Recovery Of Erections Research Articles

Doit on proposer une rééducation érectile après prostatectomie radicale ? Revue de la littérature du CAMS de l’AFU

Radical prostatectomy has evolved considerably during the last 20 years, with one hand, a thorough knowledge of the anatomy of the prostate, and secondly, the introduction of new conservation techniques of neurovascular bundles. Despite this progress, the rate of post-prostatectomy erectile dysfunction varies between 30 and 90% depending on the series and this element impacts the quality of life after radical prostatectomy. The objective of this work was to conduct a review of the literature in order to evaluate the various protocols of post-radical prostatectomy erectile rehabilitation. A systematic review of the literature from the basic PubMed search was performed using the following keywords. Therapy erectile dysfunction, radical prostatectomy, penile rehabilitation, phosphodiesterase 5 inhibitor, intracavernous injection. The critical analysis of selected studies highlights the lack of standard protocol that established erectile rehabilitation early after radical prostatectomy. These studies have shown that early treatment, injections or intracavernous PDE5 inhibitors improved recovery of erections as recommended by the French Association of Urology. Management of disorders of post-radical prostatectomy sexuality is essential, it must be organized in a well-established protocol combining pharmacological and therapeutic education assistances delivered by practitioners or nurses. It would need to develop in a clinical trial a standard protocol.

Sexualité et cancer de la prostate

All treatments for prostate cancer have a negative impact on sexuality. The objective of this review is to highlight recent developments in the management of sexual dysfunction associated with prostate cancer. We performed a literature search in the Pubmed database to select relevant articles. There is a specific profile of changes in the fields of sexual, urinary, bowel and general quality of life, according to the treatment modalities chosen. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. The results of randomized studies show that robotic radical prostatectomy allows a faster recovery of natural erections compared to classic laparoscopy. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5inhibitors [PDE5i] on demand, during the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. After the treatment of prostate cancer, one specific support sometimes assisted by networking will optimize satisfying sex life recovery.

Penile rehabilitation should not be the norm for patients post-radical prostatectomy.

Penile rehabilitation should not be the norm for patients post-radical prostatectomy.

Erectile dysfunction following retropubic prostatectomy

Prostate cancer is the most common cancer to affect men in the UK. Treatment options depend on the grade of tumour, the patient's co-existing diseases and choice of treatment. One potentially curative option is surgery, specifically a radical retropubic prostatectomy or variation thereof. As a consequence of the surgery, men commonly experience two side-effects: urinary incontinence and erectile dysfunction (ED). This paper outlines the clinical management of ED following surgery and aims to provide an overview of how to assess a man who has developed ED and discuss the various treatment options available, along with the efficacy in terms of recovery of erections.

Current rehabilitation strategy: clinical evidence for erection recovery after radical prostatectomy.

Erectile function (EF) recovery remains a prominent functional outcome underachievement of radical prostatectomy (RP), despite the success of anatomic “nerve-sparing” technique and its recent refinements in the modern surgical era. Delayed (for as much as a few years) or incomplete (partial and unusable) EF recovery commonly occurs in many men still today undergoing this surgery. “Penile rehabilitation”, alternatively termed “EF rehabilitation”, originated formally as a therapeutic practice approximately 15 years ago for addressing post-RP erectile dysfunction (ED) beyond conventional ED management. Although the premise of this therapy is conceptually sound and generally accepted, in reference to the implementation of strategies for promoting EF recovery to a naturally functional level in the absence of erectile aids (distinct from the premise of conventional ED management), the optimal manner and efficacy of currently suggested therapeutic strategies are far less established. Such strategies include regimens of standard ED-specific therapies (e.g., oral, intracavernosal, and intraurethral pharmacotherapies; vacuum erection device therapy) and courses of innovative interventions (e.g., statins, erythropoietin, angiotensin receptor blockers). An endeavor in evolution, erection rehabilitation may ideally comprise an integrative program of sexual health management incorporating counseling, coaching, guidance toward general health optimization and application of demonstrably effective “rehabilitative” interventions. Ongoing intensive discovery and rigorous investigation are required to establish efficacy of therapeutic prospects that fulfill the intent of post-RP erection rehabilitation.

Standard Operating Procedure for the Preservation of Erectile Function Outcomes After Radical Prostatectomy

Prostate cancer is common, and, thus, more men are being treated surgically. Long-term functional outcomes are of significant importance to the patient and their partners. Erectile function (EF) preservation (rehabilitation) has gained significant traction worldwide, despite the absence of definitive evidence supporting its use. To review the effectiveness of specific pharmacological therapies and other erectogenic aids in the treatment of post-radical prostatectomy (RP) erectile dysfunction. A systematic literature review of original peer-reviewed manuscripts and clinical trials reported in Medline. This review focused on the evaluation of interventions that aimed to improve EF recovery following RP. Although well documented in animal models, studies supporting the rehabilitation with phosphodiesterase type 5 inhibitors in humans are scarce. Daily sildenafil has been used in trials (only one randomized placebo-controlled trial) with a significant improvement in erection recovery when compared to placebo or no rehabilitation but with a low return to baseline rates (27% vs. 4% placebo). Nightly vardenafil vs. on demand vs. placebo has been studied in the Recovery of Erections: INtervention with Vardenafil Early Nightly Therapy trial with no difference in erection recovery following RP. Intracavernosal injections, although widely used and attractive from a rehabilitation standpoint, does not yet have definitive supporting its role in rehabilitation. Vacuum erection devices use following RP has been reported, but there are no data to support its role as monotherapy. Intraurethral alprostadil was also studied vs. sildenafil in a multicenter, randomized, open-label trial, and no superiority was found. At this time, we are unable to define what represents the optimal rehabilitation program in regard to strategies utilized, timing of intervention, or duration of treatment.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

ロボット支援腹腔鏡下前立腺全摘除術の初期成績と恥骨後式前立腺全摘除術との比較検討

To investigate the superiority in 2 radical prostatectomies, we compared the initial results of robotic-assisted radical prostatectomy (RARP) to those of retropubic radical prostatectomy (RRP) performed during the same period at Nagakubo hospital. The study was conducted on a total of 160 patients having undergone radical prostatectomy from April 2009 to March 2012 (92 patients with RARP and 68 with RRP). We investigated surgical stress, cancer control, functional outcomes and complications in both groups. Surgical stress; operation time was significantly shorter with RRP; however, blood loss and serum total protein loss were significantly less with RARP. White blood cell count at 2 days after surgery was significantly less with RARP. The rates of analgesic use and SIRS were similar. Although the date on which taking solid meals resumed did not differ, the duration of indwelling urethral catheter and admission period were significantly shorter with RARP. Cancer control; the rates of positive surgical margin were 27.2% and 19.1% with RARP and RRP, respectively (p = 0.24), and biochemical recurrence was seen in 12.0% and 19.1% with RARP and RRP, respectively (p = 0.73), which were not significantly different. Continence; urinary continence outcomes with RARP and RRP were 17% and 4% for urinary continence at discharge (p = 0.01), 1.8 and 3.3 months for no more than one pad per day (p < 0.01), and 4.3 and 6.2 months for pad free (p = 0.03), respectively. Sexual function; erection recovery within 6 mo was only observed with RARP; however, overall recovery rate of erection was 65% and 75% with RARP and RRP, respectively (p = 0.69). 1 case with a rectal injury was seen in both groups, but complication rates were 8.7% and 16.2% with RARP and RRP, respectively (p = 0.22). In spite of our initial experience of RARP, surgical stress and complications with RARP were considered to be superior to that with RRP. Cancer control and sexual function showed no significant difference between RARP and RRP, however, urinary continence outcome is significantly superior with RARP. Our data suggest that treatment outcome after initial experience with RARP is not inferior to that with RRP, and better results are expected by improving surgical techniques.

Periprostatic Implantation of Human Bone Marrow-derived Mesenchymal Stem Cells Potentiates Recovery of Erectile Function by Intracavernosal Injection in a Rat Model of Cavernous Nerve Injury

To evaluate whether periprostatic implantation (PPI) of human bone marrow-derived mesenchymal stem cells (hBMSCs) potentiates recovery of erectile function after intracavernosal injection (ICI) of hBMSCs in a rat model of cavernous nerve (CN) injury. Sprague-Dawley rats that had undergone bilateral CN injury were treated by ICI with or without PPI of hBMSCs (10 rats per group). hBMSCs were harvested from healthy human donors. Fibrin scaffolds were used for PPI of hBMSCs. After 4 weeks, erectile responses to electric pelvic ganglion stimulation were studied. The expression of neuronal nitric oxide synthase (nNOS)-positive nerve fibers and smooth muscle/collagen ratio was evaluated in each penis. ICI of hBMSCs slightly improved erectile function compared with the control group (maximal intracavernosal pressure/mean arterial pressure, 39.1% vs 21.7%; P=.060), but a combination of PPI and ICI significantly improved erectile function (45.0%, P=.007). After stem cell therapy, the number of nNOS-positive nerve fibers increased significantly in the PPI+ICI group (P=.017). The smooth muscle/collagen ratio increased significantly after stem cell therapy in the ICI and PPI+ICI groups (both P<.001). ICI of hBMSCs in a rat model of CN injury results in recovery of penile erection by decreasing corporeal smooth muscle deterioration and collagen deposition. PPI of hBMSCs potentiates recovery of erectile function by ICI of hBMSCs via regeneration of nNOS-containing nerve fibers.

Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates

Study Type--Therapy (outcomes) Level of Evidence 2a. What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a well known implication of radical prostatectomy (RP). Despite the search for technical improvement in the surgical procedure (e.g. nerve-sparing surgery, robot-assisted RP), many patients still suffer from an inability to achieve a satisfactory erection after surgery. In the last 20 years a great effort has been made to re-establish good sexual function in these patients. Many different approaches have been used, such as intracavernous prostaglandin E1 (PGE1), phosphodiesterase-5 inhibitors, vacuum devices and penile prostheses. Although many studies have addressed the main questions about efficacy of different approaches to ED, there is a lack of data about adherence to therapy and the main reasons why patients drop out of these treatment programmes. In the present study, a cohort of men treated with RP underwent a postoperative rehabilitation protocol with PGE1 intracavernous injections. During the follow-up period, we were able to assess a real-life practice pattern of adherence and dropout, evaluating the main causes of therapy discontinuation. This could be of help in the counselling of these patients during the path towards erection recovery. • To assess the rate of compliance in the first 6 months of a rehabilitation protocol that includes intracavernous alprostadil administration in patients undergoing radical retropubic prostatectomy. • To determine the reasons for and timings of dropout from the protocol by the patients and their subsequent outcomes. • All patients undergoing radical prostatectomy (RP) at our institution between 1 January 2007 and 31 December 2009 were considered for a protocol of postoperative intracavernous sexual rehabilitation and were administered entry questionnaires to evaluate their preoperative sexual activity. • Four weeks after surgery, the patients were invited to return for a first visit, where the aim of the protocol and possible risks and benefits were explained. For those who agreed to attend, subsequent visits to include assisted self-administration of increasing doses of intracavernous alprostadil and a period of autonomous homely self-administration were planned. • Patients were followed up at 3-month intervals, where data on functional outcomes, patient satisfaction, and the number of patients who dropped out and their reasons, were recorded by means of appropriate questionnaires. • Statistical analysis was performed using Student's t-test or a chi-squared test, where appropriate. • Of 430 patients, 157 (36.5%) refused to undergo the protocol of rehabilitation and 18.6% of the patients who began the protocol dropped out over the first 6 months. • Reasons for refusal were: patient's lack of sexual interest (51.6%); lack of interest by the partner (30.2%); and presence of transitory incontinence (26.7%). • Reasons for dropout were: disappointment with treatment efficacy (64.7%); injection pain (45%); and difficulties with or fear of performing the injection by themselves or by the partner (35.2%). No patient claimed the cost of the drug to be a cause for dropout. • The protocol we used, involving intracavernous alprostadil injection, proved to be a safe and efficient way of achieving sexual rehabilitation in patients who have undergone RP. Nevertheless, high patient motivation and adherence to the protocol were required. • Factors influencing patients refusal and early-to-medium time dropout were both patient- and partner-related. Appropriate information, counselling and support of the couple before the beginning and at all stages of the rehabilitation play a fundamental role in reducing the dropout rate. • The situation regarding those patients who still need adjuvant therapy after surgery is less clear and further research on this is required.

Dropout in the Treatment of Erectile Dysfunction with PDE5: A Study on Predictors and a Qualitative Analysis of Reasons for Discontinuation

Phosphodiesterase type 5 inhibitors (PDE5) are currently the first line treatment for erectile dysfunction (ED). However, previous research shows that PDE5 treatments have high discontinuation rates. Understanding the reasons for discontinuing PDE5 will be necessary to optimize the response to treatment. The main goals were: (i) to analyze discontinuation rate of PDE5; (ii) to identify the discontinuation predictors; and (iii) to study the reasons for discontinuation using a qualitative methodology. The PDE5 discontinuation rates, predictors, and reasons for discontinuation treatment. A total of 327 men with clinical diagnosis for ED who had been treated with PDE5 were successfully interviewed by telephone, after giving their informed consent by snail mail. Telephone interviews, concerning their ongoing treatment, were carried out using a standardized questionnaire form with quantitative and qualitative items. Participation rate was 71.8%. Of the total sample, 160 men (48.9%) had discontinued PDE5 treatment. The discontinuation rate was higher among men with diabetes (73%) and in iatrogenic group (65%), and lower in venogenic etiology (38.7%). We differentiated three groups of men who discontinued treatment (i) during the first 3 months (55.1%); (ii) between 4 and 12 months (26.9%); and (iii) after a period of 12 months (18%). Qualitative analyses revealed diverse reasons for discontinuation: non-effectiveness of PDE5 (36.8%), psychological factors (e.g., anxiety, negative emotions, fears, concerns, dysfunctional beliefs) (17.5%), erection recovery (14.4%), and concerns about the cardiovascular safety of PDE5 (8.7%) were the most common. Older men and men whose partners were involved in the treatment, were less likely to discontinue treatment. Half the subjects discontinued medication. Mostly, there was a combination of factors that led to discontinuation: non-effectiveness and psychosocial factors appear to be the main reasons. Addressing those factors will allow following up with appropriate focus on relevant topics in order to improve compliance.

Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

BackgroundThe advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials. ObjectiveTo compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery. Design, setting, and participantsFrom January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group. InterventionAll RARP and LRP interventions were performed with the same technique by the same single surgeon. Outcome measurements and statistical analysisThe demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ2 test, Pearson χ2 test, and multiple regression analysis were used for statistics. Results and limitationsThe two groups (RARP: n=60; LRP: n=60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group (p=0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively (p=0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively (p=0.020). The limitations included the small number of patients. ConclusionsRARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.

212 COMPARATIVE ANALYSIS OF PERIPROSTATIC IMPLANTATION AND INTRACAVERNOSAL INJECTION OF ADIPOSE TISSUE-DERIVED STEM CELLS FOR ERECTILE FUNCTION RECOVERY IN A RAT MODEL OF CAVERNOUS NERVE INJURY

You have accessJournal of UrologyStem Cell Research1 Apr 2012212 COMPARATIVE ANALYSIS OF PERIPROSTATIC IMPLANTATION AND INTRACAVERNOSAL INJECTION OF ADIPOSE TISSUE-DERIVED STEM CELLS FOR ERECTILE FUNCTION RECOVERY IN A RAT MODEL OF CAVERNOUS NERVE INJURY Dalsan You, Chunwoo Lee, Myoung Jin Jang, Jiyeon Lee, Nayoung Suh, In Gab Jeong, Kyung Hyun Moon, Sang Hyeon Cheon, Tai Young Ahn, and Choung-Soo Kim Dalsan YouDalsan You Seoul, Korea, Republic of More articles by this author , Chunwoo LeeChunwoo Lee Seoul, Korea, Republic of More articles by this author , Myoung Jin JangMyoung Jin Jang Seoul, Korea, Republic of More articles by this author , Jiyeon LeeJiyeon Lee Seoul, Korea, Republic of More articles by this author , Nayoung SuhNayoung Suh Seoul, Korea, Republic of More articles by this author , In Gab JeongIn Gab Jeong Seoul, Korea, Republic of More articles by this author , Kyung Hyun MoonKyung Hyun Moon Ulsan, Korea, Republic of More articles by this author , Sang Hyeon CheonSang Hyeon Cheon Ulsan, Korea, Republic of More articles by this author , Tai Young AhnTai Young Ahn Seoul, Korea, Republic of More articles by this author , and Choung-Soo KimChoung-Soo Kim Seoul, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.265AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Stem cell therapy using adipose tissue-derived stem cells (ADSCs) has evolved as a potential neuromodulatory mode of treatment following cavernous nerve (CN) injury. We compared periprostatic implantation (PPI) and intracavernosal injection (ICI) of ADSCs in terms of facilitation of erectile function recovery in a rat model of CN injury. METHODS Bilateral cavernous nerve dissection (BCND) was performed in 40 animals and laparotomy only in another 10 (the sham group). The 40 rats that underwent BCND were randomly divided into four groups (10 animals per group); 1) ICI of 0.1 mol/l phosphate-buffered saline (PBS) and PPI of fibrin sealant (the injured control group), 2) PPI of ADSC-seeded fibrin sealant (the PPI group), 3) ICI of ADSCs (the ICI group), and 4) PPI of ADSC-seeded fibrin sealant and ICI of ADSCs (the combination group). Erectile responses to electric pelvic ganglion stimulation were studied. Each penis was evaluated in terms of the numbers of neuronal nitric oxide synthase (nNOS)-expressing nerve fibers and smooth muscle/collagen ratios. Each prostate was examined to identify ADSCs that were differentiating into neuroglial cells. RESULTS The ratio of mean maximal intracavernosal pressure to mean arterial pressure was significantly decreased in the injured control group (24.5%) compared to the sham group (64.2%). PPI and ICI significantly improved erectile function (46.7% and 47.9%, respectively) compared to the injured control group. A combination of PPI and ICI (42.5%) did not afford any incremental effect on erectile function. After stem cell therapy, the numbers of nNOS-expressing nerve fibers in the ICI group increased only slightly, whereas the numbers in the PPI and combined treatment groups exhibited marked increases. In both the ICI and combined treatment groups, the smooth muscle/collagen ratio was similar to the sham group. However, in the PPI group, the ratio was similar to the injured control group. After 4 weeks, some CELL STAKER™-labeled ADSCs were found at the sites of transplantation. CONCLUSIONS Following PPI or ICI of ADSCs in a rat model of CN injury, recovery of penile erection was noted. Both methods were equally effective, but may address different types of pathophysiology. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e88 Peer Review Report Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dalsan You Seoul, Korea, Republic of More articles by this author Chunwoo Lee Seoul, Korea, Republic of More articles by this author Myoung Jin Jang Seoul, Korea, Republic of More articles by this author Jiyeon Lee Seoul, Korea, Republic of More articles by this author Nayoung Suh Seoul, Korea, Republic of More articles by this author In Gab Jeong Seoul, Korea, Republic of More articles by this author Kyung Hyun Moon Ulsan, Korea, Republic of More articles by this author Sang Hyeon Cheon Ulsan, Korea, Republic of More articles by this author Tai Young Ahn Seoul, Korea, Republic of More articles by this author Choung-Soo Kim Seoul, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Neuronal Nitric Oxide Signaling Regulates Erection Recovery After Cavernous Nerve Injury

Nitric oxide is the major neuronal mediator of penile erection but its role in erectile function status after cavernous nerve injury is uncertain. We determined the function of neuronal nitric oxide signaling in the pathobiology of erectile function recovery after partial cavernous nerve injury using genetic and pharmacological mouse experimental paradigms. Erectile function was evaluated in 5 to 7 wild-type and neuronal nitric oxide synthase-α knockout mice per group 1, 3 and 7 days after unilateral crush or sham injury, at day 7 in wild-type mice treated with the nitric oxide synthase inhibitor L-NAME (l-nitro arginine methyl ester) (Sigma-Aldrich®) at baseline and for 6 days after unilateral crush injury. Apoptosis in the penis was evaluated by Western blot analysis of p-Akt-S473, 3-nitrotyrosine and caspase-3 after bilateral crush injury. Intracavernous pressure was significantly decreased at 1, 3 and 7 days in wild-type mice but only at day 1 in knockout mice after unilateral crush injury compared with sham treatment values (p <0.05). L-NAME treated wild-type mice had improved erectile function compared with the vehicle treated group at day 7 after unilateral crush injury (p <0.05). In penes p-Akt-S473 was significantly decreased in vehicle treated (p <0.05) but not in L-NAME treated wild-type mice. In penes 3-nitrotyrosine was significantly decreased in L-NAME treated wild-type and vehicle treated knockout mice (p <0.05). Caspase-3 in penes was significantly increased in vehicle treated (p <0.05) but not in L-NAME treated wild-type mice and vehicle treated knockout mice. Neuronal nitric oxide signaling regulates erectile function recovery early after partial cavernous nerve injury, exerting an inhibitory role via the induction of apoptotic change in penile tissue. Therapeutic strategies to improve erectile function recovery after radical prostatectomy may consider targeting pathogenic sites of nitric oxide neurobiology.

Penile Rehabilitation

Penile erection starts when electrical impulses from the paired cavernous nerve bundles stimulate dilation of arteries supplying blood to the penis. These nerves can be thought of as fine, spiderweb‐like on/off switches that are attached to the prostate. During prostate surgery, heat, cutting, and stretch injuries can damage (and sometimes destroy) these nerves. There can also be damage to blood vessels supplying the penis and/or development of scar tissue that limits the ability of the penis to expand normally and trap blood during erection. Radiation treatments for prostate cancer can also damage the cavernous nerves and other tissues important for erections. Having a “nerve sparing” procedure does not guarantee recovery of erections. Keep the slow recovery time of nerves (6–36 months) in mind when setting expectations about erection recovery after prostate cancer treatment.

Active Patient Decision Making Regarding Nerve Sparing During Radical Prostatectomy: A Novel Approach

The motivation to preserve sexual function can vary widely among patients before prostatectomy. Increasing patient involvement may allow a more personalized experience and may improve satisfaction. We assessed a strategy of surgeon deference to patient choice in regard to nerve sparing to determine to what degree patients are rational actors and capable of active decision making. A total of 150 patients treated with prostatectomy participated in a standardized preoperative discussion regarding the concept of nerve sparing, extracapsular extension and the potential need for adjuvant radiation in the event of local recurrence. Each patient was given his nomogram predicted risk of extracapsular extension and then elected nerve sparing or nonnerve sparing. The corresponding procedure was performed unless grossly invasive disease was encountered. Of the 150 patients 109 chose nerve sparing (73%) and 41 chose nonnerve sparing (27%). In patients with a nomogram predicted risk of extracapsular extension less than 20%, 20% to 50% and greater than 50%, nerve sparing was elected by 88%, 41% and 25%, respectively. Patients with lower risks of extracapsular extension electing nonnerve sparing were older and had higher rates of erectile dysfunction. Empowering patients to decide on their nerve sparing status is a reasonable strategy that did not lead to a high rate of patients with a high risk of extracapsular extension electing nerve sparing. With proper counseling informed patients made reasonable decisions, and appeared to be conservative, prioritizing cancer control in the majority of instances where extracapsular extension risk was high. In addition, they may have been overly conservative in electing nonnerve sparing when the risk was low.

Hydrodissection of Neurovascular Bundles During Open Radical Prostatectomy Improves Postoperative Potency

Preservation of the neurovascular bundle during radical prostatectomy is important for postoperative erectile function. We determined whether hydrodissection of the neurovascular bundle during radical prostatectomy would result in improved erectile function postoperatively. Included in the study were 253 consecutive men who underwent nerve sparing radical prostatectomy, as done by 1 high volume surgeon (MIP). The first 117 and the next 136 men underwent standard dissection and hydrodissection, respectively, of the neurovascular bundle. In all men erectile function was evaluated by Sexual Health Inventory for Men score preoperatively, and 6 weeks and 6 months postoperatively. Time needed to achieve successful intercourse was also determined. In men with bilateral neurovascular bundle preservation mean Sexual Health Inventory for Men scores in the hydrodissection group were higher than in the standard dissection group by 2.8 at 6 weeks and by 3.5 at 6 months (p <0.05). In men with unilateral partial neurovascular bundle resection there was also significant improvement between the hydrodissection and standard dissection groups at 6 weeks and 6 months (p <0.05). Men with bilateral neurovascular bundle preservation who underwent hydrodissection and standard dissection required a median of 3 and 6 months, respectively, to achieve successful sexual intercourse with or without a phosphodiesterase-5 inhibitor (p <0.05). A difference was also observed in men who underwent partial neurovascular bundle resection. Hydrodissection was an independent predictor of time to successful intercourse on multivariate Cox regression analysis. Hydrodissection of the neurovascular bundle during open radical prostatectomy improves postoperative Sexual Health Inventory for Men scores and the time needed to achieve successful intercourse.

170 IMPACT OF PERIPROSTATIC IMPLANTATION OF BONE MARROW-DERIVED, MESENCHYMAL STEM CELLS ON THE RECOVERY OF PENILE ERECTION IN A RAT MODEL OF CAVERNOUS NERVE INJURY

You have accessJournal of UrologyStem Cell Research1 Apr 2011170 IMPACT OF PERIPROSTATIC IMPLANTATION OF BONE MARROW-DERIVED, MESENCHYMAL STEM CELLS ON THE RECOVERY OF PENILE ERECTION IN A RAT MODEL OF CAVERNOUS NERVE INJURY Dalsan You, Kwang Hyun Kim, Myoung Jin Jang, Jiyeon Lee, Kyung Hyun Moon, Young Hwan Ji, In Gab Jeong, Tai Young Ahn, and Choung-Soo Kim Dalsan YouDalsan You Seoul, Korea, Republic of More articles by this author , Kwang Hyun KimKwang Hyun Kim Seoul, Korea, Republic of More articles by this author , Myoung Jin JangMyoung Jin Jang Seoul, Korea, Republic of More articles by this author , Jiyeon LeeJiyeon Lee Seoul, Korea, Republic of More articles by this author , Kyung Hyun MoonKyung Hyun Moon Ulsan, Korea, Republic of More articles by this author , Young Hwan JiYoung Hwan Ji Ulsan, Korea, Republic of More articles by this author , In Gab JeongIn Gab Jeong Seoul, Korea, Republic of More articles by this author , Tai Young AhnTai Young Ahn Seoul, Korea, Republic of More articles by this author , and Choung-Soo KimChoung-Soo Kim Seoul, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.239AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Post-prostatectomy erectile dysfunction is a common complication of radical prostatectomy (RP) and it decreases the quality of life of the patient. We evaluated the effect of periprostatic implantation of mesenchymal stem cells (MSC) on the recovery of penile erection in a rat model of CN injury. METHODS Forty, eight-week-old, male Sprague-Dawley rats were randomly divided into four groups (ten rats per group) as follows: 1) only laparotomy (sham group); 2) bilateral CN dissection (BCND) and 0.1 mol/L phosphate-buffered saline instillation (injured control group); 3) BCND and fibrin glue instillation (fibrin glue group); and 4) BCND and periprostatic implantation of MSC with fibrin glue (MSC group). Four week following implantation, systemic arterial pressure (AP) and intracavernosal pressure (ICP) were recorded. To compare erectile function among the groups, the maximal ICP (ICPmax) was divided by the simultaneous AP (ICPmax/AP). After the function evaluation, the penis and bilateral prostate lobes of each rat were harvested and cryopreserved in liquid nitrogen for cGMP expression analysis and observation of nanoparticle-tagged MSC, respectively. RESULTS Mean ICPmax/AP ± S.E.M was significantly decreased in the injured control and fibrin glue groups (23.2% ± 7.1 and 24.4% ± 5.3, respectively) compared with that of the sham group (64.2% ± 5.0)(p=0.001 and p<0.001, respectively). Mean ICPmax/AP of the MSC group (41.5% ± 4.2) was lower than that of the sham group (p=0.005), although it was higher than those of the injured control and fibrin glue groups (p=0.010 and p=0.023, respectively). Mean cGMP ± S.E.M was decreased in the injured control and fibrin glue groups (5.27 fmol/mg ± 0.26 and 5.03 fmol/mg ± 0.22, respectively) compared with that of the sham group (5.87 fmol/mg ± 0.19)(p=0.126 and p=0.029, respectively). Mean cGMP of the MSC group (5.86 fmol/mg ± 0.25) was similar to that of the sham group (p=0.905). From the harvested prostate, merging of DAPI (4',6-diamidino-2-phenylindole) and nanoparticle was identified, indicating the presence of viable MSC. In addition, several MSCs were stained with p75 antibody, a marker of Schwann cells. CONCLUSIONS Following the periprostatic implantation of MSC in a rat model with CN injury, the recovery of penile erection was noted. The possible mechanism might include the differentiation of MSC into Schwann cells and resulting in inhibiting demyelination of the CN and assisting in axonal regeneration. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e71 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dalsan You Seoul, Korea, Republic of More articles by this author Kwang Hyun Kim Seoul, Korea, Republic of More articles by this author Myoung Jin Jang Seoul, Korea, Republic of More articles by this author Jiyeon Lee Seoul, Korea, Republic of More articles by this author Kyung Hyun Moon Ulsan, Korea, Republic of More articles by this author Young Hwan Ji Ulsan, Korea, Republic of More articles by this author In Gab Jeong Seoul, Korea, Republic of More articles by this author Tai Young Ahn Seoul, Korea, Republic of More articles by this author Choung-Soo Kim Seoul, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1314 NEGATIVE IMPACT OF AGING ON THE GANGLIONIC NEURON COUNT AROUND THE HUMAN PROSTATE

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation1 Apr 20111314 NEGATIVE IMPACT OF AGING ON THE GANGLIONIC NEURON COUNT AROUND THE HUMAN PROSTATE Shin-ichi Hisasue, Kohei Hashimoto, Yohei Matsuda, Hisanori Taniguchi, Masahide Kanaya, Satomi Fujii, Satoshi Takahashi, and Taiji Tsukamoto Shin-ichi HisasueShin-ichi Hisasue Sapporo, Japan More articles by this author , Kohei HashimotoKohei Hashimoto Sapporo, Japan More articles by this author , Yohei MatsudaYohei Matsuda Sapporo, Japan More articles by this author , Hisanori TaniguchiHisanori Taniguchi Osaka, Japan More articles by this author , Masahide KanayaMasahide Kanaya Sapporo, Japan More articles by this author , Satomi FujiiSatomi Fujii Kutchan, Japan More articles by this author , Satoshi TakahashiSatoshi Takahashi Sapporo, Japan More articles by this author , and Taiji TsukamotoTaiji Tsukamoto Sapporo, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1134AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We recently reported that baseline erectile function greatly influences cavernous nerve quantity and distribution around the prostate (Hisasue et al. J. Urol. 2010). Ganglionic neurons also surrounded the prostate and are believed to be responsible for the axonal regeneration or collateral sprouting of cavernous nerve. We assessed which factor predicts the ganglionic neuron count around the human prostate METHODS We investigated 46 hemispheres of 23 non-nerve sparing radical prostatectomy specimens. We performed immunohistochemical staining with nNOS-antibody, and divided the prostatic hemisphere into six zones to assess the distribution of nNOS-positive ganglionic neurons at the apex, midportion and base of the prostate. Multivariate analysis of quantity of the overall neurons used the variables of patient age (<65 years vs. ≥65 years), specimen weight (≥40g vs. <40g), body mass index (<25 kg/m2, ≥25 kg/m2), and maximum penile circumferential change using erectometer (MPCC; ≥20mm, <20mm). RESULTS Median patient age was 68 years (range 57 to 74). Median MPCC was 25.0mm (range 2.70 to 38.3). Logistic regression analysis revealed that the age was the single significant variable (p=0.046). The ganglionic neuron count was lower in the older (≥65 years) group than in the younger (<65 years) group (p=0.048; Mann-Whitney U-test). The neuron count was significantly different between the two groups in the 4 to 5 o′clock area at the mid-prostate. CONCLUSIONS This is the first study indicating that higher age has a negative impact on the nNOS-positive ganglionic neuron count in human. This result will lead to the rationale why older people show the poor outcome in their recovery of erection following radical prostatectomy. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e525-e526 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shin-ichi Hisasue Sapporo, Japan More articles by this author Kohei Hashimoto Sapporo, Japan More articles by this author Yohei Matsuda Sapporo, Japan More articles by this author Hisanori Taniguchi Osaka, Japan More articles by this author Masahide Kanaya Sapporo, Japan More articles by this author Satomi Fujii Kutchan, Japan More articles by this author Satoshi Takahashi Sapporo, Japan More articles by this author Taiji Tsukamoto Sapporo, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Sexual Rehabilitation and Penile Pain Associated with Intracavernous Alprostadil after Radical Prostatectomy

Intracavernous alprostadil injection (IAI) is widely used for sexual rehabilitation (SR) after radical prostatectomy (RP). However, the rate of spontaneous erection recovery with IAI remains unclear, and IAI causes pain that may hinder SR. To assess SR in IAI users after RP and to evaluate the course and impact on SR of postinjection penile pain. We prospectively studied 87 patients who underwent nerve-sparing laparoscopic RP, reported normal preoperative erectile function, and used IAI for 12 months. Patients started with 2.5 µg alprostadil and were advised to increase the dose gradually until erection hardness allowed vaginal penetration. At 6 and 12 months, the International Index of Erectile Function (IIEF-15) and Erection Hardness Score (EHS) were determined with and without IAI, and injection-related penile pain was assessed using a numeric rating scale. Correlations linking penile pain, IIEF-15, and EHS scores were evaluated. The mean alprostadil dose was 8.1 µg after 6 months and 9.9 µg after 12 months. With/without IAI, mean IIEF-15 scores for erectile and orgasmic function and mean EHS score were 14.6/4.6, 4.1/2.1, and 2.5/0.4, respectively, after 6 months; and 17.2/5.4, 4.9/2.6, and 2.7/0.9 after 12 months. Pain scores were 3.2±2.5/10 and 2.5±2.5/10 after 6 and 12 months, respectively. Pain intensity correlated with erectile function (r=-0.23), intercourse satisfaction (r=-0.23), and overall satisfaction (r=-0.24) after 6 months but not after 12 months. Follow-up was short and only patients who used IAI for 12 months were included. In patients who were willing and able to use IAI, erectile function improved after 1 year but remained below preoperative levels. The adverse impact of pain on SR was significant during the first 6 months and diminished over time. These data may help to counsel IAI users with painful erections.