Preservation Of Sexual Function Research Articles

Pelvic autonomic nerve preservation for patients with rectal carcinoma: Oncologic and functional outcome

Serious problems in the surgical treatment of patients with rectal carcinoma are local failure and urinary and sexual dysfunction. To resolve these problems, pelvic autonomic nerve preservation (PANP) combined with lateral lymph note dissection has been introduced. Of 238 consecutive patients with middle or low rectal carcinoma who underwent potentially curative surgery between 1987 and 1992, 214 underwent PANP according to pre- and intraoperative staging. PANP was evaluated from the perspectives of oncologic outcome and urinary and male sexual function with a retrospective questionnaire in a group of patients followed prospectively. During the median follow-up of 53 months, local recurrence developed in 5.6% of patients; no local recurrence was observed in Dukes Stage A or Dukes Stage B patients. The 5-year survival rates of Dukes Stage A (n = 55), Dukes Stage B (n = 72), and Dukes Stage C (n = 87) patients were 96.4%, 84%, and 67.3%, respectively. Of patients undergoing preservation of the unilateral pelvic plexus alone, 93.5% maintained the ability to void spontaneously. Of patients who had complete preservation of the autonomic nerve system, 70.4% maintained male sexual function, and of patients who had removal of the hypogastric nerves and preservation of the pelvic nerve plexuses, 66.7%, were capable of erection and intercourse without normal ejaculation. Early stage rectal carcinoma should be treated both with local cure and complete preservation of urinary and sexual function. In high risk patients with suspected perirectal lymph node metastases and tumors invading the perirectal fat, the appropriate PANP should be applied with consideration of the balance between achieving a cure and preserving autonomic function.

Bladder neck sparing radical prostatectomy. Impact on continence and local recurrence

Radical prostatectomy is the treatment of choice for stage A e B prostatic carcinoma and optional in locally advanced forms. This surgical treatment, however, can lead to various problems such as preservation of sexual function, urinary continence and local recurrence. We present our experience to show how preservation of bladder neck fibres can influence urinary continence without affecting local recurrence. The latter was found in 13.8% of patients, while 90.7% were continent within 24 hours after removal of the catheter.

1053 Preservation of sexual function in young prostate cancer patients after radiation therapy: A positive factor in choice of a treatment modality

1053 Preservation of sexual function in young prostate cancer patients after radiation therapy: A positive factor in choice of a treatment modality

BENIGN PROSTATIC HYPERPLASIA: Hormonal Treatment

Androgen withdrawal therapy appears to produce a 20% to 30% decrease in the volume of the hyperplastic prostate after 3 to 6 months of therapy. Longer periods of treatment do not result in further prostatic regression, but further growth of the gland is not apparent in men treated with finasteride for 4 years. Although biopsy studies indicate that epithelial regression occurs to a much more significant degree than stromal regression, this may simply reflect the relatively longer turnover of the stromal cell population. The significant placebo effect of oral medication in patients with BPH makes interpretation of clinical symptomatology and uroflow data difficult. Analysis of symptom improvement is further complicated by the relatively slow improvement of patients on hormonal therapy, as opposed to surgery, where relief is immediate. In addition to limited stromal involution and inadequate treatment duration, other biologic factors may limit the clinical efficacy of androgen withdrawal therapy. Most importantly, partial involution may not necessarily decrease urethral resistance. In addition, obstruction-induced detrusor dysfunction may persist after relief of outflow obstruction in some patients, as it does following surgery. Incomplete blockade of androgen action, as well as compliance issues, may also limit efficacy. Long-term studies validate a modest but significant clinical response rate of finasteride therapy with preservation of sexual function in most men. Of the available hormonal therapeutic agents, only finasteride appears to have an acceptable risk-benefit ratio. Other 5 alpha-reductase inhibitors in the "pipeline," such as episteride, may have similar benefits. In the long term, this class of drugs may have a much larger role in patients who present with the early signs of BPH, to prevent any further progression of the disease. Presently, no form of antiandrogen therapy is as effective as transurethral resection of the prostate in relieving symptomatology. Because of patient preferences, however, medical therapy will play an increasingly important role in the management of patients with BPH.

En Bloc Radical Cystourethrectomy with Preservation of Sexual Function

En Bloc Radical Cystourethrectomy with Preservation of Sexual Function

Sacrocolpopexy: a retrospective study of a clinician's experience.

To assess the factors that may predispose patients to the development of vaginal vault prolapse and enterocele, and to determine the success of sacrocolpopexy in correcting prolapse. A retrospective study of women with vault prolapse undergoing sacrocolpopexy over a 10 year period between 1983 and 1993, with analysis of postoperative complications and success. St. George's Hospital in London, a university teaching hospital, and private practice. Forty-one women, presenting with symptomatic vault prolapse, who desired preservation of sexual function. Forty-one patients underwent 43 sacrocolpopexies. Of these, 39 were performed by the senior author. All but four were reviewed in the clinic within the last year. Pre- and post-operative data and any interim prolapse or incontinence surgery were recorded. Success was assessed subjectively and by clinical examination for recurrence of prolapse, associated post-operative complications, subsequent voiding difficulties, and incidence of incontinence. Failure was defined as a symptomatic enterocele or evidence of a third degree enterocele on examination. The 41 patients were followed for a mean time of 21.2 months. The cure rate of vault prolapse was 88%. The most common complications were stress incontinence, urinary tract infection, and persistent vaginal discharge. Using the unpaired t-test and chi 2 analysis, there was no significant difference between failures or successes in terms of weight, parity, age, previous surgery, pulmonary history, or difficulties with defaecation, although the number of patients studied was small. Sacrocolpopexy is a successful operation for the correction of prolapse. Complications include the development of genuine stress incontinence, detrusor instability, voiding difficulty, and mesh infection.

Review: Transurethral Microwave Thermotherapy in Benign Prostatic Hyperplasia

The transurethral microwave thermotherapy (TUMT) method combines the principles of microwave radiative heating and conductive cooling to destroy tissue within the prostate while preserving the other structures of the lower urinary tract. The method is effective in benign prostatic hyperplasia (BPH), as demonstrated by laboratory and clinical studies. The ease of the 1-hour office treatment, the dramatic symptomatic improvement and reasonable uroflow rates that result, the preservation of sexual function, the apparent safety, and the durability of the result may mean that TUMT will introduce changes in the management of BPH as dramatic as those brought about in lithiasis management by ESWL.

The role of radical prostatectomy in the treatment of prostate cancer.

Recent advances in our understanding of the surgical anatomy of the prostate have led to an improved operative technique for radical prostatectomy. This technique achieves excellent results in terms of urinary continence and preservation of sexual function without compromising cancer control. It is therefore reasonable to offer radical prostatectomy for the cure of localized prostate cancer to patients who are otherwise well and have a life expectancy of more than 10 years.

Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases

We describe our experience and complications of radical retropubic prostatectomy. From March 1983 through December 1990, 620 consecutive patients have undergone an anatomical radical retropubic prostatectomy for the treatment of prostatic carcinoma. The surgical technique we used is described. In 167 patients the procedure included preservation of the neurovascular bundles. There were no modifications in the surgical technique during this period. There were no operative deaths. Mean operating time was reduced from 3hours in the first 100 patients to 1.5hours in the last 220 patients. The average blood loss was reduced remarkably as well. There were only 3 cases of rectal injury, which were closed primarily and healed completely. One patient died of acute myocardial infarction 12 days after an uneventful operation. This patient accounted for the only perioperative death in our experience. Early complications occurred in 43 patients (6.9%), including only 2 cases (0.3%) of anastomotic urinary leakage. The late complication rate, excluding incontinence and impotence, was 1.3%. No patient was totally incontinent. Among the patients who were followed for 1 year or longer 95% achieved complete urinary control and 5% experienced stress urinary incontinence. Preservation of sexual function in patients who underwent a nerve-sparing operation was achieved in 71%. Our results indicate that radical retropubic prostatectomy can be performed with low morbidity and without affecting the quality of life in the majority of patients.

Preservation of sexual function after salvage retroperitoneal node dissection following chemotherapy for testicular tumors

Salvage radical retroperitoneal node dissection for large residual masses remaining after chemotherapy for testicular cancer was performed in 41 patients. In 10 instances it was possible to carry out a radical removal and attempt to preserve the sympathetic chain on one side. Ejaculation was preserved in 8 of these cases. Where removal of the mass was complete (33 cases) active cancer was present in 6, only one of whom developed tumor recurrence. Salvage node dissection is worthwhile, and in about 25% of cases can be performed with preservation of ejaculation.

Preservation of urine voiding and sexual function after rectal cancer surgery

In order to decrease the urinary and sexual morbidity which follows radical pelvic lymphadenectomy for rectal cancer, we began selective preservation of the pelvic autonomic nerves. Between 1985 and 1987, 134 patients with rectal cancer underwent a curative resection (52 abdominoperineal resections, 82 sphincter-saving resections) with extended pelvic lymphadenectomy and selective pelvic autonomic nerve preservation (PANP). PANP was classified into five degrees depending on the extent of pelvic dissection. First-degree PANP indicates complete preservation of the nerves; second-degree PANP indicates destruction of the hypogastric plexus: third-degree PANP indicates partial preservation of the pelvic autonomic plexus; fourth-degree PANP indicates bilateral or unilateral preservation of only the fourth pelvic parasympathetic nerve; and fifth-degree PANP indicates complete destruction of the pelvic autonomic nerves. Most patients with first-degree PANP were able to spontaneously void 7-10 days following the operation. However, 78 percent (28/36) of patients with fifth-degree PANP had not regained bladder sensation by the third postoperative week and were discharged with an indwelling catheter; 58 percent (21/36) had not regained bladder sensation by the 60th postoperative day. The cystometric data indicate a progressive decline in bladder sensation and function with increasingly extensive pelvic dissection. However, preservation of only the fourth parasympathetic nerve (fourth-degree PANP) resulted in partial sparing of bladder sensation and voiding function. Evaluation of sexual function in males under 60 years of age revealed that only 31 percent (12/39) recovered erectile function and only 19 percent (6/39) recovered normal ejaculatory function in the first postoperative year. Most of these patients had complete preservation of their pelvic autonomic plexus (i.e., first-degree PANP). Four patients with partial PANP have recovered erectile function. Complete PANP is the best way to prevent urinary and sexual morbidity after rectal resection. The opposing goals of maximizing the chance for cure and minimizing morbidity must be individualized and balanced in each patient. Our data demonstrate that it is now possible to perform radical pelvic lymphadenectomy in the majority of patients with advanced rectal cancer with a minimum of voiding dysfunction. Preservation of sexual function in males is more difficult and depends on complete PANP and, as such, should be restricted to the group of patients with Dukes' A and B carcinomas.

Androgen Ablation and Blockade in the Treatment of Benign Prostatic Hyperplasia

Antiandrogen therapy appears to produce a 30 to 40 per cent decrease in the volume of the hyperplastic prostate after 3 to 6 months of therapy (Table 5). Longer treatment may result in further prostatic regression, although this remains to be seen. Biopsy studies suggest that epithelial regression occurs to a much more significant degree than does stromal regression, but this finding may simply reflect the relatively longer turnover of the stromal cell population. The significant placebo effect of oral medication in patients with BPH makes interpretation of clinical symptomatology and uro-flow data difficult. Analysis of symptom improvement is further complicated by the relatively slow improvement of patients on antiandrogen therapy, in contrast to surgery, in which relief is immediate. In addition to limited stromal involution and inadequate treatment duration, other biologic factors may limit the clinical efficacy of antiandrogen therapy. Most importantly, prostatic involution may not necessarily decrease urethral resistance. In addition, obstruction-induced detrusor dysfunction may persist after relief of outflow obstruction in some patients, as it does after surgery. Incomplete antiandrogen action of the compounds, as well as compliance issues, may likewise limit efficacy. Although there are no data to suggest that the 5 alpha-reductase inhibitor finasteride will be more effective than other antiandrogen compounds in the treatment of BPH, preliminary studies suggest that it has less toxicity. If long-term studies validate a modest but significant clinical response rate and preservation of sexual function, then finasteride therapy may well be acceptable to a subgroup of men presenting with the symptoms of BPH.(ABSTRACT TRUNCATED AT 250 WORDS)

Radical Pelvic Surgery With Preservation of Sexual Function

Recent neuroanatomical findings make it possible to identify the pelvic plexus and branches that innervate the corpora cavernosa intraoperatively. These anatomical principles have been used to modify standard radical prostatectomy and cystoprostatectomy to prevent postoperative sexual dysfunction. Radical retropubic prostatectomy has been performed on 320 men, who have been followed for 1-5 years after surgery; 74% of these men are now potent after surgery. Positive surgical margins were present in 10% of the cases; the actuarial overall local recurrence at 5 years (with or without distant metastases) is 10%. These results are consistent with past experience and data reported elsewhere in the literature. Radical cystoprostatectomy has been performed on 25 men over the past 5 years. Pathologic evaluation of all specimens demonstrated negative surgical margins, no patient has developed local recurrence, and of the patients who had cystectomy alone, 83% are now potent after surgery. With application of these principles to colorectal surgery, similar favorable impact on quality of life with improved surgical accuracy may be possible.

Radical pelvic surgery with preservation of sexual function.

Recent neuroanatomical findings make it possible to identify the pelvic plexus and branches that innervate the corpora cavernosa intraoperatively. These anatomical principles have been used to modify standard radical prostatectomy and cystoprostatectomy to prevent postoperative sexual dysfunction. Radical retropubic prostatectomy has been performed on 320 men, who have been followed for 1-5 years after surgery; 74% of these men are now potent after surgery. Positive surgical margins were present in 10% of the cases; the actuarial overall local recurrence at 5 years (with or without distant metastases) is 10%. These results are consistent with past experience and data reported elsewhere in the literature. Radical cystoprostatectomy has been performed on 25 men over the past 5 years. Pathologic evaluation of all specimens demonstrated negative surgical margins, no patient has developed local recurrence, and of the patients who had cystectomy alone, 83% are now potent after surgery. With application of these principles to colorectal surgery, similar favorable impact on quality of life with improved surgical accuracy may be possible.

Neuroanatomical Approach to Radical Cystoprostatectomy with Preservation of Sexual Function

The technique for radical cystoprostatectomy has been modified to avoid injury to the branches of the pelvic plexus that innervate the corpora cavernosa. Although the course of the neurovascular bundles in the region of the prostate and urethra has been well charted, the exact relationship of the cavernous nerves to the seminal vesicles and bladder has remained unclear. In an effort to delineate this anatomy more clearly, detailed anatomical dissections were performed on 9 male human cadavers. This study demonstrated that the pelvic plexus is located retroperitoneally on the lateral wall of the rectum 5 to 11cm. from the anal verge with its midpoint related to the tip of the seminal vesicle. The cavernous branches travel in a direct route from the pelvic plexus toward the posterolateral base of the prostate, gradually coalescing from a group of fibers approximately 12mm. wide to a more organized bundle approximately 6mm. wide at the level of the prostate. Because the bulk of the pelvic plexus and its important branches are located lateral and posterior to the seminal vesicles, the seminal vesicles can be used as a landmark intraoperatively to avoid injury to the pelvic plexus when ligating the posterior pedicle. During the last 5 years 25 men have undergone radical cystoprostatectomy. Pathological evaluation of all specimens demonstrated negative surgical margins and no patient has had locally recurrent tumor. Of the patients undergoing cystectomy alone 83 per cent are potent. Although all patients undergoing urethrectomy were able to have erections postoperatively, only 40 per cent have erections that are sufficient for intercourse. These data indicate that to date it is possible to perform radical cystoprostatectomy with preservation of sexual function in the majority of patients without compromise to the curative aspects of the radical operation.

Radical Prostatectomy, Preservation of Sexual Function, Cancer Control: The Controversy

In this article, I have addressed some of the important controversies regarding the safety and efficacy of radical prostatectomy with the preservation of sexual function: (1) How often is sexual function preserved? (2) Does preservation of sexual function interfere with cancer control? (3) Are there tricks to performing the operation? and (4) Who is a candidate? Overall, 72 per cent of patients are potent postoperatively. The probability of return of sexual function correlates with the age of the patient and the stage of the lesion. In addition, it appears that only one neurovascular bundle is necessary for the return of sexual function because 69 per cent of men who undergo wide excision of one neurovascular bundle are potent postoperatively. The question whether preservation of sexual function compromises the removal of tumor can be analyzed in several ways. On the basis of operative descriptions and the evaluation of whole-mount cross sections of prostates removed by standard radical perineal and radical retropubic techniques, it appears that the neurovascular bundles were not completely resected in the past using standard techniques. However, with knowledge of the location of these neurovascular bundles, they can now be excised more widely when necessary than was previously possible. Furthermore, evaluation of surgical margins of excision gave no indication that the nerve-sparing modification compromises the adequacy of the removal of cancer, which is determined primarily by the extent of the tumor rather than by the operative technique. However, controversy surrounding this procedure will not be settled until long-term follow-up data are available to determine whether the control of local disease and distant metastases is similar to that achieved with standard radical prostatectomies. To aid in this comparison, we have been careful not to use postoperative adjuvant hormonal or radiation therapy so that we will be able to evaluate the true impact of radical prostatectomy on the control of cancer. To preserve sexual function, a variety of fine points in surgical technique must be observed. These have been discussed in detail. It is my opinion that any patient who is a candidate for radical prostatectomy is a candidate for intra-operative assessment of the extent of tumor and the location of the neurovascular bundles. Based on this information, the surgeon can make an informed decision whether the neurovascular bundles can be safely preserved or excised widely with the specimen. In all surgical approaches to prostatic cancer, the primary goal must be excision of all tumor; preservation of sexual function should be of secondary concern.(ABSTRACT TRUNCATED AT 400 WORDS)

Radical Cystectomy With Preservation of Sexual and Urinary Function: Use of the Ileocolonic Pouch (“Le Bag”)

Current surgical technique allows radical cystectomy to be performed with preservation of both sexual and urinary function. An ileocolonic pouch (Le Bag), is created to replace the bladder, with anastomosis directly to the urethra. Continence depends on the inherent function of the residual sphincter mechanism. The ileocolonic pouch results in a highly compliant, low-pressure reservoir with a reliable antireflux ureteric implantation.

Radical Cystectomy with Preservation of Sexual and Urinary Function: Use of the Ileocolonic Pouch (“Le Bag”)

Current surgical technique allows radical cystectomy to be performed with preservation of both sexual and urinary function. An ileocolonic pouch (Le Bag), is created to replace the bladder, with anastomosis directly to the urethra. Continence depends on the inherent function of the residual sphincter mechanism. The ileocolonic pouch results in a highly compliant, low-pressure reservoir with a reliable antireflux ureteric implantation.

Radical Prostatectomy with Preservation of Sexual Function: Pathological Findings in the First 100 Cases

In an effort to preserve sexual function, a nerve-sparing technique for radical retropubic prostatectomy has been used in 100 consecutive men with clinically localized prostatic cancer. Each gland was submitted for total histological examination in a way that permitted determination of the extent of the tumor and adequacy of surgical margins. Although 41 patients had established tumor in periprostatic tissue only 7 had positive surgical margins: all 7 had extensive extraprostatic involvement by tumor, while 5 had involvement of the seminal vesicles and none had surgical margins positive only at the site of the nerve-sparing modification. Sexual function was evaluated in 60 of the patients who were potent preoperatively and who have been followed for a minimum of 1 year: 84 per cent of the patients with an intact prostatic capsule were potent compared to 43 per cent with extensive involvement of periprostatic tissue and 33 per cent with involvement of the seminal vesicles or pelvic lymph nodes. Based upon our findings there is no indication that the nervesparing modification compromises the adequacy of the removal of the cancer, which is determined primarily by the extent of the tumor rather than the operative technique. Thus, it appears possible to preserve sexual function in a majority of patients undergoing radical prostatectomy without compromising the adequacy of the cancer operation.

Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations.

The technique for radical retropubic prostatectomy has been modified to avoid injury to the branches of the pelvic plexus that innervate the corpora cavernosa. The surgical procedure is based on an understanding of the anatomical relationships between the branches of the pelvic plexus that innervate the corpora cavernosa, the capsular branches of the prostatic vessels that provide the scaffolding for these nerves, and the lateral pelvic fascia. The modifications involve two steps in the procedure: 1) the incision in the lateral pelvic fascia is placed anterior to the neurovascular bundle, which is located dorsolateral to the prostate along the pelvic sidewall; 2) the lateral pedicle is divided close to the prostate to avoid injury to the branches of the pelvic plexus that accompany the capsular vessels of the prostate. Pathologic evaluation of 16 prostatic specimens removed by this modified procedure demonstrated no compromise in the adequacy of the surgical margins. Postoperative sexual function was evaluated in 12 men who underwent the procedure 2-10 months previously. All have experienced erections and six have achieved successful vaginal penetration and orgasm. Of the six patients with sexual partners who have been followed 6 months or longer, five (83%) are fully potent. These data indicate that it is possible to cure localized prostatic cancer with surgery and maintain postoperative sexual function.