Recovery Of Erections Research Articles

Predictors of corporo-venocclusive dysfunction in men with bilateral nerve-sparing radical prostatectomy.

Erectile dysfunction (ED) is seen in some men who have undergone bilateral nerve-sparing surgery. Corporo-venocclusive dysfunction (CVOD) is the major pathway to permanent ED after radical prostatectomy (RP). To identify comorbidity factors that are associated with the presence of CVOD in men who had undergone bilateral nerve-sparing RP. We included patients who had no ED before RP, underwent bilateral nerve-sparing RP, were unresponsive to pharmacotherapy, and had a penile Duplex Doppler Ultrasound (PDDU) with a diagnosis of CVOD. PDDU was performed with a redosing vasoactive agent protocol. A logistic regression model was created to define predictors of CVOD, defined as end-diastolic velocity (EDV) ≥5cm/s bilaterally. CVOD diagnosis. 135 patients with a median age of 60 (IQR 54, 64) years were included. 45% reported ≥2 comorbidities, 10% diabetes, 28% obstructive sleep apnea (OSA), and 44% were current or former smokers. At PDDU, 34% had less than penetration hardness erections, and 43% received 100units of vasoactive agent. 44% were diagnosed with CVOD. Increased age at RP (OR 2.12 per 10years, 95% CI 2.35, 3.73, P= .007) and OSA (OR 2.44, 95% CI 1.07, 5.73, P= .036) were associated with a diagnosis of CVOD. Comorbidities, especially OSA, have a role in erection recovery after surgery. The study used a well-established institutional RP nerve-sparing score, a strict PDDU vasoactive agent redosing protocol, validated cut-offs for CVOD diagnosis, and a validated erectile function questionnaire both pre- and post-operatively. The major limitation is that this is a cohort of men seeking treatment at a sexual medicine clinic for post-operative ED, which limits the generalizability of the results to patients without ED symptoms or who decided not to seek treatment. The dichotomous definition of comorbidities is also a limitation since patients can have differing degrees of comorbidities' severity. Older patients and the presence of OSA were associated with the presence of CVOD.

Efficiency of Early Penile Rehabilitation on Erectile Function Recovery after Open Radical Prostatectomy

Prostate cancer (PC) is one of the most commonly diagnosed malignancies worldwide and the second leading cause of mortality among men (1). Nowadays, radical prostatectomy is considered the primary therapeutic modality for treating patients with localized PC (stage pT2), providing a five-year survival rate of nearly 100% (2). Sexual dysfunction in men associated with PC treatment encompasses three distinct entities: erectile dysfunction (ED) and penile shortening; ejaculatory and orgasmic dysfunction; and psychosexual dysfunction, which pertains to sexual desire, intimacy, and mental health (3). Penile rehabilitation (PR) is defined as the use of any intervention or combination of procedures aimed not only at achieving an erection sufficient for satisfactory sexual intercourse but also at restoring erectile function to its preoperative level (4). Despite eff orts to preserve the neurovascular bundle during radical prostatectomy, ED remains a common outcome. Although prevalence rates of ED after the procedure vary widely, recent studies report rates as high as 85% (5). This is primarily due to the lack of control over factors that significantly influence the erection recovery, such as the patient’s age, preoperative erectile function, comorbidities, surgical approach (open, laparoscopic, or robot-assisted), surgical technique (non-, uni-, or bilateral nerve-sparing), and the surgeon’s skills and experience. The pathophysiology of postoperative ED is multifactorial. The primary mechanisms are believed to be damage to the cavernous nerves, whether through dis-section or neuropraxia, and vascular injury, which includes damage to the accessory pudendal arteries, hypoxia and fibrosis of the endothelium and smooth muscle, resulting in penile shortening (6-8). Although there is no consensus on the optimal approach to PR, accepted modalities include the use of phosphodiesterase type 5 inhibitors (PDE-5i; such as sildenafil, vardenafil, tadalafil) and vacuum erection de-vices (VED) or vacuum constriction devices (VCD) as first-line therapies. Second-line treatments involve prostaglandin E1 preparations for intracavernous, or intraurethral (MUSE – “Medicated Urethral System for Erection”) administration. The final therapeutic option is the implantation of penile prostheses (3-10).

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

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

(160) Prospective Evaluation of Proximal Decompression for the Management of Refractory Ischemic Priapism

Abstract Introduction A prolonged undesired erection of the penis that is often unrelated to sexual arousal is referred to as priapism. Over 95% of people who experience priapism are ischemic, which causes blood to become stuck in the corpora, increase hypoxia, hypercarbia, and acidosis that resemble compartment syndrome, and hinders penile venous outflow. IP is a urological emergency due to the risk of cavernosal fibrosis and consequent permanent ED. Injections of α-agonist and corporal irrigation/aspiration are the main forms of treatment for short-duration priapism, with distal shunting as a last resort. Patients with refractory and/or prolonged ischemic priapism (PIP) find their strategy more challenging. There is a low probability that irrigation/aspiration procedures, α-agonist injections, and distal shunting will work for people who have priapism that lasts longer than 24 hours. Objective This study was conducted on 21 male patients with refractory and\or prolonged IP to evaluate the outcomes of proximal decompression in the management of those patients. The primary end point was to assess priapism resolution in the patients. While the secondary end point was to assess erection recovery in those patients and their ability to perform sexual intercourse. Methods Patients’ information had been collected from the hospital data and connection with them had been through phone calls and hospital follow-up visits. Results Among the current study patients, the most detected etiology was tramadol intake (23.8%), followed by THC addiction and idiopathic ischemic priapism, while the least common were papaverine injection and hematological disorder (4.8%). 23.8% of the patients had twice aspirations, while 33.3% had a once. 14.3% of the patients had T shunt. 33.3% had bilateral PSD, and the other 66.7% had unilateral PSD. In the present study the decompression was successful in all the patients, where all the patients showed resolution of priapism, however 57.1% were able to perform sexual intercourse. The mean duration to achieve complete detumescence after surgery in this study was 24.2 ± 8.4 days. 33.3% had no complications, 52.4% had edema, while 14.3% had wound infection. The mean baseline IIEF score of the present study patients was 22.6 ± 2.2 (most of the patients (75%) hadn’t erectile dysfunction, 9.5% had mild erectile dysfunction and 4.8% had mild to ED), which was decreased after 3 months of the surgery (7.7 ± 2.8). Three months post-operatively severe ED was detected in 52.4% of the patients, 33.3% had moderate ED and 14.3% had mild to moderate ED. Six months after surgery the erectile dysfunction improved, where the mean IIEF score was 12.2 ± 5.0. Mild ED was detected in 23.8 %, Mild to moderate ED in 33.3 %, Moderate ED in 19 % and Severe ED in 23.8 %. The difference between the IIEF scores at base line, 3 months postoperatively and 6 months postoperatively was statistically significant. Conclusions Penoscrotal decompression (PSD) is a simple, safe, highly effective, and easily reproducible procedure for resolution of RIP with glans preservation in addition to more satisfactory erectile function outcomes to a certain extent Disclosure Yes, this is sponsored by industry/sponsor: alexandria main university hospital Clarification: Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: alexandria main university hospital.

Ultrasound-targeted microbubble destruction mediates PDE5i/NO integration for cavernosum remodeling and penile rehabilitation.

Erectile dysfunction (ED) caused by cavernous nerve injury (CNI) is refractory to heal mainly ascribed to the adverse remodeling of the penis induced by ineffectual microvascular perfusion, fibrosis, and neurotrophins scarcity in cavernosum. Phosphodiesterase type V inhibitors (PDE5i) have been regarded as an alternative candidate drug for avoiding penile neuropathy. However, the therapeutic efficacy is severely limited due to poor accumulation under systemic medication and endogenous nitric oxide (NO) deficiency in cavernosum. Herein, an innovative liposomal microbubble (MB) loaded with both Sildenafil (one of PDE5i) and NO was designed. Ultrasound-targeted MB destruction (UTMD)-mediated efficient release and integration erectogenic agents into corpus cavernosum with high biosafety. On a bilateral CNI rat model, the multifunctional MB-cooperated UTMD improved microvascular perfusion in penis, simultaneously, alleviated hypoxia and oxidative stress, indicating successful activation of NO-cyclic guanosine monophosphate pathway. Also, evaluation of the endothelial/muscular composition, intracavernosal pressure, and neural integrity in the penis proved that coordinated intervention reversed the abnormal structural remodeling and promoted the recovery of functional erection. Our work demonstrates that MB loading Sildenafil and NO combined with UTMD hold great promise to "awaken" the efficacy of PDE5i in neurogenic ED, which provided a superior option for ensuring penile rehabilitation.

(547) Erectile Dysfunction Following Radical Prostatectomy: An Overview, Critique, and Guidance on Future Directions

Abstract Introduction Despite modern surgical advancements and nerve-sparing techniques, men continue to endure delayed and incomplete erection recovery after radical prostatectomy (RP). Erectile rehabilitation has been described as an approach to promote erection recovery, but thus far studies on the most beneficial approach have been indeterminate. Objective This study serves to test the hypothesis that clinical trials that are meeting appropriate rigor in advancing the management of erectile dysfunction following radical prostatectomy. Methods We searched the clinicaltrials.gov website using the keywords “Erectile Dysfunction Radical Prostatectomy”. We included all resulting clinical trials with a time span ranging from 2005-2022. The specific parameters were interrogated to include disease state definitions, demographics, study design, assessment methodology, outcome measures, and data analysis. Results 46 trials were identified. 34 were Randomized Control Clinical Trials, 7 were Single Group Clinical Trials, and 5 were Observational Trials. 18 of the trials are complete, 7 ended before completion, and 21 are in progress. The trials included interventions ranging from mechanical devices (n=11), medical therapies (n=9), regenerative therapies (n=3), biological therapies (n=4), surgical interventions (n=12), and psychosocial interventions (n=2); validation of diagnostic questionnaires (n=3); and safety studies (n=2). Amongst the 18 completed studies, rigorous methods and randomization was applied. Observations included: short-term (6-12 month) erectile function measured by IIEF scores, lack of long-term follow up after treatment, and relative lack of trials focusing on erection recovery (n=2). Confounding variables were either exclusion criteria or matched appropriately. Study groups were primarily men aged 40-70 with localized prostate cancer who had normal sexual potency measured by IIEF scores prior to RP. Definitions such as erection recovery and erectile rehabilitation used in study introductions and titles are not always consistent with the primary outcomes measured. The vast majority of patients had well-defined pre-operative functional statuses. The surgical approaches are stated and well-defined. Compared to placebo at postoperative follow-up: Biologic therapies have been shown to improve IIEF scores up to 18 months but not to statistical significance; Shockwave therapy has not been shown to improve IIEF scores at 6 months; medical therapy with PDE-5i has shown to improve IIEF scores at 3, 6, and 12 months; regenerative therapy has shown improvements in IIEF scores at 6 months but not to statistical significance; medical devices have been shown to improve IIEF scores up to 12 months; psychosocial treatments have not demonstrated improvements in IIEF scores up to 12 months; intraoperative techniques have not been demonstrated to show a difference in IIEF scores up to 12 months. Conclusions This study shows that clinical trials have a potential to advance erectile function outcomes in men after RP. Trials that are randomized, controlled, representative of diverse populations, and characterized by well-defined terms, outcomes, and baseline functional status will be most useful in assessing the benefit of a treatment. Surgical interventions, medical therapies, and mechanical devices have been the primary interventions of focus, but other treatment options continue to show promising results. Nonetheless, more studies are needed with a long-term follow up to inform erection recovery and erectile rehabilitation protocols. Disclosure No

(404) Early Experience of Penoscrotal Decompression for Refractory Ischemic Priapism and Its Impact on Sexual Function

Abstract Introduction Outcomes after distal shunting have low rates of success in cases of refractory ischemic priapism lasting more than 48 hours. Objective Our objectives are to report our institutional experience using penoscrotal decompression for the surgical treatment of prolonged and refractory ischaemic priapism. The primary end point is to assess priapism resolution in the patients. While the secondary end point is to assess erection recovery in those patients. Methods We prospectively evaluated refractory and prolonged ischemic priapism patients treated with proximal decompression from 2020-2022 at Alexandria Main University Hospital. Priapisms were confirmed as ischaemic based on clinical presentations, cavernosal blood gas abnormalities, and doppler ultrasound. Treatment with irrigation and injection of α-agonists in all patients had failed prior to PSD. Patient characteristics, peri-operative variables and outcomes, and changes in International Index of Erectile Function (IIEF) scores were evaluated. Results Thirteen patients with priapism who had treated with penoscrotal decompression from 2020 to 2022. Their age was 28-53 years. The duration of ischemic priapism was 48 hours to 10 days. Nine patients had previously undergone shunt surgery. All patients were successfully treated with Penscrotal deecompression without additional intervention and noted immediate relief of pain postoperatively. Of the 10 patients with documented sexual function status at last follow-up, six reported spontaneous erectile function adequate for penetration, while four reported erectile dysfunction. Conclusions Penoscrotal decompression proved to be an effective and safe way of managing refractory ischemic priapism. The technique showed to produce favorable results while maintaining adequate sexual function. Disclosure Yes, this is sponsored by industry/sponsor: alexandria main university hospital. Clarification Industry initiated, executed and funded study Any of the authors act as a consultant, employee or shareholder of an industry for: alexandria main university hospital.

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 ...

V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION

You have accessJournal of UrologyCME1 May 2022V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION Marcio Covas Moschovas, Travis Rogers, Jonathan Noel, Jaber Abdel, Seetharam Bhat, and Vipul Patel Marcio Covas MoschovasMarcio Covas Moschovas More articles by this author , Travis RogersTravis Rogers More articles by this author , Jonathan NoelJonathan Noel More articles by this author , Jaber AbdelJaber Abdel More articles by this author , Seetharam BhatSeetharam Bhat More articles by this author , and Vipul PatelVipul Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors. However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients. In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection. In this video compilation, we have illustrated the details of different grades of NVB preservation. METHODS: Our video describes the details of different degrees of nerve-sparing using anatomical landmarks. We have illustrated the key aspects of a full nerve sparing, partial nerve sparing and intrafascial dissection preserving the lateral prostatic fascia. RESULTS: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o’clock positions on the right and left sides, respectively. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. CONCLUSIONS: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection). Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marcio Covas Moschovas More articles by this author Travis Rogers More articles by this author Jonathan Noel More articles by this author Jaber Abdel More articles by this author Seetharam Bhat More articles by this author Vipul Patel More articles by this author Expand All Advertisement PDF downloadLoading ...

MP62-15 MAY OUTCOMES OF RALP PERFORMED AFTER AN INITIAL AS STRATEGY DIFFER FROM THOSE FROM IMMEDIATE SURGERY? A PROPENSITY SCORES MATCHED ANALYSIS ON 388 PATIENTS

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance II (MP62)1 Sep 2021MP62-15 MAY OUTCOMES OF RALP PERFORMED AFTER AN INITIAL AS STRATEGY DIFFER FROM THOSE FROM IMMEDIATE SURGERY? A PROPENSITY SCORES MATCHED ANALYSIS ON 388 PATIENTS Bernardo Rocco, Maria Chiara Sighinolfi, Marcio Covas Moschovas, Sandri Marco, Alessandra Cassani, Luca Sarchi, Simone Assumma, Salvatore Micali, and Vipul Patel Bernardo RoccoBernardo Rocco More articles by this author , Maria Chiara SighinolfiMaria Chiara Sighinolfi More articles by this author , Marcio Covas MoschovasMarcio Covas Moschovas More articles by this author , Sandri MarcoSandri Marco More articles by this author , Alessandra CassaniAlessandra Cassani More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Simone AssummaSimone Assumma More articles by this author , Salvatore MicaliSalvatore Micali More articles by this author , and Vipul PatelVipul Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002102.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Active surveillance (AS) is recommended as an initial treatment strategy for low-risk PCa patients to reduce overtreatment and to avoid possible side effects. Indications to AS are currently extending also to intermediate-risk PCa with low rate of pattern 4 (<10%). In case of disease progression, an active treatment is necessary, and robotic radical prostatectomy (RALP) could be an option. Our study compares peri-operative, oncological, and functional outcomes between patients who underwent RALP after AS strategy and patients who opted for immediate surgical treatment in a referral center. METHODS: Data from patients undergoing RALP following AS were prospectively collected in a single center and compared to patients who underwent an immediate RALP after propensity score (PS) matching. The PS analysis was performed using the covariates age, BMI, CCI, pre-op Sexual Health Inventory for Men (SHIM) score, prostate size, PSA, cT, date of surgery, length of follow up. ISUP score at the time of AS indication was matched with ISUP at RALP for the control group. Peri-operative performance, functional and oncological outcomes were compared between groups at early and intermediate follow up. RESULTS: 388 patients were included (194 RALP after AS and 194 immediate RALP). Median time of AS was 35.4 months (IQR 22-60). Median follow up was 24 and 20 months for AS and controls, respectively (p=0.1). Median console time was significantly higher in the AS group than in the control group (80 vs 75 min; p=0.03), there was no significant difference in EBL and complication rate. At final pathology, the AS group had a lower rate of ISUP 1 but a significantly higher rate of ISUP ≥ 4 (p=0.002). Lymphovascular invasion and EPE was higher in AS group (26% vs 9%, p=0.004; 38% vs 28%, p=0.05, respectively), there was no significant difference in PSM rate. The initial AS strategy improved the risk of biochemical recurrence (HR 4.2; 95%CI 1.2-14.8; p=0.02) whereas potency and continence rate did not differ significantly between groups at each interval point. In the subgroup of patients with a pre-op SHIM < 17, AS was associated with a decreased risk of potency (HR 0.4, 95% CI 0.19-0.88, p=0.02) and a higher time for recovery of erection (190 days in AS vs 92 days in immediate RALP, p=0.06). CONCLUSIONS: RALP performed after an initial AS strategy is likely to impair early and intermediate oncological outcomes maybe due to higher chances of EPE and lymphovascular invasion. In addition, the percentage of ISUP≥ 4 in AS patients was double in the final pathology. Functional outcomes (continence, potency) are similar between groups. Patients with a pre-operative moderate degree of erectile dysfunction should be informed that potency recovery could be adversely affected by a delayed surgical treatment. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1098-e1098 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bernardo Rocco More articles by this author Maria Chiara Sighinolfi More articles by this author Marcio Covas Moschovas More articles by this author Sandri Marco More articles by this author Alessandra Cassani More articles by this author Luca Sarchi More articles by this author Simone Assumma More articles by this author Salvatore Micali More articles by this author Vipul Patel More articles by this author Expand All Advertisement Loading ...

Отдаленные результаты первого опыта лечения мужчины с синдромом Мея–Тюрнера и варикозной болезнью вен органов малого таза

Recurrent and bilateral varicocele represent two least studied aspects of the disease. There is no recommendation in current urological and andrological guidelines in various countries on the diagnosis and treatment of such patients. The first experience of successful surgical treatment of a patient with recurrent varicocele due to May-Thurner syndrome is presented in this paper. The patient had a severe form of the disease and admitted with the varicocele recurrence after 5 previous intervention with chronic pelvic pain syndrome, erectile dysfunction, chronic calculous prostatitis and varicose veins of the pelvic organs. The patient underwent balloon angioplasty and stenting of the left iliac vein on 28th March, 2017 in the City hospital named after E.O. Mukhin. There was almost complete resolution of pelvic pain in the immediate postoperative period (within 1 hour). One week after surgery the patient noted a recovery of erection without any therapy. Three months later, a 45% reduction in the maximum diameter of the prostatic veins was noted according to transrectal ultrasound (TRUS) as well as a lack of antegrade blood flow according to the color Doppler TRUS at rest and during Valsalva's test. There was no deterioration of symptoms during follow-up. Overall, the venous blood flow in prostate was decreased which accompanied by the reducing in pain syndrome and restoration of sexual function without medical therapy. The reduction of diameter of testicular and epididymal varicose veins was seen 6 months after surgery. The diameter of veins of pampiniform plexus in supine position at rest was less than 2 mm. There was no retrograde flow neither in supine, nor in stand position during Valsalva maneuver. Thus, X-ray endovascular angioplasty and stenting of the iliac veins in case of arterio-venous crossing at the lower level is a pathogenetically justified and highly effective treatment of varicocele and varicose veins of the pelvic organs in men.

Nerve‐sparing in salvage robot‐assisted prostatectomy: surgical technique, oncological and functional outcomes at a single high‐volume institution

To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot-assisted radical prostatectomy (RARP). In the present institutional review board-approved retrospective analysis, between January 2008 and March 2016, 80 patients underwent salvage RARP, performed by a single surgeon (V.P), because of local recurrence after primary treatment. These patients were categorized into two groups depending on the degree of nerve-sparing (NS) performed: a good-NS group (≥50% of NVB preservation) and a poor-NS group (<50% of NVB preservation). A standard transperitoneal six-port technique, using the DaVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), was performed, and either an anterograde or a retrograde approach was used for NVB preservation. Validated questionnaires were used preoperatively (Sexual Health Inventory for Men [SHIM] and American Urological Association scores). Potency after salvage RARP was defined as the ability to achieve a successful erection with penetration >50% of the time, while full continence after salvage RARPwas defined as 0 pads used. The Kaplan-Meier method was used for survival and predictive estimations, and regression models were used to identify the predictors of potency, continence and biochemical failure (BCF). The potency rate at 12months was higher in the good-NS group (25.6% vs 4.3%; P = 0.036) regardless of previous SHIM score, and good NS tended to be predictive of potency after salvage RARP (P = 0.065). The full continence rate at 12months and BCF rate were similar in the two groups, and non-radiation primary treatment was the only predictor of continence at 12months after salvage RARP (P = 0.033). Our data support the feasibility and safety of NVB preservation for salvage RARP conducted in select patients in a high-volume institution and the subsequent better recovery of adequate erections for intercourse.

Influence of multinerve-sparing, robot-assisted radical prostatectomy on the recovery of erection in Japanese patients.

PurposeTo evaluate in Japanese patients their sexual function after robot‐assisted radical prostatectomy (RARP) and to investigate the influence of the multinerve‐sparing (NS) grade on their sexual function.MethodsIn total, 225 patients were reviewed with localized prostate cancer who underwent RARP at the authors' institution. They underwent RARP >3 months ago, without pre‐ and posthormone therapy and salvage radiation. Self‐administered International Index of Erectile Function (IIEF) questionnaires were used for assessment preoperatively and 1–48 months postoperatively. In all, 129 patients were evaluated with the preoperative IIEF‐Question 1 and who achieved a score of ≥2 by being divided into five NS groups. The recovery rates of erection (postoperative IIEF‐Question 1 score of ≥2) were calculated by using the Kaplan–Meier analysis.ResultsSeventy‐four percent of all the patients had not attempted sexual intercourse, but 60% had felt sexual desire at 24 months postoperatively. In those patients with a preoperative erection, the recovery rate of erection was 58% at 24 months after the RARP. Across the five NS groups, as the procedure was more nerve‐sparing, the recovery rate of erection became significantly higher. The postoperative effects on erection in the bilateral and unilateral NS groups were significantly superior to those in the other NS groups.ConclusionIn Japanese patients, erection after a RARP is improved with multiNS grade procedures.

Analysis of Accessory Pudendal Artery Transection on Erections During Robot-Assisted Radical Prostatectomy.

To compare the recovery of erections and potency following the transection of accessory pudendal arteries (APAs) in men undergoing robot-assisted radical prostatectomy (RARP) compared with men with normal vascular anatomy. A total of 880 consecutive patients who underwent RARP from January 1, 2007 to December 31, 2014 were included with prospectively collected data in cross-sectional analysis. Erectile function (EF) was assessed preoperatively and postoperatively at 3, 6, 12, and 24 months using the International Index of Erectile Function (IIEF)-5, a percent erection fullness compared to preoperative status, and two Expanded Prostate Cancer Index (EPIC) questions: (1) are erections firm enough for penetration and (2) are they satisfactory? Two hundred thirty-one (33.1%) men had APAs transected. There were no significant differences in baseline demographics or clinical characteristics in men with or without APAs transected. Multivariate analyses demonstrated that age (confidence interval [95% CI]: 0.94, 0.99) and baseline IIEF-5 (95% CI: 1.15, 1.26) strongly correlated with recovery of erections and potency. Transection of APAs was not a significant predictor of erectile dysfunction (ED). Good surgical technique dictates the preservation of APAs. However, when preservation is questioned, we found that APA transection had no measurable effect on recovery of erections or potency regardless of age, preoperative ED, or number of APAs transected.

Partial Priapisim: A rare presentation of sickle cell anemia

Introduction Partial segmental thrombosis of the corpus cavernosum (PSTCC); known as partial priapism; is an uncommon urological condition which predominantly affects young men in which the proximal part of one corpus cavernosum is thrombosed. Many risk factors are described in the literature, the exact etiology of penile thrombosis and its pathogenesis remains unclear. Several treatment options are available ranging from conservative medical treatment with NSAIDs, antibiotics, analgesics, low molecular weight heparin, acetylsalicylic acid and antibiotics, surgical or to a follow-up observation without treatment. In this study we presented a sickle cell patient who presented with pain and perineal swelling and diagnosed with PSTCC using MRI and was treated conservatively. Case description A 23-year-old male, known case of sickle cell anemia, presented to casualty with a 1-day history of perineal pain of a sudden onset, increasing in severity, no aggravating or relieving factors. It was associated with perineal swelling, decrease in urine output and vomiting, not associated with urethral discharge, erectile dysfunction, trauma, sexual contact, fever, abdominal pain, lower urinary tract symptoms, change in bowel habits, or bleeding per rectum. He had a past history of left pyeloplasty in childhood. He was a smoker, non-alcohol consumer with a family history of liver malignancy. Examination revealed a stable vitals, abdomen was soft and non-tender, genitourinary exam findings confirmed the absence of priapism. There was a normal circumcised penis, normal bilateral testis and epididymis, separated perineal mass slightly hard in consistency, fixed and tender at the proximal part of the penis. Digital rectal examination was unremarkable. The complete blood count showed mild leukocytosis, electrolytes, coagulation profile, urine analysis and urine culture were unremarkable. MRI perineal and penis showed the right intratunical corpus cavernosum with altered signal intensity involving the root, proximal and mid third sparing the distal third of corpus cavernosum, maximum width of 26mm (predominantly hyposignal intensity with few areas of hypersignal intensity). Visualized Buck’s fascia and tunica albuginea were intact. Features mostly suggestive of right corpus cavernosum hematoma. Conservative treatment was initiated with 6 hourly IV paracetamol and the response was observed with gradually disappearing pain, reduction in swelling size and leukocytic count. On follow up patient was pain free, reduction in swelling size with a recovery of painless erection. A follow up ultrasound of the scrotum and a hematologist referral were arranged. Results and conclusions PSTCC is not an urological crisis and has an excellent prognosis. Conservative treatment appears to be a reliable therapeutic option. Surgery is reserved for patients in whom conservative management fails.

Extended versus Standard Pelvic Lymph Node Dissection in Radical Prostatectomy on Oncological and Functional Outcomes: A Systematic Review and Meta-Analysis.

We evaluated the effect of the extent of pelvic lymph node dissection (PLND) on oncological and functional outcomes in patients with intermediate- to high-risk prostate cancer (PCa) by conducting a systematic review and meta-analysis. Two independent researchers performed a systematic review of radical prostatectomy (RP) with extended PLND (ePLND), and RP with standard (sPLND) or limited PLND (lPLND) in patients with PCa using the PubMed, EMBASE, and Cochrane Library databases and using the terms 'prostatectomy', 'lymph node excision', and 'prostatic neoplasm'. The primary outcome was biochemical-free survival, which was analyzed by extracting survival data from the published Kaplan-Meier (KM) curves. In addition, we obtained summarized survival curves by reconstructing the KM data. Secondary outcomes of the recovery of erection and continence were also analyzed. Nine studies involving over 1554 patients were included, one of which was a randomized controlled trial. The pooled analysis showed a significant difference in biochemical recurrence between ePLND and sPLND (hazard ratio 0.71, 95% confidence interval 0.56-0.90, p=0.005), with no significant between-study heterogeneity (I 2=37%). From the summary survival curves, it can be observed that the curves for the two groups diverged more and more as a function of time. From the analyses of functional outcomes including only three studies, no statistically significant differences in the recovery of erectile function and continence were observed. No evidence of significant publication bias was found. In patients with PCa, ePLND could be an oncological benefit; however, a functional compromise cannot be determined.

Bone marrow–derived mesenchymal stromal cell therapy in a rat model of cavernous nerve injury: Preclinical study for approval

Background aimsAlthough clinical studies using stem cells to treat erectile dysfunction have been performed or are ongoing, there is little consensus on the optimal protocol. We aimed to develop a protocol optimizing human bone marrow–derived mesenchymal stromal cell (hBMSC) therapy in a rat model of cavernous nerve injury. MethodsWe performed, in order, a dose-finding study, a toxicokinetic study of hBMSCs, and a study to determine the timing and number of cell injections. ResultsFrom the dose-finding study, 1 × 106 cells were selected as the dose per hBMSC injection. From the toxicokinetic study, 14 days was selected as the interval between repeat treatments. In the final study, the ratio of maximal intracavernous pressure to mean arterial pressure was significantly lower in the control group than in the sham group (23.4% vs. 55.1%, P < 0.001). An immediate single injection of hBMSCs significantly improved erectile function compared with the control group (39.8%, P = 0.035), whereas a delayed single injection showed improvement with a marginal trend (38.1%, P = 0.079). All histomorphometric changes were significantly more improved in the immediate or delayed single injection groups than in the control group. Repeat treatments did not provide any benefit for the recovery of erectile function and histomorphometric changes. ConclusionsIntracavernous injection of 1 × 106 hBMSCs results in a recovery of penile erection and histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed until 4 weeks after cavernous nerve injury.

Maintaining intimacy for prostate cancer patients on androgen deprivation therapy.

Androgen deprivation therapy (ADT) causes erectile dysfunction and increases patients' emotionality while diminishing their sexual interest. ADT has been linked to erosion of spousal bonds; however, this is not an invariant outcome. Understanding the factors that lead to these various outcomes may help couples deal with ADT. A subset of couples report that they became closer as a result of the patients going on ADT. Recent data suggest that what helps couples most is preemptive awareness of ADT's side-effects and congruence in how patients and their partners understand and accept the psychosexual impact of ADT. Sex therapy for prostate cancer patients divides along gendered lines, with distinctly 'male' (recovery of erections) and 'female' (promoting sexual practices that are not erection dependent) approaches. Unfortunately, neither is very effective for couples when the patient is on ADT. Options beyond the standard gendered framework, such as use of an external penile prosthesis, may be worth offering to ADT patients trying to find a 'new normal' that is sexually rewarding for them. Intimacy is sharing something with someone that one shares with no one else. Exploring novel sexual practices can help couples stay intimate, even when the patient is on ADT.

Long-term recovery of normal sexual function in testicular cancer survivors

Testicular cancer (TC) is the most common solid cancer in men between the third and fourth decade of life. Due to successful treatment approaches, TC survivors (TCSs) have long life expectancy, but with numerous potential long-term sequelae, including sexual dysfunction. We investigated predictors of long-term normal sexual function (SF) recovery in TCSs. Sociodemographic, medical, and psychometric data were analyzed in 143 Caucasian-European TCSs, who underwent orchiectomy at a single institution. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients completed the International Index of Erectile Function (IIEF). Statistical models tested the association between predictors (including age at surgery, body mass index, CCI, and adjuvant therapy: radiotherapy [RT], chemotherapy [CT], CT followed by retroperitoneal lymph node dissection [RPLND] and RPLND alone) and the long-term recovery of normal SF (defined as IIEF-erectile function [EF] ≥26, and sexual desire [SD], intercourse satisfaction [IS] orgasmic function [OF], and overall satisfaction [OS] domain scores in the upper tertiles). At a mean follow-up of 86 months, 35 (25.5%) TCSs had erectile dysfunction (ED), with 16 (11.2%) experiencing severe ED. Median time of EF recovery was 60, 60, and 70 months after CT, RT, and RPLND, respectively. Only adjuvant RT emerged as an independent predictor of nonrecovery of normal EF (HR: 0.55, P= 0.01). Neither adjuvant CT nor CT plus RPLND or RPLND alone significantly impaired the recovery of normal erections. Adjuvant therapy was not associated with impaired recovery of normal sexuality as a whole, considering the IIEF-SD, -OF, -IS, and OS domains.

MODIFICATIONS FOR CONTROLLING THE DORSAL VEIN COMPLEX IN ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

To investigate a superior method for controlling the dorsal vein complex (DVC) in robotic-assisted laparoscopic radical prostatectomy at Nagakubo hospital. DVC control was altered from suture ligation followed by DVC division (SL group, n = 115) to preceding division followed by suture (PD group, n = 62). Surgical margin status and functional outcomes were investigated. No notable surgical complications were found in the PD group. Operation time and estimated blood loss were significantly less in the PD group; however, changes to serum hemoglobin before and after surgery showed no significant difference. The rates of positive surgical margin were 26.1% and 11.3% in the SL and PD groups, respectively (p = 0.021). Apical margin positivity was 9.6% and 3.2% in the SL and PD groups, respectively (p = 0.12). Urinary continence outcomes of within one pad/day and pad free in the SL and PD groups until 6 mo after surgery were 93.6% and 89.1% (P = 0.21), and 67.3% and 67.5% (p = 0.96), respectively. Erection recovery within 6 mo was 43.6% and 41.7% in the SL and PD groups (p = 0.91). Preceding division followed by suture method decreased apical margin positivity and provided superior cancer control in comparison with suture ligation followed by DVC division, although, it was probably influenced by the learning curve. Functional outcomes were not significantly different with either method.