Erectile Function Recovery Rates Research Articles

MP13-15 HOLMIUM LASER ENUCLEATION OF THE PROSTATE IS ASSOCIATED WITH COMPLICATIONS AND SEQUELAE EVEN IN THE HANDS OF AN EXPERIENCED SURGEON

You have accessJournal of UrologyCME1 Apr 2023MP13-15 HOLMIUM LASER ENUCLEATION OF THE PROSTATE IS ASSOCIATED WITH COMPLICATIONS AND SEQUELAE EVEN IN THE HANDS OF AN EXPERIENCED SURGEON Francesco Montorsi, Paolo Capogrosso, Giuseppe Fallara, Eugenio Ventimiglia, Edoardo Pozzi, Federico Belladelli, Luigi Candela, Francesco Pellegrino, Federico Dehò, Andrea Salonia, and Alberto Briganti Francesco MontorsiFrancesco Montorsi More articles by this author , Paolo CapogrossoPaolo Capogrosso More articles by this author , Giuseppe FallaraGiuseppe Fallara More articles by this author , Eugenio VentimigliaEugenio Ventimiglia More articles by this author , Edoardo PozziEdoardo Pozzi More articles by this author , Federico BelladelliFederico Belladelli More articles by this author , Luigi CandelaLuigi Candela More articles by this author , Francesco PellegrinoFrancesco Pellegrino More articles by this author , Federico DehòFederico Dehò More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003233.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Holmium laser enucleation of the prostate (HoLEP) is considered a challenging procedure. However, whether long surgical experience is able to improve peri- and post-operative outcomes is still unknown. We thus investigated results and complications after HoLEP performed by a highly experienced surgeon. METHODS: This is a single-institutional prospective study (NCT03583034) performed at a tertiary referral centre including 243 consecutive patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) treated with HoLEP by a single highly experienced surgeon (>1600 cases performed). Patients were assessed using validated questionnaires, PSA measurements and uroflowmetry at baseline and several follow-up dates. Intra- and postoperative complications were recorded and graded according to Clavien-Dindo (CD) classification. The Kaplan-Meier analysis estimated urinary continence (UC) (defined as no pad) and erectile function (EF) recovery rates. Logistic regression models assessed predictors of post-operative complications. RESULTS: Median (IQR) prostate volume (PV) was 87cc (60-115) with 146 (59.8%) patients having a PV>80 cc and 78 (32.1%) having an indwelling catheter at baseline. At 3-month follow-up, 219 (90.1%) patients had a peak flow rate >20 ml/s, and 182 (74.9%) had a null residual urine volume. Improvement in subjective symptoms as assessed with the IPSS was significant already at 1-month, and it was maintained until 12-month after surgery. UC recovery was slow with estimated rates of 68% (62-74%) at 1-month and 94% (91-97%) at 12-month post-HoLEP. Increased PV (HR 0.95; 95% CI: 0.91-0.99), incontinence at baseline (HR 0.45; 95% CI: 0.27-0.73) and a higher baseline IPSS (HR 0.97; 95% CI: 0.94-0.99) were predictors of worse UC recovery rates (all p<0.04). The EF recovery rates were 53% (46-61%) at 1-month and 85% (77-90%) at 12-month post-HoLEP. Post-operative complications were reported in 36 (14.8%) patients during hospital stay [CD-2: 14 (5.8%); CD-3: 1 (0.4%)], in 34 (14%) within one month post-discharge [CD-2: 17 (6.9%); CD-3: 1 (0.4%)] and in 10 (4.1%) at later follow-up [CD-2: 3 (1.2%); CD-3: 6 (2.4%)]. Severe complications (CD≥2) were more common in patients with indwelling catheter at baseline (OR: 5.05; p=0.006). CONCLUSIONS: A highly experienced surgeon is commonly referred complex cases of LUTS due to BPE. Although HoLEP remains an effective procedure, it is not devoid of complications and sequelae even in the hands of a surgeon with more than 1600 procedures completed. Source of Funding: No © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e179 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesco Montorsi More articles by this author Paolo Capogrosso More articles by this author Giuseppe Fallara More articles by this author Eugenio Ventimiglia More articles by this author Edoardo Pozzi More articles by this author Federico Belladelli More articles by this author Luigi Candela More articles by this author Francesco Pellegrino More articles by this author Federico Dehò More articles by this author Andrea Salonia More articles by this author Alberto Briganti More articles by this author Expand All Advertisement PDF downloadLoading ...

MP80-20 FUNCTIONAL OUTCOMES OF LAPAROSCOPIC VS ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP80-20 FUNCTIONAL OUTCOMES OF LAPAROSCOPIC VS ROBOT-ASSISTED RADICAL PROSTATECTOMY Marco Paciotti, Luigi Nocera, Carlo Andrea Bravi, Cesare Saitta, Adele Piro, Luca Sarchi, Roberto Contieri, Mottaran Angelo, Maria Peraire Lores, Eleonora Balestrazzi, Federico Piramide, Ruben De Groote, Geert De Naeyer, Paolo Casale, Rozzano, Giovanni Lughezzani, Alexandre Mottrie, and Nicolò Maria Buffi Marco PaciottiMarco Paciotti More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Cesare SaittaCesare Saitta More articles by this author , Adele PiroAdele Piro More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Roberto ContieriRoberto Contieri More articles by this author , Mottaran AngeloMottaran Angelo More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Federico PiramideFederico Piramide More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Paolo CasalePaolo Casale More articles by this author , Rozzano Rozzano More articles by this author , Giovanni LughezzaniGiovanni Lughezzani More articles by this author , Alexandre MottrieAlexandre Mottrie More articles by this author , and Nicolò Maria BuffiNicolò Maria Buffi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We entered the third decade of the robotic era in prostate cancer (PCa) surgery, and robotic platforms are increasingly spreading worldwide. Robotic surgery is usually believed to facilitate critical steps of the prostatectomy, increasing the precision of the surgical act and optimizing the probability of favorable outcomes. However, strong evidence supporting superiority of robotic vs laparoscopic prostatectomy (LRP) in terms of functional results are still missing. We performed a systematic review (SR) and meta-analysis (MA) to assess the functional outcomes of LRP vs robot-assisted radical prostatectomy (RARP). METHODS: We searched for all the studies comparing LRP and RARP in Medline, Embase, the Cochrane Central Register of Controlled Trials, and abstracts from the AUA and EAU meetings up to October 2022. Results were independently reviewed by two authors following the PRISMA guidelines. A SR+MA were performed. We followed a predefined PICOS approach: (P) patients affected by PCa (I) LRP (C) RARP (O) continence and potency recovery and (S) randomized controlled trials (RCTs). Continence was defined as using no pads or one safety pad per day. Potency was defined either as IIEF-5 score >17 or capability of intercourse. Effect measures for the outcomes were relative risk (RR) and 95% CI. Random-effect models were utilized to report RR. The RoB 2 was used to assess the risk of bias. RESULTS: Three RCTs were included in this SR. A total of 966 patients undergoing RARP for localized PCa were included in the three studies. The number of patients undergoing LRP vs RARP was 60 vs 60, and 586 vs 196, and 64 vs 64 in the #1, #2 and #3 RCT, respectively. Continence recovery and erectile function (EF) at 3 months were the most reported outcomes. Across the three studies, the pooled RR for 3 months continence was 1.15 (1.06-1.24), while the pooled RR for 3 months EF was 1.55 (1.23-1.95), both in favor of robotic surgery (Table 1). Therefore, we found a significant Risk of bias was assessed for all the three studies and determined as follows: “unclear risk of bias”. CONCLUSIONS: This MA found a higher EF and urinary continence recovery rate in patients who underwent RARP vs LRP for localized PCa. Therefore, evidence from RCTs demonstrated that robotic surgery offers a significant advantage in terms of functional outcomes in these patients. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1161 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marco Paciotti More articles by this author Luigi Nocera More articles by this author Carlo Andrea Bravi More articles by this author Cesare Saitta More articles by this author Adele Piro More articles by this author Luca Sarchi More articles by this author Roberto Contieri More articles by this author Mottaran Angelo More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Federico Piramide More articles by this author Ruben De Groote More articles by this author Geert De Naeyer More articles by this author Paolo Casale More articles by this author Rozzano More articles by this author Giovanni Lughezzani More articles by this author Alexandre Mottrie More articles by this author Nicolò Maria Buffi More articles by this author Expand All Advertisement PDF downloadLoading ...

Эффективность трехмерной системы визуализации при выполнении лапароскопической радикальной простатэктомии.

Introduction. The three-dimensional (3D) imaging during laparoscopic procedures can improve the quality of that surgeries. There is a shortage of publications about the potential benefits of 3D navigation in laparoscopic surgery with urological diseases. Radical prostatectomy (RPE) is known as the gold standard of treatment of localized prostate cancer (PC), and investigation of imaging technologies in laparoscopic surgery in PC patients is a hot topic. Aim. To compare the perioperative outcomes of laparoscopic RPE performed with 3D and two-dimensional (2D) imaging. Materials and methods. We performed retrospective analysis of perioperative outcomes in 146 patients who had undergone radical surgery with localized PC. All the patients were divided into 4 groups by the surgery features: 1) 2D imaging with the technique for neurovascular bundles preservation (TNVBP) (n=52); 2) 2D without TNVBP (n=46); 3) 3D with TNVBP (n=23); 4) 3D without TNVBP (n=25). We assessed operative time, intraoperative blood loss volume (IBLV), duration of the bladder drainage, positive surgical margin (PSM) detection rate, duration of the postoperative inpatient period, urinary continence recovery rate, erectile function recovery (EFR) rate. Results and discussion. In groups 1, 2, 3, 4 the operative time was 171,4±21,1, 168,3±23,2, 98,7±17,3, 92,2±22,2 min, and the IBLV was 294,2±62,1, 281,2±53,2, 144,2±31,7, 148,5±33,0 mL, respectively. PSM detection rate was 1,92±0,11%, 2,17±0,04% in groups 1, 2, while PSM had not been detected in groups 3, 4. In all the participants, duration of the bladder drainage was 5–7 days, and the full recovery of urinary continence was detected at both 6 and 12 months after the surgery. The postoperative inpatient period was 8–10 days in groups 1, 2, and 8–9 days in groups 3, 4. The EFR at 3 months after the surgery was detected in 38,4%, 28,3%, 34.8%, 28.0% of patients, while at 12 months it was detected in 59,6%, 41,3%, 82,6%, 56,0% of patients in groups 1, 2, 3, 4, respectively. Conclusion. We revealed the following features of perioperative period of laparoscopic RPE performed with 3D imaging compared to 2D: 1) the operative time was reduced by 42–45% (р&lt;0,05); 2) the IBLV was reduced by 47–51% (р&lt;0,05); 3) the PSM had not been detected; 4) there was the tendency to the shorter postoperative inpatient period; 5) the EFR rate was increased by 1,3–1,4 times (р&lt;0,05), and the best EFR outcomes were obtained via 3D imaging together with TNVBP. Thus, our study demonstrates the advisability of usage of both 3D imaging and TNVBP during the laparoscopic RPE.

Experience with an innovative surgical approach: 321 cases modified extraperitoneal single-incision robot-assisted laparoscopic radical prostatectomy without dedicated PORT based on Da Vinci SI system.

To summarize surgical experiences with a new modified technique involving extraperitoneal single-incision robot-assisted laparoscopic radical prostatectomy based on Da Vinci SI system by reviewing case data, including follow ups, and to evaluate the safety and clinical efficacy of the surgical procedure. The case data from December 2020 to September 2022 of 321 patients undergoing modified single incision (without dedicated PORT) robotic-assisted laparoscopic radical prostatectomy via an extraperitoneal approach were reviewed. All procedures were performed by the same surgeon at our center. Perioperative data and postoperative urinary control, tumor control, and erectile function recovery were assessed. The immediate, 3-months, 6-months, 12-months, 18-months and 24-months complete urinary control rates were 34.3%, 56.6%, 79.7%, 85.7%, 89.6% and 90.7%, respectively; the 3-months, 6-months, 12-months, 18-months and 24-months biochemical recurrence rates were 3.4%, 5.2%, 9.1%, 21.7% and 30.2%, respectively; and for those with normal preoperative erectile function, the 3-months, 6-months, 12-months, 18-months and 24-months postoperative erectile function recovery rates were 52.2%, 60.0%, 70.7%, 72.2% and 73.9%, respectively. The new modified technique involving extraperitoneal single-incision robotic-assisted laparoscopic radical prostatectomy is safe and feasible. This technique has satisfactory surgical results, and this new method results in satisfactory urinary control, tumor control and recovery of erectile function. In addition, this new method is not limited to specific dedicated access devices, which facilitates its application.

Surgical gestures as a method to quantify surgical performance and predict patient outcomes

How well a surgery is performed impacts a patient’s outcomes; however, objective quantification of performance remains an unsolved challenge. Deconstructing a procedure into discrete instrument-tissue “gestures” is a emerging way to understand surgery. To establish this paradigm in a procedure where performance is the most important factor for patient outcomes, we identify 34,323 individual gestures performed in 80 nerve-sparing robot-assisted radical prostatectomies from two international medical centers. Gestures are classified into nine distinct dissection gestures (e.g., hot cut) and four supporting gestures (e.g., retraction). Our primary outcome is to identify factors impacting a patient’s 1-year erectile function (EF) recovery after radical prostatectomy. We find that less use of hot cut and more use of peel/push are statistically associated with better chance of 1-year EF recovery. Our results also show interactions between surgeon experience and gesture types—similar gesture selection resulted in different EF recovery rates dependent on surgeon experience. To further validate this framework, two teams independently constructe distinct machine learning models using gesture sequences vs. traditional clinical features to predict 1-year EF. In both models, gesture sequences are able to better predict 1-year EF (Team 1: AUC 0.77, 95% CI 0.73–0.81; Team 2: AUC 0.68, 95% CI 0.66–0.70) than traditional clinical features (Team 1: AUC 0.69, 95% CI 0.65–0.73; Team 2: AUC 0.65, 95% CI 0.62–0.68). Our results suggest that gestures provide a granular method to objectively indicate surgical performance and outcomes. Application of this methodology to other surgeries may lead to discoveries on methods to improve surgery.

Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy

Prior studies suggest that men with good erectile function shortly after radical prostatectomy (RP) can subsequently have worsened erectile function. To determine the prevalence and predictors of early erectile function recovery post-RP and of worsening erectile function after initial erectile function recovery. We retrospectively queried our institutional database. Men who underwent RP during 2008-2017 and who completed the International Index of Erectile Function erectile function domain both pre-RP and serially post-RP, constituted the population. Functional erections were defined as International Index of Erectile Function (IIEF)-6 erectile function domain scores ≥24. We analyzed factors predicting functional erections at 3 months post-RP as well as factors predicting a decrease in functional erections between 3 and 6 months, defined as ≥2-point drop in the erectile function domain. Multivariable logistic regression models were used to identify predictors of early erectile function recovery and also of subsequent decline. Erectile function recovery rates at 3 months post-RP and predictive factors; rates of erectile function decline between 3-6 months and associated predictors. Eligible patients comprised 1,655 men with median age of 62 (IQR 57, 67) years. Bilateral nerve-sparing (NS) surgery was performed in 71% of men, unilateral NS in 19%, and no NS in 10%. Of this population, 224 men (14%; 95% CI 12%, 15%) had functional erections at 3 months post-RP. On multivariable analysis, significant predictors of early erectile function recovery included: younger age (OR 0.93, P < .001), higher baseline erectile function domain score (OR 1.14, P < .001) and bilateral NS (OR 3.81, P=.002). The presence of diabetes (OR 0.43, P=.028) and a former smoking history (OR 0.63, P=.008; reference group: never smoker) was associated with the erectile dysfunction at 3 months post-RP. Of the men with early functional erections, 41% (95% CI 33%, 48%) had a ≥ 2-point decline in erectile function between 3 and 6 months. No factors were identified as predictors for this decline. Only a small proportion of men have functional erections at 3 months post-RP and a notable number of them will experience a decline in erectile function between 3 and 6 months. Strengths: large patient population and the use of validated questionnaire. single-center retrospective study. A minority of men had functional erections 3 months post-RP, about half of whom had a decline in erectile function by month 6. We recommend appropriately counseling post-RP patients on the risk of such a decline in erectile function. Salter CA, Tin AL, Bernie HL, et al. Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy. J Sex Med 2022;19:1790-1796.

Comparison of Three Approaches to Single-Port Robot-Assisted Radical Prostatectomy: Our Institution's Initial Experience.

Background: We aimed to compare three robot-assisted radical prostatectomy (RARP) approaches-Retzius sparing (RS), extraperitoneal (EP), and transperitoneal (TP)-performed at our institution using the da Vinci® single-port (SP) platform (Intuitive Surgical, Sunnyvale, CA). Materials and Methods: We retrospectively reviewed the records of 101 patients who underwent SP-RARP at our institution and stratified them into three cohorts based on the RARP approach: RS (n = 32), EP (n = 30), and TP (n = 39). Data regarding preoperative patient characteristics, perioperative characteristics, oncologic outcomes, and early functional outcomes were collected. The Fisher's exact test and chi-square tests were utilized for categorical variables, and the Kruskal-Wallis test was utilized for numerical variables. Wilcoxon rank-sum tests were utilized for pairwise comparisons. A two-tailed p < 0.05 was considered significant. Results: All three cohorts were largely similar in terms of preoperative patient characteristics. Operative time was significantly different between cohorts (p < 0.001), with the RS approach having a faster mean operating time than the TP approach (208 ± 40 minutes vs 248 ± 36 minutes, p < 0.001). Clinically significant margin rates did not differ significantly between cohorts (p = 0.861). Postoperative continence differed significantly between cohorts (p < 0.001); higher continence rates were observed in RS vs EP-94% (30/32) vs 52% (15/29), respectively, p < 0.001. Return of erectile function also differed significantly between cohorts (p = <0.001); higher erectile function recovery rates were observed in RS vs EP-88% (28/32) vs 41% (11/27), respectively, p < 0.001-and in RS vs TP-88% (28/32) vs 60% (22/37), respectively, p = 0.014. Median (IQR) follow-up time was 150 (88-377) days. Conclusions: RS SP-RARP is associated with improved early functional outcomes when compared with both EP and TP approaches. These benefits are achieved while maintaining equivalent oncologic outcomes. Further research is needed to optimize the patient selection paradigm for the SP-RARP approach.

An update on the current status and future prospects of erectile dysfunction following radical prostatectomy.

Radical prostatectomy (RP) and radiation treatment are standard options for localized prostate cancer. Even though nerve-sparing techniques have been increasingly utilized in RP, erectile dysfunction (ED) due to neuropraxia remains a frequent complication. Erectile function recovery rates after RP remain unsatisfactory, and many men still suffer despite the availability of various therapies. This systematic review aims to summarize the current treatments for post-RP-ED, assess the underlying pathological mechanisms, and emphasize promising therapeutic strategies based on the evidence from basic research. Evaluation and review of articles on the relevant topic published between 2010 and 2021, which are indexed and listed in the PubMed database. Phosphodiesterase type 5 inhibitors, intracavernosal and intraurethral injections, vacuum erection devices, pelvic muscle training, and surgical procedures are utilized for penile rehabilitation. Clinical trials evaluating the efficacy of erectogenic drugs in this setting are conflicting and far from being conclusive. The use of androgen deprivation therapy in certain scenarios after RP further exacerbates the already problematic situation and emphasizes the need for effective treatment strategies. This article is a detailed overview focusing on the pathophysiology and mechanism of the nerve injury developed during RP and a compilation of various strategies to induce cavernous nerve regeneration to improve erectile function (EF). These strategies include stem cell therapy, gene therapy, growth factors, low-intensity extracorporeal shockwave therapy, immunophilins, and various pharmacological approaches that have induced improvements in EF in experimental models of cavernous nerve injury. Many of the mentioned strategies can improve EF following RP if transformed into clinically applicable safe, and effective techniques with reproducible outcomes.

MP27-03 DELAYING POST-OPERATIVE RADIATION THERAPY AFTER RADICAL PROSTATECTOMY IS ASSOCIATED WITH INCREASED FUNCTIONAL OUTCOMES: RESULTS FROM A LARGE SINGLE, REFERRAL CENTER SERIES

You have accessJournal of UrologyCME1 May 2022MP27-03 DELAYING POST-OPERATIVE RADIATION THERAPY AFTER RADICAL PROSTATECTOMY IS ASSOCIATED WITH INCREASED FUNCTIONAL OUTCOMES: RESULTS FROM A LARGE SINGLE, REFERRAL CENTER SERIES Mario de Angelis, Elio Mazzone, Giorgio Gandaglia, Armando Stabile, Simone Scuderi, Francesco Barletta, Daniele Robesti, Luigi Nocera, Riccardo Leni, Vito Cucchiara, Marco Bandini, Emanuele Zaffuto, Nazareno Suardi, Andrea Necchi, Shahrokh F. Shariat, Francesco Montorsi, and Alberto Briganti Mario de AngelisMario de Angelis More articles by this author , Elio MazzoneElio Mazzone More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Armando StabileArmando Stabile More articles by this author , Simone ScuderiSimone Scuderi More articles by this author , Francesco BarlettaFrancesco Barletta More articles by this author , Daniele RobestiDaniele Robesti More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Riccardo LeniRiccardo Leni More articles by this author , Vito CucchiaraVito Cucchiara More articles by this author , Marco BandiniMarco Bandini More articles by this author , Emanuele ZaffutoEmanuele Zaffuto More articles by this author , Nazareno SuardiNazareno Suardi More articles by this author , Andrea NecchiAndrea Necchi More articles by this author , Shahrokh F. ShariatShahrokh F. Shariat More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002570.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Previous studies reported a detrimental effect of postoperative radiotherapy (RT) on functional outcomes in men treated with radical prostatectomy (RP). However, it is still unclear whether an optimal timing to mitigate such detrimental effect may exist. We explored the correlation between time from RP to RT on urinary continence (UC) and erectile function (EF) recovery. METHODS: We evaluated 3,867 men treated with RP between 2000 and 2018 at a single center and stratified for RT schedule (adjuvant RT [aRT], salvage RT [sRT], no RT). We examined EF and UC recovery rates at 3-year according to RT schedule, and according to time from RP to RT. UC recovery was defined as no pad use, while IIEF-EF score ≥22 defined EF recovery. Multivariable Cox regressions tested predictors of functional outcomes. Covariates consisted of type of approach (robotic vs open), nerve-sparing status, preoperative EF and UC status and year of surgery. The correlation between time from RP to RT and UC and EF recovery rates at 3-yr was explored using the Lowess function. RESULTS: Overall, 3032 (79%) received no postoperative RT, while 456 (12%) and 336 (9%) men underwent aRT or sRT. Median time to aRT and sRT were 4 and 24 months, respectively. The 3-year EF rates were 35%, 29% and 12% in men who received no RT, sRT and aRT (p <0.001). The 3-year UC rates were 84%, 60% and 70% in patients who received no RT, aRT and sRT (p <0.001). Cox regressions confirmed the negative impact of RT type on UC (aRT OR 0.51 p<0.001; sRT OR 0.71 p=0.009) and EF (aRT OR 0.27 p<0.001; sRT OR 0.58 p<0.001) recovery. At Lowess analysis, UC recovery was lower when men received postoperative RT within 18 months after RP, thereafter a substantial plateau of 3-yr UC was recorded. Similarly, the predicted 3-yr EF recovery rate progressively increased with delayed RT from RP, with rates ranging from 8 to 33% but without reaching a plateau (Fig. 1A-B). CONCLUSIONS: Postoperative RT was strongly associated with lower rates of UC and EF recovery. A variable correlation with time to RT was observed. Particularly, when postoperative RT is planned, UC recovery could be optimized if RT is administered later than 18 months from surgery. Conversely, for EF recovery, a linear correlation with time to RT was observed. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e450 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mario de Angelis More articles by this author Elio Mazzone More articles by this author Giorgio Gandaglia More articles by this author Armando Stabile More articles by this author Simone Scuderi More articles by this author Francesco Barletta More articles by this author Daniele Robesti More articles by this author Luigi Nocera More articles by this author Riccardo Leni More articles by this author Vito Cucchiara More articles by this author Marco Bandini More articles by this author Emanuele Zaffuto More articles by this author Nazareno Suardi More articles by this author Andrea Necchi More articles by this author Shahrokh F. Shariat More articles by this author Francesco Montorsi More articles by this author Alberto Briganti More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD49-07 SEXUAL FUNCTION RECOVERY FOLLOWING OPEN AND ROBOTIC RADICAL PROSTATECTOMY: RESULTS OF AN ACADEMIC PENILE REHABILITATION PROGRAM

You have accessJournal of UrologyCME1 May 2022PD49-07 SEXUAL FUNCTION RECOVERY FOLLOWING OPEN AND ROBOTIC RADICAL PROSTATECTOMY: RESULTS OF AN ACADEMIC PENILE REHABILITATION PROGRAM Ugo Falagario, Michele Di Nauta, Andrea Checchia, Marco Recchia, Anna Ricapito, Nicola D'Altilia, Pasquale Annese, Gian Maria Busetto, Luigi Cormio, Giuseppe Carrieri, and Carlo Bettocchi Ugo FalagarioUgo Falagario More articles by this author , Michele Di NautaMichele Di Nauta More articles by this author , Andrea ChecchiaAndrea Checchia More articles by this author , Marco RecchiaMarco Recchia More articles by this author , Anna RicapitoAnna Ricapito More articles by this author , Nicola D'AltiliaNicola D'Altilia More articles by this author , Pasquale AnnesePasquale Annese More articles by this author , Gian Maria BusettoGian Maria Busetto More articles by this author , Luigi CormioLuigi Cormio More articles by this author , Giuseppe CarrieriGiuseppe Carrieri More articles by this author , and Carlo BettocchiCarlo Bettocchi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002620.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical prostatectomy (RP) is the gold standard treatment for clinically localized prostate cancer (PCa) in patients with a life expectancy 10 yr. Notwithstanding improvements in surgical techniques, erectile dysfunction (ED) is a common sequela of RP.The aim of the present study was to evaluate the effect of early penile rehabilitation in a dedicated Penile Rehabilitation Program on both assisted and unassisted erectile function (EF) in men who developed ED after open and robotic RP. METHODS: All patients undergoing open or robotic RP and early penile rehabilitation were included in the present study. All patients were treated and followed up at a single academic institution in a dedicated Penile Rehabilitation Program. Treatment included phosphodiesterase type 5 inhibitors (PDE5Is), intracavernous injections and vacuum erection devices (VEDs). EF recovery was defined as IIEF>20. Both assisted and unassisted EF was evaluated. Data were prospectively collected and retrospectively reviewed. Kaplan Mayer curves were used to evaluate EF recovery. Ethical Committee approval has been obtained. RESULTS: a total of 397 patients were eligible. 168 (42.3%) underwent robotic RP. Unilateral and bilateral nerve sparing was performed in 38 (9.6%) and 116 (29.2%) patients respectively.A combination of PDE5I and intracavernous injections was the most frequently used first line treatment (233, 59%). VEDs were used in 52 patients in addition to PDE5I and intracavernous injections (39, 10%) or intracavernous injections (23, 6%). In patients with a preoperative IIEF>21, assisted and unassisted EF recovery rates were 78% and 36% respectively.In patients with a preoperative IIEF<16, assisted and unassisted EF recovery rates were 46% and 18% respectively. Sub analysis showed a moderate benefit of penile rehabilitation also in patients with a preoperative IIEF<16 undergoing bilateral nerve sparing RP.Intensive penile rehabilitation with PDE5I, intracavernous injections and VEDs led to the best patient perceived results. CONCLUSIONS: Intensive penile rehabilitation programs improves EF recovery in patients undergoing radical prostatectomy. Preservation of Neurovascular bundles should be attempted also in patients with preoperative ED. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e832 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ugo Falagario More articles by this author Michele Di Nauta More articles by this author Andrea Checchia More articles by this author Marco Recchia More articles by this author Anna Ricapito More articles by this author Nicola D'Altilia More articles by this author Pasquale Annese More articles by this author Gian Maria Busetto More articles by this author Luigi Cormio More articles by this author Giuseppe Carrieri More articles by this author Carlo Bettocchi More articles by this author Expand All Advertisement PDF DownloadLoading ...

Does the risk of obstructive sleep apnea (OSA) affect erectile function recovery (EFR) after radical prostatectomy (RP)?

ABSTRACT Introduction Obstructive sleep apnea (OSA) affects as many as 7% of adult men in the general population, higher in men with obesity and large neck sizes. OSA is associated with ED. No data to date has assessed EFR after RP in men with OSA. Objective The objective of this study was to define EFR rates 2 years post-RP. Methods Records of men who underwent RP with 24-month post-RP follow-up were reviewed. ADT and radiation therapy were exclusions. Men completed the OSA screening questionnaire, STOP-BANG (SB) pre-RP. Men were divided into OSA risk groups: high, intermediate, and low. EFR was recorded using IIEF-EFD score, with a score of at least 24 indicating recovery. Univariable and multivariable logistic regression analyses assessed predictors of EFR. Results 454 men were analyzed. Mean age 62 ± 7 years. Of the studied population,12% had a history of OSA,10% had diabetes,12% were current smokers, and 37% were former smokers. The median STOP-BANG (SB) score was 2. High, intermediate, and low risk of OSA scores were 8%, 41% and 51% respectively. Mean baseline testosterone (T) was 495 ng/dL, PSA 7.4 ng/mL, and EFD score 22. Most men had a Gleason sum of 7 (87%). 73% of patients had bilateral or unilateral neurovascular bundle preservation. At the 2-year follow up, median EFD score in high, intermediate and low OSA risk groups: were 9, 16, and 18 respectively. The low OSA risk group was significantly more likely to recover (OR = 1.6, 1.1 – 2.4) than the moderate/high group. Younger age (OR = 0.92, 0.89 – 0.95), absence of diabetes (OR = 0.31, 0.14 – 0.72), higher baseline T (OR per 100 units = 1.40, 1.04 – 1.89), higher baseline EFD score (OR = 1.16, 1.11 – 1.22), and lower Gleason score (OR = 0.53, 0.34 – 0.82) were also associated with recovery at 2 years. Conclusions In our cohort, at 2 years post-RP, increasing OSA risk is associated with poorer EFR in men post-RP. Disclosure Work supported by industry: no.

Efficacy of Tadalafil in Penile Rehabilitation Started Before Nerve-Sparing Robot-Assisted Radical Prostatectomy: A Double-Blind Pilot Study.

BackgroundDespite the widespread practice of nerve-sparing robot-assisted radical prostatectomy (nsRARP) for the treatment of localized prostate cancer (PCa), erectile dysfunction remains a significant sequela of radical prostatectomy.AimThis study aimed to compare the efficacy of tadalafil 5 mg once daily for erectile function recovery in patients who underwent nsRARP according to the timing of rehabilitation initiation.MethodsIn this double-blind, prospective pilot study, a total of 41 patients who underwent nsRARP were randomly assigned into 2 groups according to the timing of rehabilitation initiation. In the preRARP group (n = 20), tadalafil was started 2 weeks before nsRARP, and in the postRARP group (n = 21), it was started 4 weeks after nsRARP. Erectile function recovery after nsRARP was defined as an International Index of Erectile Function (IIEF-5) score of ≥17.OutcomesThe measures of EF recovery were the changes in IIEF-5 score.ResultsThe rate of erectile function recovery at 12-month follow-up was 80.0% and 71.4% in the preRARP and postRARP groups, respectively. The mean differences between baseline and postoperative IIEF-5 scores at 1-, 3-, 6-, and 12-month follow-up were −11.7 ± 3.2, −7.4 ± 3.2, −5.6 ± 1.5, and −4.1 ± 1.1 in the preRARP group and −14.7 ± 4.7, −12.0 ± 5.0, −9.7 ± 3.9, and −6.0 ± 3.1 in the postRARP group, respectively (1-month, P = .259; 3-months, P = .077; 6-months, P = .014; 12-months, P = .007).Clinical implicationsPreoperative tadalafil 5 mg once a day could be used effectively and safely as a strategy for penile rehabilitation after nsRARP.Strengths and LimitationsThis study is the first prospective trial of penile rehabilitation with tadalafil 5 mg once a day prior to nsRARP. This is a pilot study with the limitations of a small sample; further and large-scale studies with multiple cohorts, such as an untreated control group and an early immediate rehabilitation group for EF recovery, are needed.ConclusionThis study suggests that preoperative penile rehabilitation using tadalafil may lead to better erectile function recovery than postoperative penile rehabilitation using tadalafil.Noh T, Shim JS, Kang SG, et al. Efficacy of Tadalafil in Penile Rehabilitation Started Before Nerve-Sparing Robot-Assisted Radical Prostatectomy: A Double-Blind Pilot Study. Sex Med 2022;10:100508.

Does the Risk of Obstructive Sleep Apnea (OSA) Affect Erectile Function Recovery (EFR) After Radical Prostatectomy (RP)?

ABSTRACT Introduction Obstructive sleep apnea (OSA) affects as many as 7% of adult men in the general population, higher in men with obesity and large neck sizes. OSA is associated with ED. No data to date has assessed EFR after RP in men with OSA. Objective The objective of this study was to define EFR rates 2 years post-RP. Methods Records of men who underwent RP with 24-month post-RP follow-up were reviewed. ADT and radiation therapy were exclusions. Men completed the OSA screening questionnaire, STOP-BANG (SB) pre-RP. Men were divided into OSA risk groups: high, intermediate, and low. EFR was recorded using IIEF-EFD score, with a score of at least 24 indicating recovery. Univariable and multivariable logistic regression analyses assessed predictors of EFR. Results 454 men were analyzed. Mean age 62 ± 7 years. Of the studied population,12% had a history of OSA,10% had diabetes,12% were current smokers, and 37% were former smokers. The median STOP-BANG (SB) score was 2. High, intermediate, and low risk of OSA scores were 8%, 41% and 51% respectively. Mean baseline testosterone (T) was 495 ng/dL, PSA 7.4 ng/mL, and EFD score 22. Most men had a Gleason sum of 7 (87%). 73% of patients had bilateral or unilateral neurovascular bundle preservation. At the 2-year follow up, median EFD score in high, intermediate and low OSA risk groups: were 9, 16, and 18 respectively. The low OSA risk group was significantly more likely to recover (OR = 1.6, 1.1 – 2.4) than the moderate/high group. Younger age (OR = 0.92, 0.89 – 0.95), absence of diabetes (OR = 0.31, 0.14 – 0.72), higher baseline T (OR per 100 units = 1.40, 1.04 – 1.89), higher baseline EFD score (OR = 1.16, 1.11 – 1.22), and lower Gleason score (OR = 0.53, 0.34 – 0.82) were also associated with recovery at 2 years. Conclusions In our cohort, at 2 years post-RP, increasing OSA risk is associated with poorer EFR in men post-RP. Disclosure No

Utilisation of anatomic grading of nerve-spare during robot-assisted radical prostatectomy to prognosticate erectile function recovery

Objective: To determine if a precise 5-point nerve-spare (NS) scoring system at the time of robot-assisted radical prostatectomy (RARP) correlates with post-operative erectile function recovery (EFR). Patients and methods: From 2014 to 2018, 277 patients underwent RARP by a single surgeon. NS quality was recorded as: grade 1, non-NS; grade 2, &lt;50%; grade 3, 50%; grade 4, 75%; grade 5, ⩾95%. EFR rates were compared using Fisher’s exact test or Pearson’s chi-square test at 3–24 months, grouped based on the degree of NS: 1 = bilateral full NS (grade 5); 2 = bilateral NS with one good NS (⩾grade 4); 3 = unilateral good NS; 4 = incremental NS (grade 3); 5 = partial neurovascular bundle (NVB) resection (grade 2); 6 = complete NVB resection (grade 1). Results: At 24 months, EFR defined as Sexual Health Inventory for Men (SHIM) score ⩾17 was 75%, 55%, 41%, 23%, 12% and 0% for groups 1–6, respectively ( p = 0.001). EFR defined as spontaneous erection sufficient for intercourse with or without PDE5i was 60%, 58%, 40%, 33%, 0% and 11% for groups 1–6, respectively ( p &lt; 0.001). Conclusion: A precise anatomic NS scoring system at RARP allows good prognostication of EFR, which may inform patient counselling and erectile dysfunction management. Level of evidence: 4

Long-term consequences of bilateral cavernous crush injury in normal and diabetic rats: a functional study.

A recent statement from the European-Society-for-Sexual-Medicine has highlighted the limitations of using the rat model for nerve-sparing prostatectomy. The use of young rats with no comorbidities and the early evaluation of the erectile function (EF) are deemed a source of bias. Our aim was to evaluate the long-term consequences in EF of bilateral nerve cavernous crush- injury (BNCI) in type 1 diabetic (DM) rats 30-male/12-week-old rats were divided into four groups: Sham, BNCI, DM, and BNCI + DM. Sham group underwent an intraperitoneal injection (IP) of saline solution and after 1 month underwent a sham laparotomy. BNCI underwent an IP of saline solution and after 1 month to BNCI. DM underwent an IP of 60 mg/kg-1-streptozotocin (STZ) and after 1 month to a sham laparotomy. BNCI + DM underwent an IP of 60 mg/kg-1-STZ and after 1 month to BNCI. After 5 months from the induction of diabetes, all rats underwent measurement of intracorporeal pressure (ICP) and mean arterial pressure (MAP) during CN-electrostimulation. Multiple groups were compared using Kruskal-Wallis one-way analysis of variance followed by Mann-Whitney U test for post hoc comparisons. Blood glucose-level was higher (p < 0.05) in the groups with DM and BNCI + DM. After 5-months, DM and BNCI + DM also showed a lower weight compared to other groups (p < 0.05). No differences were noted in ICP/MAP between the sham and BNCI. BNCI + DM showed lower ICP/MAP compared to all the groups (p < 0.05). DM Showed lower ICP/MAP compared to Sham and BNCI (p < 0.05). BNCI in rats without comorbidities did not induce long-term erectile dysfunction (ED) suggesting a spontaneous EF recovery. BNCI in DM induced long-term ED. The results of previous short-term studies can only provide evidence on the time to recovery of spontaneous EF as to the actual EF recovery rate.

MP50-16 NEUROSAFE PROOF: A MULTI-CENTRE, PRAGMATIC, RCT FOR MEN UNDERGOING ROBOT-ASSISTED RADICAL PROSTATECTOMY. UPDATE ON A TRIAL IN PROGRESS

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III (MP50)1 Sep 2021MP50-16 NEUROSAFE PROOF: A MULTI-CENTRE, PRAGMATIC, RCT FOR MEN UNDERGOING ROBOT-ASSISTED RADICAL PROSTATECTOMY. UPDATE ON A TRIAL IN PROGRESS Eoin Dinneen, Jacques Grierson, Rosemary Clow, Aiman Haider, Alex Freeman, Clare Allen, NeuroSAFE PROOF Trial Team, and Greg Shaw Eoin DinneenEoin Dinneen More articles by this author , Jacques GriersonJacques Grierson More articles by this author , Rosemary ClowRosemary Clow More articles by this author , Aiman HaiderAiman Haider More articles by this author , Alex FreemanAlex Freeman More articles by this author , Clare AllenClare Allen More articles by this author , NeuroSAFE PROOF Trial Team More articles by this author , and Greg ShawGreg Shaw More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002076.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted Radical Prostatectomy (RARP) is an effective cure for organ confined prostate cancer but is associated with considerable post-operative functional toxicity. The NeuroSAFE technique (intra-operative frozen section analysis of the neurovascular structure adjacent margin) may help improve functional outcomes by promoting safe nerve-sparing (NS) RARP without compromising on oncological outcomes. NeuroSAFE technique has reported favourably in retrospective, single-centre studies but has never been evaluated prospectively by a randomised study. The NeuroSAFE PROOF Feasibility Study has succeeded in demonstrating feasibility and has facilitated opening of the full-scale, definitively powered NeuroSAFE Randomized Controlled Trial (RCT) (NCT03317990). We report on the design and progress of the full NeuroSAFE PROOF RCT. METHODS: Potent men (IIEF-5>21) with localised prostate cancer at 4 regional uro-oncology centres in the UK (UCLH, Bristol, Sheffield and Glasgow) are eligible. Participants are randomised 1:1 to RARP with NS decision guided by standard of care (clinical information, DRE and pre-operative mpMRI surgical plan) vs. RARP with NS decision guided by standard of care information and the NeuroSAFE technique. The primary outcome is erectile function recovery assessed by IIEF-5 score >15 at 12-months. Important secondary outcomes include detailed peri-operative outcomes, histological outcomes, post-operative complications, biochemical recurrence rates, urinary continence (assessed by ICIQ), and health related quality of life (assessed by Rand-36 and EQ-5D-5L). Aiming to demonstrate a difference of 15% in erectile function recovery rates between the arms, a total of 404 men will need to be randomised and treated. Patients will continue to be followed for outcomes until 5 years after treatment. RESULTS: At the time of writing, 159 men have been recruited and treated with RARP as per random allocation at the 4 participating sites. The independent DMC has met thrice to ensure the oncological safety of the trial and will continue to review the data at intervals. Covid-19 has led to significant challenges, including suspension of recruitment and difficulties performing follow-up. The trial team have developed new methods of recruitment, consent and follow-up to ensure conduct of the study remains in line with the highest standards of trial conduct. CONCLUSIONS: The NeuroSAFE technique has been reported as a method to optimise outcomes for men undergoing RARP for over a decade, but, in the absence of level 1 evidence, equipoise remains. We hope that our full trial (the first RCT of the NeuroSAFE technique in the world) will provide the evidence to establish whether what has long been a promising technique truly improves outcomes for men undergoing RP. Source of Funding: NeuroSAFE PROOF is funded by the JP Moulton Charitable Foundation © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e892-e893 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eoin Dinneen More articles by this author Jacques Grierson More articles by this author Rosemary Clow More articles by this author Aiman Haider More articles by this author Alex Freeman More articles by this author Clare Allen More articles by this author NeuroSAFE PROOF Trial Team More articles by this author Greg Shaw More articles by this author Expand All Advertisement Loading ...

MP27-02 DOES THE RISK OF OBSTRUCTIVE SLEEP APNEA (OSA) AFFECT ERECTILE FUNCTION RECOVERY (EFR) AFTER RADICAL PROSTATECTOMY (RP)?

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation I (MP27)1 Sep 2021MP27-02 DOES THE RISK OF OBSTRUCTIVE SLEEP APNEA (OSA) AFFECT ERECTILE FUNCTION RECOVERY (EFR) AFTER RADICAL PROSTATECTOMY (RP)? Jose M. Flores, Carolyn A. Salter, Karin Ruiz, Nicole Benfante, Elizabeth Schofield, Miranda Tan, Vincent Laudone, and John P. Mulhall Jose M. FloresJose M. Flores More articles by this author , Carolyn A. SalterCarolyn A. Salter More articles by this author , Karin RuizKarin Ruiz More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Elizabeth SchofieldElizabeth Schofield More articles by this author , Miranda TanMiranda Tan More articles by this author , Vincent LaudoneVincent Laudone More articles by this author , and John P. MulhallJohn P. Mulhall More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002024.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Obstructive sleep apnea (OSA) affects as many as 7% of adult men in the general population, higher in men with obesity and large neck sizes. OSA is associated with ED. No data to date has assessed EFR after RP in men with OSA. The objective of this study was to define EFR rates 2 years post-RP. METHODS: Records of men who underwent RP with 24-month post-RP follow-up were reviewed. ADT and radiation therapy were exclusions. Men completed the OSA screening questionnaire, STOP-BANG (SB) pre-RP. Men were divided into OSA risk groups: high, intermediate, and low. EFR was recorded using IIEF-EFD score, with a score of at least 24 indicating recovery. Univariable and multivariable logistic regression analyses assessed predictors of EFR. RESULTS: 454 men were analyzed. Mean age 62±7 years. Of the studied population, 12% had a history of OSA, 10% had diabetes, 12% were current smokers, and 37% were former smokers. The median STOP-BANG (SB) score was 2. High, intermediate, and low risk of OSA scores were 8%, 41% and 51% respectively. Mean baseline testosterone (T) was 495 ng/dL, PSA 7.4 ng/mL, and EFD score 22. Most men had a Gleason sum of 7 (87%). 73% of patients had bilateral or unilateral neurovascular bundle preservation. At the 2-year follow up, median EFD score in high, intermediate and low OSA risk groups: were 9, 16, and 18 respectively. The low OSA risk group was significantly more likely to recover (OR = 1.6, 1.1–2.4) than the moderate/high group. Younger age (OR = 0.92, 0.89–0.95), absence of diabetes (OR = 0.31, 0.14–0.72), higher baseline T (OR per 100 units = 1.40, 1.04–1.89), higher baseline EFD score (OR = 1.16, 1.11–1.22), and lower Gleason score (OR = 0.53, 0.34–0.82) were also associated with recovery at 2 years. CONCLUSIONS: In our cohort, at 2 years post-RP, increasing OSA risk is associated with poorer EFR in men post-RP. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e472-e472 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jose M. Flores More articles by this author Carolyn A. Salter More articles by this author Karin Ruiz More articles by this author Nicole Benfante More articles by this author Elizabeth Schofield More articles by this author Miranda Tan More articles by this author Vincent Laudone More articles by this author John P. Mulhall More articles by this author Expand All Advertisement Loading ...

Effect of transperineal template prostate biopsy on perioperative and functional outcomes following robotic-assisted radical prostatectomy

Objective: This study aimed to determine the effect of template transperineal (TTP) compared to transrectal (TR) biopsy on surgical and functional outcomes after robotic-assisted radical prostatectomy (RARP). Methods: From 2014 to 2018, 280 patients underwent RARP by a single surgeon. Of these, 184 had TR, and 96 had TTP biopsy. Primary outcomes were continence and erectile function recovery (EFR) rates up to 24 months postoperatively. Secondary outcomes comprised positive margin rates and markers of a difficult operation, including operative time, estimated blood loss (EBL), urethral preservation quality and ability to perform planned nerve-sparing surgery. Results: The median age was greater in the TTP group (64 vs. 62 years, p=0.028). The proportions of men with preoperative erectile dysfunction and men undergoing nerve-sparing surgery were not different between groups. Operative time, EBL, urethral preservation quality, proportion of men undergoing intended nerve-sparing procedure, positive margin rates and continence recovery rates were not different among the groups. At 24 months, men in the TR group had a higher EFR rate on univariate analysis ( p=0.036), and multivariate analysis ( p=0.03). Conclusion: TTP biopsy was not associated with markers of a more difficult RARP or worse oncological and continence recovery outcomes but did appear to impact upon long-term rates of EFR. Level of evidence: Level 4.

Penile Rehabilitation Strategy after Nerve Sparing Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Trials.

Despite the advances in nerve sparing and minimally invasive radical prostatectomy, erectile dysfunction remains an important adverse event after radical prostatectomy. Penile rehabilitation strategies have been developed to expedite and improve erectile function recovery. However, the differential efficacy and the best penile rehabilitation strategy are unclear as yet. We conducted a systematic review and network meta-analysis to investigate and compare the efficacy of different penile rehabilitation strategies. A systematic search was performed in May 2020 using PubMed® and Web of Science™ databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) extension statement for network meta-analysis. Studies that compared the erectile function recovery rate and adverse events between penile rehabilitation treatment groups (eg medications, devices and actions) and control group were included. We used the Bayesian approach in the network meta-analysis. A total of 22 studies (2,711 patients) met our eligibility criteria. Out of 16 different penile rehabilitation strategies and schedules vs placebo, only pelvic floor muscle training (OR 5.21, 95% CrI 1.24-29.8) and 100 mg sildenafil regular doses, ie once daily or nightly (OR 4.00, 95% CrI 1.40-13.4) were associated with a significantly higher likelihood of erectile function recovery. The certainty of results for 100 mg sildenafil regular dose was moderate, while pelvic floor muscle training had low certainty. The sensitivity analysis confirmed that the regular high dose of phosphodiesterase-5 inhibitors regardless of type vs placebo (OR 2.09, 95% CrI 1.06-4.17) was associated with a significantly higher likelihood of erectile function recovery with a moderate certainty. The on-demand doses of phosphodiesterase-5 inhibitors were not proven to be more beneficial than placebo. Secondary outcomes such as adverse events were not analyzed due to incomplete data in the literature. However, no serious adverse events were reported in any of the studies. Sildenafil 100 mg regular dose is the best penile rehabilitation strategy to improve erectile function recovery rates after radical prostatectomy. Although pelvic floor muscle training has been shown to be effective in increasing the erectile function recovery rate, well designed randomized controlled trials with larger sample sizes are needed to confirm the presented early results. The on-demand dose of phosphodiesterase-5 inhibitors should not be considered as a penile rehabilitation strategy.

Robot-assisted radical prostatectomy with clipless intrafascial neurovascular bundle-sparing approach: surgical technique and one-year functional and oncologic outcomes

Various neurovascular bundle-sparing techniques have been introduced to maximize recovery of erectile function after robot-assisted radical prostatectomy (RARP). The clipless intrafascial neurovascular bundle-sparing technique aims to preserve periprostatic structures and neurovascular bundles as much as possible by avoiding clipping of the vascular pedicles. This study reports 1-year functional and oncologic outcomes and postoperative complications in 105 patients with intact preoperative erectile function who underwent a modified clipless intrafascial neurovascular bundle-sparing RARP. Intact erectile function was defined as score ≥ 21 on the Sexual Health Inventory for Men questionnaire or ability to have sexual intercourse. Median follow-up was 26.5 months (IQR 15.25–48). Postoperative erectile function recovery rates were 71.4%, 81.9%, 88.6%, 92.4%, and 94.3% at 1, 3, 6, 9, and 12 months, respectively. The rate of positive surgical margins was 16.2% overall and 11.8% in patients with stage pT2 disease. The biochemical recurrence rate was 6.7% overall. The modified clipless intrafascial neurovascular bundle-sparing technique is safe and feasible and can achieve excellent recovery of erectile function after RARP. Further large-scale prospective comparative studies are warranted.