Nerve-sparing Radical Retropubic Prostatectomy Research Articles

Post Radical Prostatectomy Erectile Dysfunction. A Single Centre Experience.

This study aims to determine the effects of radical retropubic prostatectomy on post-operative erectile function. A total of 50 patients were included in this study, diagnosed with localized prostate cancer, and underwent nerve-sparing radical retropubic prostatectomy. All patients completed the International Index of Erectile Function (IIEF-5) questionnaire pre-operatively and on the third, sixth, and twelfth post-operative month and completed a self-reporting of their satisfaction with their sexual performance. Patients with a history of severe heart disease, were on erectile dysfunction medication, or had a score of 7 or less on the IIEF-5 questionnaire, were excluded from the study. Pre-operatively it was observed that the lower the IIEF-5 score, the higher the biopsy Gleason score. Post-operatively, 16 patients stated that erectile function had returned to the pre-operative IIEF-5 category. In contrast, only 13 of them stated they were happy with their sexual performance on the self-reporting scale. The rest reported dissatisfaction despite returning to their pre-operative erectile function status. IIEF-5 scores were also different when compared amongst the four age groups, with scores indicating that younger age is related to higher IIEF-5 scores. At the 3-month follow-up, no statistically significant difference was observed between age groups. Finally, patients younger than 64 reported significantly less deterioration in post-operative erectile function. Post-radical prostatectomy erectile dysfunction remains one of the most pressing issues in prostate cancer therapy. A higher Gleason score has a more significant impact on pre-operative ED, and at the same time, the best post-operative ED results are observed in younger patients. Finally, patients need extensive follow-up, therapy, and pre-and post-operative psychological support to have the best possible erectile function.

370 Increasing the Dose of Vardenafil on a Daily Base Doesn't Improve Erectile Function in the Longer Follow-up of 2 Years After Nerve-sparing Radical Prostatectomy

Several pathophysiologies are postulated for postoperative erectile function rehabilitation and several treatment regimens for rehabilitation of erectile function after nerve-sparing radical prostatectomy (nsRP) are currently discussed and performed. In previous prospective studies it was shown that using daily low dose PDE-5 inhibitors after nsRP leads to an improvement of erectile function. But the “optimal” regimen and dosage of PDE5-inhibitors for rehabilitation programs is still unknown. 36 sexual active patients were operated by nerve-sparing retropubic radical prostatectomy. All patients completed an IIEF-5 questionnaire concerning erectile function preoperatively. Group 1 (n=12 patients) received vardenafil 5mg/d versus group 2 (n=12) who received vardenafil 10mg/d at night beginning the day of catheter removal. A control of 12 patients underwent follow up without PDE-5-inhibitors. IIEF-5 questionnaire was performed 3, 6, 12, 18 and 24 months after operation. In the group of daily 5mg vardenafil (group 1) the IIEF-5 score decreased from preoperative 22.4 mean score to 4.2 at 3 months, 8.9 at 6 months, 13.4 at 12 months, 15.2 at 18 months and 18.3 mean score at 24 months after nsRP versus preoperative 22.8, 4.1 at 3 months, 7.9 at 6 months, 12.8 at 12 months, 14.9 at 18 months and 18.4 mean score at 24 months in group 2 (10mg/d vardenafil). In the control group preoperative IIEF-5 mean score 21.9 decreased to 3.8 at 3 months, 6.1 at 6 months, 8.9 at 12 months, 10.2 at 18 months and 11.3 at 24 months. Statistical evaluation showed significant difference in IIEF-5 score and time to recovery of erectile function between the groups 1 and 3 and between the groups 2 and 3 (p<0.05). No statistical differences were found between the groups 1 and 2.

Comparative Analysis of Results Between Robot-Assisted and Open Radical Prostatectomy

Summary We aimed to compare results between patients with early- stage prostate cancer who underwent robot-assisted and open radical prostatectomy. We examined preoperative and postoperative data, early and late complications, and analysed oncological and functional outcomes (continence and erectile function) during follow-up. We studied the data of 123 patients with localized prostate cancer, operated with nerve-sparing retropubic radical prostatectomy, divided into two groups. Group 1 included 70 patients who underwent robot-assisted radical prostatectomy (RARP). Group 2 included 53 patients, on whom open retropubic radical prostatectomy (RRP) was performed. We compared preoperative data, complications rate, oncological, and functional outcome (continence and erectile function) during the follow-up period. Operative time was significantly lower in the RRP group. Blood loss and earlier removal of the urinary catheter were significantly lower in the RARP group. The percentage of significant postoperative complications (Clavien-Dindo III-IV) was 0% in the first group and 3% in the second group. During follow-up, the improvement in the functional outcome - continence and erectile function was significantly better in the robot-assisted surgery patients. There were statistically significant better functional outcomes in patients operated on using the robot-assisted technique. The operating time was shorter in the classic radical prostatectomy. The application of robot-assisted radical prostatectomy may help achieve earlier recovery, as compared to open radical prostatectomy.

263 Penile Rehabilitation Program with “early” low-dose tadalafil after nerve-sparing radical prostatectomy - increased “early” nocturnal penile tumescence 8 days after nerve-sparing radical prostatectomy is correlated with further erectile function r

Cytotoxic factors in the corpora cavernosa released within the first 48 to 72 hours after surgery seem to play a major role for developing persistent erectile dysfunction. Several pathophysiologies are postulated for postoperative erectile function rehabilitation. In previous prospective studies nocturnal penile tumescense and rigidity (NPTR) in the acute phase during the first night after catheter removal was shown in 93% of the patients after nerve-sparing radical prostatectomy (nsRP) and the improvement of erectile function by using daily low dose PDE5-inhibitors. But the “optimal” time to initiate a rehabilitation program with PDE5-inhibitors is still unknown. 24 sexual active patients were operated by nerve-sparing retropubic radical prostatectomy. All patients completed an IIEF-5 questionnaire concerning erectile function preoperatively. To maintain and support recovery of spontaneous erectile function 12 patients received tadalafil 5mg/d at night starting at the 3rd night after surgery (group 1). A control of 12 patients received tadalafil 5mg/d at night beginning one day after catheter removal (group 2). 8 days after surgery the transurethral catheter was removed and an erectometer measurement of NPTR (Rigi-Scan®) was carried out on each patient at the following night. All patients completed an IIEF-5 questionnaire concerning erectile function at 3, 6, 12 and 18 months after surgery to evaluate further erectile function recovery.

72 - Early penile rehabilitation with sildenafil immediately after nerve-sparing radical retropubic prostatectomy

72 - Early penile rehabilitation with sildenafil immediately after nerve-sparing radical retropubic prostatectomy

Low-Intensity Extracorporeal Shockwave Therapy – A New Approach in the Treatment of Erectile Dysfunction after Radical Prostatectomy

Summary The experience accumulated with low-intensity extracorporeal shock wave therapy (LI-ESWT) from international clinical trials has demonstrated its safety, efficacy and good tolerance in treatment of erectile dysfunction (ED). The aim of this retrospective study was to investigate the effect of LI-ESWT in patients with ED after bilateral nerve sparing radical surgery for prostate cancer. Twenty-seven patients underwent bilateral nerve sparing radical retropubic prostatectomy (BNSRRP) at the clinic of urology of the university hospital in Pleven between January 2016 and December 2016. Twenty-one of these patients had pre-operative preserved erectile function (EF), as reported according to the International Index of Erectile Function (IIEF-5). Postoperatively, these 21 patients experienced a mild (18-21 points) impairment of EF. In 10 patients (group 1), LI-ESWT was performed. The procedure was performed once a week for 6 weeks with a LI-ESWT (BTL 6000 SWT Topline) instrument. The reading was obtained with IIEF-5 on the third and sixth month after the end of therapy. The other 11 patients (group 2) were used as a control group and did not receive treatment. In 5 patients in group 1, a recovery of EF (&gt; 21 points) as per IIEF-5 was recorded at the third month after treatment. In two patients, the same score was recorded at the sixth month. No improvement was seen in three men in group 1. In the controls (group 2), a spontaneous EF improvement in four patients at sixth month was registered. Despite the small number of patients and their short-term follow-up, our initial results indicate that LI-ESWT is effective, safe and well-tolerated. It could be an alternative for early penis rehabilitation in patients who have undergone BNSRRP.

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.

The role of water-jet dissection in improving erectile function and urinary continence after nerve-sparing prostatectomy.

The aim of this study was to assess erectile function (EF) and urinary continence (UC) recovery after nerve-sparing retropubic radical prostatectomy (NS-RRPE) and nerve-sparing laparoscopic radical prostatectomy (NS-LRPE) depending on the neurovascular bundle (NVB) dissection technique used. Twenty-four hour pad test was used to assess the degree of postoperative UC 1, 6 and 12 months after the surgery. For the purpose of EF assessment, International Index of Erectile Function-5 (IIEF-5) questionnaire was used. In addition, EF recovery assessment included the time needed to achieve a successful sexual intercourse with or without Inhibitors Phosphodiesterase 5 (IPDE5). A successful sexual intercourse was defined as an ability to achieve a strong erection enough for penetration and maintain erection for a long time, throughout the intercourse. Assessment was performed before the surgery and 8 and 6 months after the surgery. In the patient group with BNS + water jet dissection (WJD), the IIEF-5 score was considerably higher 8 weeks after the surgery (by 2.8 points) (р = 0.02). In 6 months, the difference between the group become more significant and reached 3.5 points (p = 0.01). Three months after urethral catheter removal, majority (95%) of patients in the NS-RPE + WJD group had no urinary incontinence (UI). For standard NS-RPE, that figure was 87%. Mild stress UI was observed in 5% of patients after NS-RPE + WJD and in 13% of patients after NS-RPE. Six months after urethral catheter removal, no significant differences in UC assessment were observed in the two groups. The implementation of WJD of NVB in clinical practice has made it possible to considerably improve the quality of life for postoperative patients due to good outcomes in terms of early UC and EF recovery.

The role of waterjet dissection in improving erectile function and continence after nerve-sparing prostatectomy

Erectile dysfunction (ED) and urinary incontinence (UI) following radical prostatectomy (RP) adversely impact patients psycho-emotional status reducing the quality of life and treatment satisfaction. To investigate the rates of regaining continence and erectile function (EF) after nerve-sparing radical retropubic prostatectomy (NS-RRP) and nerve-sparing laparoscopic radical prostatectomy (NS-LRP) in the early postoperative period. The study comprised 116 patients who preserved sexual activity and the ability to have sex. 64 patients underwent standard resection of NVB (34 RRP and 30 LRP) and in 52 patients the NVB resection was performed using a waterjet dissector (WD) (30 RRP and 22 LRP). All operations were performed by one surgeon with the experience of over 350 RRP and 150 LRP. The study patients had low and moderate risk prostate cancer, according to DAmico risk classification. Our study findings showed that patients who underwent the WD of NVB had significantly greater IIEF-5 scores (by 2.8 scores) at 8 weeks than after the standard NS-RP. After 6 month follow-up the scores increased by 3.5 points. Patients who underwent NS-RP + WD achieved a successful sexual intercourse 3 months after surgery (regardless of the use of PDE5 inhibitors). In the group of patients who underwent standard NS-RP, it took a longer time to achieve a successful sexual intercourse. Sixty-seven percent of patients who underwent NS-RP + WD were fully continent at one month follow-up after removal of urethral catheter, while most patients treated with standard NS-RP (41%) had mild stress UI. After 3 months follow-up, among patients who underwent NS-RP + WD only one patient had mild stress UI and the vast majority (95%) of patients were fully continent. At 6 months after removal of the urethral catheter there were no significant differences between the groups in regaining urinary continence. Waterjet dissection of NVB significantly improves patients postoperative quality of life due to early recovery of urinary continence and EF.

MP76-03 CORRELATION OF ERECTILE FUNCTION REHABILITATION WITH PRESERVATION OF NOCTURNAL PENILE TUMESCENSE 6 WEEKS AFTER NERVE-SPARING RADICAL PROSTATECTOMY – EFFECT OF DAILY LOW-DOSE SILDENAFIL

You have accessJournal of UrologySexual Function/Dysfunction: Medical, Hormonal & Non-surgical Therapy I1 Apr 2016MP76-03 CORRELATION OF ERECTILE FUNCTION REHABILITATION WITH PRESERVATION OF NOCTURNAL PENILE TUMESCENSE 6 WEEKS AFTER NERVE-SPARING RADICAL PROSTATECTOMY – EFFECT OF DAILY LOW-DOSE SILDENAFIL Andreas Bannowsky, Stefan Ückert, Daniar Osmonov, and Klaus-Peter Jünemann Andreas BannowskyAndreas Bannowsky More articles by this author , Stefan ÜckertStefan Ückert More articles by this author , Daniar OsmonovDaniar Osmonov More articles by this author , and Klaus-Peter JünemannKlaus-Peter Jünemann More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1854AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous studies showed that daily low dose sildenafil leads to improvement of the preservation of nocturnal penile tumescense and rigidity (NPTR) 6 weeks after nerve-sparing radical prostatectomy (nsRP). Aim of this study was the evaluation of NPTR-preservation on further erectile function (EF) recovery. METHODS 24 sexual active patients were operated by nerve-sparing retropubic radical prostatectomy. An erectometer measurement of NPTR (Rigi-Scan®) was carried out on each patient after removal of the transurethral catheter and again 6 weeks after surgery. To maintain and support recovery of spontaneous erectile function 12 patients with preserved nocturnal erections detected during NPTR-recordings received sildenafil 25mg/d at night starting immediately one the day after catheter removal (group 1). A control of 12 patients underwent follow up without daily PDE-5-inhibitors (group 2). All patients completed an IIEF-5 questionnaire concerning erectile function preoperatively, 3, 6, and 12 months after surgery. RESULTS Group 1 (daily 25mg sildenafil) showed 2-5 erections (mean 3.2 erections/night) during the first night after catheter removal. In the control (group 2) 1-5 erections (mean 3.1 erections/night) were recorded within this acute phase after nsRP. NPTR-recordings 6 weeks after nsRP showed a decline of nocturnal penile erections with only a slight decrease in group 1 (1-4 erections/night, mean 2.8 erections) vs. group 2 (0-2 erections/night, mean 1.1 erections/night) (p<0.05). In the group of daily sildenafil the IIEF-5 score decreased from preoperative 22.4 mean score to 3.8 at 3 months, 12.4 at 6 months and 17.5 at 12 months after nsRP. In the control group preoperative IIEF-5 mean score 23.2 decreased to 2.6 at 3 months, 7.4 at 6 months, 9.3 at 12 months. Statistical evaluation showed a correlation of NPTR-preservation with a significant increase of IIEF-5 score and time to recovery of erectile function (p<0.05). CONCLUSIONS EF rehabilitation with daily low dose sildenafil leads to significant preservation of nocturnal penile tumescense 6 weeks after nsRP which is correlated with a significant increase of erectile function recovery. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1007 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Andreas Bannowsky More articles by this author Stefan Ückert More articles by this author Daniar Osmonov More articles by this author Klaus-Peter Jünemann More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Solitary fibrous tumors of the prostate: A case report.

Increasing numbers of extrapleural solitary fibrous tumours (SFTs), including the prostate SFT, have been reported over the last 10-years. Prostate SFT is relatively uncommon, with <20 cases reported in the literature worldwide. In the present study, a prostate SFT case, which was initially misdiagnosed as benign prostatic hyperplasia, is presented. The patient was subjected to three surgeries (cystoscopy and per urethra lithocystotomy, transurethral resection of the prostate and nerve-sparing retropubic radical prostatectomy) prior to SFT diagnosis. It was demonstrated that histopathological and immunohistochemical factors (positive staining for CD34 and B cell lyphoma-2 expression) were of significant diagnostic value. Thus, nerve-sparing retropubic radical prostatectomy for total resection may be the best therapeutic strategy to treat prostate SFT, allowing the preservation of sexual function and reducing the risk of locoregional recurrence.

Current state of prostate cancer treatment in Jamaica.

Prostate cancer is the commonest cancer in Jamaica as well as the leading cause of cancer-related deaths. One report suggested that Jamaica has the highest incidence rate of prostate cancer in the world, with an age-standardised rate of 304/100,000 per year. The Caribbean region is reported to have the highest mortality rate of prostate cancer worldwide. Prostate cancer accounts for a large portion of the clinical practice for health-care practitioners in Jamaica. The Jamaica Urological Society is a professional body comprising 19 urologists in Jamaica who provide most of the care for men with prostate cancer in collaboration with medical oncologists, radiation oncologists, and a palliative care physician. The health-care system is structured in two tiers in Jamaica: public and private. The urologist-to-patient ratio is high, and this limits adequate urological care. Screening for prostate cancer is not a national policy in Jamaica. However, the Jamaica Urological Society and the Jamaica Cancer Society work synergistically to promote screening as well as to provide patient education for prostate cancer. Adequate treatment for localised prostate cancer is available in Jamaica in the forms of active surveillance, nerve-sparing radical retropubic prostatectomy, external beam radiation, and brachytherapy. However, there is a geographic maldistribution of centres that provide prostate cancer treatment, which leads to treatment delays. Also, there is difficulty in affording some treatment options in the private health-care sectors. Androgen deprivation therapy is available for treatment of locally advanced and metastatic prostate cancer and is subsidised through a programme called the National Health Fund. Second-line hormonal agents and chemotherapeutic agents are available but are costly to most of the population. The infrastructure for treatment of prostate cancer in Jamaica is good, but it requires additional technological advances as well as additional specialist services.

Survival, Continence and Potency (SCP) recovery after radical retropubic prostatectomy: A long-term combined evaluation of surgical outcomes

ObjectiveTo offer a comprehensive account of surgical outcomes on a defined series of patients treated with radical retropubic prostatectomy (RRP) for prostate cancer in a single European Center after 5-year minimum follow-up according to the Survival, Continence and Potency (SCP) system. Material and methodsWe evaluated our Institutional database of patients who underwent RRP from November 1995 to September 2008. Oncological and functional outcomes were reported according to the recently proposed SCP system. ResultsThe 5- and 10-year biochemical recurrence-free survival rates were 80.1% and 55.8%, respectively. At the end of follow-up, 611 (78.5%) patients were fully continent (C0), 107 (13.8%) used 1 pad for security (C1) and 60 (7.7%) patients were incontinent (C2). Of the 112 patients who underwent nerve-sparing RRP, 22 (19.6%) were fully potent without aids (P0), 13 (11.6%) were potent with assumption of PDE-5 inhibitors (P1) and 77 (68.8%) experienced erectile dysfunction (P2). The combined SCP outcomes were reported together only in 95 (12.2%) evaluable patients. In patients preoperatively continent and potent, who received a nerve-sparing and did not require adjuvant therapy, oncological and functional success was attained by 29 (30.5%) patients. In the subgroup of 508 patients not evaluable for potency recovery, oncological and continence outcomes were obtained in 357 patients (70.3%). ConclusionSurvival, Continence and Potency (SCP) classification offer a comprehensive report of surgical results, even in those patients who do not represent the best category, thus allowing to provide a much more accurate evaluation of outcomes after RP.

Prophylactic Sildenafil Citrate Improves Select Aspects of Sexual Function in Men Treated with Radiotherapy for Prostate Cancer

We studied adjuvant daily sildenafil citrate during and after radiotherapy for prostate cancer for erectile function preservation. We performed a randomized, prospective trial of 279patients with localized prostate cancer treated with radiotherapy who received sildenafil citrate (50 mg daily) or placebo (2:1 randomization). Medication/placebo was initiated 3 days before treatment and continued daily for 6months. Before therapy and 3, 6, 9, 12, 18 and 24 months after radiotherapy patients completed the IIEF questionnaire, including the erectile function domain, the I-PSS questionnaire and the RAND SF-36®. All IIEF domains werescored. At 12 months erectile function scores were better for sildenafil citrate than placebo (p = 0.018), 73% of patients on sildenafil citrate vs 50% on placebo had mild/no erectile dysfunction (p = 0.024) and the sildenafil citrate arm had superior overall satisfaction (p = 0.027) and IIEF total scores (p = 0.043). At 24months erectile function and IIEF scores were no longer significantly better for sildenafil citrate (p = 0.172 and 0.09, respectively) and yet overall satisfaction scores were higher (p = 0.033). Sexual desire scores in patients who received sildenafil citrate were higher at 24 months although they had completed drug therapy 18 months previously (p = 0.049). At 24 months 81.6% of patients on sildenafil citrate and 56.0% of those on placebo achieved functional erection with or without erectile dysfunction medication (p = 0.045). Daily sildenafil citrate during and after radiotherapy for prostate cancer was associated with improved overall sexual function compared with placebo for various sexual function domains. To our knowledge this is the largestrandomized, prospective, controlled trial to show the usefulness of a phosphodiesterase-5 inhibitor as a rehabilitation strategy in patients with prostate cancer who received radiation therapy.

Climacturia after Definitive Treatment of Prostate Cancer

Prostate cancer treatment results in several sexually related side effects beyond the well studied erectile dysfunction. Climacturia (leakage of urine during orgasm) has been reported after prostatectomy but studies have been limited by multiple factors. In this study we examine the prevalence, causes and impact on orgasm function of climacturia after definitive treatment of prostate cancer with surgery or radiation. A total of 906 anonymous surveys were sent to patients with prostate cancer treated with surgery and/or radiation. Respondents were asked about the presence of urinary leakage, climacturia and various elements related to sexual and orgasmic function. We estimated the prevalence of climacturia, evaluated the differences between those with and without climacturia, and assessed the impact of climacturia on orgasmic function. Overall 412 surveys were returned and available for analysis, and of these respondents 75.2% were sexually active or experiencing orgasms. Climacturia was reported by 22.6% of these respondents, and by 28.3%, 5.2% and 28.6% of those treated with surgery, radiation, or both, respectively (p <0.001). The use of aides to obtain an erection (OR 2.24, 95% CI 1.08-4.93, p = 0.035) and the presence of urinary incontinence (OR 3.09, 95% CI 1.66-5.88, p <0.001) were also associated with climacturia in a multivariate logistic regression model. Climacturia had no significant impact on orgasmic function and satisfaction. Climacturia is experienced by a substantial proportion of men after undergoing definitive treatment of prostate cancer. We found a complex relationship between stress urinary incontinence and climacturia, and noted that the presence of climacturia does not necessarily negatively impact sexual satisfaction.

Laparoscopic versus open bilateral intrafascial nerve-sparing radical prostatectomy after TUR-P for incidental prostate cancer: surgical outcomes and effect on postoperative urinary continence and sexual potency

To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRPT) and nerve-sparing retropubic radical prostatectomy (nsRRPT) after TUR-P for incidental prostate cancer. Between January 2003 and August 2011, 125 nsLRPT and 128 nsRRPT for incidental prostate cancer diagnosed after TUR-P were performed at our clinic. Demographic data, peri- and postoperative measurements and functional outcomes were compared. The mean operative time was 153.1 ± 35.4 min for nsLRPT and 122.5 ± 67.5 min for nsRRPT (p = 0.03). The mean catheterization time was 8 ± 1 days in the laparoscopic group and 11 ± 2 days in the open group (p = 0.02). Also, the length of hospitalization presents statistical significant difference in the two groups. Positive margins were detected in 2.4 and 4.7% of patients with pT2c tumours in the laparoscopic and open groups, respectively (p = 0.09). At a mean follow-up of 26.9 ± 9.3 months for the nsLRPT group and of 27.8 ± 9.7 months for the nsRRPT group, all patients were alive with no evidence of tumour recurrence. Twelve months postoperatively, complete continence was reported in 96.8% of patients who underwent an nsLRPT and in 89.4% of patients in the nsRRPT group (p = 0.02). At that time, 74.4% of patients in the nsLRPT group and 53.1% in the nsRRPT group reported the ability to engage in sexual intercourse (p = 0.0004). nsLRPT after TUR-P, performed by expert surgeons, results to be a safe procedure with excellent functional outcomes with regard to the urinary continence and sexual potency.

The Martini-Clinic technique of open radical retropubic prostatectomy

Despite the emergence of robotic approaches, the technique of open radical retropubic prostatectomy (RP) is still the predominant approach for surgical treatment of clinically localized prostate cancer in most clinics worldwide. The principles of this technique and its oncological efficacy were published decades ago; however, the surgery carried out today has undergone continuous refinements, reducing the morbidity rate and significantly improving postoperative functional outcomes such as urinary continence and erectile function. We report on the current technique of open nerve-sparing radical RP with data analysis to address the issues of urinary continence, potency, cancer control rates and perioperative morbidity. The analyses are based on 1875 patients who were treated with nerve-sparing RP in the Martini-Clinic. The key elements of open radical RP are a selective ligation of the dorsal vein complex and early release of the neurovascular bundles using a high anterior tension-free and energy-free intrafascial technique, intraoperative frozen section (NeuroSAFE technique) and full functional length urethral sphincter preparation (FFLU technique). During dissection of the urethra, the posterior insertion at Denonvilliers' fascia is preserved and remains in situ, and is selectively opened above the seminal vesicles. The later seminal vesicles are completely removed inside Denonvilliers' fascia and six muscle-sparing interrupted sutures are used for anastomosis. Functional and oncological outcome data were determined, which were prospectively collected using validated questionnaires and intraoperative and perioperative morbidity data were also evaluated. Patient age and the extent to which the nerve-sparing approach was influenced by urinary continence and potency. Overall, 97.4% of men less than 60 years of age, and 84.1% of men over 70 years, had complete urinary continence 1 year after nerve-sparing RP. In preoperative potent men, erections sufficient for intercourse were seen in 84–92% of patients who underwent bilateral nerve sparing and in 58.3–70% of men who underwent unilateral nerve sparing. Median blood loss was 590 ml (range 130–1800 ml) and the transfusion rate was 4.5%. Median operative time was 175 minutes (range 95–215 minutes). In organ-confined cancers, recurrence-free survival and cancer-specific survival at 10 years after RP were 87% and 98.3%, respectively. Open intrafascial nerve-sparing RP combines excellent long-term cancer control rates with superior functional outcome and a low morbidity.

Comparison of efficacy and satisfaction profile, between penile prosthesis implantation and oral PDE5 inhibitor Tadalafil therapy, in men with nerve‐sparing radical prostatectomy erectile dysfunction

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Erectile dysfunction after nerve-sparing radical retropubic prostatectomy constitutes a challenge to the urologist. The mainstay of medical treatment after radical prostatectomy to restore spontaneous erectile function remains phosphodiesterase (PDE5) inhibitors, despite the fact that data from animal studies suggesting that PDE5 inhibitors can prevent smooth muscle apoptosis and fibrosis have not yet been extrapolated to humans because of a lack of standardized protocols. If the above treatment fails, second-line therapies such as intraurethral prostaglandins, penile injection therapy and vacuum devices are offered. When less invasive therapies are ineffective, interventions that preserve sexual function such as penile prosthesis implantation become the treatment of choice. Our study reveals the alternative of penile prosthesis implantation as first-line treatment in erectile dysfunction after nerve-sparing radical prostatectomy. It also highlights its superiority to the oral PDE5 inhibitor treatment, regarding the erection, frequency, firmness, maintenance and penetration ability. This suggests that a concept of an early penile intervention in the future would be promising for those patients who wish to remain sexually active without depending on oral formulations with doubtful and delayed results. To evaluate the outcome of penile prosthesis surgery in comparison to oral phosphodiesterase type 5 (PDE5) inhibitor administration, in men with erectile dysfunction after nerve-sparing radical prostatectomy, as early penile intervention therapy. A total of 174 patients treated by nerve-sparing retropubic radical prostatectomy (RRP) for clinically localized prostate cancer, between January 2006 and September 2009 enrolled in the study, 153 patients fulfilled the inclusion criteria, and 69 (45%) patients presented with post-RRP erectile dysfunction 6 months after primary surgery. Fifty-four patients were disease-free and subdivided into two arms according to treatment modality, either tadalafil three times/week or penile prosthesis implantation. All patients were evaluated using the International Index of Erectile Function (IIEF) questionnaire preoperatively and at 6, 12 and 24 month postoperatively. Repeated measurements analysis of variance was conducted to evaluate the effect of time and group on IIEF total score. There was a significant reduction in IIEF score from preoperative values to the first measurement after surgery in both treatment groups. The overall degree of change from the first time point immediately after surgery to 2 years was greater in the penile prosthesis group than the tadalafil group (20.4 ± 1.3 vs 8.1 ± 2.4, P < 0.001). The efficacy and satisfaction results of both treatment types are considered acceptable. However, regarding the erection frequency, firmness, penetration ability, maintenance and erection confidence it seems that penile prosthesis implantation is superior to oral treatment. The concept of early penile intervention should be considered and is promising for all patients with post-RRP erectile dysfunction.

Commentary: Robotic Radical Prostatectomy is an Effective Approach for Treating Localized Prostate Cancer—is it Technique or Technician?

In this issue of The Journal Liss et al (page 2205) confirm that robotic prostatectomy is an oncologically safe and effective modality with 5-year biochemical recurrence-free survival outcome comparable to that of open radical prostatectomy.1 In their study, while biological variables such as Gleason grade and pathological stage were the major determinants of biochemical recurrence, an iatrogenic positive surgical margin also increased the risk for recurrence. In that regard, the masters of open radical prostatectomy taught us that attaining negative surgical margin while preserving continence and sexual recovery is a challenging task and that a continued learning process based on feedback can result in improved surgical technique.2 To compare and appreciate the differences in surgical techniques in attempting to reduce apical positive margin rates,3 we selected the video “Nerve-sparing retropubic radical retropubic prostatectomy with extracapsular dissection: quality of surgical excision” (2010 V0476) and the video “Anatomic retro-apical technique for synchronous posterior-anterior approach to apical transection during robotic radical prostatectomy” (2010 V0474). We wish to emphasize that clear understanding of surgical anatomy, delicate tissue handling and attention to details are the common factors for attaining optimal outcomes regardless of surgical approach.

The Impact of Anatomical Radical Retropubic Prostatectomy on Cancer Control: The 30-Year Anniversary

Radical prostatectomy has decreased prostate cancer specific mortality in men with clinically localized prostate cancer. We report oncological outcomes of the longest running series of nerve sparing radical retropubic prostatectomy on the 30th anniversary of the inaugural operation. A total of 4,478 men underwent anatomical radical retropubic prostatectomy, as performed by a single surgeon (PCW), at the Johns Hopkins Medical Institutions from 1982 to 2011, without neoadjuvant or adjuvant therapy. During a median followup of 10 years (range 1 to 29), we examined progression-free, metastasis-free and cancer specific survival. The overall 25-year progression-free, metastasis-free and cancer specific survival rates were 68%, 84% and 86%, respectively, although there were significant differences in treatment outcomes between men treated in the pre-PSA and PSA eras. In each era, there were significant differences in progression-free, metastasis-free and cancer specific survival by D'Amico risk groups. In multivariable models considering prostatectomy features, pathological stage and grade were significantly associated with the risk of metastatic progression and disease specific mortality. Excellent prostate cancer specific survival was demonstrated up to 30 years after surgery. Clinical risk categories and pathological tumor features were significant predictors of long-term disease specific outcomes, supporting their ongoing use in risk stratification and management decisions. Anatomical radical retropubic prostatectomy continues to represent the gold standard in the surgical management of clinically localized prostate cancer to which alternate treatment options should be compared.