Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function

Technical surgical skill assessment of neurovascular bundle dissection and urinary continence recovery after robotic-assisted radical prostatectomy

Purpose

To examine the association between the quality of neurovascular bundle dissection and urinary continence recovery after robotic-assisted radical prostatectomy.

Materials and Methods

Patients who underwent RARPs from 2016 to 2018 in two institutions with ≥1-year postoperative follow-up were included. The primary outcomes were time to urinary continence recovery. Surgical videos were independently assessed by 3 blinded raters using the validated Dissection Assessment for Robotic Technique (DART) tool after standardized training. Cox regression was used to test the association between DART scores and urinary continence recovery while adjusting for relevant patient features.

Results

121 RARP performed by 23 surgeons with various experience levels were included. The median follow-up was 24 months (95% CI 20 - 28 months). The median time to continence recovery was 7.3 months (95% CI 4.7 - 9.8 months). After adjusting for patient age, higher scores of certain DART domains, specifically tissue retraction and efficiency, were significantly associated with increased odds of continence recovery (p<0.05).

Conclusions

Technical skill scores of neurovascular bundle dissection vary among surgeons and correlate with urinary continence recovery. Unveiling the specific robotic dissection skillsets which impact patient outcomes has the potential to focus surgical training.

Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies

BACKGROUND

Due to the lack of sufficient evidence, it is not clear whether robotic-assisted radical prostatectomy (RARP) or laparoscopic radical prostatectomy (LRP) is better for prostate cancer. The authors conducted this study by separately pooling and analysing randomised controlled trials (RCTs) and non-randomised studies to compare the perioperative, functional, and oncologic outcomes between RARP and LRP.

METHODS

A systematic literature search was performed in March 2022 using Cochrane Library, Pubmed, Embase, Medline, Web of Science, and China National Knowledge Infrastructure. Two independent reviewers performed literature screening, data extraction and quality assessment according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Subgroup analysis and sensitivity analysis were performed.

RESULTS

A total of 46 articles were included, including 4 from 3 RCTs and 42 from non-randomised studies. For RCTs, meta-analysis showed that RARP and LRP were similar in blood loss, catheter indwelling time, overall complication rate, overall positive surgical margin and biochemical recurrence rates, but quantitative synthesis of non-randomised studies showed that RARP was associated with less blood loss [weighted mean difference (WMD)=-71.99, 95% CI -99.37 to -44.61, P <0.001], shorter catheterization duration (WMD=-1.03, 95% CI -1.84 to -0.22, P =0.010), shorter hospital stay (WMD=-0.41, 95% CI -0.68 to -0.13, P =0.004), lower transfusion rate (OR=0.44, 95% CI 0.35-0.56, P <0.001), lower overall complication rate (OR=0.72, 95% CI 0.54-0.96, P =0.020), and lower biochemical recurrence rate (OR=0.78, 95% CI 0.66-0.92, P =0.004), compared with LRP. Both meta-analysis of RCTs and quantitative synthesis of non-randomised studies showed that RARP was associated with improved functional outcomes. From the results of the meta-analysis of RCTs, RARP was higher than LRP in terms of overall continence recovery [odds ratio (OR)=1.60, 95% CI 1.16-2.20, P =0.004), overall erectile function recovery (OR=4.07, 95% CI 2.51-6.60, P <0.001), continence recovery at 1 month (OR=2.14, 95% CI 1.25-3.66, P =0.005), 3 (OR=1.51, 95% CI 1.12-2.02, P =0.006), 6 (OR=2.66, 95% CI 1.31-5.40, P =0.007), and 12 months (OR=3.52, 95% CI 1.36-9.13, P =0.010) postoperatively, and potency recovery at 3 (OR=4.25, 95% CI 1.67-10.82, P =0.002), 6 (OR=3.52, 95% CI 1.31-9.44, P =0.010), and 12 months (OR=3.59, 95% CI 1.78-7.27, P <0.001) postoperatively, which were consistent with the quantitative synthesis of non-randomised studies. When sensitivity analysis was performed, the results remained largely unchanged, but the heterogeneity among studies was greatly reduced.

CONCLUSION

This study suggests that RARP can improve functional outcomes compared with LRP. Meanwhile, RARP has potential advantages in perioperative and oncologic outcomes.

Effects of nerve-sparing procedures on surgical margins after robot-assisted radical prostatectomy

BACKGROUND

Nerve-sparing (NS) techniques could potentially increase positive surgical margins after robot-assisted radical prostatectomy (RARP). Nevertheless, the available studies have revealed ambiguous results among distinct groups. This study purposed to clarify the details of NS techniques to accurately estimate their influence on margin status.

METHODS

We studied RARPs performed by one surgeon from 2010 to 2018. Surgical margins were evaluated by the laterality and levels of NS techniques in site-specific prostate lobes. The multivariable analysis evaluated the effects of nerve-sparing procedures, combined with other covariate factors, on margin status.

RESULTS

Overall, 419 RARPs involving 838 prostate lobes were analyzed. Notably, 181 patients (43.4%) had pT2-stage, and 236 (56.6%) had pT3-stage cancer. The PSM rates for patients who underwent unilateral, bilateral, and non NS procedures were 30.3%, 28.8%, and 50%, respectively ( p = 0.233) or in stratification by pT2 ( p = 0.584) and pT3 ( p = 0.116) stage. The posterolateral PSM rates among site-specific prostate lobes were 10.9%, 22.4%, and 18.9% for complete, partial, and non NS techniques, respectively ( p = 0.001). The partial NS group revealed a significant increase in PSM rate compared with the complete NS (OR 2.187, 95% CI: 1.19-4.03) and non NS (OR 2.237, 95% CI: 1.01-4.93) groups in site-specific prostate lobes.

CONCLUSION

Partial NS procedures have a potential risk of increasing the positive surgical margins rate than complete and non NS procedures do. Therefore, correct case selection is required before performing partial NS techniques.

Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes

BACKGROUND

The use of surgical clips for athermal dissection of the lateral prostatic pedicles and ligation during pelvic lymph node dissection (PLND) while performing robotic-assisted radical prostatectomy (RARP) has been the gold standard. Clips are used to prevent thermal injury of the unmyelinated nerve fibers and lymphceles, respectively.

OBJECTIVE

To compare oncological and functional outcomes of a new technique of clipless, lateral pedicle control and PLND with RARP with bipolar energy (RARP-bi) versus the standard RARP technique with clips (RARP-c).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted among 338 men who underwent RARP between July 2018 and March 2020.

SURGICAL PROCEDURE

RARP-c versus RARP-bi.

MEASUREMENTS

We prospectively collected data and retrospectively compared demographic, clinicopathological, and functional outcome data. Urinary as well as sexual function was assessed using the Expanded Prostate Cancer Index for Clinical Practice, and complications were assessed using Clavien-Dindo grading. Multivariable regression modeling was used to examine whether the technical approach of RARP-bi versus RARP-c was associated with positive surgical margins (PSMs) or sexual and urinary function scores.

RESULTS AND LIMITATIONS

A total of 144 (43%) and 194 (57%) men underwent RARP-bi and RARP-c, respectively. Overall, there were no differences in functional and oncological outcomes between the two approaches. On multivariable regression analysis, the RARP-bi technique was not associated with significant differences in PSMs (odds ratio [OR] = 1.04, 95% confidence interval [CI] 0.6-1.8; p = 0.9), sexual function (OR = 0.4, 95% CI 0.1-1.5; p = 0.8), or urinary function (OR = 0.5, 95% CI 0.2-1.4; p = 0.2). The overall 30-d complication rates (12% vs 16%, p = 0.5) and bladder neck contracture rates (2.1% vs 3.6%, p = 0.5) were similar between the two groups. There was no difference in lymphocele complications (1.4% vs 0.52%, p = 0.58). All complications were of Clavien-Dindo grade I-II.

CONCLUSIONS

Despite the concerns for an increased risk of nerve injury secondary to the use of bipolar energy for prostatic pedicle dissection, we demonstrate that this technique is oncologically and functionally similar to the standard approach with surgical clips. There was no difference in complications or lymphocele formation for techniques with versus without clips.

PATIENT SUMMARY

We describe a modified technique for prostatic pedicle dissection during robotic-assisted radical prostatectomy, which utilizes bipolar energy and is associated with shorter operative time, without compromising functional or oncological outcomes.

Toggling Technique Allows Retrograde Early Release to Facilitate Neurovascular Bundle Sparing During Robot-Assisted Radical Prostatectomy: A Propensity Score-Matching Study

BACKGROUND

This study aimed to present the surgical facilitation of neurovascular bundle (NVB) sparing using the toggling technique (30° lens down/up switching) and to evaluate erectile dysfunction (ED) recovery after robot-assisted radical prostatectomy (RARP).

METHODS

We assessed 144 patients (group with toggling, n = 72; group without toggling, n = 72) who underwent RARP with bilateral NVB sparing using propensity score matching. Inclusion criteria were ≥ 1 year follow-up and preoperative potency as per the Sexual Health Inventory for Men (SHIM) questionnaire (≥ 17 points). Recovery of ED after RARP was defined as return to baseline sexual function or self-assessment regarding successful intercourse. The subjective surgeon's nerve sparing (SNS) score and tunneling success rates were used to evaluate surgical facilitation. The recovery rate of ED between the groups was analyzed using Kaplan-Meier analysis.

RESULTS

A better ED recovery trend was confirmed according to the SNS score (R² = 0.142, P = 0.004). In the analysis of NVB sparing ease, the toggling group showed higher SNS scores (on right/left side: P = 0.011 and < 0.001, respectively) and overall tunneling success rates (87% vs. 74%, P = 0.001) than the group without toggling. Overall, ED recovery rates were 82% (59/72) and 75% (54/72) in the groups with and without toggling, respectively, at the 1-year follow-up (P = 0.047), and the toggling group showed a faster ED recovery rate at 3 months (47% vs. 35%, P = 0.013). In a specific analysis of the potent cohort (< 60 years, bilateral full NVB spared, SHIM score ≥ 22), the ED recovery rate reached 87% (14/16) in the toggling group.

CONCLUSION

The retrograde early release with the toggling technique improves the facilitation of NVB sparing, leading to improved ED recovery.

Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation

Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP NS technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes after RARP to optimize postoperative potency.

Impact of penile rehabilitation with phosphodiesterase-5 inhibitors on recovery of erectile function in patients undergoing robot-assisted radical prostatectomy: A propensity score-matched analysis

OBJECTIVE

To investigate the impact of penile rehabilitation on the recovery of erectile function after robot-assisted radical prostatectomy.

METHODS

Patients who underwent robot-assisted radical prostatectomy in our department from 2010 to 2019 were included. For penile rehabilitation, a phosphodiesterase-5 inhibitor (tadalafil 20 mg) was administered twice a week for 1-6 months postoperatively. The International Index of Erectile Function questionnaire (question 1 and erectile function domain) and the Expanded Prostate Cancer Index Composite questionnaire (sexual function) were used.

RESULTS

After propensity score matching, there were 79 patients in the penile rehabilitation group and 79 patients in the non-penile rehabilitation group. There was no significant difference in baseline characteristics between the two groups. Significantly higher scores were seen in the penile rehabilitation group compared with the non-penile rehabilitation group at postoperative 3, 6 and 9 months in the International Index of Erectile Function questionnaire-question 1, at 3, 6, 9 and 12 months in erectile function domain, and at 3, 6, 12 and 24 months in Expanded Prostate Cancer Index Composite questionnaire sexual function (P < 0.05). There were significant improvements in the erectile recovery rate in the penile rehabilitation group compared with the non-penile rehabilitation group in the nerve sparing (P = 0.006) and partial nerve sparing (P = 0.037) groups.

CONCLUSIONS

The present findings suggest that robot-assisted radical prostatectomy patients who undergo not only nerve sparing, but also those who undergo patial nerve sparing could benefit from penile rehabilitation using a phosphodiesterase-5 inhibitor.

Optimizing Surgical Techniques in Robot-Assisted Radical Prostatectomy

Robot-assisted radical prostatectomy (RARP) is the most common surgical treatment of localized prostate cancer. The ideal procedure would achieve maximum oncological efficacy while minimizing associated side effects, such as erectile dysfunction and urinary incontinence. Surgeon experience and surgical technique affect RARP outcomes. Here, the authors review RARP technical modifications aimed at optimizing cancer control and postoperative urinary and sexual function.

Surgical management of high-risk, localized prostate cancer

High-risk prostate cancer is a heterogeneous disease that lacks clear consensus on its ideal management. Historically, non-surgical treatment was the preferred strategy, and several studies demonstrated improved survival among men with high-risk disease managed with the combination of radiotherapy and androgen deprivation therapy (ADT) compared with ADT alone. However, practice trends in the past 10-15 years have shown increased use of radical prostatectomy with pelvic lymph node dissection for primary management of high-risk, localized disease. Radical prostatectomy, as a primary monotherapy, offers the potential benefits of avoiding ADT, reducing rates of symptomatic local recurrence, enabling full pathological tumour staging and potentially reducing late adverse effects such as secondary malignancy compared with radiation therapy. Retrospective studies have reported wide variability in short-term (pathological) and long-term (oncological) outcomes of radical prostatectomy. Surgical monotherapy continues to be appropriate for selected patients, whereas in others the best treatment strategy probably involves a multimodal approach. Appropriate risk stratification utilizing clinical, pathological and potentially also genomic risk data is imperative in the initial management of men with prostate cancer. However, data from ongoing and planned prospective trials are needed to identify the optimal management strategy for men with high-risk, localized prostate cancer.

Retzius-sparing Robot-assisted Radical Prostatectomy Leads to Durable Improvement in Urinary Function and Quality of Life Versus Standard Robot-assisted Radical Prostatectomy Without Compromise on Oncologic Efficacy: Single-surgeon Series and Step-by-step Guide

BACKGROUND

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to improve continence. However, questions remain regarding feasibility and generalizability of technique and outcomes.

OBJECTIVE

To compare the outcomes of 140 consecutive standard robot-assisted radical prostatectomy (S-RARP) versus RS-RARP.

DESIGN, SETTING, AND PARTICIPANTS

A total of 70 S-RARPs were performed followed by 70 RS-RARPs. Demographic, pathologic, and functional outcomes were compared preoperatively and through 12 mo. Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) was used to compare functional outcomes. Logistic and linear regression analyses were utilized to analyze variables associated with EPIC-CP urinary incontinence and overall quality of life (QOL) scores, and oncologic outcomes. Cox regression analysis was used to analyze incontinence at 12 mo.

SURGICAL PROCEDURE

RS-RARP versus S-RARP.

MEASUREMENTS

Patient and tumor characteristics (age, body mass index, prostate-specific antigen, Charlson Comorbidity Index, Gleason group, clinical stage, and Prostate Imaging Reporting and Data System score), perioperative outcomes (console time, estimated blood loss, postoperative complications, and length of stay), oncologic outcomes (positive surgical margin [PSM], and biochemical recurrence), overall and 12-mo continence rates (zero pads and zero to one safety pad), time to continence, potency (erection sufficient for sexual activity), EPIC-CP urinary incontinence, sexual function, and overall QOL scores.

RESULTS AND LIMITATIONS

Median follow-up for S-RARP versus RS-RARP was 46.3 versus 12.3 mo. RS-RARP versus S-RARP had improved overall continence rates at total follow-up (95.7% vs 85.7%, p = 0.042) and 12-mo follow-up (97.6% vs 81.4%, p = 0.002), and faster return to continence (zero to one safety pad, 44 vs 131 d, p < 0.001). RS-RARP EPIC-CP urinary incontinence and overall QOL scores remained significantly better at 12 mo. There were no differences in overall PSM rates, although RS-RARP had lower rates of nonfocal PSMs. There were no differences in sexual function. In multivariate analysis, RS-RARP was significantly associated with improved 12-mo EPIC-CP urinary incontinence and improved QOL scores, but was not associated with PSM or biochemical recurrence. Limitations include retrospective study design and unequal follow-up; however, significantly better RS-RARP continence at 12 mo is striking despite fewer patients attaining 12-mo follow-up.

CONCLUSIONS

RS-RARP significantly improves early and long-term continence without compromising oncologic outcomes and leads to overall improved QOL.

PATIENT SUMMARY

Retzius-sparing robot-assisted radical prostatectomy is an emerging technique for robotic radical prostatectomy that improves urinary function and quality of life without compromising cancer control.

Nerve-sparing robot-assisted radical prostatectomy: Current perspectives

Robotic-assisted radical prostatectomy (RARP) is the current standard of care with long term cure in organ-confined disease. The introduction of nerve-sparing (NS) to standard RARP has shown positive results in terms of functional outcomes in addition to the oncological outcomes. This article reviews the current perspectives of NS-RARP in terms of applied anatomy of the prostatic fascial planes, the neurovascular bundle (NVB), various NS techniques and postoperative functional outcomes. A non-systematic review was done using PubMed, Embase and Medline databases to retrieve and analyse articles in English, with following keywords "prostate cancer", "robotic radical prostatectomy", "nerve-sparing". The Delphi method was used with an expert panel of robotic surgeons in urology to analyse the potency outcomes of various published comparative and non-comparative studies. The literature has shown that NS-RARP involves various techniques and approaches while there is a lack of randomized studies to suggest the superiority of one over the other. Variables such as preoperative risk assessments, baseline potency, surgical anatomy of individual patients and surgeons' expertise play a major role in the outcomes. A tailored approach for each patient is required for applying the NS approach during RARP.

[Robot-assisted radical prostatectomy. Functional result. Part I. (in Russian only)]

Robot-assisted operations as widely used in urology, gynecology, general and cardiovascular surgery are considered by many experts as a new 'gold standard' of surgical treatment of various diseases in developed countries. Robot-assisted radical prostatectomy for prostate cancer is the most common robotic procedure. Better functional outcomes of robot-assisted radical prostatectomy are due to another (new) understanding of pelvic surgical anatomy, new approach implying dissection and preservation of external urethral sphincter and neurovascular structures. Prostate neuroanatomy, various approaches to preserve neurovascular structures and own experience of nerve-sparing robot-assisted radical prostatectomy with functional results are reviewed in the article.

Precision prostate cancer surgery: an overview of new technologies and techniques

Over the past few years several new technologies have become available for the management of PCa. The implementation of robotic surgery allowed an unprecedented refinement of surgical techniques, and the RARP procedure is constantly evolving. Nowadays research is mainly focused towards a "tailored" case-specific surgical approach that might allow to achieve PCa control while preserving urinary continence and erectile function. Therefore, in contemporary urology era, several new tools have been introduced to optimize surgical planning, to aid surgical navigation, and to refine surgical execution. In this non-systematic review emerges that a better imaging technique in the preoperative setting can facilitate surgical planning. Moreover, in the intraoperative setting, new tools for image-guided surgical navigation are promising and will allow real time understanding of surgical anatomy. In the next future, a more personalized approach for the minimally invasive surgical treatment of PCa will be available, and the achievement of the best oncological and functional outcomes will be obtained.

[Ablative therapy in urology: Good practice and perspective]

INTRODUCTION

To expose the main point of discussion from present ablative therapies' guidelines and propose global perspectives.

MATERIALS AND METHODS

A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com/) using different associations of keywords "ablative therapy" ; "prostate cancer"; "kidney cancer"; "guidelines"; "hybrid operating room". Publications obtained were selected based on methodology, language and relevance.

RESULTS

Present guidelines on ablative therapies in urology are, considering authors and organs, either particularly prudent (EAU guidelines for prostate and kidney) or relatively optimistic (CIRSE guidelines). This discrepancy is related to a low level of proof. So, a new approach is mandatory: more homogeneous in methodology, and especially more open to a new organization sparing economic efficiency. The objective will be to get multifunctional and multidisciplinaries platforms, in facts and in minds. It will induce, in the future, a deep reflection about training and boundaries' specialties.

CONCLUSION

Ablative therapies represent a crucial stake for urology and a clear example of medicosurgical evolution in future, based on new technologies (energy, robotic, imaging). A serious and deep reflection is necessary to prepare it and be deeply involved in.

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

PURPOSE

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.

MATERIALS AND METHODS

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?

RESULTS

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).

CONCLUSION

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.

Nerve-sparing techniques and results in robot-assisted radical prostatectomy

Nerve-sparing techniques in robot-assisted radical prostatectomy (RARP) have advanced with the developments defining the prostate anatomy and robotic surgery in recent years. In this review we discussed the surgical anatomy, current nerve-sparing techniques and results of these operations. It is important to define the right and key anatomic landmarks for nerve-sparing in RARP which can demonstrate individual variations. The patients' risk assessment before the operation and intraoperative anatomic variations may affect the nerve-sparing technique, nerve-sparing degree and the approach. There is lack of randomized control trials for different nerve-sparing techniques and approaches in RARP, therefore accurate preoperative and intraoperative assessment of the patient is crucial. Current data shows that, performing the maximum possible nerve-sparing using athermal techniques have better functional outcomes.

Current status of various neurovascular bundle-sparing techniques in robot-assisted radical prostatectomy

Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.

Penile rehabilitation after radical prostatectomy: does it work?

CONTEXT

Erectile dysfunction (ED) represents one of the most common long-term side effects in patients with clinically localized prostate cancer (PCa) undergoing nerve-sparing radical prostatectomy (RP).

OBJECTIVE

To analyze the role of penile rehabilitation in the recovery of erectile function (EF) after nerve-sparing RP.

EVIDENCE SYNTHESIS

Penile rehabilitation is defined as the use of any intervention or combination with the goal not only to achieve erections sufficient for satisfactory sexual intercourses, but also to return EF to preoperative levels. The concept of rehabilitation is based on the implementation of protocols aimed at improving oxygenation, preserving endothelial structure, and preventing smooth muscle structural alterations. Nowadays, the most commonly adopted approaches for penile rehabilitation after nerve-sparing RP are represented by the administration of phosphodiesterase type-5 inhibitors (PDE5-Is), intracorporeal injection therapy, vacuum erection devices (VED), and the combination of these therapies. Several basic science studies support the rational for the adoption of penile rehabilitation protocols. Particularly, rehabilitation, set as early as possible, seems to be better than leaving the erectile tissues unassisted. On the other hand, results from solid prospective randomized trials finally assessing the long-term beneficial effects of PDE5-Is, intracavernosal injections, or VED on EF recovery after surgery are still lacking.

CONCLUSIONS

Although preclinical evidences support the rationale for penile rehabilitation after nerve-sparing RP, clinical studies reported conflicting results regarding its efficacy on long-term EF recovery. Nowadays, which is the optimal rehabilitation program still represents a matter of debate.

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.

Robotic colorectal surgery

INTRODUCTION

Minimally invasive surgery has many potential benefits, and the application of recently developed robotic technology to patients with colorectal diseases is rapidly gaining popularity.

QUALITY AND OUTCOMES

However, the literature evaluating such techniques, including the outcomes, risks, and costs, is limited. In this review, we evaluate and summarize the existing information, calling attention to areas where future investigation should occur.

Erectile Function Following Prostate Cancer Treatment: Factors Predicting Recovery

Prostate cancer represents the most common nonskin malignancy encountered in men, and the excellent long-term survival achieved in the majority of patients has allowed more attention to be given to the side effects associated with its treatment. Erectile function is one of the main concerns of patients when considering treatment options for prostate cancer. Not surprisingly, post-treatment sexual function is closely related to outcome satisfaction and has long-lasting effects on quality of life. Radical prostatectomy is currently the most commonly employed therapy for prostate cancer. Conflicting rates of erectile dysfunction have been reported after surgery, owing not only to different surgical techniques but also because of dissimilar patient populations and definitions. Providing accurate information to individual patients in regards to their chances of recuperating the ability to have intercourse after treatment is important not only because it allows patients to make informed decisions but also because it has the potential to reduce treatment dissatisfaction. This article mainly focuses on discussing predictors of erectile function after radical prostatectomy. Patient factors, surgical aspects, including comparisons between open, laparoscopic, and robotic approaches, and postoperative management issues that impact sexual outcomes are evaluated. Prediction models combining multiple factors are described. The definition and chronology of erectile function recovery and impact of sexual function on quality of life after surgery are also discussed. Teloken PE and Mulhall JP. Erectile function following prostate cancer treatment: Factors predicting recovery. Sex Med Rev 2013;1:91-103.

Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes

Prostate cancer is the second leading cause of cancer death among men in the USA. Use of robot-assisted radical prostatectomy (RARP) for the management of localized prostate cancer has increased dramatically in recent years. This review focuses on comparing quality of life following RARP versus retropubic radical prostatectomy. RARP is associated with improved perioperative outcomes, such as reduced blood loss and fewer transfusions. In addition, cancer control after RARP versus retropubic radical prostatectomy is equivalent, with similar incidences of positive surgical margins and comparable early oncological outcomes. RARP appears to provide advantages in recovery of continence, potency and quality of life compared with retropubic radical prostatectomy; however, methodological limitations exist in current literature.

Retrograde versus antegrade nerve sparing during robot-assisted radical prostatectomy: which is better for achieving early functional recovery?

BACKGROUND

Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated.

OBJECTIVE

To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups.

SURGICAL PROCEDURE

RARP with antegrade NS (n=172) or RARP with retrograde NS (n=172).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied.

RESULTS AND LIMITATIONS

Positive margin rates were similar (11.1% vs 6.9%; p=0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482-4.089; p=0.001) at 3, 4.024 (95% CI, 2.171-7.457; p<0.001) at 6, and 2.145 (95% CI, 1.019-4.514; p=0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study.

CONCLUSIONS

In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.

Costs of radical prostatectomy for prostate cancer: a systematic review

CONTEXT

Robot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a new approach for radical prostatectomy (RP) in patients with prostate cancer (PCa). The use of new technology may increase costs for RP.

OBJECTIVE

To summarize data on direct costs of various approaches to RP and to discuss the consequences of cost differences.

EVIDENCE ACQUISITION

A systematic literature search was performed in March 2012 using the PubMed, Web of Science, and Cochrane Library databases. A complex search strategy was applied. Articles were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Articles reporting on direct costs of RP (open retropubic [RRP], radical perineal [RPP], laparoscopic [LRP], RALP) in men with clinically localized PCa were eligible for study inclusion.

EVIDENCE SYNTHESIS

Of 1218 articles initially screened by title, the multistep, systematic search identified 11 studies presenting direct costs of different approaches to RP. Of the 11 studies, 7 compared the costs of different RP approaches. Minimally invasive RP (MIRP) (ie, LRP or RALP) was more expensive than RRP in most studies, mainly due to increased surgical instrumentation costs. In the comparative studies, costs ranged from (in US dollars) $5058 to $11,806 for MIRP and from $4075 to $6296 for RRP, with RALP having the highest direct costs. In one study applying standardized, health economic-evaluation criteria, RALP was not found to be cost effective. Limitations of this review include significant differences in observational study designs and an absence of prospective comparative studies. Moreover, there are limited post-RP data on the costs of adjuvant treatments and other health care-related expenses after PCa surgery.

CONCLUSIONS

Few studies compared direct costs of different approaches to RP. The use of new technology, particularly RALP, results in added costs for the procedure. Cost effectiveness of new technologies should be assessed before widespread adoption. To date, in the lone study to evaluate this, RALP was not found to be cost effective from a health care, economic standpoint. However, longer follow-up of patients is required to better evaluate its impact on overall costs and quality of PCa care.