Bilateral Radical Research Articles

Preoperative Evaluation of Sexual Function in Patients Undergoing Bilateral Nerve-Sparing Radical Retropubic Prostatectomy

Summary During the last few years, prostate cancer is more frequently diagnosed in young patients. This lays emphasis on the necessity to preoperatively evaluate the sexual function in patients undergoing bilateral nerve sparing radical retropubic prostatectomy (BNSRRP). The aim of our study was to make an objective evaluation of the basic sexual function in patients with clinically localized prostate cancer and candidates for BNSRRP, using internationally validated questionnaires. We also tried to find a correlation between these questionnaires and the individual assessment of candidates, on one hand, and between comorbidities of the patients and degree of erectile dysfunction (ED), on the other hand. From January 2014 to March 2017, at the urology clinic of University Hospital – Pleven, 64 patients opted BNSRRP and reported to have preserved erectile function (EF), wishing to maintain this function after surgery. The patients’ histories and comorbidities were recorded on the day of hospitalization. The subjective assessment of the patients’ potency was compared with International Index of Erectile Function (IIEF). According to the EF domain of the IIEF, baseline EF was assessed in 28 patients. Twelve patients had mild ED, 9 patients had mild to moderate ED, seven patients had moderate, and eight had severe ED. The results showed that a significant number of patients with clinically localized prostate cancer who were candidates for BNSRRP reported to be fully potent but actually had impaired EF preoperatively. There was also a pronounced correlation between concomitant diseases and EF.

Treatment effects of phosphodiesterase-5 inhibitors may improve with time following nerve-sparing radical prostatectomy

Objective: Erectile dysfunction (ED) is common following radical prostatectomies, and phosphodiesterase type 5 inhibitors (PDE5 inhibitors) are generally considered the first choice of treatment. The purpose of this study was to analyze the long-term efficacy of PDE5 inhibitors in a group of men who did not achieve sufficient erectile function from the medication in the short term following surgery.Materials and methods: Prospectively collected data from patients with postprostatectomy ED, initial failure of PDE5-inhibitor treatment at 3 and/or 6 months and at least 12 months’ follow-up were included. All patients had completed the International Index of Erectile Function short-form questionnaires (IIEF-5) before surgery and at follow-up visits. Response to PDE5 inhibitors was defined as an IIEF-5 score of at least 17.Results: The inclusion criteria were fulfilled by 349 patients. At 12 months, 228 patients were still using PDE5 inhibitors. Of these patients, 92 had undergone bilateral and 120 had undergone unilateral nerve-sparing radical prostatectomies. Overall, 42 PDE5-inhibitor users (18%) were responders at 12 months. Bilateral nerve sparing was the only independent predictor of a late response (odds ratio = 2.9). Thus, 28% of bilaterally nerve-spared patients were responders, while corresponding numbers for unilaterally nerve-spared patients and non-nerve-spared patients were 13% and 6%, respectively.Conclusions: Patients who have undergone bilateral nerve-sparing radical prostatectomy should be rechallenged periodically with PDE5 inhibitors even if the treatment is unsuccessful initially. Unilaterally nerve-spared patients and especially non-nerve-spared patients are likely to need more aggressive treatment.

Quality of life after brachytherapy or bilateral nerve-sparing robot-assisted radical prostatectomy for prostate cancer: a prospective cohort.

To provide comparative data on quality of life (QoL) after prostate cancer treatment to help patients make an informed decision regarding their choice of treatment. Patients with pathologically proven, non-metastatic, T1-T3bN0 prostate cancer were included in this prospective non-randomized study if they were to receive treatment with curative intent. Sample size was at least 181 patients per cohort/treatment type. QoL was recorded at baseline and at each follow-up using the Expanded Prostate Cancer Index Composite (EPIC) instrument. The minimal clinically important difference was defined as half of the standard deviation of the baseline score for each domain. A mixed effects model was used to compare the different treatments. Data are presented on the brachytherapy and the bilateral nerve-sparing robot-assisted radical prostatectomy (RARP) cohorts. Hormonotherapy was not allowed. Between November 2007 and January 2013, 181 patients who received brachytherapy and 210 patients who underwent RARP were included. Of the patients who underwent RARP, 178 had bilateral nerve-sparing and were included in the present analysis. Response rate to EPIC questionnaires were higher in the brachytherapy than in the RARP arm: 82% vs 57% at 2years after treatment and 55% vs 45% at 4years after treatment. In the mixed effects model, patients in the RARP arm had better QoL with regard to urinary irritation/obstruction or bother and bowel function, and lower QoL regarding sexual function and urinary incontinence. Results were confirmed in a propensity score-matched model. Patient satisfaction was significantly higher in the brachytherapy group at 1, 2 and 3years after treatment. This prospective non-randomized study shows long-term differences in QoL domains after bilateral nerve-sparing RARP and brachytherapy. Differences in patient satisfaction should be further explored. These results could be used to counsel patients in the decision-making process.

A Double-Blind, Randomized Trial on the Efficacy and Safety of Hyperbaric Oxygenation Therapy in the Preservation of Erectile Function after Radical Prostatectomy

We evaluated the efficacy and safety of hyperbaric oxygenation therapy to preserve erectile function as part of penile rehabilitation after robot assisted bilateral nerve sparing radical prostatectomy for prostate cancer. We performed a prospective, randomized, double-blind study from January 2009 to April 2013. Men 40 to 65 years old who underwent robot assisted bilateral nerve sparing radical prostatectomy were randomized 1:1 to the control or the treatment group. Participants were exposed to air as the control or to 100% oxygen as the treatment in hyperbaric conditions. The primary outcome was erectile function at 18 months as measured by IIEF (International Index of Erectile Function). Secondary outcomes were 12-month urinary symptoms, and 18-month sexual, urinary, bowel and hormonal related symptoms as measured by EPIC-26 (Expanded Prostate Index Composite-26). Adverse events and long-term cancer outcomes were monitored. Primary and secondary outcomes in the 2 groups were compared by the independent group t-test, the Wilcoxon rank sum test and the chi-square test of proportion. A total of 109 potent men were randomized to hyperbaric oxygenation therapy or the control group. A total of 43 men in the air group and 40 in the hyperbaric oxygenation therapy group completed the 18-month followup. No statistically significant differences were observed between the 2 groups on any outcome measure. This study revealed no difference in erectile recovery in men treated with hyperbaric oxygenation therapy vs placebo. Larger studies involving more diverse comorbidities and different hyperbaric oxygenation therapy regimens are needed to better evaluate the usefulness of hyperbaric oxygenation therapy for penile rehabilitation after radical prostatectomy.

COMPARISON OF ONSITE INFILTRATION AND CONSTANT RATE INFUSION FOR POSTOPERATIVE ANALGESIA IN DOGS WITH MAMMARY TUMORS UNDERGOING BILATERAL RADICAL MASTECTOMY AND OVARIOHYSTERECTOMY

Analgesia of the wide surgical excision region in surgeries such as bilateral radical mastectomy plays an important role in postoperative care. Opioids are effective in alleviating pain; however, they are sometimes difficult to obtain in most local veterinary hospitals. The objective of this research was to compare the efficacies of (1) onsite infiltration analgesia with lidocaine and bupivacaine (group I, [Formula: see text]) and intravenous injection with buprenorphine and (2) constant rate infusions (CRIs) of fentanyl and ketamine (group II, [Formula: see text]) for postoperative analgesia after bilateral radical mastectomy and ovariohysterectomy in dogs with mammary tumors. The results showed that a combination of infiltration with lidocaine and bupivacaine and intravenous injection with buprenorphine was as effective as CRIs of fentanyl and ketamine. Infiltration analgesia with lidocaine and bupivacaine may be an option for analgesia in dogs undergoing bilateral mastectomy and ovariohysterectomy and may help reducing pure [Formula: see text]-opioid requirements.

Prevalence of silent breast cancer in autopsy specimens, as studied by the disease being held by image-guided biopsies: The pilot study and literature review.

Breast cancer epidemiological patterns vary in European countries, which present different incidence rates. Data have suggested that the reduction in breast cancer mortality is not only due to the early detection of the disease, but is, in almost equal part, due to screening and to the advances that have been made in molecular medicine and the development of novel therapies. The aim of the present study is to quantify the actual number of cases of breast cancer present in both of the sexes by calculating the prevalence of silent breast cancer in corpses. To achieve this quantification, bilateral subcutaneous radical mastectomies are performed in corpses of either sex above 40 years of age that lacked any clinical manifestation of the disease, and where the breast cancer or its complications was not the cause of death. Only five publications exist in the international literature based on medico-legal autopsies that were designed to define the ‘natural reservoir’ of the disease. To the best of our knowledge, the present study is the first one to appraise breast tissue via imaging by means of orienting the biopsy incision. In conclusion, to the best of our knowledge, the design of the present study is the first of its type, where image-guided biopsies are used to define the prevalence of silent breast cancer. The study aims to demonstrate that the ‘disease reservoir’ is, in reality, higher than was originally considered to be so. Furthermore, the study aims to contribute towards an improved definition of the disease by determining which tumour profiles potentially do not benefit from aggressive treatments (for example, in case where a high prevalence of low-grade ductal carcinoma in situ is to be detected). According to our pilot study, this analysis represents a feasible protocol.

Ex-vivo renal surgery and auto-transplantation for benign and malignant renal pathologies: our early evolving experience of three cases

Objectives: We describe our experience of ex-vivo renal surgery and autotransplantation for complex renal pathologies. These cases were carried out in the urology and transplant departments between July 2015 and January 2016. Materials and methods: Case 1 was a 63-year-old man presenting with spontaneous bleed from a renal mass in a solitary functional right kidney. Case 2 was a 50-year-old man with bilateral renal tumours involving renal veins. Case 3 was a 50-year-old man with two previous failed right-sided pyeloplasties. Results: No intraoperative complications were encountered. Case 1 underwent laparoscopic nephrectomy, ex-vivo partial nephrectomy followed by autotransplantation. There was no disease recurrence after 6 months’ follow-up, with stable renal functions. Case 2 had bilateral open radical nephrectomies performed. On the right autotransplantation was performed after ex-vivo partial nephrectomy. On the left, a further procedure was abandoned after radical nephrectomy due to extensive disease involvement. Postoperatively, the patient became anuric with poor Doppler signals. Exploration suggested complete renal vein obstruction with infarction of the autotransplanted right kidney requiring nephrectomy. Disease recurrence at the native renal bed was found at 6 months’ follow-up. Case 3 had laparoscopic nephrectomy, ex-vivo pyeloplasty and autotransplantation was performed. At 12 months’ follow-up, the patient was asymptomatic with stable renal functions. Conclusions: Ex-vivo renal surgery is a viable option for complex renal conditions. However, appropriate patient selection is essential to achieve good outcomes.

Reply to 'Non-surgically related causes of erectile dysfunction after bilateral nerve-sparing radical prostatectomy'.

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V8-12 COMBINING ANTEGRADE AND RETROGRADE DISSECTION DURING SALVAGE ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate and Renal Oncology1 Apr 2017V8-12 COMBINING ANTEGRADE AND RETROGRADE DISSECTION DURING SALVAGE ROBOTIC RADICAL PROSTATECTOMY Mariaconsiglia Ferriero, Giuseppe Simone, Riccardo Mastroianni, Gabriele Tuderti, Leonardo Misuraca, Francesco Minisola, Salvatore Guaglianone, and Michele Gallucci Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Giuseppe SimoneGiuseppe Simone More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Francesco MinisolaFrancesco Minisola More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , and Michele GallucciMichele Gallucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2348AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recently published series of salvage robotic radical prostatectomy for radiorecurrent prostate cancer showed the feasibility and the safety of this complex surgical procedure with favorable perioperative and satisfactory functional outcomes. This video shows surgical steps of a salvage robotic radical prostatectomy with pelvic lymph node dissection for radio recurrent prostate cancer. METHODS We present a case of a 60 yr old patient who underwent primary radiation therapy in 2007 for a G7(3+4) prostate cancer. Due to a raising PSA, a prostate biopsy showed a G7(4+3) prostate cancer of the right lobe. A 18F Choline PET/CT was negative for nodal and distant metastasis. With the patient in a steep trendelenburg position a five trocar access was performed. Bilateral extended pelvic lymph node dissection was completed. The Retzius space was developed and the endopelvic fascia bilaterally incised. After sealing the dorsal vein complex with Ligasure, urethral stump was meticulously prepared and transected. The apex was retrogradely dissected up to identifying the Denonvilliers fascia, before moving to bladder neck isolation. Bladder neck was isolated and sectioned and seminal vesicles dissected. The Denonvilliers fascia was identified and opened and the dissection plane, previously prepared retrogradely, was identified. Bilateral extrafascial radical prostatectomy was completed. A Van Velthoven anastomosis with posterior muscolo-fascial reconstruction was performed. RESULTS Operative time was 132 minutes. Blood loss was 300 ml. Postoperative course was uneventful and the patient was discharged on 3rd postoperative day. Pathologic examination showed a pT2bN0 G7(4+3) prostate cancer with negative surgical margins. One-mo PSA levels were 0.01 ng/mL. At 6 month follow up PSA level remained 0 and patient was continent. CONCLUSIONS Combining retrograde and antegrade dissections during salvage robotic radical prostatectomy may contribute to a safe development of the posterior dissection plane. Salvage robot assisted radical prostatectomy is a feasible treatment option for patients with radiorecurrent prostate cancer. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e910 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Mariaconsiglia Ferriero More articles by this author Giuseppe Simone More articles by this author Riccardo Mastroianni More articles by this author Gabriele Tuderti More articles by this author Leonardo Misuraca More articles by this author Francesco Minisola More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Penile rehabilitation after nerve-sparing prostatectomy: Fact or fiction?

A 65-year-old man is seen in the clinic two months after a robot-assisted bilateral nerve-sparing radical prostatectomy. He is completely continent and has been since the catheter was removed. The main reason for his referral is erectile dysfunction. Pre-operatively his SHIM score was 25 (maximum score 25). He currently experiences some thickening with stimulation, and an erection hardness score of 2. He has a pleasurable sensation of orgasm during which he remains dry. His sex drive remains normal. He has a long-standing history of hypertension and raised LDL cholesterol, managed with amlodipine and simvastatin respectively. He has no other overt cardiovascular or ischaemic heart disease, and he is not a diabetic, but has an elevated fasting glucose of 6.0 mmol per litre. He stopped smoking five years ago, is 5 feet 11 inches tall, a weight of 95 kg, has a waist measurement of 44 inches (BMI 29 – upper end of overweight) (range <18.50 underweight; 18.50–24.99 healthy weight; 25.00–29.99 overweight; >30.00 obese). He performs no regular exercise. His wife is 60. He is keen to try to regain his erectile function.

Metastatic follicular thyroid carcinoma of the proximal humerus 20 years after subtotal thyroidectomy: A Case report and literature review

Though rare, metastatic thyroid carcinoma may present as thyrotoxicosis. We present a case of thyrotoxicosis caused by metastatic follicular thyroid carcinoma in the right proximal humerus. A 75-year-old female presented with pain and movement restriction of her right proximal upper arm for 1 month. She received a bilateral subtotal thyroidectomy 20 years ago for thyroid cancer. Images from roentgenogram and magnetic resonance (MR) studies revealed a lobulated mass arising from the proximal humerus. Her thyroid stimulating hormone (TSH) level was non-detectable, and free T4 was 0.8 ng/dl. A bilateral radical thyroidectomy was performed, and the histopathological diagnosis was nodular goiter. Wide excision of the tumor and right proximal humerus was also performed, and the histopathological diagnosis was metastatic follicular thyroid carcinoma. Her TSH and free T4 levels began to normalize after surgery. Postoperatively, she was treated with ^(131)I and has remained free from thyroid cancer recurrence or metastasis. Functioning metastatic lesions from thyroid cancer can present many years after the initial treatment for thyroid cancer, and surgical removal of the metastatic lesions can lead to normalization of thyroid function. Treatment with ^(131)I should be administered to eliminate the possibility of residual tumor.

Role of diffusion weighted magnetic resonance imaging in a rat model of testicular torsion

The purpose of this study was to investigate the usefulness of diffusion-weighted imaging (DWI) in the detection of different degrees of testicular torsion (TT) at the 8th hour and testicular salvageability at the 24th hour of torsion. 31 rats were randomly classified into 4 groups. In Group 1 (sham-control group), the left testicle was kept outside and replaced. Left testicles were kept outside and twisted 360° in Group 2, 720° in Group 3 and 1080° in Group 4. Later, DWI was performed at 8th and 24th hours. After DWI, bilateral radical orchiectomy and histopathological examination were performed. Apparent diffusion coefficient (ADC) maps were obtained with b-factors of 0 and 800 s mm-2. Comparisons of ADC values and damage in testicles were performed with Kruskal-Wallis test. Sensitivity of DWI in the diagnosis of TT was 12.5% for 360° torsion, 100% for 720° torsion and 1080° torsion at the 8th hour of torsion. Mean ADC values of the left testicles increased significantly at the 24th hour of torsion in Groups 3 and 4. All testicles in Groups 3 and 4 were observed to be irrecoverable on histopathological examination. Increased ADC values in the affected testicle may represent irreversible tissue damage. So, immediate surgery is not required at this stage, which may reduce morbidity and mortality caused by immediate surgery and anaesthesia. Advances in knowledge: TT can be diagnosed easily by DWI without administrating any contrast material. DWI findings in the affected testicle may represent testicular salvageability.

A rare case of a mesothelioma in the tunica vaginalis of a dog

A 14-year-old American Staffordshire cross was presented with a history of enlargement of the right testicle of two months duration. Findings included hormonally active testicular tumour, epididymitis, unilateral hydrocele of...

Use of low-dose tacrolimus and associated hypomagnesemia in the prevention of erectile dysfunction following prostatectomy for prostate cancer.

Hypomagnesemia with urinary magnesium wasting is a well described adverse event with calcineurin inhibitor therapy. Prostate cancer is the most prevalent cancer in men in the United States. Injury to the cavernous nerves during radical prostatectomy frequently results in erectile dysfunction. Tacrolimus has been shown to be neuroprotective in the rat cavernous nerve injury model, an animal model representative of the neural injury that occurs in humans at the time of radical prostatectomy. In a randomized, double-blind, placebo-controlled trial, the utility of tacrolimus was assessed for prevention of erectile dysfunction following bilateral nerve-sparing radical prostatectomy. Low dose tacrolimus, associated with low trough levels, resulted in mild hypomagnesemia, which was an early and persistent finding. As early as one week after institution of therapy, mean and median serum magnesium levels were significantly lower in the tacrolimus arm as compared to the placebo arm (p<0.001 for both). While the mean and median levels were within the normal range at Week 1, 10.9% of tacrolimus-treated patients had levels <1.8mg/dL, compared to none in the placebo arm (p=0.017). Median and mean levels remained significantly different at Week 5, Month 3 and Month 6. No clinical manifestations of hypomagnesemia were noted and no subject required treatment with magnesium. Changes in serum magnesium occurred earlier than other potential metabolic adverse events described with tacrolimus (changes in serum glucose, creatinine or potassium). These data indicate that mild hypomagnesemia is an early and sensitive biomarker for the effect of tacrolimus on the kidney.

Robot-Assisted Simultaneous Bilateral Radical Inguinal Lymphadenectomy Along with Robotic Bilateral Pelvic Lymphadenectomy: A Feasibility Study.

To report the surgical technique, procedure outcomes, and feasibility of robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy. Three consecutive patients of penile and urethral carcinoma with palpable inguinal lymphadenopathy who underwent robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy in our institution from May 2013 to October 2015 were included in the study. Surgical technique is described and feasibility of the procedure is assessed. Three patients aged 58, 76, and 35 years underwent robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy with a mean operative duration of 453.33 minutes (range 420-490 minutes). Average blood loss was 66.66 mL (range 50-80 mL) and mean time to removal of last drain was 44.66 days (range 28-72 days). Mean lymph node yield in left inguinal region, right inguinal region, left pelvic region, and right pelvic region was 18, 14.6, 13.3, and 16.6, respectively. The perioperative period was uneventful. No skin flap-related complications were seen. One patient suffered lymphocele postoperatively, which was managed successfully with needle aspiration. One patient developed lung metastasis in follow-up and none of them had local recurrence. Robot-assisted simultaneous bilateral radical inguinal with bilateral pelvic lymphadenectomy is feasible, safe, and may result in decreased morbidity compared to conventional open lymphadenectomy.

Editorial Comment

No AccessJournal of UrologyAdult Urology1 Aug 2016Editorial Comment Bertram Yuh Bertram YuhBertram Yuh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2994AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 196(2), pp. 512–513 References 1 : Extended versus limited pelvic lymph node dissection during bilateral nerve-sparing radical prostatectomy and its effect on continence and erectile function recovery: long-term results and trifecta rates of a comparative analysis. World J Urol2015; . Epub ahead of print. Google Scholar 2 : The impact of magnetic resonance imaging on prediction of extraprostatic extension and prostatectomy outcome in patients with low-, intermediate- and high-risk prostate cancer: try to find a standard. J Endourol2015; 29: 1396. Google Scholar © 2016 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 196Issue 2August 2016Page: 512-513 Advertisement Copyright & Permissions© 2016 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bertram Yuh More articles by this author Expand All Advertisement PDF downloadLoading ...

HP-01-002 The impact of age difference between the patient and his female partner on the couple's sexual life after bilateral nerve sparing radical prostatectomy

HP-01-002 The impact of age difference between the patient and his female partner on the couple's sexual life after bilateral nerve sparing radical prostatectomy

Effects of Tadalafil Once-Daily or On-Demand vs Placebo on Return to Baseline Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy--Results from a Randomized Controlled Trial (REACTT).

The multicenter, randomized, double-blind, double-dummy, placebo-controlled REACTT trial suggested that treatment with tadalafil once daily (OaD) started early after bilateral nerve-sparing radical prostatectomy (nsRP) for prostate cancer may contribute to erectile function (EF)-recovery, which was predefined as achieving an International Index of Erectile Function (IIEF)-EF score ≥22. Here, we report descriptive post-hoc analyses, using the more strict definition for EF-recovery of returning back to the pre-surgery IIEF-EF-level ("back-to-baseline analysis"). REACTT included 422 men <68 years with adenocarcinoma of the prostate and preoperative IIEF-EF ≥22 who underwent nsRP at 50 centers from 9 European countries and Canada. Patients were randomized post-nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg OaD (n= 139), tadalafil 20 mg on-demand (pro-re-nata, PRN; n= 142), or placebo (n= 141), followed by 6-week drug-free washout (DFW) and 3-month open-label tadalafil OaD treatment (OLT). Proportion of patients returning to their preoperative IIEF-EF category (22-25 or ≥26) at the end of DBT, DFW, and OLT. Overall, 92.4% of patients had pre-surgery (baseline) IIEF-EF scores ≥26 (tadalafil OaD 94.2%, PRN 91.6%, placebo 91.5%), 7.4% had IIEF-EF 22-25. At the end of DBT, 22.3% of patients on tadalafil OaD had achieved "back-to-baseline" IIEF-EF, compared with 11.3% on tadalafil PRN and 7.8% on placebo. Of all 58patients "back-to-baseline" at the end of DBT, only 1 PRN-group patient had started from a baseline IIEF-EF <26. The treatment-group difference at the end of DBT was not maintained after DFW. After 3 months of OLT with tadalafil OaD, the proportion of patients with "back-to-baseline" IIEF-EF had almost doubled in all 3groups. Changing the definition for EF-recovery from IIEF-EF ≥22 to the more strict definition of "returning back-to-baseline IIEF-EF" had no major impact. Tadalafil OaD started early after nsRP improved drug-assisted EF, but had no effect on unassisted EF following treatment cessation after 9 months.

Erectile Function Recovery After Nerve-Sparing Radical Prostatectomy for Prostate Cancer: Is Back to Baseline Status Enough for Patient Satisfaction?

Several definitions of erectile function (EF) recovery after bilateral nerve-sparing radical prostatectomy (BNSRP) have been proposed based on the results of the International Index of EF (IIEF). We aimed at evaluating overall satisfaction (OS) after BNSRP according to the ability to achieve the pretreatment EF. We evaluated data of 652 patients treated with BNSRP for clinically localized prostate cancer (PCa). Erectile dysfunction (ED) was classified according to the IIEF-EF domain score. Return to baseline EF was defined as patients who reached the same preoperative ED category during the 3-year follow-up. Cox regression analyses were fitted to predict return to baseline IIEF-EF and to predict OS defined according to the IIEF-OS in the overall population. Logistic regression analyses were performed to analyze OS in men who reached the back to baseline status. The outcome of the study was to evaluate back to baseline EF status and to correlate it with postoperative OS. Preoperative satisfaction was reported by 218 (33.4%) patients. Postoperative satisfaction was achieved by 103 patients. Overall, 383 patients were able to achieve the preoperative IIEF-EF score. However, only 26.9% reported being satisfied. Age and preoperative IIEF-EF score were significantly associated with baseline IIEF-EF recovery (all P ≤ .02). Patients who were able to return to baseline IIEF-EF were more likely to be satisfied (P<.001). Time elapsed between surgery and achievement of baseline IIEF-EF was significantly associated with OS (P < .001). Among patients who were able to achieve the baseline IIEF-EF score, a preoperative IIEF-EF of 22-25 and 26-30 was significantly associated with postoperative satisfaction (all P < .001). After BNSRP, reaching the baseline IIEF-EF score is not always sufficient to obtain patient satisfaction. Only patients with a preoperative IIEF-EF ≥22 who reached the baseline score after surgery considered themselves satisfied. This should be taken into account in preoperative patient counseling.

Exploratory Decision-Tree Modeling of Data from the Randomized REACTT Trial of Tadalafil Versus Placebo to Predict Recovery of Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy

BackgroundUnderstanding predictors for the recovery of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) might help clinicians and patients in preoperative counseling and expectation management of EF rehabilitation strategies. ObjectiveTo describe the effect of potential predictors on EF recovery after nsRP by post hoc decision-tree modeling of data from A Study of Tadalafil After Radical Prostatectomy (REACTT). Design, setting, and participantsRandomized double-blind double-dummy placebo-controlled trial in 423 men aged <68 yr with adenocarcinoma of the prostate (Gleason ≤7, normal preoperative EF) who underwent nsRP at 50 centers from nine European countries and Canada. InterventionPostsurgery 1:1:1 randomization to 9-mo double-blind treatment with tadalafil 5mg once a day (OaD), tadalafil 20mg on demand, or placebo, followed by a 6-wk drug-free-washout, and a 3-mo open-label tadalafil OaD treatment. Outcome measurements and statistical analysisThree decision-tree models, using the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score at the end of double-blind treatment, washout, and open-label treatment as response variable. Each model evaluated the association between potential predictors: presurgery IIEF domain and IIEF single-item scores, surgical approach, nerve-sparing score (NSS), and postsurgery randomized treatment group. Results and limitationsThe first decision-tree model (n=422, intention-to-treat population) identified high presurgery sexual desire (IIEF item 12: ≥3.5 and <3.5) as the key predictor for IIEF-EF at the end of double-blind treatment (mean IIEF-EF: 14.9 and 11.1), followed by high confidence to get and maintain an erection (IIEF item 15: ≥3.5 and <3.5; IIEF-EF: 15.4 and 7.1). For patients meeting these criteria, additional non-IIEF–related predictors included robot-assisted laparoscopic surgery (yes or no; IIEF-EF: 19.3 and 12.6), quality of nerve sparing (NSS: <2.5 and ≥2.5; IIEF-EF: 14.3 and 10.5), and treatment with tadalafil OaD (yes and no; IIEF-EF: 17.6 and 14.3). Additional analyses after washout and open-label treatment identified high presurgery intercourse satisfaction as the key predictor. ConclusionsExploratory decision-tree analyses identified high presurgery sexual desire, confidence, and intercourse satisfaction as key predictors for EF recovery. Patients meeting these criteria might benefit the most from conserving surgery and early postsurgery EF rehabilitation. Strategies for improving EF after surgery should be discussed preoperatively with all patients; this information may support expectation management for functional recovery on an individual patient level. Patient summaryUnderstanding how patient characteristics and different treatment options affect the recovery of erectile function (EF) after radical surgery for prostate cancer might help physicians select the optimal treatment for their patients. This analysis of data from a clinical trial suggested that high presurgery sexual desire, sexual confidence, and intercourse satisfaction are key factors predicting EF recovery. Patients meeting these criteria might benefit the most from conserving surgery (robot-assisted surgery, perfect nerve sparing) and postsurgery medical rehabilitation of EF. Trial registrationClinicalTrials.gov, NCT01026818