Improving the Preservation of the Urethral Sphincter and Neurovascular Bundles During Open Radical Retropubic Prostatectomy

Restoring Quality of Life: A Comprehensive Review of Penile Rehabilitation Techniques Following Prostate Surgery

Prostate cancer is the most common type of cancer in men, and its treatment options include surgery, radiation therapy, and chemotherapy. Prostate surgery can often result in erectile dysfunction (ED), significantly impacting patients' quality of life. Penile rehabilitation techniques have been developed to restore erectile function following prostate surgery. This review discusses the different penile rehabilitation techniques available, their effectiveness, and the factors affecting their success. This paper also addresses the importance of addressing the psychological aspects of ED in these patients and the need for personalized and tailored rehabilitation plans. By providing a comprehensive understanding of penile rehabilitation techniques, this paper can assist clinicians in restoring the quality of life of patients who have undergone prostate surgery.

Impact of Early Dorsal Venous Complex Ligation on Urinary Continence Recovery after Robot-assisted Radical Prostatectomy: Results from a Phase 3 Randomized Controlled Trial

BACKGROUND

Whether early ligation of the dorsal venous complex (DVC) might improve recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) has never been investigated in a prospective randomized study.

OBJECTIVE

To assess whether early DVC ligation might affect UC recovery after RARP.

INTERVENTION

DVC ligation (early vs standard).

DESIGN, SETTING, AND PARTICIPANTS

A total of 312 patients with prostate cancer underwent primary RARP at a tertiary care institution.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was UC recovery at 1 and 4 mo after RARP. UC was defined as 0 pads/1 safety pad per day. All patients completed the International Prostate Symptom Score (IPSS) and International Consultation of Incontinence Questionnaire (ICIQ)-Short Form questionnaires. Secondary outcomes were early (≤4 mo) erectile function recovery, the positive surgical margin (PSM) rate, 30-d Clavien-Dindo complications, and biochemical recurrence rates. Quality of life was assessed using the EQ-5D-5L questionnaire. The association between treatment arm and UC recovery was also tested using multivariable regression models.

RESULTS AND LIMITATIONS

After surgery, 23 patients withdrew their consent and 29 were lost to follow-up, leaving 261 patients available for per-protocol analyses. Of these, 32 patients (24%) in the experimental group and 37 (29%) in the control group used no pad/one safety pad at 1 mo after RARP, whereas 96 (72%) in the control group versus 83 (65%) in the control group were continent at 4-mo follow-up (both p = 0.3). Median ICIQ and IPSS scores did not differ between the groups at both time points. The results were confirmed on multivariable regression analyses. PSMs were observed for 32 patients (25%) in the experimental group versus 30 (22%) in the control group (p = 0.6). The incidence of postoperative complications (17% experimental vs 13% control) and the 1-yr biochemical recurrence-free survival did not differ between the groups.

CONCLUSIONS

In this randomized clinical trial, we did not find evidence that early ligation of the DVC during RARP was associated with better UC recovery after surgery in comparison to the standard technique. Given its safety in terms of surgical margins and complications, this technique may be considered as an option for surgical dissection according to the physician's preference.

PATIENT SUMMARY

Our trial showed that for patients undergoing robot-assisted surgical removal of the prostate, the timing of a specific step to control bleeding from a network of veins draining the prostate did not affect recovery of urinary continence after surgery. The results indicate that earlier control of these veins may be considered as an option according to the surgeon's preference.

Clinical evaluation and disease management of PI-RADS 3 lesions. Analysis from a single tertiary high-volume center

OBJECTIVE

To evaluate the clinical and pathological implications of Prostate Cancer (PCa) patients with a Prostate Imaging - Reporting and Data System (PI-RADS) 3 lesion at multi parametric magnetic resonance imaging (mpMRI).

METHODS

We included 356 patients with a PI-RADS score 3 lesion at mpMRI who underwent prostate biopsy for a suspect of PCa at a single tertiary high-volume centre between 2013 and 2016.We developed Uni- (UVA) and multi variable (MVA) logistic regression analyses assessing the predictors of three endpoints: 1) diagnosis of PCa, 2) active surveillance (AS) criteria and 3) clinically significant (CS) PCa at final pathology.

RESULTS

PCa was diagnosed in 285 patients (80%), out of these 154 (56%) were eligible for AS according to Prostate Cancer Research International Active Surveillance (PRIAS) criteria. Over the 228 (64%) patients who underwent surgery, 93 (40.8%) had a CS disease at final pathology. Hundred and ninety-three (84.6%) had a pT2 disease and 35 (15.4%) had a pT3 disease. The size of the main lesion, age, PSA and prostate volume efficiently predicted PCa at MVA (all p < 0.05). None of our predictors were significantly associated with AS characteristics. Over those patients who underwent surgery, the biopsy Gleason Score (p = 0.007) efficiently predicted a CS PCa at final pathology.

CONCLUSIONS

mpMRI-detected PI-RADS 3 lesions should be sent to a prostate biopsy if other clinical parameters suggest the presence of a PCa. In case of diagnosis of a PCa, patients should undergo confirmatory biopsy before being included in AS protocols to avoid underestimation of a CS disease.

Strategies to improve nerve regeneration after radical prostatectomy: a narrative review

Peripheral nerves are complex organs that spread throughout the entire human body. They are frequently affected by lesions not only as a result of trauma but also following radical tumor resection. In fact, despite the advancement in surgical techniques, such as nerve-sparing robot assisted radical prostatectomy, some degree of nerve injury may occur resulting in erectile dysfunction with significant impairment of the quality of life. The aim of this review was to provide an overview on the mechanisms of the regeneration of injured peripheral nerves and to describe the potential strategies to improve the regeneration process and the functional recovery. Yet, the recent advances in bio-engineering strategies to promote nerve regeneration in the urological field are outlined with a view on the possible future regenerative therapies which might ameliorate the functional outcome after radical prostatectomy.

Comparison of intrafascial and non-intrafascial radical prostatectomy for low risk localized prostate cancer

In this meta-analysis study, we compared the oncological and functional outcomes of intrafascial radical prostatectomy (IFRP) with non-intrafascial radical prostatectomy (NIFRP) in the treatment of patients with low risk localized prostate cancer (PCa). Relevant articles were identified by searching PubMed, EMBASE, Cochrane Library, Ovid, and the ISI Web of Knowledge databases. A total of 2096 patients were included from 7 eligible studies. Results of the pooled data showed that the oncological outcomes including gleason score, positive surgical margin and biochemical free survival rates were similar between the two groups. IFRP was superior to NIFRP with lower postoperative complication rates (RR 0.57, 95% CI 0.38, 0.85, p = 0.006), higher continence rates at 3 months post-operation (RR: 1.14; 95% CI, 1.04, 1.26; p = 0.006), and higher potency rates at 6 months (RR: 1.53; 95% CI, 1.07, 2.18; p = 0.02) and 12 months post-operation (RR: 1.38; 95% CI, 1.11, 1.73; p = 0.005). Additionally, there was a tendency towards higher potency rate in patients ≤65 years old compared with patients >65 years old after IFRP. Overall, these findings suggest that IFRP in young patients with low risk localized PCa had less postoperative complications, shortened time to return to continence and improved potency rate without compromising complete tumor control.

Visualization of prostatic nerves by polarization-sensitive optical coherence tomography

Preservation of prostatic nerves is critical to recovery of a man's sexual potency after radical prostatectomy. A real-time imaging method of prostatic nerves will be helpful for nerve-sparing radical prostatectomy (NSRP). Polarization-sensitive optical coherence tomography (PS-OCT), which provides both structural and birefringent information of tissue, was applied for detection of prostatic nerves in both rat and human prostate specimens, ex vivo. PS-OCT imaging of rat prostate specimens visualized highly scattering and birefringent fibrous structures superficially, and these birefringent structures were confirmed to be nerves by histology or multiphoton microscopy (MPM). PS-OCT could easily distinguish these birefringent structures from surrounding other tissue compartments such as prostatic glands and fats. PS-OCT imaging of human prostatectomy specimens visualized two different birefringent structures, appearing fibrous and sheet-like. The fibrous ones were confirmed to be nerves by histology, and the sheet-like ones were considered to be fascias surrounding the human prostate. PS-OCT imaging of human prostatectomy specimens along the perimeter showed spatial variation in the amount of birefringent fibrous structures which was consistent with anatomy. These results demonstrate the feasibility of PS-OCT for detection of prostatic nerves, and this study will provide a basis for intraoperative use of PS-OCT.

Erectile Function Recovery After Nerve-Sparing Radical Prostatectomy for Prostate Cancer: Is Back to Baseline Status Enough for Patient Satisfaction?

INTRODUCTION

Several definitions of erectile function (EF) recovery after bilateral nerve-sparing radical prostatectomy (BNSRP) have been proposed based on the results of the International Index of EF (IIEF).

AIM

We aimed at evaluating overall satisfaction (OS) after BNSRP according to the ability to achieve the pretreatment EF.

METHODS

We evaluated data of 652 patients treated with BNSRP for clinically localized prostate cancer (PCa). Erectile dysfunction (ED) was classified according to the IIEF-EF domain score. Return to baseline EF was defined as patients who reached the same preoperative ED category during the 3-year follow-up. Cox regression analyses were fitted to predict return to baseline IIEF-EF and to predict OS defined according to the IIEF-OS in the overall population. Logistic regression analyses were performed to analyze OS in men who reached the back to baseline status.

MAIN OUTCOME MEASURES

The outcome of the study was to evaluate back to baseline EF status and to correlate it with postoperative OS.

RESULTS

Preoperative satisfaction was reported by 218 (33.4%) patients. Postoperative satisfaction was achieved by 103 patients. Overall, 383 patients were able to achieve the preoperative IIEF-EF score. However, only 26.9% reported being satisfied. Age and preoperative IIEF-EF score were significantly associated with baseline IIEF-EF recovery (all P ≤ .02). Patients who were able to return to baseline IIEF-EF were more likely to be satisfied (P < .001). Time elapsed between surgery and achievement of baseline IIEF-EF was significantly associated with OS (P < .001). Among patients who were able to achieve the baseline IIEF-EF score, a preoperative IIEF-EF of 22-25 and 26-30 was significantly associated with postoperative satisfaction (all P < .001).

CONCLUSION

After BNSRP, reaching the baseline IIEF-EF score is not always sufficient to obtain patient satisfaction. Only patients with a preoperative IIEF-EF ≥22 who reached the baseline score after surgery considered themselves satisfied. This should be taken into account in preoperative patient counseling.

Comparison of Acute Kidney Injury After Robot-Assisted Laparoscopic Radical Prostatectomy Versus Retropubic Radical Prostatectomy: A Propensity Score Matching Analysis

Acute kidney injury (AKI) is associated with extended hospital stay, a high risk of progressive chronic kidney diseases, and increased mortality. Patients undergoing radical prostatectomy are at increased risk of AKI because of intraoperative bleeding, obstructive uropathy, older age, and preexisting chronic kidney disease. In particular, robot-assisted laparoscopic radical prostatectomy (RALP), which is in increasing demand as an alternative surgical option for retropubic radical prostatectomy (RRP), is associated with postoperative renal dysfunction because pneumoperitoneum during RALP can decrease cardiac output and renal perfusion. The objective of this study was to compare the incidence of postoperative AKI between RRP and RALP.We included 1340 patients who underwent RRP (n = 370) or RALP (n = 970) between 2013 and 2014. Demographics, cancer-related data, and perioperative laboratory data were evaluated. Postoperative AKI was determined according to the Kidney Disease: Improving Global Outcomes criteria. Operation and anesthesia time, estimated blood loss, amounts of administered fluids and transfused packed red blood cells, and the lengths of the postoperative intensive care unit and hospital stays were evaluated. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences between the RRP and RALP groups.After performing 1:1 propensity score matching, the RRP and RALP groups included 307 patients, respectively. The operation time and anesthesia time in RALP were significantly longer than in the RRP group (both P < 0.001). However, the estimated blood loss and amount of administered fluids in RALP were significantly lower than in RRP (both P < 0.001). Also, RALP demonstrated a significantly lower incidence of transfusion and smaller amount of transfused packed red blood cells than RRP (both P < 0.001). Importantly, the incidence of AKI in RALP was significantly lower than in RRP (5.5% vs 10.4%; P = 0.044). Furthermore, the length of hospital stay in RALP was also significantly shorter (P < 0.001).The incidence of AKI after RALP is significantly lower than after RRP. RALP can therefore be a better surgical option than RRP in terms of decreasing the frequency of postoperative AKI.

Prospective comparison of one year follow-up outcomes for the open complete intrafascial retropubic versus interfascial nerve-sparing radical prostatectomy

Current work provides a prospective direct comparison between Open complete intrafascial-radical-prostatectomy (OIF-RP) and interfascial-RP in all outcomes in single centre series. Both techniques were done prospectively in 430 patients. Inclusion criteria for OIF-RP (n=241 patients) were biopsy Gleason-score ≤6 and PSA ≤10 ng/ml while for interfascial-RP (n=189) were Gleason-score ≤7 and PSA ≤15. The perioperative parameters (e.g. operative time, complications etc.), pathologic results, surgical margins and revisions were reviewed. Pre- and postoperative (3 and 12 months) evaluation of continence and potency was performed. All patients have preoperative IIEF-score of ≥15. Continence was classified as complete (no pads), mild (1-2 pads/day) and incontinence (>2 pads/day). Median patients’ age was 63.7 vs. 64.5 years for OIF-RP vs. Interfascial-RP, respectively. Preoperative PSA-level was significantly lower in OIF-RP (5.8 vs. 7.1), otherwise, similar perioperative data in both groups except for more frequent pT3-tumors in interfascial-RP group (18%). No statistical significance regarding continence was observed between OIF-RP vs. Interfascial-RP groups at 3 (82% vs. 85%) and 12 months (98% vs. 96%) postoperatively. Potency rates (IIEF ≥15) after OIF-RP were 96% (≤55 years), 72% (55-65), and 75% (>65 years) at 12 months. The respective rates for interfascial-group were 58%, 61% and 51%. There was an advantage for OIF-RP potency-outcomes without significance over Interfascial-RP in weak potency patients (IIEF=15-18). We conclude that OIF-RP is associated with better functional results without compromising early oncological results compared to interfascial-RP. Complete preservation of periprostatic fasciae provides significantly better postoperative recovery of sexual function even for weak potency patients. Longer follow-up is mandatory to further evaluate the outcome results of this technique.

A comprehensive review of neuroanatomy of the prostate

Although oncologic efficacy is the primary goal of radical prostatectomy, preserving potency and continence is also important, given the indolent clinical course of most prostate cancers. In order to preserve and recover postoperative potency and continence after radical prostatectomy, a detailed understanding of the pelvic anatomy is necessary to recognize the optimal nerve-sparing plane and to minimize injury to the neurovascular bundles. Therefore, we reviewed the most recent findings from neuroanatomic studies of the prostate and adjacent tissues, some of which are contrary to the established consensus on pelvic anatomy. We also described the functional outcomes of radical prostatectomies following improved anatomical understanding and development of surgical techniques for preserving the neurovascular bundles.

Effect of mesenchymal stem cells associated to matrixen on the erectile function in the rat model with bilateral cavernous nerve crushing injury

OBJECTIVES

To evaluate the effect of mesenchymal stem cells (MSCs) and MSCs mixed with Matrixen as a cell carrier on the erectile dysfunction caused by bilateral cavernous nerve crushing injury.

MATERIALS AND METHODS

White male Sprague-Dawley rats were divided into 4 groups: sham-operated control group (n = 5), bilateral cavernous nerve crushing group (BCNC group, n = 10), BCNC administered with MSCs group (n = 10,1x106 in 20 µL), BCNC administered with Matrixen group (n = 10.1x106 in 20 µL), BCNC administered with MSCs/Matrixen group (n = 10.1x106 in 20 µL). After functional assessment at 4 weeks, major pelvic ganglion (MPG) and penile tissue were collected. Immunofluorescent staining of MPG was performed with PKH26 and Tuj1. Western blot analysis of endothelial nitric oxide synthase (eNOS) and neuronal nitric oxide synthase (nNOS) were done in corpus cavernosum.

RESULTS

ICP/MAP ratios of BCNC with MSCs and MSCs/Matrixen groups were significantly increased compared with BCNC and BCNC with Matrixen group. Moreover, ICP/MAP ratios of MSCs/Matrixen group were significantly increased compared with BCNC with MSCs group. In MPG, the more implantation of MSCs and increased expression of nerve cells were observed in MSCs/Matrixen group compared with BCNC with MSCs group. Significant increase expression of eNOS and nNOS was also noted in BCNC with MSCs/Matrixen group.

CONCLUSION

The erectile function was more preserved in MSCs/Matrixen group compared with the administration of MSCs alone in the rats with bilateral cavernous nerve crushing injury. Therefore, we consider that the use of transplant cell carrier such as Matrixen may help the implantation of MSCs and improve the therapeutic effect of MSCs.

Safe digital isolation of the santorini plexus during radical retropubic prostatectomy

Background

We describe a safe and easily reproducible technique to control Santorini plexus during radical retropubic prostatectomy (RRP) which uses simple digital dissection.

Methods

We retrospectively reviewed 56 consecutive patients who underwent RRP for clinically localised prostate cancer from November 2008 to November 2010. Santorini plexus was isolated and secured in all patients using a new technique of simple digital dissection in which the index finger is used not to only localize the catheter inside the urethra, but also to develop the right plane between Santorini plexus and urethra. This is obtained by gentle bilateral digital dissection through the lateral aspects of periprostatic fascia which are eventually breached by the fingers, developing a right plane just above the urethra. Santorini plexus is then easily ligated and divided. Indicators of outcomes included estimated blood loss, transfusion requirements, operative time, positive margins and complication rates of the technique.

Results

The maneuver was successful in 53/56 (95%) patients. Mean (range) blood loss and overall operative time for RRP were 620 ml (100–1500) and 130 min. (80–190), respectively. Transfusion rate was 8,9% (5/56). Positive surgical margin rate was 14% (8/56). No complication related to the employed technique was recorded.

Conclusions

Digital dissection of Santorini plexus during RRP is simple and easily feasible. It speeds up the process of finding the right plane just above the urethra allowing good haemostasis in the surgical field and proper apical dissection.

Prevention and management of postprostatectomy sexual dysfunctions. Part 1: choosing the right patient at the right time for the right surgery

CONTEXT

Sexual dysfunction is common in patients following radical prostatectomy (RP) for prostate cancer (PCa).

OBJECTIVE

To review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics and intra- and postoperative factors that may influence EF recovery.

EVIDENCE ACQUISITION

A literature search was performed using Google and PubMed database for English-language original and review articles either published or e-published up to November 2011.

EVIDENCE SYNTHESIS

The literature demonstrates great inconsistency in what constitutes normal EF before surgery and what a man may consider a normal erection after RP. The use of validated psychometric instruments with recognised cut-offs for normalcy and severity during the pre- and postoperative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative erectile dysfunction (ED), the concept of spontaneous or pharmacologically assisted erections, and the difference between "back to baseline" EF and "erections adequate enough to have successful intercourse" clearly emerge as key issues in the eventual understanding of the prevention of ED and promotion of satisfactory EF recovery post-RP. Patient factors (including age, baseline EF, and status of comorbid conditions), cancer selection (unilateral vs bilateral nerve sparing), type of surgery (ie, intra- vs inter- vs extrafascial surgeries), surgical techniques (ie, open, laparoscopic, and robot-assisted RP), and surgeon factors (ie, surgical volume and surgical skill) represent the key significant contributors to EF recovery.

CONCLUSIONS

The complexity of the issues discussed throughout this review culminates in the simple concept that optimal outcomes are achieved by the careful choice of the correct patient for the correct type of surgery.

Prediction of functional outcomes after nerve-sparing radical prostatectomy: results of conditional survival analyses

BACKGROUND

In prostate cancer (PCa) patients treated with radical prostatectomy (RP), the rate of urinary continence (UC) and erectile function (EF) recovery may change significantly depending on the time interval between surgery and patient assessment. This effect, known as conditional survival, has not yet been assessed.

OBJECTIVE

Evaluate the conditional rates of UC and EF recovery after nerve-sparing RP (NSRP).

DESIGN, SETTING, AND PARTICIPANTS

We included 1135 PCa patients treated between January 2000 and June 2011 at a single referral center.

INTERVENTION

All patients underwent NSRP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The Kaplan-Meier method assessed the time to recovery of UC (defined as an International Consultation on Incontinence Questionnaire score<6) and of EF (defined as an International Index of Erectile Function-Erectile Function score≥22). Cumulative survival estimates were used to generate conditional recovery rates assessed at a 6-mo interval. Multivariable Cox regression analyses were performed to predict functional outcomes recovery after accounting for confounders.

RESULTS AND LIMITATIONS

UC recovery rates were 89.5%, 94.7%, and 97.0% at 6-, 24-, and 36-mo follow-up, respectively. Corresponding EF recovery rates were 53.6%, 65.0%, and 67.5%, respectively. In patients who were still incontinent at 1, 6, 12, 18, 24, 30, and 36 mo after surgery, UC recovery rates in the following 6-mo period significantly decreased as the time from surgery increased: 74.9%, 58.2%, 41.4%, 14.9%, 24.8%, 24.6%, and 13.3%, respectively. Similarly, in patients still impotent at the same time points, the 6-mo rate of sexual potency recovery was 36.9%, 26.8%, 17.8%, 8.2%, 3.1%, 4.0%, and 0%, respectively. Multivariable analyses confirmed these results. The study is limited by its retrospective design.

CONCLUSIONS

In incontinent and/or impotent patients, the period elapsed from surgery represents an important predictor of the recovery of subsequent functional outcomes. The highest increments in UC and EF recovery were observed during the first year after surgery; they were virtually null after 36 mo.

Optimizing radical prostatectomy for the early recovery of urinary continence

Radical prostatectomy remains the gold-standard treatment for clinically localized prostate cancer. Although cancer control is the primary goal, secondary outcomes such as continence recovery are of great importance to patients. Thus, it is a challenge for prostate cancer surgeons to optimize continence outcomes without compromising oncologic results. Many high-volume surgeons have demonstrated excellent long-term continence rates in their patients, but early continence is variable and less than ideal even in expert hands. A plethora of individual technical maneuvers exist to optimize early recovery of continence, but as yet there is no composite technique that incorporates the relevant anatomic principles of minimizing damage to the urinary sphincters and their nerves, maximizing functional urethral length, creating a secure and watertight vesicourethral anastomosis, providing circumferential fascioligamentous support to the anastomosis and external sphincter, and ameliorating postoperative bladder descent. Our ten-step approach to collating these individual maneuvers into a unified technique could be used by surgeons to obtain the best possible early recovery of urinary control for their patients, without risking their oncologic outcomes.

Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging

PURPOSE

We determined whether pelvic soft tissue and bony dimensions on endorectal magnetic resonance imaging influence the recovery of continence after radical prostatectomy, and whether adding significant magnetic resonance imaging variables to a statistical model improves the prediction of continence recovery.

MATERIALS AND METHODS

Between 2001 and 2004, 967 men undergoing radical prostatectomy underwent preoperative magnetic resonance imaging. Soft tissue and bony dimensions were retrospectively measured by 2 raters blinded to clinical and pathological data. Patients who received neoadjuvant therapy, who were preoperatively incontinent or had missing followup for continence were excluded from study, leaving 600 patients eligible for analysis. No pad use defined continent. Logistic regression was used to identify variables associated with continence recovery at 6 and 12 months. We evaluated whether the predictive accuracy of a base model was improved by adding independently significant magnetic resonance imaging variables.

RESULTS

Urethral length and urethral volume were significantly associated with the recovery of continence at 6 and 12 months. Larger inner and outer levator distances were significantly associated with a decreased probability of regaining continence at 6 or 12 months, but they did not reach statistical significance for other points. Addition of these 4 magnetic resonance imaging variables to a base model including age, clinical stage, prostate specific antigen and comorbidities marginally improved the discrimination (12-month AUC improved from 0.587 to 0.634).

CONCLUSIONS

Membranous urethral length, urethral volume, and an anatomically close relation between the levator muscle and membranous urethra on preoperative magnetic resonance imaging are independent predictors of continence recovery after radical prostatectomy. The addition of magnetic resonance imaging variables to a base model improved the predictive accuracy for continence recovery, but the predictive accuracy remains low.

Choosing the best candidates for penile rehabilitation after bilateral nerve-sparing radical prostatectomy

INTRODUCTION

Controversy exists regarding the ideal candidates for penile rehabilitation after bilateral nerve-sparing radical prostatectomy (BNSRP).

AIM

To test the effect of penile rehabilitation according to preoperative patient characteristics.

METHODS

We included 435 consecutive patients treated with BNSRP between 2004 and 2008. Preoperative age, International Index of Erectile Function (IIEF) and Charlson Comorbidity Index (CCI) were used to subdivide patients into three groups according to foreseen risk of erectile dysfunction (ED) after surgery: low (age ≤65, IIEF-erectile function (EF) ≥26, CCI ≤1; N = 184), intermediate (age 66-69 or IIEF-EF 11-25, CCI ≤1; N = 115), and high (age ≥70 or IIEF-EF ≤10 or CCI ≥2; N = 136). The Kaplan-Meier method was used to test the difference in EF recovery rates among patients left untreated after surgery (N = 193), those receiving on-demand phosphodiesterase type 5 inhibitors (PDE5-I; N = 147), and those treated with chronic use of PDE5-I (taken every day or every other day for 3-6 months; N = 95). The same analyses were repeated within each risk category.

MAIN OUTCOME MEASURE

Erectile function (EF) was evaluated using the International Index of Erectile Function (IIEF). Recovery of EF after BNSRP was defined as an IIEF-EF domain score ≥22.

RESULTS

No difference in terms of EF recovery was found between patients receiving on-demand vs. daily PDE5-I (P = 0.09) in the overall population. Similarly, comparable efficacy of the two treatment schedules (on-demand vs. chronic) was demonstrated in patients with low and high risk of ED (all P ≥ 0.8). Conversely, daily therapy with PDE5-I showed significantly higher efficacy for the EF recovery rate compared with the on-demand PDE5-I administration schedule in patients with intermediate risk of ED (3-year EF recovery: 74% vs. 52%, respectively; P = 0.02).

CONCLUSION

The ideal candidates for penile rehabilitation after surgery are patients at intermediate risk of ED.

Surgical anatomy of the prostate in the era of radical robotic prostatectomy

PURPOSE OF REVIEW

New insights in the anatomy of the prostate and the surrounding tissue evolve the technique of radical prostatectomy for the treatment of prostate cancer.

RECENT FINDINGS

Regarding the course of the erectile nerves along the prostate, recent studies confirmed the presence of parasympathetic pro-erectile nerve fibers at the anterolateral aspect of the prostate. Another study of intraoperative electrostimulation of those nerves confirmed an increase in intracavernosal pressure by stimulations between the 1 and 3 o'clock position. Therefore, it is very likely that these anterior nerve fibers have an effect on erectile function. Regarding the urethral sphincter in the male, a study showed no attachment of the external sphincter to the levator ani muscle, probably resulting in an absence of a levator ani support to the continence mechanism. The male urinary sphincter seems to be in isolation responsible for urinary continence.

SUMMARY

The nerve fibers at the anterolateral aspect of the prostate seem to participate in erectile function, which renders the concept of a high anterior release during nerve sparing beneficial. The isolated urinary sphincter mechanism results in the need to conserve as much urethral length as possible during radical prostatectomy to avoid urinary incontinence.