1-year follow-up. Outcomes were measured as mean IIEF score, EFR (IIEF<17 or ≥17), grade of ED: severe (IIEF<17), moderate (17-21), mild (22-25) and no ED (>25). A total of 120 patients were enrolled. Group A included 40 consecutive patients who received traditional hemostasis, and Group B included 80 consecutive patients in which Floseal® was additionally used. No differences were observed in terms of preoperative mean IIEF score (p=0.65). Group B patients showed a trend toward a higher mean IIEF score 3months after surgery (p=0.06) but no differences in terms of EFR (p=1.000). Long-term results (6, 9, 12months after surgery) showed a significantly and progressively higher mean IIEF score (p=0.04, 0.003, 0.003) and EFR (p=0.043, 0.027, 0.004) in Group A patients. Comparison between the groups in terms of severe, moderate, mild and no ED becomes significant at 9 and 12months (p=0.002, 0.006). The results of our study suggest that local use of Floseal® worsens the long-term erectile function recovery in patients selected for nerve-sparing RALP.

MP46-02 RADICAL PROSTATECTOMY AND RECOVERY OF URINARY CONTINENCE IN PATIENTS WITH LOCALLY ADVANCED PROSTATE CANCER

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy1 Apr 2017MP46-02 RADICAL PROSTATECTOMY AND RECOVERY OF URINARY CONTINENCE IN PATIENTS WITH LOCALLY ADVANCED PROSTATE CANCER Jung Keun Lee, In Jae Lee, Tae Jin Kim, Hakmin Lee, Jong Jin Oh, Sangchul Lee, Jeong Hyun Kim, Sung Kyu Hong, Seok-Soo Byun, Sang Eun Lee, and Seong Jin Jeong Jung Keun LeeJung Keun Lee More articles by this author , In Jae LeeIn Jae Lee More articles by this author , Tae Jin KimTae Jin Kim More articles by this author , Hakmin LeeHakmin Lee More articles by this author , Jong Jin OhJong Jin Oh More articles by this author , Sangchul LeeSangchul Lee More articles by this author , Jeong Hyun KimJeong Hyun Kim More articles by this author , Sung Kyu HongSung Kyu Hong More articles by this author , Seok-Soo ByunSeok-Soo Byun More articles by this author , Sang Eun LeeSang Eun Lee More articles by this author , and Seong Jin JeongSeong Jin Jeong More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1441AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Few studies have been reported on the evaluation for recovery of urinary continence after radical prostatectomy in patients with locally advanced prostate cancer. We conducted a study of ≥pT3 patients to improve understanding of the natural history of continence state and to identify predictors useful in patient selection for incontinence management. METHODS We reviewed the data ofpatientswith prostate cancer managed by open retropubicor robotic radical prostatectomyfrom January 2004 to May 2015. Excluding patients requesting short-term follow-up (< 12 months), 1,859 subjects were eligible for the study. Achievement of continence was defined as no pads or an occasional security pad. A total of 547 patients were diagnosed ≥pT3 disease. Multivariate logistic regression analyses were used to determine predictors for early continence (recovery within 3 months) or for persistent incontinence (no recovery after 12 months). Furthermore, ≤ pT2 patients were matched 1:1 to ≥pT3 patients based on the propensity score. Predictors of recovery of urinary continence were compared between ≥pT3 and ≤ pT2 patients. RESULTS Of the 547 patients with ≥pT3, 63% underwent robotic surgery and 42%received bilateral nerve sparing procedure. Continence recovery at 1 month, 3 months, 6 months, 9 months, and 12 months was observed in 27%, 76%, 89%, 92%, and 95% of patients, respectively. Age (OR 0.967, p = 0.045), membranous urethra length (OR 1.120, p = 0.004), and bilateral nerve saving (OR 1.956, p = 0.006) had the significant predictive value for early continence. Additionally, open surgery (vs. robotic) was an independent risk factor for persistent incontinence (OR 3.146, p = 0.002). Of the ≤ pT2 patients, age, membranous urethra length, and bilateral nerve saving were also statistically associated with early continence recovery. However, open surgery did not show a significance to predict persistent incontinence (OR 0.656, p = 0.305) (table). CONCLUSIONS Urinary continence was achieved in most patients with ≥pT3 prostate cancer managed by radical prostatectomy. Our results highlight the advantage of robotic surgery for continence outcomes in patients with ≥pT3 prostate cancer compared with ≤ pT2. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e619 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jung Keun Lee More articles by this author In Jae Lee More articles by this author Tae Jin Kim More articles by this author Hakmin Lee More articles by this author Jong Jin Oh More articles by this author Sangchul Lee More articles by this author Jeong Hyun Kim More articles by this author Sung Kyu Hong More articles by this author Seok-Soo Byun More articles by this author Sang Eun Lee More articles by this author Seong Jin Jeong More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Early Catheter Removal after Robot-assisted Radical Prostatectomy: Surgical Technique and Outcomes for the Aalst Technique (ECaRemA Study)

BackgroundRobot-assisted radical prostatectomy (RARP) is a widespread option for the treatment of patients with clinically localised prostate cancer. Modifications in the surgical technique may help to further improve functional outcomes. ObjectiveTo assess the outcome of early catheter removal 48h after surgery, as opposed to standard catheter removal 6 d after surgery following RARP, using a newly developed surgical technique for posterior reconstruction and anastomosis (Aalst technique). Design, setting, and participantsPatients scheduled for RARP were prospectively scheduled for early catheter removal at postoperative d 2 (group A, n=37) and standard catheter removal at postoperative d 6 (group B, n=37). Surgical procedureRARP was performed using the Da Vinci Si system. The Aalst technique for the urethro-vesical anastomosis including posterior reconstruction was used as previously described. Outcome measurements and statistical analysisThe primary endpoint was spontaneous voiding after catheter removal. Secondary endpoints were rate of anastomotic urinary leakage after catheter removal, presence and severity of urethral, perineal, and abdominal pain, as well as patient's bother after catheter removal using visual analogue scale (VAS) scores. Rate and severity of urinary incontinence after catheter removal were assessed using the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) questionnaire. Results and limitationsThere was no significant difference between the groups with regard to baseline and perioperative parameters, as well as pathological features; however, significantly more patients underwent bilateral nerve-sparing procedures in group A (34 vs 23, p=0.008). After catheter removal, patients in both groups showed spontaneous voiding, whereas only 11% and 8% of the patients in group A and group B experienced urinary retention after catheter removal (p=0.7). Patients in group B had significantly higher maximum flow rates, but lower voided volumes after catheter removal in comparison with patients in group A (21ml/s vs 10ml/s, p≤0.001 and 170ml vs 200ml, p≤0.001, respectively). ICIQ-MLUTS questionnaire and VAS scores showed no significant differences between the groups at any time point. ConclusionsThe Aalst technique allows the removal of catheters 2 d after RARP and results in spontaneous voiding. Early removal showed no increased rate of urinary leakage, no negative impact on short-term continence and on perineal, urethral or penile pain, and no increase in urinary retention rates. Future studies have to confirm these results with longer follow-up including detailed parameters on return to daily activity. Patient summaryWe provide evidence that it is possible to remove the bladder catheter as early as 2 d after robot-assisted radical prostatectomy without any negative effects on voiding and pain parameters. Thus, leaving the hospital early without a catheter in place could represent a significant and relevant benefit for the patient.

The association between nerve sparing and a positive surgical margin during radical prostatectomy

PurposeA positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins. MethodsWe evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model. ResultsOf 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97–2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80–1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25–2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65–1.12). ConclusionsBilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.

The effect of nerve-sparing robot-assisted radical cystoprostatectomy on erectile function in a preoperatively potent population.

To evaluate the effects on the potency of a bilateral cavernosal nerve-sparing approach to robot-assisted radical cystectomy (RARC) in a preoperatively potent population. We conducted a retrospective review of 254 patients who underwent RARC between 2003 and 2012 at our single institution. We identified 33 men who were younger than 65 years and had evidence of preoperative erections on chart review. Twenty-nine of them underwent a bilateral nerve-sparing procedure, with 28 (97%) having concomitant creation of a continent urinary diversion. Median follow-up was 32.9 months. Postoperatively, 13 (45%) patients had documented erections sufficient for penetration with or without the use of phosphodiesterase 5 inhibitors. Additional 6 (21%) were potent with intracavernosal injections (ICI), and the remaining 10 (34%) failed ICI usage, had on-going medical issues, or lost interest in sexual activity. With univariate analysis, no significant difference was found between those who recovered erections and those who did not on a wide range of demographic, operative, and perioperative factors, including age, comorbidities, operative time, or pathologic stage. Despite neurovascular bundle preservation, there was no local cancer recurrence and no positive soft tissue margins. A cavernosal nerve-sparing robot-assisted approach to radical cystectomy allows for recovery of potency without sacrificing oncologic outcomes even with higher risk disease as compared to historical open or laparoscopic series. Further studies are required to help elucidate why some men have better recovery in this setting than others.

Do Patients Know Their Nerve-sparing Status After Radical Prostatectomy?

To determine patients' knowledge regarding their nerve-sparing status (NSS) after radical prostatectomy (RP) and what factors during their clinical treatment are associated with this. One hundred consecutive patients attending an erectile dysfunction clinic in Toronto, Canada, with a prior RP were surveyed from December 2010 to June 2011. Patients were questioned whether they had undergone a nerve-sparing procedure and, if so, whether it was unilateral or bilateral. Patients were assessed on both knowledge (known vs unknown) and accuracy (correct vs incorrect) regarding their NSS. Operative reports were used to determine the true NSS of each patient. Thirty-nine percent of patients had no knowledge of their NSS. Forty-five percent of patients were able to correctly identify their NSS, including only 19% of patients undergoing a non-nerve-sparing procedure. On univariate analysis, factors associated with patients correctly knowing their NSS were age, having a nerve-sparing strategy dictated in the preoperative clinic note, nerve sparing included in the surgical consent form, and type of nerve-sparing procedure performed. On multivariate analysis, planned nerve-sparing approach dictated in the preoperative note (odds ratio [OR], 4.86), nerve sparing included in surgical consent (OR, 3.76), time since surgery (OR, 0.99), and having a bilateral nerve-sparing procedure (OR, 5.91) were associated with correctly identifying one's NSS. After RP, a significant proportion of patients with erectile dysfunction have no knowledge of whether they underwent a nerve-sparing procedure. By discussing with patients the planned nerve-sparing technique preoperatively and counseling them on their NSS postoperatively, urologists may be able to improve on patient recollection of their NSS.

171 Use of proerectile medication (PDE5-I) is an independent risk factor for PSA recurrence following radical prostatectomy

INTRODUCTION AND OBJECTIVES: The objective of this study was confirmation or rejection of the effect of proerectile drugs (mostly PDE5-I) on biochemical recurrence (BCR) following radical prostatectomy for prostate cancer as shown at the AUA 2012. METHODS: We expanded the original cohort form January 1996 and December 2010 and refreshed follow up. More than 7000 patients underwent radical retropubic prostatectomy. A homogeneous cohort of 4752 patients, all with a bilateral nerve sparing procedure was analyzed. Follow up was done annually with mailed questionnaires. Potency was evaluated with the IIEF5 questionnaire, and patients stated the use or disuse of potency drugs. Patients with missig information were excluded. RESULTS: Of the 4752 patients, 3642 documented no use of proerectile medication, and 1110 regularly used potency drugs. Both groups were comparable with respect to age, preoperative PSA, pathological results (pT, pN, Gl, margin), smokers, and time of follow up. Kaplan Meier analysis showed significant more BCR for patients on potency drug. Multivariate analysis demonstrated that use of proerectile medication as an independent significant risk factor for BCR, while smoking was not a risk factor. This was also true after propensity score match of the potency drug users with disusers. Fig. 1: Survival plot, all patients (n: 4723) Fig. 2: multivariate analysis all patients (n: 4723) CONCLUSIONS: Again, use of proerectile medication seems to be a significant independent risk factor for PSA recurrence in patients after radical prostatectomy. Limitations: we had no information on kind of proerectile drug, dosage, length of medication, comorbidities, and co medication. Nevertheless, these results were based on a large number of patients, and should be evaluated further.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

Preliminary results of robot‐assisted laparoscopic radical prostatectomy (RALP) after fellowship training and experience in laparoscopic radical prostatectomy (LRP)

• To ascertain whether prior experience in laparoscopic radical prostatectomy (LRP) shortens the 'learning curve' and therefore improves early patient outcomes when transitioning to robot-assisted laparoscopic RP (RALP). • Retrospective analysis of prospectively collected data of the most recent 87 cases of LRP compared with the initial 73 cases of RALP. • LRP was performed via a five-port extraperitoneal approach, while transperitoneal RALP was performed using a four-arm da Vinci S unit. • The median operative duration for RALP (skin-to-skin, including docking time) rapidly reduced, although never exceeded 3.5 h, for each consecutive set of 10 cases. • Oncological outcomes were preserved with no cases of pT2 positive surgical margins (PSMs) in any group. pT3 PSM rates were not significantly different at 50% and 38% for LRP and RALP, respectively. • Penetrative intercourse rates at 3 months for bilateral nerve-sparing procedures in preoperatively potent patients were similar, at 50% for LRP (median Sexual Health Inventory for Men [SHIM] 17) and 48.1% for RALP (median SHIM 18). The pad-free rate at 3 months was significantly better for RALP at 59.7%, compared with 39.8% for LRP (P= 0.043). • Complications were minimal and comparable for the two groups except for a higher LRP radiological anastomotic leak rate of 16 vs 1% (P= 0.004). • In this comparative series fellowship training and prior experience in LRP resulted in no significant RALP learning curve with regards to oncological and functional outcomes, while maintaining a low complication rate. • A short learning curve existed for operative duration but this improved rapidly and there were no prolonged cases. • Differences in early continence and radiological leaks may reflect changing from an interrupted anastomosis (LRP) to a continuous anastomosis with posterior rhabdosphincter reconstruction (RALP).

Real-Time Robotic Transrectal Ultrasound Navigation During Robotic Radical Prostatectomy: Initial Clinical Experience

To describe a novel robotic transrectal ultrasound platform for real-time navigation during robot-assisted laparoscopic radical prostatectomy (RALP) and to report its early clinical application. Five men undergoing RALPs at our Institution agreed to participate in this Institutional Review Board-approved pilot study. All of them were eligible for a bilateral nerve sparing procedure. Before docking the da Vinci robot, a transrectal ultrasound tri-plane side-fire probe was placed. A modified ViKY Endoscope Holder was used during RALPs to move the probe thanks to a remote control placed under the console surgeon's control during RALPs. During each procedure, attempt was made to estimate prostate volume, define 12 reference points, and to precisely identify location of the neurovascular bundles using Doppler ultrasound. The TilePro was used during the procedures to allow real-time ultrasound imaging to guide robotic instruments during dissection. Median robotic transrectal ultrasound probe holder (R-TRUS) setup time was 11 minutes (interquartile range [IQR], 10-14). Prostate volume calculation, reference point definition, neurovascular bundle identification, and instrument tip visualization were successful in all men. In 1 patient with a large prostate (120 mL), R-TRUS was withdrawn during recto-prostatic dissection. There were no rectal injuries. R-TRUS during RALPs is feasible and safe. It allows real-time TRUS navigation and guidance. Further studies are needed to evaluate its impact on oncological and functional outcomes.

The relationship between continence and perineal body tone before and after radical prostatectomy: A pilot study

Recent preliminary studies showed that tonic-trophic characteristics of the pelvic muscles are related to postoperative male urinary incontinence. The aim of the current study was to test whether perineal body tone (PBT), evaluated using the Beco perineometer (Perineocaliper), is related to urinary continence recovery after robot-assisted laparoscopic prostatectomy (RALP). The study population consisted of 48 patients who underwent RALP between January and July 2009. Surgical interventions were performed by a single surgeon and patients were evaluated by a single physiotherapist. All patients were taught pelvic floor muscle exercises (PFME). PBT was evaluated in each patient preoperatively, as well 30 days and 3 months after surgery. In addition, patients were evaluated with a 24-hr pad-test and the International Consultation on Incontinence-questionnaire (ICI-Q). Mean age at surgery was 65.5 years (range 46-63). Twenty-four patients underwent a bilateral nerve-sparing procedure (50%). One-month after surgery, 25 (52.1%) patients were continent while 23 (47.9%) patients were still incontinent. A statistically significant difference in preoperative perineometric measures was observed between continent and incontinent patients (mean 1.36 cm vs. 0.80 cm; P < 0.001). This difference was even more pronounced when comparing postoperative perineometric measures (mean 1.24 cm vs. 0.43 cm; P < 0.001). Evaluation of patients 3 months after surgery showed an increase in perineometric measures (mean increase 0.76 cm). The increase was significantly higher in patients who became continent after 3 months relative to patients who were still incontinent despite PFME (mean perineometric measures 1.45 cm vs. 1.00 cm; P = 0.021). Our results demonstrate that urinary continence recovery is related to PBT recovery. Further studies are needed to confirm whether perineometric measures may be used as a predictive tool for the risk-stratification of postoperative UI.

Comparison of outcomes between pure laparoscopic vs robot‐assisted laparoscopic radical prostatectomy: a study of comparative effectiveness based upon validated quality of life outcomes

To compare perioperative, oncological and functional outcomes of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP) with emphasis on health-related quality of life (HRQOL) data as few studies exist. Patients underwent RALP or LRP by a single, fellowship trained surgeon with a standard clinical care pathway. HRQOL data using the Expanded Prostate Cancer Index Composite (EPIC) were collected at 0, 3, 6 and 12 months after 175 consecutive LRP and 174 RALP procedures. Urinary and sexual function outcomes were compared using two methods: (1) EPIC summary/subscale analyses described as percent return to baseline function and (2) traditional single-question analysis. The two groups were statistically similar with respect to demographics, clinical stage, perioperative outcomes, stage-specific surgical margin rates, and baseline urinary and sexual function scores. There was no statistical difference in postoperative urinary function between RALP and LRP using EPIC or single-question analyses at 3, 6 and 12 months. EPIC questionnaire data showed a greater return to baseline sexual function over time (mixed model analysis) in RALP than in LRP patients who had a bilateral nerve sparing procedure (Sexual Summary Score, P= 0.005; Sexual Function and Bother Subscales, P= 0.007). Using EPIC, RALP patients receiving a bilateral nerve sparing procedure showed improved percent return to baseline potency at 3 and 6 months (P < 0.025) compared with LRP patients, but had similar outcomes at 12 months (73.7% vs 66.2%, P= 0.3). Single-question analysis suggested improved potency after RALP compared with LRP, with a greater percentage of RALP patients reporting successful sexual intercourse in the past 4 weeks (87.5% vs 66.7% at 12 months, P= 0.06). When comparing surgical techniques, RALP and LRP groups showed statistically similar postoperative urinary function outcomes. RALP patients had an earlier return of sexual function when compared with LRP patients after a bilateral nerve sparing procedure.

Evaluation of combined oncologic and functional outcomes after robotic-assisted laparoscopic extraperitoneal radical prostatectomy: Trifecta rate of achieving continence, potency and cancer control

ObjectivesOutcomes of continence, erectile function, and oncologic control are well-described in isolation especially for the retropubic open approach. However, only few series have yet reported combined results after radical prostatectomy. To determine the proportion of men who are continent, potent, and cancer-free (trifecta rate) 2 years after robot-assisted laparoscopic radical prostatectomy (RALRP). Materials and methodsWe included patients who underwent a RALRP at our department and who were followed during at least 2 years. Men who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 500 men were included. All patients prospectively completed validated questionnaires (IIEF-5, ICS) before the medical visit and concerning their voiding and sexual disorders, preoperatively, 3, 6, 12, 18, and 24 months after RALRP. Biochemical recurrence was defined as any detectable serum PSA (≥0.2 ng/ml). The study end point was the trifecta rate (cancer control, continence, and potency) at 2 years of the surgery. Predictive factors of the trifecta outcome were assessed in univariate and multivariate analyses. ResultsMedian age and PSA level were 62.2 years and 9.7 ng/mL. A trifecta outcome was achieved in 44% and 53% of men at 12 and 24 months, respectively. The 2-year trifecta rate reached 62% in men undergoing bilateral nerve-sparing surgery and 71% in men < 60 years. Age < 60 years, PSA level < 10 ng/ml, organ-confined disease, and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome. ConclusionTwo years after RALRP, the trifecta outcome is achieved in 53% of preoperatively potent and continent men.

Pelvimetric Dimensions do not Impact upon Nerve Sparing or Erectile Function Recovery in Patients Undergoing Radical Retropubic Prostatectomy

The impact of unfavorable pelvic anatomy on the likelihood of having a nerve sparing radical retropubic prostatectomy (RRP) and the potential correlation between pelvic dimensions and recovery of erectile function (EF) after RRP have not been previously evaluated. To determine the impact of different pelvic bony and soft tissue dimensions as well as apical prostate depth on the likelihood of performing bilateral nerve sparing and on recovery of EF after RP. Between November 2001 and June 2007, 644 potent men undergoing RRP had preoperative MRI where pelvimetry was performed with bilateral nerve sparing in 504 men. Outcomes including varying degrees of recovery of EF (level 1: normal; level 2: partial erections routinely sufficient for intercourse; level 3: partial erections occasionally sufficient for intercourse) were assessed. Median follow-up was 44.1 (interquartile range: 29.2, 65.3) months. We evaluated independent predictors of performing a bilateral nerve sparing procedure and of recovery of EF using multivariable Cox proportional hazards methods. Likelihood of performing bilateral nerve sparing as well as recovery of EF after RRP. Patients with higher clinical stage and biopsy Gleason score are less likely to undergo bilateral nerve sparing. Surgeon is also a factor in the likelihood of having bilateral nerve sparing RRP. On multivariate Cox regression analysis, factors predictive of recovery of EF were age, pretreatment erectile function, surgeon, and modified Charlson score. None of the pelvimetric dimensions were significant predictors of any degree of recovery of EF. However, the study is limited by its retrospective nature and by being based on MRI evaluations useful for cancer staging rather than anatomical evaluation of pelvimetric dimensions. We did not find unfavorable pelvic anatomy to impact the likelihood of performing a nerve sparing procedure or to be predictive of any degree of recovery of EF after RRP.