Erectile Function Recovery Rates Research Articles

Back to Baseline: Erectile Function Recovery after Radical Prostatectomy from the Patients' Perspective

IntroductionA variety of erectile function recovery (EFR) rates are reported post‐radical prostatectomy (RP), with some suggesting EFR rates over 90% [1]. Clinical experience suggests that patients view EFR as getting back to their baseline (BTB) erectile functioning (EF) without the use of medication. AimThis study explores EFR defined as BTB. MethodMen pre‐RP and 24 months post‐RP completed the Erectile Function Domain (EFD) of the International Index of Erectile Function and one question on phosphodiesterase type 5 inhibitor (PDE5i) use. Men using a PDE5i at baseline were excluded. Main Outcome MeasuresAt 24 m, “back to baseline” was defined as achieving the baseline EFD score (within 1 point or higher). Analyses included descriptive statistics, chi‐square, and logistic regression. ResultsOne hundred eighty men had an average age at RP of 59 (SD = 7) years. When including men who were using a PDE5i at 24 months, 43% (N = 78, 95% CI: 36–51%) returned BTB. When considering BTB without the use of a PDE5i, 22% (N = 39, 95% CI: 16% to 28%) returned BTB. When focusing on a subset of men with baseline EFD ≥ 24 (N = 132), 36% (N = 47, 95% CI: 28% to 44%) returned BTB at 24 months using a PDE5i and 16% (N = 21, 95% CI: 11% to 23%) without the use of a PDE5i. For this group, there was a significant difference by age (<60 years, 23% vs. ≥60 years, 4%, P < 0.001), which remained a significant predictor (OR = 6.25, 95% CI: 1.88 to 50, P < 0.001) in multivariable analysis. ConclusionsTwenty‐two percent of the entire sample and 16% of the men with functional (EFD ≥ 24) baseline erections returned to BTB EF without the use of medication. Only 4% of men who were ≥60 years old with functional erections pre‐surgery achieved BTB EF. Although gaining partial EF is also important, men pre‐RP should be educated on EFR and the chance of “back to baseline” EF.

Pathological confirmation of nerve‐sparing types performed during robot‐assisted radical prostatectomy (RARP)

What's known on the subject? and What does the study add? Incremental nerve-sparing techniques (NSTs) improve postoperative erectile function after robot-assisted radical prostatectomy (RARP). However, there are no studies to date that histologically confirm the surgeon intended NST. Thus, in the present study, we histologically confirmed that the surgeon performed the nerve preservation as his intended NSTs during RARP. Also, we found that there was more variability in fascia width outcome on the left side compared with the right. Therefore, when performing nerve preservation on the surgeon's non-dominant side, we need to pay more close attention. Objectives To confirm that the surgeon achieved true intended histological nerve sparing during robot-assisted radical prostatectomy (RARP) by studying RP specimens. To aid the novice robotic surgeon to develop the skills of RARP. Patients and Methods Between June 2008 and May 2009, 122 consecutive patients underwent RARP by a single surgeon (K.K.B.). The degree of nerve sparing (wide resection [WR], interfascial nerve sparing [ITE-NS], intrafascial nerve sparing [ITR-NS]) on both sides was recorded. The posterior sectors of RP specimens from distal, mid, and proximal parts were evaluated. Fascia width (FW) of each position in RP specimens were compared across nerve-sparing types (NSTs). FW was recorded at 15 ° intervals (3–9 o'clock position), measured as the distance between the outermost prostate gland and surgical margin. The slides were reviewed by an experienced uropathologist who was ‘blinded’ to the NST. Results In all, 93 men were included. The overall mean (sd) FW was the greatest in the order of WR, ITE-NS, and ITR-NS, at 2.42 (1.62), 1.71 (1.40) and 1.16 (1.08) mm, respectively (P < 0.001). FW was statistically significantly correlated with the surgical technique used. When the surgeon intended to perform various levels of nerve sparing, these were reflected in the FW. Interestingly, the left-side FW showed more variability than the right side. We suspect that this was a result of the surgeon's right-hand dominance. Erectile function (EF) recovery rate according to NST was 88.9%, 77.3%, 65.6%, 56.3%, and 0% in bilateral ITR-NS, ITR-NS/ITE-NS, bilateral ITE-NS, ITE-NS/WR, and bilateral WR, respectively. To further validate and confirm these preliminary findings, additional studies involving multicentre cohorts would be required. Conclusions The surgeon intended dissection and FW correlate, with ITR-NS providing the narrowest FW and the EF recovery rate was the highest in bilateral ITR-NS. There was more variability in FW outcome on the left side than the right. The novice robotic surgeon should consider this variability when performing RARP. It may have implications for technique improvement on nerve preservation for EF.

Extended Pelvic Lymph Node Dissection Does Not Affect Erectile Function Recovery in Patients Treated with Bilateral Nerve‐Sparing Radical Prostatectomy

Extended pelvic lymph node dissection (ePLND) might be associated with damages to the pelvic plexus, potentially affecting erectile function (EF) recovery after radical prostatectomy (RP). However, the impact of the extent of pelvic lymph node dissection (PLND) on EF has never been addressed. The aim of this study is to evaluate the impact of ePLND on potency recovery in patients who underwent bilateral nerve-sparing RP (BNSRP). The study included 396 patients with prostate cancer treated with BNSRP by two high-volume surgeons. Patients were retrospectively divided into two groups based on PLND status: no PLND (N=161; 40.9%) and ePLND (N=235; 59.1%) at the time of BNSRP. All patients had preoperative functional and oncological data. Univariable and multivariable Cox regression models tested the association between ePLND and EF recovery after surgery, after accounting for confounders. The International Index of Erectile Function (IIEF) was used to evaluate EF after BNSRP. Postoperative EF recovery was defined as an IIEF-EF domain score ≥ 22. At a mean follow up of 33.2 months after surgery (median 30), 183 patients (46.2%) recovered EF. Overall, postoperative EF recovery rate at 2 years was 48.4%. No significant differences were recorded when patients were stratified according to the extent of PLND (EF recovery rates at 2-year: 46.6% vs. 49.7% for patients who did not undergo PLND vs. those treated with ePLND; P=0.33). These results were confirmed at multivariable analyses, where only age at surgery and preoperative IIEF-EF (all P ≤ 0.03), but not ePLND (P=0.8), represented independent predictors of EF recovery. The extent of PLND is not associated with potency after BNSRP. Conversely, other factors such as age at surgery and preoperative EF represent the major predictors of postoperative potency recovery. Therefore, when indicated, ePLND can be safely performed without compromising EF outcomes.

1379 THE KEY ROLE OF TIME IN PREDICTING POST-RADICAL PROSTATECTOMY ERECTILE FUNCTION RECOVERY: CONDITIONAL SURVIVAL ANALYSES

1379 THE KEY ROLE OF TIME IN PREDICTING POST-RADICAL PROSTATECTOMY ERECTILE FUNCTION RECOVERY: CONDITIONAL SURVIVAL ANALYSES

Prediction of Functional Outcomes After Nerve-Sparing Radical Prostatectomy: Results of Conditional Survival Analyses

BackgroundIn prostate cancer (PCa) patients treated with radical prostatectomy (RP), the rate of urinary continence (UC) and erectile function (EF) recovery may change significantly depending on the time interval between surgery and patient assessment. This effect, known as conditional survival, has not yet been assessed. ObjectiveEvaluate the conditional rates of UC and EF recovery after nerve-sparing RP (NSRP). Design, setting, and participantsWe included 1135 PCa patients treated between January 2000 and June 2011 at a single referral center. InterventionAll patients underwent NSRP. Outcome measurements and statistical analysisThe Kaplan-Meier method assessed the time to recovery of UC (defined as an International Consultation on Incontinence Questionnaire score <6) and of EF (defined as an International Index of Erectile Function-Erectile Function score ≥22). Cumulative survival estimates were used to generate conditional recovery rates assessed at a 6-mo interval. Multivariable Cox regression analyses were performed to predict functional outcomes recovery after accounting for confounders. Results and limitationsUC recovery rates were 89.5%, 94.7%, and 97.0% at 6-, 24-, and 36-mo follow-up, respectively. Corresponding EF recovery rates were 53.6%, 65.0%, and 67.5%, respectively. In patients who were still incontinent at 1, 6, 12, 18, 24, 30, and 36 mo after surgery, UC recovery rates in the following 6-mo period significantly decreased as the time from surgery increased: 74.9%, 58.2%, 41.4%, 14.9%, 24.8%, 24.6%, and 13.3%, respectively. Similarly, in patients still impotent at the same time points, the 6-mo rate of sexual potency recovery was 36.9%, 26.8%, 17.8%, 8.2%, 3.1%, 4.0%, and 0%, respectively. Multivariable analyses confirmed these results. The study is limited by its retrospective design. ConclusionsIn incontinent and/or impotent patients, the period elapsed from surgery represents an important predictor of the recovery of subsequent functional outcomes. The highest increments in UC and EF recovery were observed during the first year after surgery; they were virtually null after 36 mo.

Erectile Function Outcome after Bilateral Nerve Sparing Radical Prostatectomy: Which Patients May Be Left Untreated?

Several studies have shown that erectile function (EF) recovery in patients undergoing bilateral nerve sparing radical prostatectomy (BNSRP) improves significantly when phosphodiesterase type 5 inhibitors (PDE5) are administered following surgery. The aim of this article was to identify patients who may recover EF after retropubic BNSRP (BNSRRP) without PDE5. We included 293 patients treated with BNSRRP at a single center. Postoperative EF recovery was defined as an EF domain score of the International Index of Erectile Function (IIEF) ≥22. No patient received any treatment for postoperative erectile dysfunction (ED). Kaplan-Meier curves assessed time to EF recovery according to patient age, preoperative EF, and Charlson comorbidity index (CCI). Univariable and multivariable Cox regression models tested the association between predictors and EF recovery. Finally, the rate of EF recovery of untreated patients after BNSRP was compared with a subset of patients with similar preoperative characteristics but receiving PDE5. The main outcome measure of this article was the IIEF-EF domain score. Overall, 105/293 (35.8%) reached an IIEF-EF ≥22 after a mean follow-up of 26.8 months. At multivariable analyses, age, preoperative IIEF-EF, and CCI achieved independent predictor status (all P≤0.04). Patients <55 years had a 72.4% EF recovery rate compared with 30% of patients >70 years (P<0.001). Similarly, preoperatively fully potent patients (IIEF-EF ≥26) had a 56.6% chance of recovering EF after surgery compared with 18% of patients with severe ED before surgery (P<0.001). The rate of EF recovery in untreated patients <55 years and with a pre-op IIEF-EF ≥22 was higher but did not differ significantly from comparable patients receiving PDE5 (P=0.11). Overall, the rate of EF postoperative recovery in patients left untreated after surgery is modest (35.8%). Although younger patients with a good preoperative EF may experience good EF recovery rates even without any treatment, use of PDE5 after surgery further improved their functional outcomes. Therefore, a therapy for ED should be offered to all patients treated with BNSRP.

Choosing the Best Candidates for Penile Rehabilitation after Bilateral Nerve‐Sparing Radical Prostatectomy

Controversy exists regarding the ideal candidates for penile rehabilitation after bilateral nerve-sparing radical prostatectomy (BNSRP). To test the effect of penile rehabilitation according to preoperative patient characteristics. We included 435 consecutive patients treated with BNSRP between 2004 and 2008. Preoperative age, International Index of Erectile Function (IIEF) and Charlson Comorbidity Index (CCI) were used to subdivide patients into three groups according to foreseen risk of erectile dysfunction (ED) after surgery: low (age ≤65, IIEF-erectile function (EF) ≥26, CCI ≤1; N = 184), intermediate (age 66-69 or IIEF-EF 11-25, CCI ≤1; N = 115), and high (age ≥70 or IIEF-EF ≤10 or CCI ≥2; N = 136). The Kaplan-Meier method was used to test the difference in EF recovery rates among patients left untreated after surgery (N = 193), those receiving on-demand phosphodiesterase type 5 inhibitors (PDE5-I; N = 147), and those treated with chronic use of PDE5-I (taken every day or every other day for 3-6 months; N = 95). The same analyses were repeated within each risk category. Erectile function (EF) was evaluated using the International Index of Erectile Function (IIEF). Recovery of EF after BNSRP was defined as an IIEF-EF domain score ≥22. No difference in terms of EF recovery was found between patients receiving on-demand vs. daily PDE5-I (P = 0.09) in the overall population. Similarly, comparable efficacy of the two treatment schedules (on-demand vs. chronic) was demonstrated in patients with low and high risk of ED (all P ≥ 0.8). Conversely, daily therapy with PDE5-I showed significantly higher efficacy for the EF recovery rate compared with the on-demand PDE5-I administration schedule in patients with intermediate risk of ED (3-year EF recovery: 74% vs. 52%, respectively; P = 0.02). The ideal candidates for penile rehabilitation after surgery are patients at intermediate risk of ED.

594 The key role of time in predicting post-radical prostatectomy erectile function recovery rate: Conditional survival analysis

594 The key role of time in predicting post-radical prostatectomy erectile function recovery rate: Conditional survival analysis

1540 BACK TO BASELINE: ERECTILE FUNCTION RECOVERY (EFR) AFTER RADICAL PROSTATECOMTY (RP) FROM THE PATIENTS' PERSPECTIVE

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation1 Apr 20111540 BACK TO BASELINE: ERECTILE FUNCTION RECOVERY (EFR) AFTER RADICAL PROSTATECOMTY (RP) FROM THE PATIENTS' PERSPECTIVE Christian Nelson, Peter Scardino, and John Mulhall Christian NelsonChristian Nelson New York, NY More articles by this author , Peter ScardinoPeter Scardino New York, NY More articles by this author , and John MulhallJohn Mulhall New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1535AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is a wide variety of EFR rates reported post-RP, with some suggesting EFR rates over 90%. Most of these reports use favorable selection criteria and “erections good enough for penetration” as the benchmark of EFR. Patients', however, view EFR as getting back to their baseline erectile functioning (EF) without medication. METHODS We assessed men pre-RP and then 24 months(m) post-RP. All men scheduled to have an RP were eligible. Men completed the Erectile Function Domain (EFD) of the IIEF and one question on PDE5 use. Demographic information and nerve sparing status (NSS) were recorded. At 24m, difference scores in EF of > −1 were considered “back to baseline.” −1 (rather than 0) was used to account for measurement error of +/−1. Descriptive statistics are reported for the entire sample, and for those with penetration hardness erections (EFD>=24) at baseline. RESULTS 250 men had an average age at RP of 59+/−8 years. For the entire sample, the average baseline and 24m EFD = 24.5+/−8 and 17+/−10. 12% (30) of men had one nerve resected, and 6% (15) had both nerves resected. The percent of men who had an EFD>=24 at baseline and 24m was 74% (186) and 36% (90). 39% (97) returned to their baseline EF. Of these men, 55% (53) were using PDE5's. 44 men who were not using PDE5's returned to their baseline EFD, representing 18% of the entire sample. Of the men who had an EFD>=24 at baseline, 32% (60) returned to baseline EF at 24m. 60% (36) of these men were using PDE5's. 24 men who were not using PDE5's returned to their baseline, representing 13% of men who had penetration hardness erections at baseline. CONCLUSIONS Only 18% of the entire sample and 13% of the men with penetration hardness erections at baseline returned to their baseline EF without the use of medication. These figures are significantly lower than most reported EFR rates, and men pre-RP should be educated on the meaning of EFR. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e618 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Nelson New York, NY More articles by this author Peter Scardino New York, NY More articles by this author John Mulhall New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1628 AT LEAST ONE PHOSPHODIESTERASE TYPE 5 INHIBITOR DOSE PER WEEK SHOULD BE TAKEN IN ORDER TO IMPROVE ERECTILE FUNCTION RECOVERY AFTER BILATERAL NERVE SPARING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized1 Apr 20111628 AT LEAST ONE PHOSPHODIESTERASE TYPE 5 INHIBITOR DOSE PER WEEK SHOULD BE TAKEN IN ORDER TO IMPROVE ERECTILE FUNCTION RECOVERY AFTER BILATERAL NERVE SPARING RADICAL PROSTATECTOMY Andrea Gallina, Alberto Briganti, Nazareno Suardi, Marco Bianchi, Manuela Tutolo, Umberto Capitanio, Antonino Saccà, Fabio Castiglione, Andrea Salonia, Lorenzo Rocchini, Valerio Di Girolamo, Giorgio Guazzoni, Patrizio Rigatti, and Francesco Montorsi Andrea GallinaAndrea Gallina Milan, Italy More articles by this author , Alberto BrigantiAlberto Briganti Milan, Italy More articles by this author , Nazareno SuardiNazareno Suardi Milan, Italy More articles by this author , Marco BianchiMarco Bianchi Milan, Italy More articles by this author , Manuela TutoloManuela Tutolo Milan, Italy More articles by this author , Umberto CapitanioUmberto Capitanio Milan, Italy More articles by this author , Antonino SaccàAntonino Saccà Milan, Italy More articles by this author , Fabio CastiglioneFabio Castiglione Milan, Italy More articles by this author , Andrea SaloniaAndrea Salonia Milan, Italy More articles by this author , Lorenzo RocchiniLorenzo Rocchini Milan, Italy More articles by this author , Valerio Di GirolamoValerio Di Girolamo Milan, Italy More articles by this author , Giorgio GuazzoniGiorgio Guazzoni Milan, Italy More articles by this author , Patrizio RigattiPatrizio Rigatti Milan, Italy More articles by this author , and Francesco MontorsiFrancesco Montorsi Milan, Italy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1737AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES No study tested the association between the number of phosphodiesterase type 5 inhibitors (PDE5-I) doses (a proxy of sexual activity) and erectile function (EF) recovery after bilateral nerve sparing radical prostatectomy (BNSRP). We hypothesized that the number of sexual attempts is a major determinant of EF recovery after BNSRP. METHODS The study included 927 consecutive patients treated with BNSRP between 2005 and 2010 at a tertiary referral center. Of these, 238 (25.7%) used PDE5-I on demand and represented the study cohort. All patients were assessed post-operatively every 3 months and were asked to complete the International Index of Erectile Function (IIEF) during each visit. Moreover, the number of PDE5-I doses taken per week during each time interval was recorded. Complete data on the number of doses were available for 187 out of 238 (78.6%) pts. Post-operative EF recovery was defined as an EF domain score of the IIEF (IIEF-EF) ≥22. Kaplan-Meier curves assessed the time to EF recovery according to the number of doses dichotomized according to the most-informative cut-off for EF recovery. The association between the number of pills and EF recovery was also assessed in univariable and multivariable Cox regression analyses after accounting for age at surgery and pre-operative EF. RESULTS Pre-op IIEF-EF assessment showed severe, moderate, mild to moderate, mild and no ED in 21.1,2.7,2.7,13.6 and 59.9% of pts, respectively. Overall, 116/187 (62%) pts reached a IIEF-EF≥22 after a mean follow-up of 22.7 months (median 19). The mean number of doses taken over the entire period of therapy was 0.9 per week. When pts were dichotomized according to the most informative cut-off (namely ≥ 1 pill per week vs <1), significantly higher EF recovery rates were found at 1 and 2 year follow-up in pts taking at least 1 dose per week (n= 43) vs those taking <1 dose per week (n=144; 88 and 95% vs 29 and 56%, respectively; p<0.001). The same results were obtained in pre-operatively fully potent (IIEF-EF≥26) patients (EF recovery at 1 and 2 year-follow-up: 90 and 93% vs 36 and 62%, respectively; p<0.001). This association was confirmed at multivariable analyses after adjusting for age and pre-operative EF (p<0.001; HR 4.0). CONCLUSIONS The number of PDE5-I doses taken on demand represents a major determinant of EF recovery in pts treated with BNSRP. At least 1 dose of PDE5-I per week should be taken to improve EF recovery after surgery regardless of pre-operative erectile status. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e653 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrea Gallina Milan, Italy More articles by this author Alberto Briganti Milan, Italy More articles by this author Nazareno Suardi Milan, Italy More articles by this author Marco Bianchi Milan, Italy More articles by this author Manuela Tutolo Milan, Italy More articles by this author Umberto Capitanio Milan, Italy More articles by this author Antonino Saccà Milan, Italy More articles by this author Fabio Castiglione Milan, Italy More articles by this author Andrea Salonia Milan, Italy More articles by this author Lorenzo Rocchini Milan, Italy More articles by this author Valerio Di Girolamo Milan, Italy More articles by this author Giorgio Guazzoni Milan, Italy More articles by this author Patrizio Rigatti Milan, Italy More articles by this author Francesco Montorsi Milan, Italy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of Obesity on Early Erectile Function Recovery after Robotic Radical Prostatectomy

Studies are limited regarding the impact of obesity on early erectile functional outcomes after robotic radical prostatectomy. Our goal was to determine this impact using patient-reported validated questionnaires. International Index of Erectile Function (IIEF-6) scores were prospectively collected with institutional review board approval, for patients who underwent robotic radical prostatectomy with bilateral nerve sparing from February 2007 to October 2009. The data were categorized into nonobese and obese groups and subsequently into 2 subgroups based on risk for postprostatectomy erectile dysfunction. Low risk is preoperative IIEF-6 ≥19 and high risk is IIEF-6 <19. The groups and subgroups were compared using chi-square analysis. Of 190 consecutive patients, 67 were excluded for preoperative severe erectile dysfunction (IIEF-6<7), or lack of IIEF-6 scores, or both. There were 69 nonobese patients of which 88% were potent preoperatively and 20% regained potency at 12 months postoperatively. Of 54 obese patients, 85% were potent preoperatively and 25% at 12 months. There was no difference in erectile function recovery rates between the groups (P=0.755). In both groups, patients with low risk of postoperative erectile dysfunction had statistically similar postoperative mean IIEF-6 scores at 6 and 12 months (P=0.580 and P=0.389, respectively), and no difference in erectile function recovery rates existed at 12 months (P=0.735). Obesity has no major contribution to the rate of early erectile function recovery after robotic radical prostatectomy. Preoperative erectile function remains the determining factor in postradical prostatectomy erectile dysfunction.

Comparison of Penile Size and Erectile Function after High-intensity Focused Ultrasound and Targeted Cryoablation for Localized Prostate Cancer: A Prospective Pilot Study

Erectile dysfunction (ED) represents a common quality-of-life issue of any treatment used for prostate cancer, including high-intensity focused ultrasound (HIFU) and targeted cryoablation of the prostate (TCAP). There is a paucity of comparative studies regarding the difference in the erectile function and penile size of patients undergoing HIFU or TCAP. The aim of this study is to compare the erectile function and penile size of patients undergoing HIFU or TCAP. Patients with a preoperative erectile function domain of the International Index of Erectile Function (IIEF-EF) score ≥ 26 were prospectively included. All patients were preoperatively evaluated by IIEF-EF and penile color Doppler ultrasound. Penile length and circumference were measured in flaccidity and at maximum erection. At 6, 12, 18, 24, 36 months after surgery, patients were assessed with the same protocol. IIEF-EF score, penile color Doppler ultrasound, penile length, and circumference at different time points. There were 55 patients in the HIFU group and 47 in the TCAP group. At each time point, there were significant differences in mean IIEF-EF scores and penile color Doppler results between the two groups. At 36 months, TCAP patients experienced lower erectile function recovery rate compared with HIFU patients (TCAP=46.8%; HIFU=65.5%; P=0.021). No significant decreases in penile length and circumference were found in the two groups (all P values ≥ 0.05). Our data demonstrate TCAP caused significantly decreased erectile function than HIFU. We found no change in penile size after HIFU or TCAP. The option of HIFU may be more attractive to the patient who wants to avoid ED afterward, to maintain their quality of life.

Predicting Erectile Function Recovery after Bilateral Nerve Sparing Radical Prostatectomy: A Proposal of a Novel Preoperative Risk Stratification

No multivariable model is currently available for the prediction of erectile function (EF) recovery after bilateral nerve sparing radical prostatectomy (BNSRP). The aim of this study was to develop a novel preoperative risk stratification aimed at assessing the probability of EF recovery after BNSRP. The International Index of Erectile Function (IIEF) was used to evaluate EF after BNSRP. This study included 435 patients treated with retropubic BNSRP between 2004 and 2008 at a single Institution. Preoperative data, including age, IIEF, Charlson comorbidity index (CCI), and body mass index (BMI) were available for all patients. Moreover, all patients were assessed postoperatively every 3 months and were asked to complete the IIEF during each visit. Cox regression models tested the association between preoperative predictors (age at surgery, preoperative IIEF-EF domain score, CCI, BMI) and EF recovery. Independent predictors of EF recovery were then used to stratify patients into three groups according to the risk of erectile dysfunction (ED) after surgery: low (age <or= 65 years, IIEF-EF >or= 26, CCI <or= 1; n = 184), intermediate (age 66-69 years or IIEF-EF 11-25,CCI <or= 1; n = 115), and high (age >or= 70 years or IIEF-EF <or= 10 or CCI >or= 2; n = 136). Kaplan-Meier curves assessed the time to EF recovery (defined as IIEF-EF score >or= 22). Predictive accuracy of our proposed classification was quantified using the AUC method. Of 435 patients, 242 (55.6%) received phosphodiesterase type 5 inhibitors (PDE5-I) either on demand or every day for a period of 3-6 months. Overall, EF recovery rate was 58% at 3-year follow-up. Patients treated with PDE5-I had significantly higher 3-year EF recovery rate as compared with patients left untreated after surgery (73 vs. 37%; P < 0.001). Except for BMI (P = 0.7), all preoperative covariates showed a significant association with EF recovery (all P <or= 0.04). The 3-year EF recovery rate significantly differed between the three groups, being 85, 59, and 37% in patients with low, intermediate, and high risk of postoperative ED, respectively (P < 0.001). Multivariable Cox regression analysis confirmed a highly significant association between the risk classification and EF recovery (P < 0.001). The proposed patient stratification tool showed a 69.1% accuracy. Similar results were achieved when patients were stratified according to the use of ED treatment after surgery (all P < 0.001). We report the first preoperative risk stratification tool aimed at assessing the probability of EF recovery after BNSRP. It is based on routinely available baseline data such as patient age, preoperative erectile function, and comorbidity profile.

1491 IF A PRO-ERECTILE PHARMACOLOGICAL APPROACH IS CONSIDERED AFTER BILATERAL NERVE SPARING RADICAL PROSTATECTOMY, THIS SHOULD BE INITIATED SOON AFTER SURGERY

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Medical and Non-Surgical Therapy II1 Apr 20101491 IF A PRO-ERECTILE PHARMACOLOGICAL APPROACH IS CONSIDERED AFTER BILATERAL NERVE SPARING RADICAL PROSTATECTOMY, THIS SHOULD BE INITIATED SOON AFTER SURGERY Andrea Gallina, Alberto Briganti, Andrea Salonia, Luigi Barbieri, Manuela Tutolo, Fabio Castiglione, Lorenzo Rocchini, Giulio Gadda, Antonino Saccà, Patrizio Rigatti, and Francesco Montorsi Andrea GallinaAndrea Gallina More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Luigi BarbieriLuigi Barbieri More articles by this author , Manuela TutoloManuela Tutolo More articles by this author , Fabio CastiglioneFabio Castiglione More articles by this author , Lorenzo RocchiniLorenzo Rocchini More articles by this author , Giulio GaddaGiulio Gadda More articles by this author , Antonino SaccàAntonino Saccà More articles by this author , Patrizio RigattiPatrizio Rigatti More articles by this author , and Francesco MontorsiFrancesco Montorsi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1228AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Controversy exists with regards to the optimal timing of pro-erectile treatments administration after bilateral nerve sparing radical prostatectomy (BNSRP). While animal evidences support the association between early prophylaxis and erectile function (EF) recovery, the correlation between timing of drug administration and EF recovery has been poorly assessed in humans. We hypothesized that the earlier a pro-erectile treatment is given, the higher rates of EF recovery can be expected after BNSRP METHODS The study included 154 patients treated with BNSRP between 2005 and 2009 at a single tertiary referral center. Complete pre-op data, including age and International Index of Erectile Function (IIEF) were available for all patients. Patients were assessed post-op every 3 months and were asked to complete the IIEF during each visit. Post-op EF recovery was defined as an IIEF-EF ≥22. All patients received therapy for ED either as on-demand (n=96; 62.43%) or as rehabilitation treatment (n=58; 37.7%). Patients were sub-divided into 2 groups according to time to treatment initiation (namely ≤60 days, or >60 days, after BNSRP). Kaplan-Meier curves assessed the time to EF recovery in both the overall patient population and in each group. The association between time to treatment initiation and EF recovery was tested in multivariable Cox regression analyses after accounting for age and pre-op EF RESULTS Mean age was 59.8 yrs (median 59.8; range 46-72 yrs). Pre-op IIEF-EF domain score assessment showed severe, moderate, mild to moderate, mild and no ED in 14.5, 4.8, 4.8, 18.5 and 57.3% of patients, respectively. Overall, 105/154 (68.2%) reached a IIEF-EF ≥22 after a mean follow-up of 24.2 months (median 19; range: 2-51). The 1 and 2yrs EF recovery rates were significantly higher for patients initiating EF treatment '60 days as compared to those treated after 60 days from BNSRP (81 and 81% vs 50 and 71%, respectively; p=0.01). At multivariable Cox regression analyses time to treatment initiation was significantly inversely associated with EF recovery (p=0.002) even after accounting for patient age and pre-op EF. Patients treated within 60 days from BNSRP had a 2.8 fold higher chance of EF recovery as compared with patients treated >60 days from BNSRP (p=0.002) CONCLUSIONS We demonstrated that patients treated within 2 months after BNSRP have better EF outcome as compared those treated later, regardless of the type of treatment administered. Therefore, if a post-op treatment is planned this should be initiated soon after surgery Milan, Italy© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e575 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrea Gallina More articles by this author Alberto Briganti More articles by this author Andrea Salonia More articles by this author Luigi Barbieri More articles by this author Manuela Tutolo More articles by this author Fabio Castiglione More articles by this author Lorenzo Rocchini More articles by this author Giulio Gadda More articles by this author Antonino Saccà More articles by this author Patrizio Rigatti More articles by this author Francesco Montorsi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Erectile Function Recovery Rate after Radical Prostatectomy: A Meta-Analysis

IntroductionErectile function recovery (EFR) rates after radical prostatectomy (RP) vary greatly based on a number of factors, such as erectile dysfunction (ED) definition, data acquisition means, time-point postsurgery, and population studied. AimTo conduct a meta-analysis of carefully selected reports from the available literature to define the EFR rate post-RP. Main Outcome MeasuresEFR rate after RP. MethodsAn EMBASE and MEDLINE search was conducted for the time range 1985–2007. Articles were assessed blindly by strict inclusion criteria: report of EFR data post-RP, study population ≥50 patients, ≥1 year follow-up, nerve-sparing status declared, no presurgery ED, and no other prostate cancer therapy. Meta-analysis was conducted to determine the EFR rate and relative risks (RR) for dichotomous subgroups. ResultsA total of 212 relevant studies were identified; only 22 (10%) met the inclusion criteria and were analyzed (9,965 RPs, EFR data: 4,983 subjects). Mean study population size: 226.5, standard deviation = 384.1 (range: 17–1,834). Overall EFR rate was 58%. Single center series publications (k = 19) reported a higher EFR rate compared with multicenter series publications (k = 3): 60% vs. 33%, RR = 1.82, P = 0.001. Studies reporting ≥18-month follow-up (k = 10) reported higher EFR rate vs. studies with <18-month follow-up (k = 12), 60% vs. 56%, RR = 1.07, P = 0.02. Open RP (k = 16) and laparoscopic RP (k = 4) had similar EFR (57% vs. 58%), while robot-assisted RP resulted in a higher EFR rate (k = 2), 73% compared with these other approaches, P = 0.001. Patients <60 years old had a higher EFR rate vs. patients ≥60 years, 77% vs. 61%, RR = 1.26, P = 0.001. ConclusionsThese data indicate that most of the published literature does not meet strict criteria for reporting post-RP EFR. Single and multiple surgeon series have comparable EFR rates, but single center studies have a higher EFR. Younger men have higher EFR and no significant difference in EFR between ORP and LRP is evident. Tal R, Alphs HH, Krebs P, Nelson CJ, and Mulhall JP. Erectile function recovery rate after radical prostatectomy: A meta-analysis. J Sex Med 2009;6:2538–2546.

Dysfonction érectile après prostatectomie totale : physiopathologie, évaluation et traitement

Radical prostatectomy (RP) is the gold standard treatment for localized prostate cancer; yet erectile dysfunction (ED) in selected series is still reported as high as 80% after this surgery. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of postoperative ED. Pharmacological treatment of postoperative ED, using either oral or local approaches, is effective and safe. Thus, most men need adjuvant treatments to be sexually active following RP. These include intracorporeal injections of vasoactive drugs, vacuum constriction devices and transurethral dilators, all of which have reported response rates of 50 to 70%. Unfortunately, long-term compliance is sub-optimal, with a discontinuation rate of nearly 50% at 1year. These non-oral options should be offered on an individual basis to patients who have failed oral therapy (IPDE5) since efficacy and compliance vary. Also, these options should be considered in the early postoperative period to enhance sexual activity and penile oxygenation, which may prevent corporeal fibrosis. Early penile rehabilitation with intracavernosal injections is the gold standard for partients over 60years old and those who underwent non-sparing surgery. In younger patients and/or when preservation of nerve tissue was feasible, oral IPDE5 may be effective in promoting an earlier return of erectile function. Recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in cases of properly selected young patients treated with a bilateral nerve-sparing approach by experienced urologists.

79 PREDICTING ERECTILE FUNCTION RECOVERY AFTER BILATERAL NERVE SPARING RADICAL PROSTATECTOMY: A PROPOSAL OF A NOVEL RISK STRATIFICATION

Introduction. No multivariable model is currently available for the prediction of erectile function (EF) recovery after bilateral nerve sparing radical prostatectomy (BNSRP). Aim. The aim of this study was to develop a novel preoperative risk stratification aimed at assessing the probability of EF recovery after BNSRP. Main Outcome Measure. The International Index of Erectile Function (IIEF) was used to evaluate EF after BNSRP. Methods. This study included 435 patients treated with retropubic BNSRP between 2004 and 2008 at a single Institution. Preoperative data, including age, IIEF, Charlson comorbidity index (CCI), and body mass index (BMI) were available for all patients. Moreover, all patients were assessed postoperatively every 3 months and were asked to complete the IIEF during each visit. Cox regression models tested the association between preoperative predictors (age at surgery, preoperative IIEF-EF domain score, CCI, BMI) and EF recovery. Independent predictors of EF recovery were then used to stratify patients into three groups according to the risk of erectile dysfunction (ED) after surgery: low (age 65 years, IIEF-EF 26, CCI 1; n = 184), intermediate (age 66–69 years or IIEF-EF 11-25,CCI 1; n = 115), and high (age 70 years or IIEF-EF 10 or CCI 2; n = 136). Kaplan-Meier curves assessed the time to EF recovery (defined as IIEF-EF score 22). Predictive accuracy of our proposed classification was quantified using the AUC method. Results. Of 435 patients, 242 (55.6%) received phosphodiesterase type 5 inhibitors (PDE5-I) either on demand or every day for a period of 3–6 months. Overall, EF recovery rate was 58% at 3-year follow-up. Patients treated with PDE5-I had significantly higher 3-year EF recovery rate as compared with patients left untreated after surgery (73 vs. 37%; P < 0.001). Except for BMI (P = 0.7), all preoperative covariates showed a significant association with EF recovery (all P 0.04). The 3-year EF recovery rate significantly differed between the three groups, being 85, 59, and 37% in patients with low, intermediate, and high risk of postoperative ED, respectively (P < 0.001). Multivariable Cox regression analysis confirmed a highly significant association between the risk classification and EF recovery (P < 0.001). The proposed patient stratification tool showed a 69.1% accuracy. Similar results were achieved when patients were stratified according to the use of ED treatment after surgery (all P < 0.001). Conclusions. We report the first preoperative risk stratification tool aimed at assessing the probability of EF recovery after BNSRP. It is based on routinely available baseline data such as patient age, preoperative erectile function, and comorbidity profile. Briganti A, Gallina A, Suardi N, Capitanio U, Tutolo M, Bianchi M, Passoni N, Salonia A, Colombo R, Di Girolamo V, Guazzoni G, Rigatti P, and Montorsi F. Predicting erectile function recovery after bilateral nerve sparing radical prostatectomy: A proposal of a novel preoperative risk stratification. J Sex Med 2010;7:2521–2531.

Management of erectile dysfunction after radical prostatectomy in 2007

As radical prostatectomy (RP) remains a commonly used procedure in the treatment of clinically localized prostate cancer, we critically analyzed the evidence suggesting the role of pharmacological prophylaxis and treatment of erectile dysfunction (ED) after surgery. Systematic literature review using Medline and Cancerlit from January 1997 to December 2006. Abstracts published in the journals European Urology, The Journal of Urology, The International Journal of Impotence Research and The Journal of Sexual Medicine as official proceedings of internationally known scientific Societies held in the same time period were also assessed. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of post-operative erectile function. Pharmacological treatment of post-operative ED, using either oral or local approaches, is effective and safe. Moreover, recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in case of properly selected young patients treated with a bilateral nerve-sparing approach by experienced surgeons. In this context, pharmacological prophylaxis may potentially have a significant expanding role in future strategies aimed at preserving post-operative erectile function.

Bilateral Cavernous Nerve Interposition Grafting During Radical Retropubic Prostatectomy: Memorial Sloan-Kettering Cancer Center Experience

Cavernous nerve graft is an option for men requiring bilateral cavernous nerve resection for cancer control during radical prostatectomy. We determined the success rate and identified determinants of success of bilateral cavernous nerve grafting following resection of the 2 nerves during radical prostatectomy in patients who were potent preoperatively. We retrospectively reviewed the records of 44 consecutive patients who underwent bilateral nerve grafting from 1999 to 2004. Postoperative erectile function was defined as the achievement of erections satisfactory for intercourse with or without oral medication. We calculated cumulative erectile function recovery rates using Kaplan-Meier curves. The log rank test was used to compare variables affecting erectile function recovery with p <0.0083 considered significant after adjusting for the number of variables evaluated using the Bonferroni correction. The overall 5-year cumulative recovery of erectile function permitting penetration was 34% and the rate of consistent penetration was 11%. None of the analyzed variables were significantly associated with recovery of postoperative erectile function, including patient age (p = 0.3), incomplete bilateral cavernous nerve resection (p = 0.045), sural nerve grafts compared to genitofemoral or ilioinguinal nerves as donor sites (p = 0.067), post-radiation salvage radical prostatectomy (p = 0.15), neoadjuvant hormone therapy (p = 0.7) and comorbidities (p = 0.15) or medications (p = 0.4) affecting EF. Bilateral cavernous nerve grafts might be beneficial in select patients. A definitive answer awaits the performance of a multi-institutional, randomized, controlled trial.