Preservation Of Erectile Function Research Articles

Erectile function preservation after salvage radiation therapy for biochemically recurrent prostate cancer after prostatectomy: Five-year results of the SAKK 09/10 randomized phase 3 trial

ObjectivesTo evaluate effects of dose intensified salvage radiotherapy (sRT) on erectile function in biochemically recurrent prostate cancer (PC) after radical prostatectomy (RP). Materials and methodsEligible patients had evidence of biochemical failure after RP and a PSA at randomization of ≤ 2 ng/ml. Erectile dysfunction (ED) was investigated as secondary endpoint within the multicentre randomized trial (February 2011 to April 2014) in patients receiving either 64 Gy or 70 Gy sRT. ED and quality of life (QoL) were assessed using CTCAE v4.0 and the EORTC QoL questionnaires C30 and PR25 at baseline and up to 5 years after sRT. Results344 patients were evaluable. After RP 197 (57.3 %) patients had G0-2 ED while G3 ED was recorded in 147 (42.7 %) patients. Subsequently, sexual activity and functioning was impaired. 5 years after sRT, 101 (29.4 %) patients noted G0-2 ED. During follow-up, 44.2 % of patients with baseline G3 ED showed any improvement and 61.4 % of patients with baseline G0-2 ED showed worsening. Shorter time interval between RP and start of sRT (p = 0.007) and older age at randomization (p = 0.005) were significant predictors to more baseline ED and low sexual activity in the long-term. Age (p = 0.010) and RT technique (p = 0.031) had a significant impact on occurrence of long-term ED grade 3 and worse sexual functioning. During follow-up, no differences were found in erectile function, sexual activity, and sexual functioning between the 64 Gy and 70 Gy arm. ConclusionED after RP is a known long-term side effect with significant impact on patients’ QoL. ED was further affected by sRT, but dose intensification of sRT showed no significant impact on erectile function recovery or prevalence of de novo ED after sRT. Age, tumor stage, prostatectomy and RT-techniques, nerve-sparing and observation time were associated with long-term erectile function outcome.ClinicalTrials.gov. Identifier: NCT01272050.

Propensity score matched analysis of functional outcome in five thousand cases of robot-assisted radical prostatectomy versus high-intensity focused ultrasound

BackgroundTo evaluate functional outcome after robot-assisted radical prostatectomy (RARP) and high-intensity focused ultrasound (HIFU) ablation for prostate cancer. MethodsWe retrospectively reviewed 4,983 RARP and 230 HIFU procedures performed at a single tertiary center. A 1:4 ratio propensity score matching (PSM) was performed to achieve baseline equivalence in age, body mass index (BMI), comorbidities, clinical stage, prostate specific antigen (PSA), prostate volume, biopsy grade, and number of positive cores. Functional outcomes based on International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) scores, and incontinence rates were evaluated at 6, 12, and 24 months. Resultstotal of 193 HIFU cases matched to 760 cases of RARP, were included. No differences were observed in perioperative IPSS at all follow-up periods. Despite comparative erectile function at baseline, HIFU showed significantly better erectile function preservation compared to RARP, with mean IIEF-5 scores of 9.5 versus 4.8, 9.5 versus 5.8, and 8.4 versus 6.7 at 6, 12, and 24 months, respectively (all P < 0.001). Pad-free rates at 6 and 12 months were comparable, with over 96% achieving continence at 12 months in both groups, although the rate of ≤1 pad/day at last follow-up was slightly better in HIFU (98.9% vs. 96.7%, P = 0.049). Subgroup analysis on partial (PGA) and whole gland ablation (WGA) showed no differences in IIEF-5 and incontinence but increased voiding difficulty in WGA versus PGA after 12 months of therapy (P < 0.05). Preoperative IIEF-5 ≥17 and HIFU were significant predictors of early erectile function recovery at 6 months (HR 4.4 and 5.0; all P < 0.001). No differences were observed in treatment-free survival between PGA, WGA, and RARP. ConclusionHIFU shows better performance in early recovery and preservation of erectile function after treatment for prostate cancer without increasing the risk of treatment failure. Patients with moderate to severe erectile dysfunction (IIEF-5 <17) prior to surgery should be warned of poor recovery after treatment.

The impact of water vapor thermal therapy of the prostate (rezūm) on sexual functions: a narrative review

Background: Senile prostate enlargement is an age-related condition. Many sexually active patients fear formal prostate surgeries owing to their negative impact on sexual performance. Minimally invasive procedures, including prostate water vapor thermal therapy (Rezūm®), were devised to make ends meet. This study aims to present a comprehensive narrative synthesis about the impact of prostate water vapor therapy on sexual functions. Methods: A narrative literature review was performed in May 2023, using MEDLINE, Cochrane Library, Ovid-Embase, Scopus, Science Direct, and Google Scholar; for the MeSH term “rezum AND sexual functions”. Selected reports were published articles from 2018 to date (the last 5 years). Only open-access journals in English were analyzed. Efforts were made to focus on the 2 main domains of sexual functions; erection and ejaculation. Results: As per the concise MeSH term “rezum AND sexual functions”, a score of 207 hits appeared on the initial search. After eliminating duplicate and irrelevant papers, only 7 articles fulfilled the inclusion criteria and were subjected to analysis. The analyzed articles were critically appraised to point out the studies` strengths and limitations. The gathered data were found to be consistent with one another as no outliers were detected. Conclusion: Water vapor thermal therapy of the prostate showed satisfying preservation of erectile function with minimal ejaculatory dysfunction.

(039) Clinical Outcomes of Corporal Burnett “Snake” Maneuver Modification for Ischemic Priapism

Abstract Introduction The conventional approach for managing ischemic priapism (IP) involves a stepwise process that includes corporal aspiration and irrigation, intracavernosal sympathetic agent injection, shunt surgeries with or without snaking, and penile prosthesis implantation. It is crucial to determine the most appropriate surgical shunt procedure for patients who do not achieve detumescence with medical treatment, as complication rates are known to increase with ischemia time. Objective This study compared the effectiveness and clinical outcomes of distal penile shunt procedures with or without corporal Burnett "Snake" maneuver in patients presenting with IP. Methods We conducted a retrospective study involving patients who presented to our emergency department with IP and underwent surgical treatment at our institution between 2005 and 2021. The patients were divided into two groups: Group 1 (n = 26) underwent distal shunt + Burnett snake maneuver, and Group 2 (n = 56) underwent distal shunt-only. Clinical history, clinical parameters of IP, medical and surgical treatment details, and follow-up information, including IP recurrence, erectile function (EF), and complications, were determined through physician-patient interviews during preoperative assessment and postoperative visits. Successful priapism resolution was defined as pain relief, detumescence, and no further intervention required until discharge. Priapism recurrence was defined as a new presentation to the hospital with IP. EF was assessed before distal shunt surgeries and during post-op visits. EF was graded on a 4-point patient-reported scale: 1 = fully rigid, always capable of penetration, 2 = diminished erection, capable of penetration with phosphodiesterase-5 inhibitors, 3 = diminished erection, capable of penetration with intracavernosal/intraurethral injection or vacuum pump, 4 = insufficient erection despite non-surgical treatment methods. Results The patient's demographic characteristics are shown in Table 1. IP resolution was observed in 24 out of 26 patients (92.3%) in Group 1 and in 30 out of 56 patients (53.6%) in Group 2 (p &amp;lt; 0.001) with a single surgical intervention. IP recurrence was observed in 1 out of 24 patients (4.2%) in Group 1 and in 18 out of 30 patients (60%) in Group 2 among those successfully treated with a single surgical intervention (p &amp;lt; 0.001). When comparing the EF status between groups, 6 out of 14 patients (42.8%) in Group 1 compared to 13 out of 26 patients (50%) in Group 2 had functional preservation of EF (level 1 + level 2) after priapism surgery, among those successfully treated with a single surgical intervention which had EF data in their charts (p = 0.66). Conclusions Our study demonstrates that Burnett snake maneuver is more effective than distal shunt-only procedures in resolving acute IP. Furthermore, this technique shows greater success in preventing IP recurrences. Regarding EF recovery, Burnett snake maneuver is at least as successful as distal shunt-only procedures, even in cases with longer ischemia times. Disclosure No.

Comparative Analysis of Rapid Transurethral and Reverse Sequential Resection with Plasma Excision Equipment for BPH Treatment

Objective: To compare the rapid transurethral sequential excision and reverse sequential excision combined with plasma excision equipment for BPH treatment of benign prostatic hyperplasia (BPH) and traditional transurethral resection of prostate (TURP) in patients with BPH. Methods: The study conducted at the Department of Urology, the First Affiliated Hospital of Jinzhou Medical University, aimed to compare the efficacy of two surgical approaches for treating benign prostatic hyperplasia (BPH) with traditional transurethral resection of the prostate (TURP). From October 2021 to October 2023,128 BPH patients were divided into two groups: 64 underwent rapid transurethral sequential excision and reverse sequential excision combined with plasma excision equipment, while the other 64 underwent TURP. Results: The excision weight was higher, and intraoperative blood loss was lower in the group using plasma excision equipment compared to TURP. Additionally, this group experienced shorter procedure times, less bladder irrigation, catheterization duration, and shorter hospital stays (P &lt; 0.05). Postoperative follow-up at three months revealed significant improvements in the International Prostate Symptom Score (IPSS) and Overactive Bladder Score (OABSS) in both groups, with greater improvement in the plasma excision equipment group (P &lt; 0.05). At one- and three-months post-surgery, bladder function, urodynamics, and bladder compliance were compared between the groups. The plasma excision equipment group showed better bladder compliance and urinary flow rates than the TURP group, while residual urine volume was higher in the plasma excision equipment group (P &lt; 0.05). Conclusion: rapid transurethral sequential excision and reverse sequential excision combined with plasma excision equipment demonstrated superior perioperative indicators, treatment efficacy, preservation of erectile function, and improvement in urodynamics compared to traditional TURP for BPH treatment.

The effectiveness of medical penile rehabilitation after radical prostatectomy

Background. Among the drug methods of penile rehabilitation in patients after nerve-sparing prostatectomy, the use of phosphodiesterase-5 (PDE-5) inhibitors is proposed as the first line of therapy, which have shown high efficiency, ease of use, good tolerability and safety, improving the quality of life of patients.Aim. To evaluate the effectiveness of drug-induced penile rehabilitation after nerve-sparing prostatectomy in the restoration of erectile function (EF) with an analysis of the factors influencing it.Materials and methods. The study included 108 patients with localized prostate cancer who underwent nerve-sparing prostatectomy. All patients were randomized into two groups. In Group 1 patients did not receive drug therapy for the prevention and treatment of erectile dysfunction. In Group 2 patients in the postoperative period received daily PDE-5 inhibitors (tadalafil) at a minimum dosage of 5 mg for 12 months as a drug therapy. Initially and at the annual stage of the study, the state of EF, erectile rigidity, night penile test, and quality of life were assessed. An analysis was also made of the factors affecting the preservation of EF one year after nerve-sparing radical prostatectomy.Results. The best reliable results in terms of maintaining EF at the annual stage of the study were obtained in the group whose patients received postoperative drug therapy with PDE-5 inhibitors. It was possible to identify the most significant factors influencing the state of EF in the postoperative period after radical prostatectomy: the type of operation – bilateral nerve sparing, taking PDE-5 inhibitors, the patient’s age, the presence/absence of diabetes mellitus, the state of EF (International Index of Erectile Function-5 value) before the operation.Conclusion. Daily intake of PDE-5 inhibitors at a low dose of 5 mg is indicated for patients after nerve-sparing prostatectomy as an effective means of penile rehabilitation in order to preserve EF, as it provides better results compared to no drug therapy. Patients who meet criteria such as young age, no diabetes, high preoperative International Index of Erectile Function-5 levels may benefit most from nerve-sparing surgical techniques and early postoperative participation in a penile rehabilitation program for erectile dysfunction.

Comparative analysis of 10-year functional outcomes of robot-assisted radical prostatectomy and radical retropubic prostatectomy. Experience of the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry

Background. Prostate cancer is the 3rd most common diagnosis among malignant tumors. The first robot-assisted radical prostatectomy (RARP) was performed in 2001. Studies comparing RARP and radical retropubic prostatectomy (RRP) are limited. In Russia, the Da Vinci robot was first installed in 2007. At the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry the program of robot-assisted surgery started in November of 2008.Aim. To perform first in Russia evaluation of 10-year functional treatment outcomes for patients with localized prostate cancer after RARP. To perform comparative analysis with RRP outcomes.Materials and methods. Medical histories of 211 patients from the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry were analyzed. Among them, 62 patients did not satisfy the inclusion criteria. Therefore, the study included 149 patients who underwent surgical treatment for localized prostate cancer between January of 2009 and December of 2011. Depending on the technique of surgical intervention, patients were divided into 2 groups: 1st – RARP (n = 82), 2nd – RRP (n = 67). All RARP were performed by a single surgeon, RRP by 2 experienced surgeons (experience &gt;1000 RRP).Results. Median follow-up was 120 months in both groups. Overall survival in the 1st and 2nd groups was 85.4 and 86.6 %, respectively (p &gt;0.05). For accuracy of functional outcomes analysis, patients who died during follow-up were excluded from the study. Frequency of neurovascular bundle preservation in the 1st and 2nd groups was 60.9 % (50/82) and 40.2 % (27/67), respectively (p = 0.01). Erectile function was preserved in 60.0 and 44.4 % males of the 1st and 2nd groups, respectively (p = 0.01). Age below 60 years (р = 0.009) and disease stage рТ2 (p = 0.026) were predictors of erectile function preservation after RARP. Continence frequency was 92.7 and 82.1 % in the 1st and 2nd groups, respectively (p = 0.048).Conclusion. Ten-year comparative analysis shows that RARP allows to achieve significantly better parameters of urinary continence and erectile function preservation in men with localized prostate cancer than RRP.

Molecular mechanisms of penile traction for penile rehabilitation in a bilateral cavernous nerve crush injury rat model.

Prostate cancer is the most common solid-organ malignancy in adult men. Early detection and treatment of prostate cancer with radical prostatectomy (RP) has improved cancer-specific survival but is associated with penile shortening and erectile dysfunction. Penile traction therapy (PTT) has been demonstrated to increase stretched penile length (SPL) prior to penile prosthesis placement and may improve erectile function (EF) in patients with Peyronie's disease. We aimed to evaluate the efficacy of PTT in preserving penile length and EF after bilateral cavernous nerve crush injury (BCNI) in a rat model. Twenty-four male Sprague-Dawley rats aged 11-13 weeks were randomly assigned to three groups (n=8, each): sham operation with no PTT (Sham), BCNI without PTT (Crush), and BCNI with PTT (Traction). PTT was started on postoperative day 3. A traction force of 1 Newton was applied to the penis for 30 minutes each day for 28 days. After 28 days of traction, the cavernous nerve was stimulated while recording the intracavernosal pressure (ICP) and the mean arterial pressure (MAP) simultaneously. Cavernosal tissue was excised, and western blot analysis for endothelial nitric oxide synthase (eNOS) was performed. Significance was determined by using ANOVA with Tukey-Kruger post-hoc testing. At 4 weeks after nerve injury, the Traction group had significantly greater SPL compared to the Sham and Crush groups (30 vs. 28 and 27 mm, respectively). The Sham group had significantly greater EF (ΔICP/MAP) compared to the Crush group at 2.5, 5, and 7.5 V. The EF of the Traction group was between that of the Sham and Crush groups and was not significantly different from the Sham group at any voltages. Further downstream analysis revealed that the Traction group had significantly greater eNOS expression in cavernosal tissue compared to the Crush group, which was confirmed on western blot analysis and immunohistochemistry (IHC) staining. Findings from this animal study suggest that PTT has the potential to mitigate penile retraction after RP. While more studies are needed to determine the effect of PTT on preservation of EF, the increased eNOS expression observed in the Traction group offers a potential protective mechanism of action.

(294) Trends and Clinical Practice Patterns of Prostatic Urethral Lift (PUL): An Analysis of the American Board of Urology Case Logs

Abstract Introduction Prior studies have shown that among benign prostatic hyperplasia (BPH) surgical treatments, PUL has a higher likelihood of preserving sexual function. As a result, the 2021 AUA guidelines on management of BPH note that PUL may be offered as a treatment option to those eligible patients who desire preservation of erectile and ejaculatory function. Objective We investigated practice trends associated with PUL utilization and hypothesized that PUL would be performed more frequently for younger patients and by urologists subspecializing in andrology (infertility and/or sexual medicine). Methods We obtained de-identified, self-reported American Board of Urology (ABU) case logs from 2015-2021. We identified 4,131 urologists who performed 48,610 surgeries with an indication for BPH per ICD codes. CPT codes distinguished PUL from transurethral incision, electrosurgical resection, laser coagulation/vaporization, laser enucleation, and thermotherapy. We identified 786 urologists who performed 7,895 PUL procedures representing 19.2% of all BPH surgeries. Additionally, 24 urologists only performed PUL, and 3,345 urologists did not perform any PUL. A logistic regression model assessed factors independently associated with performing PUL. Results The number of annual PUL performed has ranged from 101 to 2,852, comprising an increasing proportion of BPH surgeries from an initial 1.6% in 2015 to 32.5% of all BPH surgeries performed in 2020. In adjusted analyses, factors associated with higher odds of performing PUL included subspecialization in andrology (odds ratio [OR] 4.01, 95% CI 1.94-8.29); practice area population &amp;gt;1,000,000 (OR 1.55, 95% CI 1.01-2.38); and government (OR 4.22, 95% CI 1.83-9.74), private practice group (OR 2.68, 95% CI 1.53-4.68), and salaried hospital employment (OR 1.94, 95% CI 1.00-3.96). The operative year (OR 1.66 per year, 95% CI 1.54-1.80) and surgeon BPH surgical volume (OR 1.02 per case increase, 95% CI 1.01-1.02) were associated with increased odds of performing PUL. Endourology subspecialization was associated with lower odds of PUL (OR 0.40, 95% CI 0.2-0.8). Geographic region, surgeon age, surgeon gender, certification vs recertification status, and patient age were not associated with use of PUL. Conclusions Based on 7 years of ABU case log data, PUL is more likely to be performed by andrologists, urologists practicing in large metropolitan areas, higher volume BPH surgeons, and urologists in private practice group, government, or hospital salaried employment. Contrary to our hypothesis, lower patient age was not associated with a higher odds of undergoing PUL. The use of PUL has increased significantly and currently comprises one third of all BPH surgeries. More study is needed to determine the extent to which patient demand for ejaculation preservation is driving the rapid adoption of PUL reflected in the ABU case logs. Disclosure No

(295) Prostatic Urethral Lift (PUL) is Superior to TURP in the Preservation of Ejaculatory Function in Patients with Obstructive Median Lobes (OML)

Abstract Introduction For the past several years, the AUA has recommended PUL as a treatment option for eligible patients who desire preservation of erectile and ejaculatory function. Objective This analysis serves as the first detailed assessment of sexual function and symptom outcomes among patients treated with PUL, TURP or sham in controlled and real-world studies of PUL. Methods Outcomes including MSHQ bother and ejaculatory function scores were compared for the following groups through 12 months: 66 patients from the L.I.F.T. pivotal RCT with lateral lobe (LL) obstruction randomized to sham, 36 men with LL obstruction in the BPH6 RCT randomized to TURP, and 45 men with OML in MedLift, the FDA-approved IDA extension of the LIFT trial. Patients in the large RWR study were filtered to approximate the MedLift population and results for the 187 OML patients were compared with MedLift. Results OML patients treated with PUL demonstrated superior ejaculatory function and bother scores compared to TURP LL only at all timepoints (Figure 1); at 1- and 3 months, MedLift subjects also experienced significantly better IPSS and QoL improvement post-PUL compared to TURP. IPSS improvement was 170% greater for MedLift subjects than sham LL at 3 months; MedLift subjects experienced significantly better QoL, Qmax, and BPHII improvements over the same time period. IPSS, QoL, Qmax, and PVR outcomes were equivalent for MedLift and RWR OML groups at 3-, 6-, and 12 months post-PUL; overall adverse events were not elevated in the RWR OML group. Conclusions Compared to TURP, PUL provides quicker symptom improvement during the early post-operative period with superior ejaculatory function outcomes through 12 months post-treatment in patients with OML. PUL continues to preserve sexual function for BPH patients despite LL or OML obstruction. Disclosure Yes, this is sponsored by industry/sponsor: Neotract, Inc./Teleflex Clarification Industry initiated, executed and funded study Any of the authors act as a consultant, employee or shareholder of an industry for: Neotract, Inc./Teleflex.

Functional outcomes and health-related quality of life following penile cancer surgery: a comprehensive review.

Organ-sparing surgery (OSS) in penile cancer management aspires to maintain organ form and function and preserve health-related quality of life (HRQoL), yet there is a lack of integrated evidence exploring these outcomes. The aim sought to review HRQoL, functional, aesthetic, and psychological outcomes following OSS or radical penectomy for penile cancer. A systematic review of MEDLINE and Cochrane databases included studies reporting on function (sexual, urinary or sensory), genital appearance or HRQoL/psychological well-being following surgical treatment of primary penile cancer. English-language reports (2000-2022), incorporating patient-reported or objective clinical outcome measures, were eligible. Studies of nonsurgical treatment strategies and those in the context of metastatic disease were excluded. Data were compiled and analyzed. Twenty-six studies were included. Sexual function was the most studied outcome (754 pooled respondents; 19 studies), most frequently with the original 15-item and abridged 5-item International Index of Erectile Function. Preservation of erectile function following OSS is generally described, with some reduction in overall sexual satisfaction cited. Heterogeneous assessment of voiding function with little preoperative evaluation render interstudy comparison difficult. Most patients appear able to void from a standing position following OSS, with spraying the most common symptom. Maintenance of some sensory function is described with both split-thickness skin grafting and urethral glanduloplasty following radical glansectomy. Limited studies suggest reasonable patient satisfaction with genital cosmesis post-OSS. A negative impact on HRQoL is described in most studies following penile cancer surgery, variably correlated with aggressiveness of penile surgery and addition of lymphadenectomy. Anxiety, depression, and reduced self-esteem have been reported in penile cancer survivors. Relationship well-being varies, with some survivors reporting this to be unchanged. OSS can preserve elements of sexual, urinary, and sensory function, supporting advantages over radical penectomy for eligible patients. However, a comprehensive understanding remains limited due to small, heterogeneous patient cohorts, challenges in obtaining premorbid data, and variability in outcome measures. Standardization of patient-reported outcomes following OSS is desirable.

PD26-10 PREDICTING ERECTILE FUNCTION PRESERVATION AFTER PROSTATE CANCER TRIPLE THERAPY

You have accessJournal of UrologyCME1 Apr 2023PD26-10 PREDICTING ERECTILE FUNCTION PRESERVATION AFTER PROSTATE CANCER TRIPLE THERAPY Samantha L. Thorogood, Jose M. Flores, Nicole Benfante, James A. Eastham, Craig E. Grossman, Michael Zelefsky, and John P. Mulhall Samantha L. ThorogoodSamantha L. Thorogood More articles by this author , Jose M. FloresJose M. Flores More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , James A. EasthamJames A. Eastham More articles by this author , Craig E. GrossmanCraig E. Grossman More articles by this author , Michael ZelefskyMichael Zelefsky 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.0000000000003304.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Men with prostate cancer initially treated with radical prostatectomy (RP) who later undergo radiation (RT) and androgen deprivation therapy (ADT) in the adjuvant or salvage setting are at high risk for erectile dysfunction; however, this risk is not well quantified. We aimed to identify predictors of erectile function (EF) preservation this cohort treated with “triple therapy” (TTX). METHODS: We included men who underwent RP and subsequent adjuvant or salvage RT+ADT aka TTX but excluded men treated with ADT pre-RP. We extracted data on pre-RP ED-related comorbidities, total testosterone (T) levels, cancer and treatment characteristics, and sexual function. We analyzed International Index of Erectile Dysfunction (IIEF) Erectile Function Domain (EFD) score and phosphodiesterase 5 inhibitor (PDE5i) use documented pre-RP, 12 months (m) post-RP, and 12 m and 24 m post-TTX. PDE5i use was scored on a Likert scale of 0-3 (0: never; 3: routinely). NSS of each side (R/L) was scored on a 1-4 scale: 1 complete vs 2 near complete preservation (both considered nerve-sparing) and 3 partial vs 4 complete resection (both considered non-nerve-sparing). We then classified overall NS status as bilateral, unilateral, or not-spared. Multivariable analysis (MVA) was performed to define factors associated with EFD scores ≤10 (severe ED) and ≥24 (functional erections) at 24 m after TTX completion. RESULTS: We analyzed 163 men with a mean age of 63 years. 47% had ≥2 comorbidities. Median (IQR) total T 361 (26, 456) ng/dL. 18% had pre-RP T<300. 50% had bilateral NS. Median time between RP and start of RT was 18 (9, 34) m. Median duration of ADT: 4 (3, 6) m; 66% received >3 m ADT. Median EFD pre-RP=26 (17, 30) vs 6 (2, 20) at 24 m post-TTX. Mean difference in EFD pre-RP vs 24 m post-TTX was 11 (95% CI 9-12, p<0.0001). 18% had EFD≤10 pre-RP vs 62% at 24 m post-TTX. 60% had EFD≥24 pre-RP vs 15% at 24 m post-TTX. On MVA (Table 1), pre-RP EFD and bilateral NS were found to be significantly (p<0.05) associated with both EFD≤10 and EFD≥24. Age, ≥2 comorbidities, time between RP and RT, duration of ADT, and routine PDE5i use were not significant predictors in either model. CONCLUSIONS: This analysis identified pre-RP EF and surgeon-reported NS score as the only significant predictors of severe ED and functional recovery of erections 24 m after completion of TTX. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e738 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samantha L. Thorogood More articles by this author Jose M. Flores More articles by this author Nicole Benfante More articles by this author James A. Eastham More articles by this author Craig E. Grossman More articles by this author Michael Zelefsky More articles by this author John P. Mulhall More articles by this author Expand All Advertisement PDF downloadLoading ...

MP73-02 FOCAL THERAPY - 7 YEARS EXPERIENCE WITH FOCAL HIGH INTENSITY FOCUSED ULTRASOUND IN 164 PATIENTS WITH PROSTATE CANCER: SINGLE CENTER RESULTS

You have accessJournal of UrologyCME1 Apr 2023MP73-02 FOCAL THERAPY - 7 YEARS EXPERIENCE WITH FOCAL HIGH INTENSITY FOCUSED ULTRASOUND IN 164 PATIENTS WITH PROSTATE CANCER: SINGLE CENTER RESULTS Yamini Nagaraj, Fabian Falkenbach, Valia Veleva, Randi Marisa Pose, Jonas Ekrutt, Raisa Abrams-Pompe, Jaideep Ratkal, Pierre Tennstedt, Derya Tilki, Hans Heinzer, Markus Graefen, and Georg Salomon Yamini NagarajYamini Nagaraj More articles by this author , Fabian FalkenbachFabian Falkenbach More articles by this author , Valia VelevaValia Veleva More articles by this author , Randi Marisa PoseRandi Marisa Pose More articles by this author , Jonas EkruttJonas Ekrutt More articles by this author , Raisa Abrams-PompeRaisa Abrams-Pompe More articles by this author , Jaideep RatkalJaideep Ratkal More articles by this author , Pierre TennstedtPierre Tennstedt More articles by this author , Derya TilkiDerya Tilki More articles by this author , Hans HeinzerHans Heinzer More articles by this author , Markus GraefenMarkus Graefen More articles by this author , and Georg SalomonGeorg Salomon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003341.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal therapy aims to selectively ablate tumor lesions and preserve prostate tissue, thus minimizing side effect whilst providing oncological control. The experience of the first 2 years lead to improved diagnostic work up prior to HIFU with better patient selection and less tumor recurrence in the following 5 years. The strong recommendation of control biopsy in the follow up, lead to a reliable and early selection of patients requiring salvage therapy and thus improving oncological results. METHODS: This is a prospective evaluation of 164 patients undergoing focal high intensity focused ultrasound (HIFU) in our institution from July 2015 till June 2022. Patients were required to have a unilateral Gleason score (GS) ≤7, stage T1 or T2 and a PSA level of≤15 ng/ml. Tumor localization was done using multiparametric MRI followed by mainly transrectal targeted and systematic biopsies of any lesion PI-RADS≥3. Systematic biopsy was recommended 1 year after HIFU with PSA levels every 3 months. An MRI was scheduled at 3 years post HIFU. In the control biopsy significant cancer recurrence was defined as >3mm GS 3+3, >3 positive cores or any GS≥3+4; these patients were offered further treatment; either a repeat HIFU, radical prostatectomy (RP) or radiation therapy (RT). Urinary and erectile function were assessed using validated questionnaires. RESULTS: Median PSA prior to HIFU was 6 ng/ml, the median follow-up was 61 months. 38% of the patients had low, 60% intermediate and 2% high risk disease. Median PSA level 2 years post HIFU was 1.9 ng/ml. Of the 119 control biopsies 50% had no evidence of tumor, 36% had insignificant tumor evidence and 14 % showed evidence of significant prostate cancer according to the above defined criteria. Significant infield recurrence occurred in 6 patients (4%) and significant outfield recurrence was seen in 10 patients (6%). 5 patients received a repeat HIFU, 4 patients a RT and 7 had a RP. There were no cases of distant metastasis, no need for palliative antiandrogen therapy (ADT) and no major complications. Urinary continence and erectile function were preserved in 99.5% and 85% respectively. CONCLUSIONS: At 7 years, HIFU therapy showed efficient oncological control rates with a radical treatment free survival rate of 93%. Significant infield recurrence was seen in 4% and significant outfield recurrence in 6% of patients. There was no distant metastasis and no need for palliative ADT. HIFU is associated with excellent preservation of continence and erectile function with very low morbidity. Source of Funding: Non funded © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1034 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yamini Nagaraj More articles by this author Fabian Falkenbach More articles by this author Valia Veleva More articles by this author Randi Marisa Pose More articles by this author Jonas Ekrutt More articles by this author Raisa Abrams-Pompe More articles by this author Jaideep Ratkal More articles by this author Pierre Tennstedt More articles by this author Derya Tilki More articles by this author Hans Heinzer More articles by this author Markus Graefen More articles by this author Georg Salomon More articles by this author Expand All Advertisement PDF downloadLoading ...

Effects of platelet-rich plasma glue placement at the prostatectomy site on erectile function restoration and cavernous nerve preservation in a nerve-sparing prostatectomy rat model

BackgroundDespite the widespread use of nerve-sparing prostatectomy techniques, the incidence of post-operative erectile dysfunction (ED) remains high. Early intracavernous (IC) injection of platelet-rich plasma (PRP) after nerve crushing improves erectile function (EF) in rats by promoting cavernous nerve (CN) regeneration and preventing structural changes in the corpus cavernosum. However, the neuroprotective effects of the in situ application of PRP glue in rats after CN-sparing prostatectomy (CNSP) remain unclear. AimThis study aimed to investigate the effects of PRP glue treatment on EF and CN preservation in rats after CNSP. MethodsAfter prostatectomy, male Sprague–Dawley rats were treated with PRP glue, IC PRP injection, or their combination. The intracavernous pressure (ICP), mean arterial pressure (MAP), and CN preservation status in the rats were evaluated after 4 weeks. Results were corroborated using histology, immunofluorescence, and transmission electron microscopy. ResultsThe PRP glue-treated rats showed 100% CN preservation and significantly higher ICP responses (the ratio of maximum ICP to MAP (0.79 ± 0.09)) than the CNSP rats (the ratio of maximum ICP to MAP (0.33 ± 0.04)). PRP glue also significantly increased neurofilament-1 expression, indicating its positive effect on the CNs. Furthermore, this treatment significantly increased the expression of α-smooth muscle actin. Electron micrographs revealed that PRP glue preserved the myelinated axons and prevented atrophy of the corporal smooth muscle by maintaining the adherens junctions. ConclusionsThese results indicate that PRP glue is a potential solution for EF preservation by neuroprotection in patients with prostate cancer who are likely to undergo nerve-sparing radical prostatectomy.

Preservation of Erectile Function after Stereotactic Radiosurgery with CyberKnife for Prostate Cancer

Prostate carcinoma is one of the most significant social oncological diseases among the male population. With the improvement of early diagnosis through PSA screening, new therapeutic options are open to patients. After the introduction of prostatectomy, it was clear the curative treatment for prostate cancer could have unpleasant effect on the erectile function and in this way to worsen the sexual health of men. The alternative of radical surgical treatment is radiotherapy. For that reason, the treatment by Stereotactic Body Radiation Therapy with Cyberknife for low- and intermediate-risk prostate cancer is gaining more and more popularity and scientific evidence. Even that the preservation of the erectile function after prostate radiation is still an ongoing challenge for the modern radiation oncology and the question of how to improve therapeutic techniques to achieve better results remains open

Daily online contouring and re-planning versus translation-only correction in neurovascular-sparing magnetic resonance-guided radiotherapy for localized prostate cancer.

Neurovascular bundle (NVB) and internal pudendal artery (IPA) sparing during magnetic resonance-guided radiotherapy (MRgRT) for prostate cancer aims for preservation of erectile function. Our present workflow involves daily online contouring and re-planning on a 1.5 T MR-linac, as alternative to conventional (rigid) translation-only corrections of the prostate. We compared planned dose for the NVB and IPA between strategies. Total planned dose was significantly lower with daily online contouring and re-planning for the NVB, but not for the IPA. For the NVB and IPA, the intrapatient difference between highest and lowest fraction dose was significantly smaller for the contouring and re-planning plans.

Recent advances in understanding and treating priapism.

Priapism is a rare condition that can lead to long-term erectile dysfunction if left untreated. It is one of the few urological emergencies that require prompt medical intervention. Priapism refers to a penile erection that lasts for more than 4 hours and is unrelated to sexual stimulation or orgasm. The aims of immediate intervention for ischaemic priapism are to resolve the painful erection and preserve the cavernosal smooth muscle function. The aim of this review is to evaluate the latest advances in the management of priapism. Despite the continuous challenge in providing an optimal treatment for this rare urological condition, our understanding and management of it have been advanced by decades of clinical and basic science research. Proximal shunts (Quackels or Grayhack) are no longer routinely performed. Distal shunt procedures are currently the most commonly used techniques. A novel penoscrotal decompression technique has recently been described. Ischaemic priapism can be managed conservatively in most cases with the preservation of erectile function. In cases where ischaemic priapism has persisted for more than 36 hours, the majority will develop erectile dysfunction. Early penile prosthesis with thorough patient counselling should be considered in such cases. In some cases of long-standing non-ischaemic priapism, patients can develop fibrosis within the distal corpora, and, therefore, early treatment with super-selective embolisation is required to prevent this.

Better preservation of erectile function in localized prostate cancer patients with modern proton therapy: Is it cost-effective?

Stereotactic body radiation therapy (SBRT) has gradually been recognized as favorable curative treatment for localized prostate cancer (PC). However, the high rate of erectile dysfunction (ED) after traditional photon-based SBRT remains an ongoing challenge that greatly impacts the quality of life of PC survivors. Modern proton therapy allows higher conformal SBRT delivery and has the potential to reduce ED occurrence but its cost-effectiveness remains uninvestigated. A Markov decision model was designed to evaluate the cost-effectiveness of proton SBRT versus photon SBRT in reducing irradiation-related ED. Base-case evaluation was performed on a 66-year-old (median age of PC) localized PC patient with normal pretreatment erectile function. Further, stratified analyses were performed for different age groups (50, 55, 60, 65, 70, and 75 years) and threshold analyses were conducted to estimate cost-effective scenarios. A Chinese societal willingness-to-pay (WTP) threshold (37,653 US dollars [$])/quality-adjusted life-year [QALY]) was adopted. For the base case, protons provided an additional 0.152 QALY at an additional cost of $7233.4, and the incremental cost-effectiveness ratio was $47,456.5/QALY. Protons was cost-effective for patients ≤62-year-old at the WTP of China (≤66-year-old at a WTP of $50,000/QALY; ≤73-year-old at a WTP of $100,000/QALY). For patients at median age, once the current proton cost ($18,000) was reduced to ≤$16,505.7 or the patient had a life expectancy ≥88 years, protons were cost-effective at the WTP of China. Upon assumption-based modeling, the results of current study support the use of proton SBRT in younger localized PC patients who are previously potent, for better preservation of erectile function. The findings await further validation using data from future comparative clinical trials.

The Gullwing Technique: A Novel Method of Transcorporal Artificial Urinary Sphincter Placement for the Fragile Urethra

To describe the novel gullwing technique for artificial urinary sphincter (AUS) placement. The transcorporal technique for AUS placement is beneficial in patients with 'fragile urethras' (previous failed AUS, urethroplasty or history of radiation) however limitations include insufficient lateral and ventral urethral support in addition to potential cinching during corporotomy closure which, in the absence of additional grafting may restrict our ability to conserve internal corporal capacity and limit options for future preservation of erectile function via penile prosthesis placement. The gullwing variation of the technique offers the potential to circumvent these disadvantages. This case describes the gullwing variation of transcorporal AUS placement in a complex patient with a history of abdominopelvic trauma and prior failed AUS placements secondary to urethral erosion. Transcorporal AUS placement in patients with prior urethral compromise has been shown to result in lower revision and erosion rates. The gullwing modification of the technique is a novel variation providing improved circumferential urethral protection and, with the addition of corporal grafting, aims to enable the preservation of the three-dimensional corporal volume necessary for ease of subsequent penile prosthesis implantation. However, studies assessing the long-term functional outcomes and durability of this technique are needed.

Directions of Development of Modern Genital Surgery. Features, Details, Nuances

The quality of life and self-esteem of a modern man are largely determined by the appearance and functional state of his genitals. The quite high demand for improving the morpho-functional properties of the penis is the driving force of progress in the field of penile surgery. Despite the positive meaning of the surgical arsenal diversity for meeting the needs of the patient, the latter puts additional requirements for standardization, safety assessment and development of algorithms for their selection. Under these circumstances, there is a significant need for publications that inform specialist with the practical aspects of external genital surgery in men. The objective: to analyze modern algorithms for managing patients with various pathologies / defects of the penis (penile dysmorphophobia, erectile dysfunction, Peyronie’s disease, congenital deviation, priapism, cavernous fibrosis, trauma and tumors) and methods of their surgery. Materials and methods. Bibliosemantic material that covers current aspects and trends of genital surgery over the past 10 years, and case reports of patients who applied to the Department of Sexopathology and Andrology of the Institute of Urology of the National Academy of Medical Sciences of Ukraine with penile pathology that required surgical correction. Results. It is demonstrated that the algorithm of managing a patient with anatomical defects of the penis, should include: analysis and correction of deformation based on geometric principles; increase in size and / or elongation of the short side (small curvature); minimization of complications (loss of sensitivity, hematoma, necrosis); preservation or restoration of erectile function; restoration of the urethra (length and caliber), normalization of the urination, restoration of a full sexual life with adequate psychological adaptation. It has been shown that severe erectile dysfunction, which is not amenable to therapeutic correction, requires the penile implantation. On the other hand, penile implantation is contraindicated in uncompensated diabetes mellitus, decompensation of the cardiovascular system, late-stage cancer, acute inflammatory processes of various localizations, mental illness, skin lesions of various etiologies in the area of the scrotum and penis, in patients with a high frequency of repeated endoscopic procedures, tissue defects in the area of operation with the predicted inability to stretch, hypersensitivity to silicone, the mismatch of the size of the corpora cavernosa to the size of the selected type of implant. It has been proven that ligamentotomy and corporoplasty prevent the loss of penis length after implantation, but increase the likelihood of complications. Complications of penile implantation include: prosthesis-associated infection, erosions, migration or extrusion of the prosthesis, migration of proximal tips, mechanical failure of the prosthesis, tissue and / or allergic reaction, acute urinary retention, pain, hematoma, edema, edema and lymphoma intraoperative perforation of the urethra or corpora cavernosa. Clinical cases of certain complications and methods of their elimination are given. The choice of method of correction of penile deviation is determined by the state of erectile function, the length of the penis, the angle of curvature, the wishes of the patient. Grafting (short penis, angle of curvature&gt; 60 °, presence of deformities) or plication (sufficient length of the penis, angle of curvature &lt;60 °, no deformities) can be performed if erectile function or pharmacotherapy is preserved. At erectile dysfunction at condition of inefficiency of pharmacotherapy implantation is shown. Conclusion. At the present stage, the main direction of movement in genital surgery is a combination of aesthetics and functionality. A specialist in penile surgery must have the skills of a urologist, andrologist, aesthetic surgeon and psychologist. In patients with penile dysmorphophobia, subjective assessment of the appearance of the genitals correlates with psychological status. The main psychological feature of a patient with penile dysmorphophobia is dissatisfaction with the size of the penis (length and / or thickness) at normal anatomical proportions. The modern arsenal of penile surgery is diverse and includes methods of correction of deviations / deformations, increase in size (length / thickness); axial rigidity, urethral capacity (length and caliber), during which implants can be used. Penile surgery is associated with the risk of severe complications: loss of sensitivity of the penile glans, hematoma, necrosis, prosthetic infection, rupture of the the corpora cavernosa and urethra. Further research should determine optimal algorithms for selecting certain surgical techniques taking into account aesthetic, functional criteria and safety.