Postoperative Erectile Function Research Articles

Surgical outcomes in penile fractures: A single center experience in China

IntroductionPenile fracture is an uncommon urological emergency resulting from tunica albuginea rupture during penile erection. It is a rare condition requiring urgent surgery. Despite immediate surgical repair, the patients' erectile functions may still be impacted by penile fracture. This study aims to investigate the efficacy of surgical repair in penile fractures and its impact on erectile function. MethodsOur cohort was composed of patients diagnosed with penile fractures and received surgical repair from September 2014 to August 2022 in Peking University First Hospital. Penile color Doppler ultrasound confirmed the diagnosis. Surgical exploration was conducted, and postoperative complications were evaluated during follow-up. Erectile function was assessed using the International Index of Erectile Function-5 (IIEF-5) score. Univariate analysis was conducted employing the chi-square test, t-test, and Mann-Whitney U test to identify factors that may impact postoperative erectile function. Furthermore, multivariate analysis was conducted using logistic regression and linear regression to determine the independent risk factors influencing postoperative erectile function. ResultsA total of 58 patients were enrolled in our study. The majority of injuries (69.0 %, 40/58) resulted from vigorous sexual intercourse. Most of the patients (69.0 %, 40/58) presented within 24 h. Sixteen patients (27.6 %) presented with concomitant urethral injury. The median size of the tunical tear was 1.5 (IQR, 1.0–2.0) cm. Presentation delay correlated significantly with the difference in IIEF-5 score before and after surgery, with corresponding p values of 0.028. Urethral injury correlated significantly with postoperative erectile dysfunction (ED), postoperative IIEF-5 score, and the difference in IIEF-5 score before and after surgery, with corresponding p values of 0.002, 0.004, and 0.002, respectively. ConclusionsTo conclude, surgical repair of penile fracture provides good functional results with few morbidities and urethral injury may adversely affect postoperative erectile function after penile fracture repair.

Optimizing erectile function evaluation pattern in postoperative pelvic fracture-urethral injury patients: introducing PFUI pEF PROM.

To establish a psychometric validated pelvic fracture-urethral injury postoperative erectile function patient reported outcome measure (PFUI pEF PROM). We also aim to explore PFUI patients' potential classification and suitable postoperative erectile function assessment pattern. A total of 93 PFUI patients who treated by excisionandprimaryanastomotic (EPA) urethroplasty from January 2020 to August 2022 were enrolled to this study. Patients who had intercourse completed the IIEF-5, those who had sexual stimulation other than intercourse finished PFUI pEF PROM, and those who performed both completed the IIEF-5, and PFUI pEF PROM. Erection Hardness Score (EHS) was completed by all patients. This PROM was performed psychometric validation and used to find PFUI patients potential classification through latent class analysis. Then, we determined the cut-off value though receiver-operating characteristic (ROC) curve and performed univariate analysis subgroups feature. The PFUI pEF PROM demonstrated high reliability and validity with a Cronbach's alpha of 0.928. It correlated significantly with IIEF-5 (r = 0.550, p < 0.001) and EHS (r = 0.909, p < 0.001). The latent class analysis identified three patient subgroups, with 14.5 as the subgroup cut-off value. Urethral stricture length, IIEF-5, and EHS score were identified as influence factors for maximal erection potential. An assessment pattern combining IIEF-5, EHS, and the PFUI pEF PROM covered 92.5% of patients. This PROM effectively addresses the current limitation in assessing erectile function in PFUI patients. This study provides a promising tool for stratified assessment, prediction erection recovery, and treatment guidance in the PFUI Erectile dysfunction field.

Robot-assisted vs open retropubic radical prostatectomy: a propensity score-matched comparative analysis based on 15 years and 18,805 patients.

To compare oncological, functional, and surgical outcomes of a large cohort of patients who underwent open retropubic radical prostatectomy (ORP) or robot-assisted radical prostatectomy (RARP). Data from 18,805 RPs performed with either the open or the robot-assisted approaches at a single tertiary referral center between 2008 and 2022 were analyzed. The impact of surgical approach on biochemical recurrence-free survival, salvage radiotherapy-free survival, and metastasis-free survival was analyzed by log-rank test and Kaplan-Meier analysis in a propensity score (PS)-based matched cohort. Intraoperative and postoperative surgical outcomes were assessed. One-week, 3-month, and 12-month continence rates and 12-month erectile function (EF) were analyzed. No statistically significant differences in oncological outcomes were found between ORP and RARP. A slight statistically significant difference in favor of RARP was noted in urinary continence at 3 months (RARP vs. ORP: 81% vs. 77%, p = 0.007) and 12 months (91% vs. 89.3%, p = 0.008), respectively. The rate of EF was statistically significantly higher (60%) after RARP than after ORP (45%, p < 0.001). Both RARP and ORP yielded similar oncological outcomes. RARP offered a slight advantage in terms of continence recovery, but its clinical significance may be less meaningful. RARP resulted in significantly improved postoperative EF, suggesting a potential influence of both surgical experience and minimally invasive approach.

(097) 3 Year Follow Up After Modified Grid Incision and Sealing with Collagen Fleece for Treatment of Peyronie’s Disease

Abstract Introduction Previously, we introduced a less invasive modified technique by multiple grid incisions of Peyronie’s plaque. Objective To assess the efficacy of technique in 32 patients with 3 year follow-up. Methods From 2018, 32 patients with stable Peyronie’s disease were included with 3 major steps of surgery; 1) dissection of neurovascular bundle/urethra according to plaque location, 2) multiple deep grid incisions of plaque for complete correction of curvature/deformity, 3) sealing with TachoSil®. Prospectively, the stretched penile length (SPL), totally straightness, penile sono, erectile function at preoperative, and 6, 12, 24, 36 months postoperatively under approval of Institutional Review Board. Results Mean age was 59.2 years (46–72). Mean curvature was 53.5 (40–80) degree, 8 with hinge and 7 with hourglass deformity. IPP was inserted in 4 and 1 at postoperative 30 months for poor erectile function. Mean follow-up was 35.4 months (12–57). Daily massage softened the hard thickening of penis gradually from 3 months until 3 year. On follow-up sonography, subcutaneous thickening gradually decreased to near normal at 1–3 year and tunical breakage by grid incision reunited at postoperative 10–12 months. 2 patients immediately recurred dorsal curvature but most patients achieved totally straightness. Most patients gained preoperative length after 1.6 year. 96% of patients satisfied in GAQ at 2 year. Minor skin problem was occurred in two of IPP. Subcutaneous bulging hematoma was occurred in 3 patients but subsided in two within 3 months. One patients need revision surgery. In postoperative erectile function of 23 patients without IPP, spontaneous hard erection was recovered in 5 and the rest are satisfied with PED5 inhibitors. Conclusions Our prospective progress reports with technical modification of various plaque incisions shows that one can achieve a sufficient surgical effect without making defect of tunica albuginea but need long term follow up for 3 years at best. Disclosure No.

(205) Functional Outcomes in Non-Transecting Excision-Anastomosis Urethroplasty for Lengthy (≥2cm) Urethral Strictures

Abstract Introduction Spongiosal sparing non-transecting anastomotic bulbar urethroplasty has rapidly become the preferred technique for many reconstructive urologists due to reported improvement in postoperative erectile function outcomes. For strictures &amp;lt;2cm, non-transecting techniques without the use of graft augmentation are typically deployed. However, for lengthy bulbar strictures (≥2cm), many advocate for oral mucosa substitution urethroplasty due to the theoretical concern of penile shortening, tethering, or other erectile function related side effects. Although effective, substitution bulbar urethroplasty is associated with additional graft harvest morbidity and may have lower success rates relative to non-substitution non-transecting techniques. Objective We describe outcomes of an extended non-transecting excision-anastomosis urethroplasty for lengthy urethral strictures without the use of graft augmentation. Methods A tertiary center’s urethroplasty database was queried for patients that underwent non-transecting bulbar urethroplasty from 2017-2023. Patients with penile urethral strictures or concurrent urethroplasty procedures were excluded. Stretch penile length (SPL) was assessed by applying gentle traction on the penis and measuring from the base of the penis to the tip of the glans. SPL was assessed perioperatively and at 3-6 month follow-up. Urethral stricture recurrence was defined as need for repeat urethral intervention. Urethral stricture length was determined by intra-operative measurement. Accordingly, patients were then stratified based on stricture length (&amp;lt;2 cm vs ≥2 cm) and tested for association between categorical outcomes (worsening erectile function and reconstructive success) and continuous outcomes (change in SPL) using Fischer’s exact test and Mann Whitney U test. Results A final cohort of 90 patients were identified, with a median urethral stricture length of 1.5 cm (range 0.5-6cm). In addition to dorsal urethrotomy (median 3cm), ventral mucosectomy was performed in 29 (32%) patients (median 2cm). Early postoperative complications occurred in 13 (15%) including UTI (N=4), contrast extravasation at VCUG (N=3), and epididymo-orchitis (N=3). At a median follow up of 13 months (IQR 4-18), a total of 5.5% (5/90) developed stricture recurrence. The overall median change in SPL was 0% (IQR 0-6.7%). De novo ED occurred in 7% (5/67). When stratified by stricture length ≥2cm (N=41) and &amp;lt;2cm (N=49) median length of urethrotomy was 3 cm (2.6-4.0) vs 2 cm (2.0-3.0; p &amp;lt;0.001), respectively. Those with strictures ≥2 cm had greater decreases in relative SPL (median 3.5% vs. 0%, p = 0.003) and higher absolute PVR (median 71 ml vs. 34 ml, p =0.03) at 3 months after surgery. There were no significant differences in relative improvement of Qmax or PVR, stricture recurrence (8% vs 4%), worsening erectile function (10% vs 6%), or complication rates (15% vs 14%) between groups (p-value&amp;gt; 0.05 for all comparisons). Conclusions Spongiosal sparing non-transecting urethroplasty is an effective surgical option for patients with lengthy urethral strictures. It offers comparable relative improvement in functional (Qmax, PVR) and erectile function outcomes, while having a modest impact on SPL all while avoiding the morbidity of graft harvesting. Disclosure No.

(014) Expectations of Patients and Their Partners After Penile Rehabilitation Programs After Nerve-Sparing Prostatectomy: Are There Relevant Differences?

Abstract Introduction Several strategies are published for postoperative erectile function rehabilitation after nerve-sparing radical prostatectomy (nsRP). Expectations of the partners of the patients are rarely subject of most of these rehabilitation studies. Objective The aim of our study was to evaluate the expectations of patients and of the partners of patients undergoing nerve-sparing radical prostatectomy and penile rehabilitation programs and possible relevant differences between the expectations. Methods We performed a questionnaire sent to patients and their partners of all enrolled patients of 3 different penile rehabilitation studies after nsRP with a regular dose of different PDE5-inhibitors (sildenafil/vardenafil/tadalafil). 124 patients (mean age 69 years) had been enrolled in the rehabilitation studies and their partners (mean age 66 years) were included in this study. The survey consists of different questions, e.g. if the patients and their partners believe in the rehabilitation concept and what they expect with regards to the outcome. Results 89 patients and 78 partners of the 124 patients (72% / 63%) completed and returned the questionnaire. Before rehabilitation treatment 81 patients (91%) and 51 partners (65%) believed in the concept of rehabilitation, 55 patients (62%) but only 32 partners (41%) expected partly to fully rehabilitation of erectile function caused by the initiated penile rehabilitation program. After the end of the study treatment, 2 years after nsRP, 64% of patients and 45% of their partners are satisfied by the recovery of erectile function. Conclusions Despite the fact that 91% of patients within penile rehabilitation programs believe in the concepts of rehabilitation only 62% of the patients and only 41% of their partners expect partly to fully recovery of erectile function after nsRP. Satisfaction rate with erectile function recovery was reported by 64% of patients and 45% of their partners 2 years after nsRP. Disclosure No.

Long-term outcomes after plaque excision grafting for Peyronie's disease and subanalysis of patients who undergo the procedure despite preoperative counseling against it.

Plaque excision and grafting (PEG) has been recommended for patients with Peyronie's disease (PD) with >60° curvature and/or hinge effect and strong preoperative erections, while placement of an inflatable penile prosthesis (IPP) is recommended when rigidity is suboptimal. Nevertheless, many patients counseled to undergo an IPP decline and insist on proceeding with PEG due to personal preference or desire to avoid an implant. We aim to review long-term outcomes in patients who underwent PEG for PD at our institution and investigate whether there is any difference in long-term outcomes in patients who undergo PEG despite a recommendation to undergo IPP. We conducted a retrospective chart review from 2007 to 2021 on PEG surgery performed at a single tertiary care institution in patients ≥18years old who had >3months of follow-up. Postoperative information was gathered from the electronic medical record, including postoperative erectile function, patient satisfaction, and the ability to engage in penetrative sexual intercourse. An overall 251 patients underwent PEG with a median follow-up of 12 months (IQR, 6-54). Among these, 54 (22%) were initially advised to undergo IPP but elected for PEG. Patients who underwent PEG despite counseling to undergo IPP reported lower postoperative ability to engage in intercourse (51% vs 76%). Seven (13%) patients initially advised to undergo IPP eventually received an IPP, relative to 7 (4%) initially advised to undergo PEG. Thorough preoperative assessment of erectile function and penile deformity can guide clinician counseling and manage patient expectations during decision making between PEG surgery and IPP implantation for PD. Limitations of this study include its retrospective nature, high attrition to follow-up, and risk of recall and selection bias. This is a large study with a median follow-up of 12months, with a high-volume single surgeon who treats patients in a specialized population of complex cases. Patients who were initially counseled to undergo IPP due to suboptimal erectile rigidity but elected for PEG had worse postoperative ability to engage in penetrative intercourse, and a higher proportion of these patients eventually received an IPP.

Robot-assisted versus open radical prostatectomy: a systematic review and meta-analysis of prospective studies.

The study aims to synthesize all available prospective comparative studies and reports the latest systematic analysis and updated evidence comparing robot-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) for perioperative, functional, and oncological outcomes in patients with clinically localized prostate cancer (PCa). PubMed, Embase, Web of Science, and the Cochrane Library were retrieved up to March 2023. Only randomized controlled trials (RCTs) and prospective comparative studies were included, and weighted mean differences (WMD) and odds ratios (OR) were used to evaluate the pooled results. Twenty-one articles were included in the present meta-analysis. The results indicated that compared to ORP, RARP had longer operative time (OT) (WMD: 51.41min; 95%CI: 28.33, 74.48; p < 0.0001), reduced blood loss (WMD: -516.59mL; 95%CI: -578.31, -454.88; p < 0.00001), decreased transfusion rate (OR: 0.23; 95%CI: 0.18, 0.30; p < 0.00001), shorter hospital stay (WMD: -1.59days; 95%CI: -2.69, -0.49; p = 0.005), fewer overall complications (OR: 0.61; 95%CI: 0.45, 0.83; p = 0.001), and higher nerve sparing rate (OR: 1.64; 95%CI: 1.26, 2.13; p = 0.0003), as well as was more beneficial to postoperative erectile function recovery and biochemical recurrence (BCR). However, no significant disparities were noted in major complications, postoperative urinary continence recovery, or positive surgical margin (PSM) rates. RARP was superior to ORP in terms of hospital stay, blood loss, transfusion rate, complications, nerve sparing, postoperative erectile function recovery, and BCR. It is a safe and effective surgical approach to the treatment of clinically localized PCa.

Partial gland ablation using high-intensity focused ultrasound versus robot-assisted radical prostatectomy: a propensity score-matched study.

We compared the clinical outcomes of robot-assisted radical prostatectomy (RARP) and partial gland ablation (PGA) using high-intensity focused ultrasound (HIFU) in localized prostate cancer. We analyzed 3,859 patients who had undergone RARP and PGA using HIFU. According to the propensity score for each treatment, 137 patients after PGA were matched to 3,722 patients after RARP at a 1:4 ratio using the nearest neighbor method. The matched cohort comprised 685 subjects (RARP, 548; PGA, 137), with a median follow-up period of 22months. Treatment failures were identified in 13.9% and 9.1% of patients in the PGA and RARP groups, respectively, after a median follow-up of 36months postoperatively. Kaplan-Meier analyses revealed significantly longer failure-free (P<0.001) and salvage-free survival (P=0.003) in the RARP group than in the PGA group. There was no significant difference in the postoperative urinary symptom score (P=0.748), but the postoperative erectile function score was significantly higher in the PGA group (P<0.001). The rate of urinary incontinence (any pad) was significantly lower in the PGA group than that in the RARP group (P<0.001). Postoperative complications were more frequent in the PGA group (P=0.003); however, there was no significant difference in high-grade complications (≥3) (P=0.467). PGA using HIFU showed statistically inferior oncological outcomes compared with RARP for failure-free survival and salvage-free survival. However, functional outcomes regarding postoperative incontinence and erectile dysfunction were more favorable in the PGA group.

Immediately repaired penile fractures: age is the only predictor of postoperative long-term functional outcomes.

Penile fractures can lead to many functional complications, especially erectile dysfunction (ED). Few studies have evaluated the factors that predict late complications of an immediately repaired penile fracture. To identify the potential predictors of long-term poor functional outcomes following immediate surgical intervention for penile fractures. Sixty-eight consecutive patients with suspected penile fracture between 2003 and 2022 were retrospectively reviewed. Functional outcomes, postoperative complications, and follow-up duration were obtained from the records of follow-up visits. Age at presentation, location and length of the tunical tear, the presence of urethral rupture, and time to surgery were all analyzed as potential risk factors for postoperative functional outcomes. Postoperative erectile function and intercourse satisfaction were measured by the IIEF-5 (the 5-item version of the International Index of Erectile Function). Penile curvature, a palpable nodule, and paresthesia/numbness were detected by physical examination. Uroflowmetry was used to assess urinary flow in patients who underwent urethral repair. Fifty-eight patients were analyzed. The mean ± SD age was 38.1 ± 10.4years; the median follow-up was 79.0 months (range, 13-180); the median time to surgery was 9.8 hours (4-30); and the median tunical tear length was 15.5 mm (4-40). Urethral rupture was observed in 8 patients (13.8%). In univariable analyses, urethral rupture was associated with postoperative complications (P = .034). In addition, age at presentation and tunical tear size were significantly associated with postoperative complications and ED (P < .05). However, in multivariable analyses, only age at presentation significantly predicted postoperative complications and ED (P = .004 and P = .037). Age at presentation is the most important factor determining the prognosis of immediate surgical repair of the penile fracture, which aids in predicting potential complications and discussing them with patients prior to surgical intervention and during the follow-up period. The study's retrospective design is an important limitation. Furthermore, there were no data on an IIEF-5 outcome measuring preoperative erectile function. These results revealed an association between (1) urethral rupture, longer tunical tears, and older age and (2) the development of late complications. The remarkable finding of this study was that age at presentation was the only significant predictor of functional complications based on multivariable analyses. This relationship also remained robust in tests evaluating the covariance of the effects of aging on ED.

Initial experience and short-term outcomes of single-port extraperitoneal transvesical robot-assisted radical prostatectomy: a two-center study.

This study presents the procedure of single-port extraperitoneal transvesical approach to robot-assisted radical prostatectomy (SETvRARP) on the da Vinci Xi platform coupling with a 4-channel single port and evaluated the short-term outcomes in the first 72 prostate cancer (PCa) patients. Seventy-two patients with localized PCa were enrolled. Each operation was conducted by the same single robotic surgery group in two centers using the da Vinci Xi system. The median operation time was 150 min, and the median estimated blood loss was 50 mL. All operations were successfully carried out without open conversion or transfusion. No ≥ Grade II complications were noted. Urethral catheters were routinely removed on postoperative day 7. Sixty-eight (94.4%) patients recovered to immediate urinary continence after surgery, with 72 (100%) patients achieving full continence on postoperative day 14. A positive surgical margin was observed in 15 (20.8%) patients. Postoperative urodynamic studies regarding peak urinary flow, bladder capacity, and residual urine were not statically different from the preoperative results. No biochemical recurrence was noted in all patients within the follow-up period. Postoperative erectile function was not statistically different from the preoperative results (P=0.1697). SETvRARP using the da Vinci Xi system coupling with a 4-channel single port is a valid radical prostatectomy technique in well-selected PCa patients, resulting in superior postoperative recovery of urinary continence. Meanwhile, the outcomes in functional protection and cancer control need to be further investigated with a long-term follow-up duration.

(138) Smaller Tunical Defect With Pre-graft Plication Technique During Peyronie's Disease Surgery May Reduce Postoperative Erectile Function Loss

Abstract Introduction Peyronie’s disease (PD) is a progressive and benign acquired connective tissue disease characterized by disordered wound healing and local fibrosis of the tunica albuginea (TA). PD has two phases: acute and chronic. Surgery is the gold standard option for the correction of penile deformity in the PD chronic phase. Methods used in surgical treatment include plication, graft repair, and penile prosthesis implantation. Plaque incision (PIG) or excision (PEG) and graft placement are performed during graft repair. However, this technique can cause postoperative erectile dysfunction (ED) related to the size of the TA defect. Objective In our clinic, we use a novel "pre-graft plication technique" to reduce disruption of the integrity of the TA in patients with unidirectional curvature &amp;gt; 60 degrees. In this technique, we place 2 or 3 Essed–Schroder sutures on the convex side of the curvature before incision or excision and grafting on the plaque side. Thus, we pull the curvature angle down before PIG/PEG. We aim to improve post-op erectile function by using smaller grafts and TA incisions (figure 1). Our goal for this study was to compare the results of this technique with the standard PIG/PEG technique. Methods All patients who were operated on for PD in our clinic between 2010 and 2021 were screened. Patients aged between 40 and 70 years who underwent grafted PD repair were included in the study. Patients who underwent previous penile surgery or hormonal therapy, had significant preoperative ED (IIEF-5 &amp;lt; 17), or who received diagnoses of malignancy or depression were excluded from the study. We found 45 patients on whom we applied the pre-graft plication technique (group 1) and 32 patients on whom we applied the standard grafting technique who were appropriate for our inclusion and exclusion criteria. Demographic characteristics of the patients, comorbidities, preoperative IIEF-5 scores, stretched penile lengths, plaque sizes detected during surgery, graft sizes and types, postoperative IIEF-5 scores at the 3rd and 12th months, and 3-month postoperative penis lengths were recorded. Penile massage and daily 5 mg tadalafil were recommended as post-op rehabilitation. The results were compared with Student’s T-test. Results There were no significant differences between the groups in terms of preoperative IIEF-5 scores, penile lengths, age, or comorbidities. While there was no significant difference between the groups in the plaque sizes detected during the operation, the graft size used was significantly smaller in Group 1 than in Group 2. At follow-up, the IIEF-5 scores of the Group 1 were, on average, 1.97 and 2.36 points higher than Group 2 at 3 and 12 months of follow-up, respectively. This difference was statistically significant. There was no significant difference between the groups in terms of penile length (table-1). Conclusions Reducing post-op erectile function loss is possible with pre-graft plication technique. The extra plication suture does not cause a significant reduction in penile length. Disclosure No

(336) Penile Rehabilitation Programs after Nerve-sparing Prostatectomy: What are the Expectations of the Partners?

Abstract Introduction Several strategies are published for postoperative erectile function rehabilitation after nerve-sparing radical prostatectomy (nsRP). Expectations of the partners of the patients are rarely subject of most of these rehabilitation studies. Objective The aim of our study was to evaluate the expectations of the partners of patients undergoing nerve-sparing radical prostatectomy and penile rehabilitation programs. Methods We performed a questionnaire sent to the partners of all enrolled patients of 3 different penile rehabilitation studies after nsRP with a regular dose of different PDE5-inhibitors (sildenafil/vardenafil/tadalafil). 124 patients (mean age 69 years) had been enrolled in the rehabilitation studies and their partners (mean age 66 years) were included in this study. The survey consists of different questions, e.g. if the partners believe in the rehabilitation concept and what they expect with regards to the outcome. Results 78 partners of the 124 patients (63%) completed and returned the questionnaire. Before rehabilitation treatment 51 partners (65%) believed in the concept of rehabilitation, but only 32 partners (41%) expected partly to fully rehabilitation of erectile function of the partners caused by the initiated penile rehabilitation program. After the end of the study treatment, 2 years after nsRP, 45% of the partners are satisfied by the recovery of erectile function of their partners. Conclusions Only 41% of the partners of patients within penile rehabilitation programs expect partly to fully recovery of erectile function after nsRP. Satisfaction rate with erectile function recovery was reported by 45% of the partners 2 years after nsRP. Disclosure No

(487) Long-term Outcomes Following Partial Plaque Excision and Grafting (PEG) for Peyronie’s Disease and Subanalysis of Patients Who Undergo PEG Despite Pre-operative Counseling Against PEG

Abstract Introduction Peyronie’s Disease (PD) is a debilitating condition characterized by progressive scarring of the tunica albuginea. The resulting deformities are often emotionally devastating to patients, and include erectile dysfunction, painful erections, penile curvature, indentation, hourglass, and hinge deformities. According to previously published surgical algorithm for PD in 1997, partial plaque excision and grafting (PEG) is recommended for patients with &amp;gt;60 degree curvature +/− hinge and strong pre-operative erections while placement of an inflatable penile prosthesis (IPP) is recommended when rigidity is sub-optimal.* Nevertheless, many patients counseled to undergo an IPP refuse and insist on proceeding with PEG due to personal preference. We hypothesize that men counseled to undergo IPP but choose to undergo PEG will report lower satisfaction rates and reduced ability to engage in sexual intercourse post-operatively. Objective Our objective was to evaluate and compare long-term patient-reported outcomes in men who underwent PEG at a single institution between 2007 and 2021. Methods A retrospective chart review was conducted from 2007 to 2021 on PEG surgeries performed at a single, tertiary-care institution in patients ≥18 years old who had &amp;gt;3 months of follow up. Results 251 patients underwent PEG with a mean follow up was 35.5 months. 54 patients (22%) were initially advised to undergo IPP but elected for PEG. Of these 54 patients, 17 (32%) had pre-operative 9-10 subjective erectile rigidity, relative to 110 of 197 (56%) patients who were initially counseled to undergo PEG (p=0.002). On duplex penile ultrasound, patients counseled to undergo IPP had a mean objective erectile rigidity of 7.8, compared to a mean objective rigidity of 8.6 in patients initially counseled to undergo PEG (p 15 units for pre-operative duplex ultrasound evaluation were less likely to be able to engage in post-operative intercourse following PEG surgery (48.6%) relative to those who needed &amp;lt;15 units (71.1%) (p=0.02). Conclusions Patients who were initially counseled to undergo IPP due to sub-optimal erectile rigidity but elected for PEG procedure had worse post-operative ability to engage in penetrative intercourse. Significantly more of these patients also eventually underwent IPP. Pre-operative trimix dosing &amp;lt;15U is a predictor of post-operative erectile function as it may be reflective of better pre-operative erectile quality. Subjective and objective measures of erectile function appear to be critical predictors of post-operative erectile function in patients who had underwent PEG, confirming the previously published 1997 algorithm on the surgical management of PD.* *J Urol 1997; 158: 2149-52. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific (Consultant)

Spider silk erectile nerve reconstruction in robot-assisted radical prostatectomy: a first-in-men feasibility analysis.

To investigate the safety and feasibility of spider silk interposition for erectile nerve reconstruction in patients undergoing robotic radical prostatectomy (RARP). The major-ampullate-dragline from Nephila edulis was used for spider silk nerve reconstruction (SSNR). After removal of the prostate with either uni- or bilateral nerve-sparing, the spider silk was laid out on the site of the neurovascular bundles. Data analysis included inflammatory markers and patient reported outcomes. Six patients underwent RARP with SSNR. In 50% of the cases, only a unilateral nerve-sparing was performed, bilateral nerve-sparing could be performed in three patients. Placement of the spider silk conduit was uneventful, contact of the spider silk with the surrounding tissue was mostly sufficient for a stable connection with the proximal and distal ends of the dissected bundles. Inflammatory markers peaked until postoperative day 1 but stabilized until discharge without any need for antibiotic treatment throughout the hospital stay. One patient was readmitted due to a urinary tract infection. Three patients reported about erections sufficient for penetration after three months with a continuous improvement of erectile function both after bi- and unilateral nerve-sparing with SSNR up to the last follow-up after 18months. In this analysis of the first RARP with SSNR, a simple intraoperative handling without major complications was demonstrated. While the series provides evidence that SSNR is safe and feasible, a prospective randomized trial with long-term follow-up is needed to identify further improvement in postoperative erectile function due to the spider silk-directed nerve regeneration.

Study on clinical outcomes between non-transecting urethroplasty and lingual mucosal urethroplasty for iatrogenic bulbar urethral stricture treatment

BackgroundThis study aimed to compare the clinical outcomes of non-transecting urethroplasty and lingual mucosal urethroplasty in the treatment of iatrogenic bulbar urethral stricture.ResultsA total of 25 patients with iatrogenic bulbar urethral stricture were enrolled, 12 of whom underwent lingual mucosal urethroplasty, 13 patients who underwent non-transecting urethroplasty. All patients were followed-up and evaluated at 3 postoperative months. Evaluations included urethrography, maximum urine flow rate (Qmax), nocturnal erectile function testing, International Index of Erectile Function (IIEF-5) assessment, and Anxiety Related Scale (SAS) assessment. In terms of operation time, there was a significant difference between non-transecting urethroplasty and lingual mucosal urethroplasty. However, there was no significant intergroup difference in intraoperative blood loss. Both techniques were associated with significantly improved Qmax relative to preoperative rates, but there was no significant difference between the groups in this regard over 3 months of postoperative follow-up. Nocturnal penile tumescence and rigidity results showed that there was no significant change in tip hardness after surgery in the non-transecting urethroplasty group. Moreover, IIEF-5 scores indicated that there was no significant intergroup difference in terms of subjective postoperative erectile function. According to the preliminary psychological evaluations during postoperative follow-up, the anxiety scores of patients undergoing non-transecting urethroplasty significantly improved, but there was no significant change in the mean SAS score among patients who underwent lingual mucosal urethroplasty.ConclusionBoth surgical methods can achieve the clinical goal of treating iatrogenic bulbar urethral stricture. Non-transecting urethroplasty has the characteristics of short operation time, relative technical simplicity, and retention of the original erectile function of most patients, and the surgical outcomes of non-transecting urethroplasty are not inferior to those of lingual mucosal urethroplasty, and it is a promising technique for widespread use to treat bulbar urethral strictures.

Effects of different surgical modalities for nerve-sparing robot-assisted radical prostatectomy on postoperative erectile function: a systematic review and one-arm meta-analysis

ABSTRACT Maintaining erectile function is an important quality of life issue for patients with localized prostate cancer treated with robotic-assisted radical prostatectomy (RARP). However, most existing studies are retrospective and inherently weak and cannot conclude which NS approach is most effective in restoring function in patients. We therefore performed a consistent and objective assessment of sexual function outcomes in RARP using different nerve-sparing methods to optimize postoperative outcomes. A systematic review and meta-analysis was performed based on PRISMA and STROBE statement criteria. Statistical analysis was performed using StataMP software version 14. The Newcastle-Ottawa scale was used to assess the risk of bias. This single-arm meta-analysis included 3 randomized controlled trials and 14 cohort studies with a total of 3756 patients. Our meta-analysis found that patients had the highest efficiency rate of 0.86 (0.78, 0.93) after the NS technique using the retrograde method. Overall, there are significant differences between RARP NS techniques and outcomes, and the ideal technical strategy to optimize outcomes remains controversial. However, there is consensus on the importance of careful separation, dissection of the NVB, reduction of traction and thermal injury, and preservation of the fascia around the prostate. We still need more well-designed randomized controlled trials with videos describing the details of the different surgical techniques before they can be replicated.

Urinary Incontinence and Sexual Function After the Introduction of NeuroSAFE in Radical Prostatectomy for Prostate Cancer

BackgroundNerve-sparing (NS) radical prostatectomy (RP) results in better functional outcomes. Intraoperative neurovascular structure–adjacent frozen section examination (NeuroSAFE) significantly increases the frequency of NS surgery. The effect of NeuroSAFE on postoperative erectile function (EF) and continence is not yet clear. ObjectiveTo describe EF and continence outcomes for men undergoing RP with the NeuroSAFE technique. Design, setting, and participantsBetween September 2018 and February 2021, 1034 men underwent robot-assisted RP. Data for patient-reported outcomes were collected via validated questionnaires. InterventionNeuroSAFE technique for RP. Outcome measurements and statistical analysisContinence was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) or Expanded Prostate Cancer Index Composite short form (EPIC-26) and defined as use of 0–1 pads/d. EF was evaluated using EPIC-26 or the International Index of Erectile Function short form (IIEF-5), with data converted according to the Vertosick method and categorized. Descriptive statistics were used to asses and describe tumor characteristics and continence and EF outcomes. Results and limitationsOf the 1034 men who underwent RP after introduction of the NeuroSAFE technique, 63% and 60% completed a preoperative and at least one postoperative questionnaire on continence and EF, respectively. Of the men who underwent unilateral or bilateral NS surgery, use of 0–1 pads/d was reported by 93% after 1 yr and 96% after 2 yr; the corresponding rates for men who underwent non-NS surgery were 86% and 78%. Overall, use of 0–1 pads/d was reported by 92% of the men at 1 yr and by 94% at 2 yr after RP. Men in the NS group had a good or intermediate Vertosick score after RP more often than the non-NS group. Overall, 44% of the men had a good or intermediate Vertosick score at 1 and 2 yr after RP. ConclusionsAfter introduction of the NeuroSAFE technique, the continence rate was 92% at 1 yr and 94% at 2 yr after RP. The NS group had a greater percentage of men with an intermediate or good Vertosick score and a higher continence rate after RP in comparison to the non-NS group. Patient summaryOur study shows that after introduction of the NeuroSAFE technique during removal of the prostate, the continence rate among patients was 92% at 1 year and 94% at 2 years after surgery. Some 44% of the men had a good or intermediate score for erectile function 1 and 2 years after surgery.

PD30-01 USING MACHINE LEARNING TO CLASSIFY PROCEDURE-SPECIFIC SURGICAL EXPERIENCE BASED ON SURGICAL GESTURE RECOGNITION IN A RADICAL PROSTATECTOMY SIMULATION

You have accessJournal of UrologyCME1 Apr 2023PD30-01 USING MACHINE LEARNING TO CLASSIFY PROCEDURE-SPECIFIC SURGICAL EXPERIENCE BASED ON SURGICAL GESTURE RECOGNITION IN A RADICAL PROSTATECTOMY SIMULATION Nathan Schuler, Lauren Shepard, Tyler Holler, Patrick Saba, and Ahmed Ghazi Nathan SchulerNathan Schuler More articles by this author , Lauren ShepardLauren Shepard More articles by this author , Tyler HollerTyler Holler More articles by this author , Patrick SabaPatrick Saba More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003316.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Effectiveness of nerve sparing robot assisted radical prostatectomy (NS-RARP) is mainly based on recovery of postoperative erectile function. Previously, robotic kinematic data differentiated surgical expertise in suturing tasks and predicted continence rates. Using a validated realistic NS-RARP simulation with embedded sensors measuring torque on neurovascular bundles (NVB), our objective was to apply machine learning algorithms to classify surgical experience based on pure surgical gesture data inputs. METHODS: 50 certified urologists with average robotic case volumes (RV) of 1206 (range 100 - >5000) completed surveys and a NS-RARP simulation, during which video and force sensor data were collected. Videos were annotated for ten approved individual surgical gestures (e.g., cut, traction etc.) and aggregated based on instrument used and combinations of multiple gestures. Total force, average force, and number of force peak events were calculated. With a total of 33 inputs, output included total/NS-RARP case volume and NVB force data. Data was fit to a Gaussian Mixture model, then separated based on gesture utilization patterns. Tukey’s HSD test was used to determine significance in inter-group comparisons of RV and force metrics. RESULTS: Participants were clustered into 3 groupings based on mean total RV: 14 Super-Users (SU) (2221), 14 High Volume (HV) (1017), and 5 Low Volume (LV) (110) urologists (Figure 1). Significant differences were found between SU and HV for both Robotic case (p=0.03) and RARP volumes (p=0.008). Gesture pattern comparisons showed significant differences between SU vs HV and HV v LV in 64% and 30% of gesture inputs respectively. Force sensor comparisons showed significant differences in Total Force and Force Peak events between SU vs LV (p=0.014; p=0.021) and HV vs LV (p=0.021; p=0.046) groups. No significant differences in forces between SU and HV were found. CONCLUSIONS: This machine learning algorithm successfully categorized surgical experience into caseload and force applied, based solely on gesture inputs within a realistic simulated NS-RARP task. Differences in gestures differentiated HV from SU urologists, alluding to potential for targeted areas of improvement in gesture patterns, even for HV surgeons. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e830 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Schuler More articles by this author Lauren Shepard More articles by this author Tyler Holler More articles by this author Patrick Saba More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

MP80-02 ASSEMBLING THE EXPERTS: A NOVEL GRADING EXERCISE FOR NERVE-SPARING PERFORMANCE

You have accessJournal of UrologyCME1 Apr 2023MP80-02 ASSEMBLING THE EXPERTS: A NOVEL GRADING EXERCISE FOR NERVE-SPARING PERFORMANCE Ashwin Ramaswamy, Runzhuo Ma, Jim Hu, and Andrew Hung Ashwin RamaswamyAshwin Ramaswamy More articles by this author , Runzhuo MaRunzhuo Ma More articles by this author , Jim HuJim Hu More articles by this author , and Andrew HungAndrew Hung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Proficient preservation of the nerves during radical prostatectomy (RP) is critical to achieving post-operative erectile function (EF). However, terms such as nerve-sparing (NS) vs. non-NS do not explain the significant and currently unexplained heterogeneity in observed EF outcomes among high-volume surgeons. Utilizing the novel “NERVE” tool in a virtual video-based Delphi method, we report the degree of consensus regarding optimal NS technique among RP experts. METHODS: Eleven RP experts (from 5 centers) reviewed four NS videos sourced from the public domain comprising of 3 "expert" videos (C-SATS repository) and 1 video presented at a live surgical demonstration (YouTube). Experts graded videos using the NERVE tool (Figure 1) and predicted 1-year EF outcome in quintiles assuming perfect preoperative EF. Degree of expert agreement and correlation between total NERVE score and predicted EF outcome was evaluated by the intraclass and Pearson correlation coefficient, respectively. RESULTS: Overall NS technical skill assessment using the NERVE tool demonstrated a higher degree of expert agreement (ICC 0.75, p<0.001) than predicting EF outcome (ICC 0.41, p<0.01). Experts demonstrated significant variation in the degree of concordance using the NERVE tool: Nerve Plane (ICC 0.44, p<0.01), Electrocautery (ICC 0.83, p<0.01), Retraction (ICC 0.33, p<0.01), Visualization (ICC 0.50, p<0.01), and Effect (ICC 0.40, p<0.01). A strong positive correlation existed between total NERVE scores and predicted EF outcome (r=0.63, p<0.01) (Figure 2). CONCLUSIONS: There is expert consensus that improved NS performance is significantly correlated with EF outcomes; however, uncertainty remains on how likely better technical proficiency will produce a good outcome. Furthermore, near complete agreement in Electrocautery and poor agreement in Retraction highlights areas of considerable disagreement on what constitutes optimal NS technique. Future directions include recruiting more RP experts and incorporating videos with known 1-year EF outcomes. Source of Funding: UCF Residency Research Award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1151 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ashwin Ramaswamy More articles by this author Runzhuo Ma More articles by this author Jim Hu More articles by this author Andrew Hung More articles by this author Expand All Advertisement PDF downloadLoading ...