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

Global research trends on the links between prostate cancer and erectile dysfunction between 2003 and 2023: A bibliometrics and visualized study

Background

The incidence of prostate cancer (PC) has increased in recent years. Erectile dysfunction (ED) after prostate cancer treatment has aroused extensive attention. Bibliometric analysis was designed to investigate a systematic understanding of developments between PC and ED during the past 20 years.

Methods

Literatures on PC and ED were retrieved from the Web of Science Core Collection database (WoSCC). By using the VOS viewer and CiteSpace software to analysis the metrics of bibliometric literature, such as number of articles, journals, countries, institutions, authors, keywords and associated information. The number of publications per year was statistically analysed and plotted thorough Microsoft Office. In addition, Pajek software was used to adjust the visual map.

Results

A total of 2332 screened articles were included in the analysis. The Journal of Sexual Medicine, ranking first among the analysed journals, published 235 articles. The United States and Canada were leaders in PC and ED research. There is a need to strengthen inter-agency cooperation in this area of research on a global scale. Mulhall JP, as the most prolific author in this area of research, published 80 articles. And Rosen RC was the author with the most co-citated (693 co-citated). The main research focus on the prevention, treatment and management of ED after PC treatment in this field through the keyword analysis.

Conclusions

Research on PC and ED is expected to expand further worldwide. We found ED, as new sustainable treatment modalities, scientific postoperative management and psychological interventions for patients, may become the research hotspots and should be closely concerned in this study.

Salvage procedures for infected penile implants: A comprehensive review and analysis of functional outcomes

BACKGROUND

The salvage procedure for infected penile implants (IPs) has been a subject of interest since its inception in the late 1980s, yet its widespread adoption remains limited. The aim of this study was to realize a systematic literature review to provide a comprehensive analysis of salvage techniques for IPs and assess their efficacy, specifically focusing on functional success.

METHODS

A systematic literature review was conducted using PubMed, employing Mesh terms related to penile prosthesis, penile implant, infection, and salvage procedures. Articles in French or English were considered for the final analysis, with exclusion of literature reviews.

RESULTS

Fifteen articles detailing various salvage techniques for IPs were identified. Mulcahy's initial technique was described in 1996, and consisted of complete removal of infected components, extensive lavage, and subsequent replacement with a similar implant. Success rates ranged from 80% to 100%, with emerging trends favoring the use of malleable implants during salvage. Unfortunately, functional data remained limited. When salvage penile prosthesis placement involved a malleable prosthesis, between 20% and 33% of patients underwent conversion to hydraulic prosthesis.

CONCLUSION

The salvage procedure for infected penile implants is a reliable method, with success rates surpassing 80%. The need for comparative studies assessing the type of implant used during salvage is required to tailor conservative management strategies for optimal patient outcomes. Finally, few data have been published regarding subsequent conversions from malleable penile implants to hydraulic penile implants after salvage.

Impact of multiparametric magnetic resonance imaging targeted biopsy on functional outcomes in patients following robot-assisted laparoscopic radical prostatectomy

Introduction

Multiparametric magnetic resonance imaging guided prostate biopsy (mpMRI PBx) leads to a higher rate of successful nerve-sparing in robot-assisted laparoscopic prostatectomy (ns-RALP) for prostate cancer (PCa). This study aimed to evaluate the impact of mpMRI PBx compared to standard ultrasound-guided PBx on functional outcomes focusing on erectile function in patients following ns-RALP.

Material and methods

All RALPs performed between 01/2016 and 06/2021 were retrospectively stratified according to (attempted) ns vs. non ns RALPs and were then categorized based on the PBx technique (mpMRI PBx vs. standard PBx). We compared RALP outcomes such as pathological tumor stage, rates of secondary nerve resection (SNR) and positive surgical margin status (PSM). Furthermore, we explored the association between PBx-technique and patient-reported outcomes assessed 12 months after RALP using the prospectively collected 26-item Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire. Chi-square tests and logistic regression analysis were conducted.

Results

A total of 849 RALPs included 517 (61%) procedures with (attempted) ns. Among these, 37.5% were diagnosed via preoperative mpMRI PBx. Patients with a preoperative standard PBx had a 57% higher association of PSM (p = 0.030) compared to patients with mpMRI PBx and a 24% higher risk of erectile dysfunction (ED) 12 months post RALP (p = 0.025). When ns was attempted, we observed a significantly higher rate of SNR in patients who underwent a standard PBx compared to those who received a mpMRI PBx (50.8% vs. 26.7%, p < 0.001) prior RALP. In comparison, upgrading occurred more often in the standard PBx group (50% vs. 40% mpMRI PBx, p = 0.008).

Conclusion

The combination of mpMRI PBx for PCa diagnosis followed by ns-RALP resulted in significantly fewer cases of SNR, better oncological outcomes and reduced incidence of ED 1 year after surgery. This included fewer PSM and a lower rate of postoperative tumor upgrading.

Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy: Does preoperative tumor recognition reduce the positive surgical margin in a specific location? Experience from a Thailand prostate cancer specialized center

Objective

Multiparametric magnetic resonance imaging (MRI) has become the standard of care for the diagnosis of prostate cancer patients. This study aimed to evaluate the influence of preoperative MRI on the positive surgical margin (PSM) rates.

Methods

We retrospectively reviewed 1070 prostate cancer patients treated with radical prostatectomy (RP) at Siriraj Hospital between January 2013 and September 2019. PSM rates were compared between those with and without preoperative MRI. PSM locations were analyzed.

Results

In total, 322 (30.1%) patients underwent MRI before RP. PSM most frequently occurred at the apex (33.2%), followed by posterior (13.5%), bladder neck (12.7%), anterior (10.7%), posterolateral (9.9%), and lateral (2.3%) positions. In preoperative MRI, PSM was significantly lowered at the posterior surface (9.0% vs. 15.4%, p=0.01) and in the subgroup of urologists with less than 100 RP experiences (32% vs. 51%, odds ratio=0.51, p<0.05). Blood loss was also significantly decreased when a preoperative image was obtained (200 mL vs. 250 mL, p=0.02). Multivariate analysis revealed that only preoperative MRI status was associated with overall PSM and PSM at the prostatic apex. Neither the surgical approach, the neurovascular bundle sparing technique, nor the perioperative blood loss was associated with PSM.

Conclusion

MRI is associated with less overall PSM, PSM at apex, and blood loss during RP. Additionally, preoperative MRI has shown promise in lowering the PSM rate among urologists who are in the early stages of performing RP.

Comparison of perioperative, oncologic, and functional outcomes between 3D and 2D laparoscopic radical prostatectomy: a systemic review and meta-analysis

Objectives

Literature regarding experience with 3D laparoscopy about prostatectomy has remained scanty, and this could be related to the rise of robotic assisted laparoscopic surgery. This study aimed to perform a systemic review and meta-analysis to evaluate the perioperative, functional, and oncologic outcomes between 3D and 2D laparoscopic radical prostatectomy (LRP).

Methods

We systematically searched the PubMed, Embase, and Cochrane Library databases for studies that compared perioperative, functional, or oncologic outcomes of both 3D and 2D LRP. The Newcastle-Ottawa Scale (NOS) tool and Jadad scale were used to assess the risk of bias in the included studies. Review Manager 5.3 was used for the meta-analysis.

Results

Seven studies with a total of 542 patients were included in the analysis. Among them, two were RCTs. There was no difference between groups in terms of preoperative characteristics. Anastomosis time, hospital day, and overall complication rates were similar in 3D than 2D group. However, operative time [mean difference (MD) -36.96; 95% confidence interval [CI] -59.25 to -14.67; p = 0.001], blood loss (MD -83.5; 95% CI -123.05 to -43.94; p <0.0001), and days of drainage (MD -1.48; 95% CI -2.29 to -0.67; p = 0.0003) were lower in 3D LRP. 2D and 3D LRP showed similarity in the positive surgical margin (PSM) rate and biochemical recurrence (BCR) rate at 3, 6, and 12months postoperatively. Additionally, there was no significant differences in continence and potency recovery rate between two group except higher continence rate of 3D LRP at 3 months.

Conclusion

Current evidence shows that 3D LRP offers favorable outcomes compared with 2D LRP, including operative time, blood loss, days of drainage, and early continence. However, there was no conclusive evidence that 3D LRP was advantaged in terms of oncologic and functional outcomes (except for continence rate at 3 months).

Systematic review registration

The study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023426403).

Assessment of the Impact of Pentafecta Parameters Affecting the Quality of Life of Patients Undergoing Laparoscopic Radical Prostatectomy

Prostate cancer is being detected in increasingly younger men. These patients expect to preserve their current quality of life and quickly recover after treatment. Medical technology and surgical techniques are advancing along with the growing expectations of patients. In addition, the universal method of assessing the quality of outcomes after operations is constantly being researched. As of today, biochemical remission alone, after radical prostatectomy, is insufficient for the patient. Therefore, multi-parametric evaluation methods are being developed, such as trifecta, which assesses biochemical remission, continence, and erectile function. The improvement over the trifecta is the pentafecta, which additionally evaluates postoperative complications and infiltration of surgical margins. Our study was conducted within a group of patients who were surgically treated for prostate cancer in 2017 at the Clinic of Urology and Urological Oncology of the Pomeranian Medical University. We recruited 237 men for the study. From that group, 131 men met the criteria to be included in the analysis. Maintaining continence (87.78%) is the easiest pentafecta parameter to obtain and will have the greatest impact on quality of life in the future. Maintaining biochemical remission (82.44%) is the second most important aspect for the patient. Retaining erectile function is the most difficult pentafecta parameter to obtain (29.01%) while having little impact on the quality of life. Negative surgical margins (66.41%) showed a negligible impact on the quality of life. The occurrence of complications (32.07%) has a negative impact on the quality of life of patients, but only during the treatment of complications.

Efficacy and Safety of Udenafil Once Daily in Patients with Erectile Dysfunction after Bilateral Nerve-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blind, Placebo-Controlled Study

PURPOSE

To evaluate the efficacy and safety of udenafil 75 mg once daily in patients with erectile dysfunction following bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (BNS-RALP).

MATERIALS AND METHODS

A multi-center, prospective, randomized, controlled, double-blind study was conducted. Among patients with localized prostate cancer with international index of erectile function-erectile function domain (IIEF-EF) score of 18 or higher before BNS-RALP, those who developed postoperative erectile dysfunction (IIEF-EF score 14 or less at 4 weeks after BNS-RALP) were enrolled. Enrolled patients were randomly assigned to the udenafil 75 mg daily group or the placebo group in a 2:1 ratio. Each subject was followed up at 8 weeks (V2), 20 weeks (V3), and 32 weeks (V4) to evaluate the efficacy and safety of udenafil.

RESULTS

In all, 101 patients were screened, of whom 99 were enrolled. Of the 99 patients, 67 were assigned to the experimental group and 32 to the control group. Ten (14.93%) patients in the experimental group and 10 (31.25%) in the control group dropped out of the study. After 32 weeks of treatment, IIEF-EF score of 22 or higher was seen in 36.51% (23/63) of patients in the experimental group and 13.04% (3/23) patients in the control group (p=0.021). The proportion of patients with IIEF-EF improvement of 25% or more compared to the baseline was 82.54% (52/63) in the experimental group and 62.96% (17/27) in the control group (p=0.058).

CONCLUSIONS

Udenafil 75 mg once daily after BNS-RALP improved the erectile function without any severe adverse effects.

An EPO ‐loaded multifunctional hydrogel synergizing with adipose‐derived stem cells restores neurogenic erectile function via enhancing nerve regeneration and penile rehabilitation

Neurogenic erectile dysfunction (nED) is one of the most common and intractable postoperative complications of rectal and prostate cancer surgery and sometimes accompanies patients lifelong. The transplantation of stem cells has been proved a promising way for treatment. However, the therapeutic efficacy is severely impaired by excessive cell loss and death and poor accumulation in the injury site along with the traditional implantation strategy. Herein, an EPO‐loaded multifunctional hydrogel was designed. The hydrogels' adhesive property and mechanical strength were enhanced by adding catechol‐catechol adducts, thus significantly improving adipose‐derived stem cells (ADSC) retention and rescuing cell loss in the injury site. Meanwhile, the sustained release of EPO effectively ameliorated the viability and paracrine activity of ADSC, leading to enhanced migration of Schwann cells and differentiation of PC12 cells in vivo. On a bilateral cavernous nerve injury rat model, the present stem cell‐EPO‐hydrogel implanted strategy could significantly alleviate erectile dysfunction. The higher expression of Tuj1 and lower expression of GFAP in the major pelvic ganglia (MPG) indicated the acceleration of neural differentiation while the suppressing development of astrocytes. Also, the combined therapy restored the expression levels of eNOs, nNOs, and α‐SMA in penile tissues, suggesting the rehabilitation of the penis. Further analysis of Masson trichrome staining and apoptosis evaluation of the corpus cavernosum showed the preservation of vascular endothelium content and the prevention of penile fibrosis after denervation. Overall, we believe that this combined strategy presents a promising way not only for restoring neurogenic erectile function but also for the clinical translation of stem cell therapy.

Validation of standardized training system for robot-assisted radical prostatectomy: comparison of perioperative and surgical outcomes between experienced surgeons and novice surgeons at a low-volume institute in Japan

INTRODUCTION

Although robot-assisted radical prostatectomy (RARP) has become a standard treatment modality in patients with prostate cancer (PCa), RARP is a complicated and difficult surgical procedure due to the risk of serious surgery-related complications. This study aimed to evaluate the validation of a standardized training system for RARP in patients with PCa at a single institute.

MATERIAL AND METHODS

We retrospectively reviewed the clinical and pathological records of 155 patients with PCa who underwent RARP at Gifu University between August 2018 and April 2021. We developed an institutional program for new surgeons based on the separation of the RARP procedure into six checkpoints. The primary endpoints were surgical outcomes and perioperative complications among three groups (expert, trainer, and novice surgeon groups).

RESULTS

The console time was significantly longer in the novice surgeon group than in the other groups. Regarding bladder neck dissection, ligation of lateral pedicles, and vesicourethral anastomosis, the operative time was significantly shorter in the expert group than in the other groups. Surgery-related complications occurred in 15 patients (9.7%).

CONCLUSIONS

Our training system for RARP might help reduce the influence of the learning curve on surgical outcomes and ensure that the surgeries performed at low-volume institutions are safe and effective.

Is there a role for stem cell therapy in erectile dysfunction secondary to cavernous nerve injury? Network meta-analysis from animal studies and human trials

Introduction:

We carried out systematic review and network meta-analysis to investigate the role of stem cell therapy (SCT) in the management of erectile dysfunction (ED) secondary to cavernous nerve injury in rats and post-radical prostatectomy (RP) in humans.

Patients and Methods:

The protocol was registered with PROSPERO database. We searched studies analyzing the efficacy of SCT for ED due to bilateral cavernous nerve injury (BCNI) in rats using Healthcare Databases Advanced Search (HDAS) Export software (MEDLINE, EMBASE, Scopus) from inception to September 2020. The outcome measurements, for 29 animal studies, were intracavernosal pressure (ICP), ICP/MAP (mean arterial pressure) ratio, and histological/molecular changes. All three available human trials evaluating SCT in post-RP ED were assessed for International Index for Erectile Function (IIEF) Score and Erection Hardness Score (EHS).

Results:

For ICP measurement, animal studies were divided into adipose-derived stem cells (ADSCs) subgroup and bone marrow–derived stem cells (BMSCs) subgroup. Pooled analysis of these studies showed a beneficial effect of SCT in improving erectile function in rats with BCNI using network meta-analysis (95% confidence interval, CI; p < 0.001). There was an increase in ICP/MAP ratio in stem cell groups (including co-intervention) compared with control BCNI group. Histological and molecular evaluation of penile tissue revealed an increase in neuronal nitric oxide synthase (nNOS), smooth muscle content, and anti-apoptotic activity. Human trials revealed improved IIEF (70–150% from baseline at 6 months) and EHS (80–200% from baseline).

Conclusion:

Our results confirm that SCT does improve the erectile function in rats having cavernous nerve injury. Similarly, early human results have shown promising results.

PROSPERO registration ID:

CRD42020201343.

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.

Post-Radical Prostatectomy Erectile Dysfunction Assessed Using the IIEF-5 Questionnaire - A Systematic Literature Review

Erectile dysfunction is common postoperative complication after radical prostatectomy. The aim of this study is to evaluate erectile dysfunction among the population of men who have undergone radical prostatectomy. Finally, 21 articles are included in the current qualitative analysis. The results suggest that recovery in potency occurs after 12 months after surgery, and that different adjuvant treatment can be used to accelerate recovery and increase effectiveness. However, conclusions are not derived from all the selected articles, but are rather based on those which present clear numerical scores according to the IIEF-5 questionnaire.

Assessment of changes in penile sensation by electrophysiological study after radical prostatectomy: A pilot study

Background:

To evaluate the changes in penile sensation by electrophysiological tests in patients who underwent radical prostatectomy (RP) and to demonstrate the role of dorsal penile nerve injury in postoperative erectile dysfunction.

Materials and methods:

Twenty-six volunteer patients who were eligible for RP were included in the study. Preoperative penile sensory electromyography and the International Index of Erectile Function-5 (IIEF-5) questionnaire were done for each patient. Erectile function assessment and electrophysiological evaluation of penile sensation were repeated at postoperative 3rd and 6th months.

Results:

Postoperative IIEF-5 scores and electromyography values were significantly lower than preoperative findings (p < 0.05). The IIEF-5 scores in the nerve sparing-RP (NS-RP) group were significantly higher than the non-nerve sparing-RP (NNS-RP) group in the postoperative period. Nerve conduction velocity values in the NS-RP group were also higher than the NNS-RP group at the postoperative 3rd and 6th months. However, these changes were not statistically significant (p > 0.05).

Conclusions:

Patients who underwent RP have decreased penile sensation due to cavernous nerve damage and a possible dorsal penile nerve injury. The decrease of penile sensation may be associated with postoperative erectile dysfunction.

Focusing on sexual rehabilitation besides penile rehabilitation following radical prostatectomy is important

Erectile dysfunction is commonly reported after radical prostatectomy. Besides the loss of erections, sexual life after prostatectomy is impacted by urinary incontinence, orgasmic dysfunction, and psychological stress. In this review, we describe classical medical therapies used for erectile function rehabilitation such as PDE5 inhibitors and injection therapy. A vast amount of data support the idea of focusing on restoration of sexual function on top of erectile function after prostatectomy. The important strategies described to rehabilitate sexual function include pelvic floor muscle therapy, couple therapy, appropriate preoperative counseling, and focusing on non-penetrative alternatives. A multidisciplinary approach and including the partner is important. Erectile function alone is not sufficient for satisfactory sexual experience and may not be used as a proxy for sexual quality of life. Adding full-spectrum sexual rehabilitation to a standard penile rehabilitation regimen has the highest chances of obtaining satisfactory sexual outcomes in men and their partners after radical prostatectomy.

Climacturia: a comprehensive review assessing pathophysiology, prevalence, impact, and treatment options regarding the "leak of pleasure"

Aim of this review is to summarize and evaluate the current literature on the pathophysiology, prevalence, sociosexual impact, and potential treatment options of climacturia. Climacturia, defined as orgasm-associated urinary incontinence and characterized by great prevalence variability, ranging between 15.7 and 93% was, so far, a relatively neglected post-radical prostatectomy functional side-effect. Recent studies have shown that it can significantly impact the quality of life of couples after prostate cancer treatment. A knowledge gap characterizes the pathophysiologic pathways while treatment is based on empirically chosen treatment options (condom use, presexual intercourse urination) or on therapeutic modalities proposed by low-quality studies (pelvic floor muscle training, penile applied devices). Evidence regarding efficacy of surgical techniques (artificial urinary sphincter, male sling, or dual implantation of penile prosthesis with a sling) for climacturia treatment are limited but with an increasing trend of relevant published data in the last 5 years. The mini-jupette sling plus inflatable penile prosthesis placement is a promising surgical technique that has been studied in a multi-institutional cohort with encouraging results regarding climacturia, erectile dysfunction, and mild-incontinence control. However, future studies with longer follow-up and larger sample sizes are certainly needed to confirm the long-term safety and benefits of this intervention.

Enhanced effects of salidroside on erectile function and corpora cavernosa autophagy in a cavernous nerve injury rat model

We explored the efficacy and mechanisms of salidroside treatment for erectile dysfunction induced by bilateral cavernous nerve injury (BCNI). Forty male rats were divided into four groups as follows: sham (cavernous nerves exposed only) (S); BCNI (M); BCNI + rapamycin (M + rapamycin); and BCNI + salidroside (M + salidroside). Erectile function in the rats was measured by intracavernosal pressure. Penile tissue was harvested for transmission electron microscopy, immunohistochemistry, immunofluorescence, Masson's trichrome staining, haematoxylin-eosin staining, TdT-mediated dUTP Nick End Labeling and western blotting. The M group exhibited a decrease in erectile responses and increased apoptosis and fibrosis compared to these in the S group. Meanwhile, nerve content and the penile atrophy index were also decreased in the M group. Treatment with salidroside and rapamycin for 3 weeks partially restored erectile function and significantly attenuated corporal apoptosis, fibrosis, nerve content and penile atrophy in the M group. Moreover, the autophagy level was further enhanced in the M + salidroside group, which was the same as that in the positive observation group (M + rapamycin). Salidroside treatment not only improved erectile function in rats with BCNI, but also inhibited apoptosis and fibrosis and ameliorated the loss of nerve content and endothelial and corpus cavernosum smooth muscle cells by promoting protective autophagy.

A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy

BACKGROUND

Although the concept of penile rehabilitation after radical prostatectomy (RP) has been advocated for decades, there is little definitive evidence regarding its utility or the best strategy to optimize patient outcomes.

AIM

The goal of this study is to analyze the ability of 3 different pharmacological strategies to preserve the ability of men to achieve spontaneous (non-medication assisted) erections after bilateral nerve-sparing RP.

METHODS

This IRB- and FDA-approved study studied penile rehabilitation in a 3-arm fashion with a target enrollment of 200 patients. (i) Control arm: nightly placebo with sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (ii) nightly sildenafil arm: nightly sildenafil 50 mg and sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (iii) combination therapy arm: nightly sildenafil 50 mg (5 nights/week) plus intracavernosal injections twice/week. Inclusion criteria included bilateral nerve-sparing surgery, normal serum total testosterone, and good preoperative baseline erectile function as measured by the erectile function domain score of the IIEF (EFD) (≥24). Patients were followed with a medication use diary and the IIEF questionnaire at 6 weeks, 3 m, 6 m, 12 m, 18 m and 24 m.

OUTCOMES

A difference was seen in the IIEF-EFD scores between the 3 groups at 24 months after RP. Secondary end points include the time to return of spontaneous functional erections, the time for patients to respond to oral erectogenic therapy, and the proportion of patients who have normalization of their IIEF-EFD scores.

RESULTS

The study was interrupted because of failure to recruit the target study population in a reasonable timeframe. A total of 76 subjects with median age of 57 (IQR: 51, 63) years and mean IIEF-EFD of 29 (IQR: 27, 30) were initially randomized, but at 24 months, the sample sizes by group were (i) n = 4; (ii) n = 18; and (iii) n = 10, with median IIEF-EFD 24 (IQR: 18, 28), 24 (IQR: 18, 28), and 21 (IQR: 9, 26), respectively. There was no statistical difference among the groups in the final analysis.

CLINICAL IMPLICATIONS

Definitive evidence for the ability of different pharmacological rehabilitation strategies to improve long-term EF outcomes might never be available.

STRENGTHS & LIMITATIONS

This was a well-designed randomized and 3-arm designed trial intended to provide decisive evidence regarding the utility of penile rehabilitation. Failure to recruit the target population is the main limitation.

CONCLUSION

The limited number of patients in the present trial precludes definitive interpretation. However, results indicate how challenging it is to conduct true rehabilitation studies. Miranda EP, Benfante N, Kunzel B, et al. A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy. J Sex Med 2021;18:423-429.

Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery

A nerve-sparing procedure during robot-assisted radical prostatectomy has been considered one of the most important techniques for preserving postoperative genitourinary function. The reason is that adequate nerve-sparing procedures could preserve both erectile function and lower urinary tract function after surgery. When a nerve-sparing procedure is carried out, the cavernous nerves themselves cannot be visualized, despite the magnified viewing field during robot-assisted radical prostatectomy. Thus, nerve-sparing procedures have been considered challenging operations, even now. However, because not all surgeons have carried out a sufficient number of nerve-sparing procedures, the development of new nerve-sparing procedures or new methods for mapping the cavernous nerves is required. Recently, various new operative techniques, for example, Retzius-sparing robot-assisted radical prostatectomy, transvesical robot-assisted radical prostatectomy and retrograde release of neurovascular bundle technique during robot-assisted radical prostatectomy, have been developed. In addition, new surgical devices, for example, biological/bioengineering solutions for cavernous nerve protection and devices for identifying the cavernous nerves during radical prostatectomy, have developed to preserve the cavernous nerves. In contrast, limitations or problems in preserving cavernous nerves and postoperative erectile function have become apparent. In particular, the recovery rate of erectile function, the positive surgical margin rate at the site of nerve-sparing and the indications for nerve sparing have become obvious with the accumulation of much evidence. Furthermore, predictive factors for postoperative erectile function after nerve-sparing procedures have also been clarified. In this article, the importance of a comprehensive approach for early recovery of erectile function in the robot-assisted radical prostatectomy era is discussed.

Generating comprehensive comparative evidence on various interventions for penile rehabilitation in patients with erectile dysfunction after radical prostatectomy: a systematic review and network meta-analysis

Background

We aim to present a comprehensive comparison of various treatments in the management of penile recovery after radical prostatectomy (RP) and provide recommendations for future research.

Methods

Literature search of electronic databases including PubMed, the Cochrane Library, Embase, PsycInfo, and Web of Science, and manual retrieval were conducted from inception through March 2020. “Erectile dysfunction” and “prostatectomy” were used as the Mesh terms. The patients, intervention, comparison, outcome, and study design (PICOS) approach were used to define study eligibility. Two authors independently selected studies, evaluated the methodological quality, and extracted data using Cochrane Collaboration’s tools. The data analysis was completed by STATA version 14.2.

Results

A total of 24 studies with 3,500 patients were incorporated in the final analysis after screening 6,131 records. Our findings indicated that vacuum constriction devices (VCD) ranked 1st which meant that patients in VCD group had the best effect regarding mean IIEF scores within 3 months after RP, and no significant difference was observed between VCD and VCD with 20 mg/day tadalafil (V20DT) (MD: 5.44; 95% CI: −0.81 to 11.69). VCD and 50 mg/day sildenafil (VC50DS) showed superiority over 50 mg/day sildenafil (50DS) (MD: 3.75; 95% CI: 2.74–4.76) and intraurethral alprostadil 125–250 µg (MD: 3.05; 95% CI: 0.38 to 5.72), respectively. Moreover, V20DT showed significant superiority over the other interventions for ≥6 months mean International Index Erectile of Function (IIEF) scores after RP. Monotherapy appeared to have similar efficacy in terms of mean IIEF scores and proportion of patients return to baseline, and the effect of phosphodiesterase type 5 inhibitors (PDE5is) did not seem to be affected by the patterns of administration (regular or on demand).

Conclusions

The combination therapy showed certain advantages over monotherapy, and we recommended the combination of VCD and PDE5is to be considered in the clinical management of penile rehabilitation after RP.

Autologous fat grafting for nerve regeneration and neuropathic pain: current state from bench-to-bedside

Despite recent advances in microsurgical techniques, functional recovery following peripheral nerve injury remains slow and inadequate. Poor peripheral nerve regeneration not only leaves patients with significant impairments, but also commonly leads to the development of debilitating neuropathic pain. Recent research has demonstrated the potential therapeutic benefits of adipose-derived stem cells, to enhance nerve regeneration. However, clinical translation remains limited due to the current regulatory burdens of the US FDA. A reliable and immediately translatable alternative is autologous fat grafting, where native adipose-derived stem cells present in the transferred tissue can potentially act upon regenerating axons. This review presents the scope of adipose tissue-based therapies to enhance outcomes following peripheral nerve injury, specifically focusing on their role in regeneration and ameliorating neuropathic pain.

Aging and erectile function

The authors review and discuss numerous factors that influence erectile function and their interactions, based on the published literature. Of critical importance are vascular nitric oxide; nutrition; exercise; weight control and maintaining insulin sensitivity; early treatment of hypertension with attention to effects on erectile function; avoiding sources of oxidative stress such as obesity and smoking; reducing inflammation (e.g. from gingivitis); improving pelvic floor muscle strength; and inhibiting cyclic GMP break-down. The described interventions act on different aspects of erectile biochemistry and physiology. Therefore, combining multiple therapeutic approaches will yield maximum benefits for erectile and vascular and general health.

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.

Impact of Sarcopenia on Erectile Function after Nerve-Sparing Robot-Assisted Radical Prostatectomy

PURPOSE

To determine the impact of sarcopenia on erectile functional outcomes after a nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) using patient-reported validated questionnaires.

MATERIALS AND METHODS

In this retrospective study, RARP was performed on 841 patients at Okayama University Hospital, of which 132 underwent NS RARP. Erectile functional outcomes were assessed using the 5-item version of the International Index of Erectile Function (IIEF-5) and the Expanded Prostate Cancer Index Composite before and 1, 3, 6, and 12 months after surgery. Automated measurement of skeletal muscle at L3 was achieved using volume analyzer software and normalizing for height (cm²/m²) to calculate skeletal muscle index (SMI). Patients who had an IIEF-5≤4 comprised the group with erectile dysfunction (ED), and those with an IIEF-5≤5 made up the non-ED group.

RESULTS

This study enrolled 95 patients of median age 65 years with a preoperative IIEF-5 of 16. There were no significant differences between patients with and without sarcopenia among those with preoperative IIEF-5. Postoperatively, in the ED group, SMI and preoperative IIEF-5 were significantly lower than in the non-ED group. Multiple linear regression analysis revealed that (1) both SMI and preoperative IIEF-5 were independent predictors of ED, and (2) sarcopenia and preoperative IIEF-5 were predictors of ED at 12 months after NS RARP.

CONCLUSIONS

Patients with sarcopenia can have worse erectile functional outcomes after NS RARP. Sarcopenia and a lower preoperative IIEF-5 score may be predictive of postoperative ED.

Current management strategy of treating patients with erectile dysfunction after radical prostatectomy: a systematic review and meta-analysis

The aim of this study is to present a summary of current evidence concerning the various treatments in the management of penile rehabilitation after radical prostatectomy (RP) and provide recommendations for future research. Randomized controlled trials (RCTs) were identified from electronic databases including PubMed, the Cochrane Library, Embase, and Web of Science from inception through March 2020 with no limitation to language. Comparable data from each study were combined in a meta-analysis where possible, otherwise data were synthesized narratively. The data analysis was completed by Review Manager version 5.3. A total of 39 RCTs were included in this study. At present, phosphodiesterase type 5 inhibitors (PDE5is) remain the first-line treatment for patients with erectile dysfunction (ED) after RP. Compared with the placebo group, patients in regular PDE5is group (mean difference (MD): 0.76; 95% confidence interval (CI): 1.69-4.44; p < 0.0001) and on demand group (MD: 3.92; 95% CI: 2.95-4.88; p < 0.00001) had a significantly higher mean Erectile Function domain of the International Index of Erectile Function (IIEF-EF) scores within 3 months after RP. As for the proportion of IIEF-EF ≥ 22, patients in regular PDE5is group and on demand PDE5is group had significantly higher proportion than those in placebo group 6 months after RP, and the odds ratios were 1.87 (95% CI: 1.32-2.66; p = 0.0005) and 2.17 (95% CI: 1.20-3.93; p = 0.01), respectively. No significant difference was observed between regular PDE5is group and on demand group regardless of mean IIEF-EF score or the proportion of IIEF-EF ≥ 22. Intracorporeal injection therapy seemed to have similar efficacy to PDE5is. The International Index of Erectile Function-5 items (IIEF-5) scores were significantly higher in vacuum constriction devices group than control group at 6-9 months after RP (MD: 6.70, 95% CI: 2.30-11.10, p = 0.003) with great between-study heterogeneity (p = 0.06, I² = 72%). The other therapeutics including low-intensity extracorporeal shockwave therapy, statin therapy, psychotherapy interventions, and pelvic floor muscle training plus electrical stimulation showed certain improvement on erectile function. We found that the combination therapy showed certain advantages over monotherapy. Currently, PDE5is-based combination therapy remains the mainstream treatment for ED after RP. Intracorporeal injection therapy and vacuum therapy could be served as alternative treatments if PDE5is are ineffective and contraindicated.

The role of body image in treatment decision-making and post-treatment regret following prostatectomy

Three main treatments are offered to men with localised prostate cancer: active monitoring, radiotherapy and prostatectomy. The aim of this research was to explore the role of body image in treatment decision-making and post-treatment regret following prostatectomy for localised prostate cancer. Data were collected via nine semi-structured interviews. Interviews underwent thematic analysis and four themes emerged: need to prolong life, loss of function and self, post-surgery effects on body image and confidence, and coping strategies. Participants revealed that loss of erectile function following surgery resulted in reduced self-confidence, and changes in their perception of their body.

Pericyte-Derived Extracellular Vesicle-Mimetic Nanovesicles Restore Erectile Function by Enhancing Neurovascular Regeneration in a Mouse Model of Cavernous Nerve Injury

BACKGROUND

Extracellular vesicle (EV)-mimetic nanovesicles (NVs) from embryonic stem cells have been observed to stimulate neurovascular regeneration in the streptozotocin-induced diabetic mouse. Pericytes play important roles in maintaining penile erection, yet no previous studies have explored the effects of pericyte-derived NVs (PC-NVs) in neurovascular regeneration in the context of erectile dysfunction.

AIM

To investigate the potential effect of PC-NVs in neurovascular regeneration.

METHODS

PC-NVs were isolated from mouse cavernous pericytes, and neurovascular regeneration was evaluated in an in vitro study. Twelve-week-old C57BL/6J mice were used to prepare cavernous nerve injury model. Erectile function evaluation, histologic examination of the penis, and Western blots were assessed 2 weeks after model creation and PC-NVs treatment.

OUTCOMES

The main outcomes of this study are PC-NVs characterization, intracavernous pressure, neurovascular regeneration in the penis, and in vitro functional evaluation.

RESULTS

The PC-NVs were extracted and characterized by cryotransmission electron microscopy and EV-positive (Alix, TSG101, CD81) and EV-negative (GM130) markers. In the in vivo studies, PC-NVs successfully improved erectile function in cavernous nerve injury mice (∼82% of control values). Immunofluorescence staining showed significant increases in pericytes, endothelial cell, and neuronal contents. In the in vitro studies, PC-NVs significantly increased mouse cavernous endothelial cells tube formation, Schwann cell migration, and dorsal root ganglion and major pelvic ganglion neurite sprouting. Finally, Western blot analysis revealed that PC-NVs upregulated cell survival signaling (Akt and eNOS) and induced the expression of neurotrophic factors (brain-derived neurotrophic factor, neurotrophin-3, and nerve growth factor).

CLINICAL IMPLICATIONS

PC-NVs may be used as a strategy to treat erectile dysfunction after radical prostatectomy or in men with neurovascular diseases.

STRENGTHS & LIMITATIONS

We evaluated the effect of PC-NVs in vitro and in a mouse nerve injury model, cavernous nerve injury. Additional studies are necessary to determine the detailed mechanisms of neurovascular improvement. Further study is needed to test whether PC-NVs are also effective when given weeks or months after nerve injury.

CONCLUSION

PC-NVs significantly improved erectile function by enhancing neurovascular regeneration. Local treatment with PC-NVs may represent a promising therapeutic strategy for the treatment of neurovascular diseases. Yin GN, Park S-H, Ock J, et al. Pericyte-Derived Extracellular Vesicle-Mimetic Nanovesicles Restore Erectile Function by Enhancing Neurovascular Regeneration in a Mouse Model of Cavernous Nerve Injury. J Sex Med 2020;17:2118-2128.

Role of application of tadalafil 5 mg once-daily (≥6 months) in men with erectile dysfunction from six randomized controlled trials

This meta-analysis was performed to assess the efficacy and safety of taking tadalafil 5 mg once-daily for at least 6 months in the treatment of erectile dysfunction (ED). Based on databases: MEDLINE, EMBASE and Cochrane Controlled Trials Register, this analysis was performed to collect randomized controlled trials (RCTs) of tadalafil 5mg once-daily in treating ED over 6 months. Reviewers also investigated the references of each literature. The meta-analysis covered a total of 1,596 patients in six RCTs. The tadalafil group performed a better effect in terms of the international index of erectile function-erectile function (IIEF) domain (P=0.005) for the treatment of ED compared with the placebo group. Safety assessments including discontinuations due to adverse events (AEs) (P=0.31) and treatment-emergent AEs (P=0.06) indicated that the tadalafil group had a better tolerate. The analysis elucidates that the dose of 5 mg per day of tadalafil showed a good effect after the treatment of at least 6 months relative to the control group with fewer side effects.

Three-piece inflatable penile prosthesis: Ectopic reservoir placement

INTRODUCTION

The complications associated to the placement of the reservoir are infrequent but potentially serious. Therefore, technical alternatives have been developed for the performance of the procedure in different locations (ectopic). The aim of this review is to revise the evidence available on the different options for the ectopic placement of the reservoir.

MATERIAL AND METHOD

Narrative review based on a bibliographical search limited to PubMed- indexed relevant manuscripts, in Spanish or English, for the period 2000-2019, using «penile prosthesis», «ectopic reservoir», radical prostatectomy», «radical cystectomy», «pelvic radiotherapy», and «renal transplantation» as key words. Non original articles and reviews were not considered eligible. A total of 11 manuscripts were included.

RESULTS

Pelvic alterations after surgery and/or radiotherapy increase the difficulty in the placement of the prosthesis reservoir. In order to minimize the risk of complications, different modifications have been performed on the devices, and technical innovations have been developed for the submuscular placement of the reservoir. The available evidence regarding the functionality and complications of these techniques is limited to single institution, low volume, and retrospective series with short follow-up periods. The functionality seems to be adequate using the adapted devices. The complications are infrequent and mild in severity.

CONCLUSIONS

Although the available evidence is still limited, the ectopic placement of the reservoir may be considered a safe, effective, and reproducible technique. In addition, it may result particularly useful in cases of altered pelvic anatomy.

Intracavernous injection of size-specific stem cell spheroids for neurogenic erectile dysfunction: Efficacy and risk versus single cells

BACKGROUND

Intracavernous injection (ICI) of adipose-derived stem cells (ADSCs) has been demonstrated promising for neurogenic erectile dysfunction (ED). However, due to the sponge-like structure of corpus cavernosum (CC) with abundant vessels, ICI was indeed like intravenous injection. Thus, the cell escaping may be a concern of safety and limited therapy, but the issue has not been clearly demonstrated yet.

METHODS

Suspensions of free ADSCs (FAs) and ADSCs-based spheroids (ASs) with suitable size were intracavernously injected at doses of 0.5, 1, 2, or 4 million cells. The cell loss and safety after ICI, erectile function and histopathologic change, etc. were analyzed with multimodality of methods.

FINDINGS

Most FAs escaped from sponge-like CC after ICI due to their small size, weakening stem-cell therapeutic efficacy. Worse still, the escaped cells were shown to cause widespread pulmonary embolism (PE), and even death in some animals. Further, it was founded that the therapeutic effect of FAs may be ascribed to the larger cell clusters which spontaneously aggregated before ICI and were trapped within CC after ICI. In comparison, cell loss and PE were significantly avoided by transplanting ASs. Importantly, better therapeutic outcomes were detected after ICI of ASs when compared to FAs with the same cell number.

INTERPRETATION

Transplantation of size-specific ASs instead of single-cell suspension of FAs for neurogenic ED may be a wiser choice to achieve steady therapeutic outcome and to reduce risks for the future clinical application. FUND: This work was supported by the National Natural Science Foundation of China (81701432) (to Y. Xu). Youth Training Project for Medical science (16QNP129) and Beijing Nova Program of science and technology (Z171100001117115) (to Z. Liu).

Erectile Function and Sexual Satisfaction: The Importance of Asking About Sexual Desire

INTRODUCTION

Erectile function, libido, and sexual bother are incompletely correlated: a man may or may not be satisfied for a given level of erectile function; similarly, 2 men may have the same erectile function and different levels of sexual desire.

AIM

To explore the relationship between erectile function, sexual satisfaction and sexual desire.

METHODS

We examined the Spearman correlation among erectile function (International Index of Erectile Function [IIEF-6]), sexual desire, and sexual bother in 3,944 questionnaires completed by patients after radical prostatectomy as part of routine care. IIEF-6 scores were adjusted if a patient indicated that the reason for not having intercourse was other than lack of ability of confidence (eg, lack of partner).

MAIN OUTCOME MEASURE

Patient-reported outcome instruments.

RESULTS

Median age at surgery and preoperative IIEF-6 were 63 years and 26, respectively. Among questionnaires completed after surgery, there was moderate correlation among the IIEF-6 score and both sexual desire (Spearman rho: 0.41) and sexual bother (Spearman rho: 0.30). In men who reported high or moderate bother relating to sexual function, there was a narrow distribution of erectile function scores, with most men reporting poor function (median IIEF-6: 6, interquartile range 3, 11). For men who reported small or no problem with sexual function, the distribution of erectile function scores was wide, and particularly bimodal as a function of sexual desire. Among patients with high desire, the correlation between sexual bother and erectile function was 0.61 (ie, the poorer is your function, the greater you are bothered), whereas it was -0.081 among patients with low desire, meaning that some men are not bothered by poor erections.

CLINICAL IMPLICATIONS

We provided useful insights to help physicians during sexual counselling after surgery for prostate cancer.

STRENGTH & LIMITATIONS

The study included a large number of patients and provides evidence for implementation of patient-reported outcome insturments. Limitations include the retrospective nature of our data.

CONCLUSION

Sexual desire helps explain the moderate correlation between erectile function and sexual bother. Sexual desire and bother questions should be incorporated in patient-reported outcome instruments for male sexual function. Bravi CA, Tin A, Montorsi F, et al. Erectile Function and Sexual Satisfaction: The Importance of Asking About Sexual Desire. J Sex Med 2020;17:349-352.

Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model

INTRODUCTION

The human placenta provides a bountiful and noncontroversial source of stem cells which have the potential for regeneration of injured tissue. These cells may restore erectile function after neurovascular tissue injury such as that seen in radical pelvic surgeries and pelvic trauma.

AIM

To determine the effect of human placenta-derived stem cells on erectile function recovery and histological changes at various time points in a cavernous nerve injury rat model and to study the fate of injected stem cells throughout the regenerative process.

METHODS

Human placental stem cells (PSCs) were dual labeled with monomeric Katushka far red fluorescent protein (mKATE)-renLUC using a lentivirus vector. A pelvic neurovascular injury-induced erectile dysfunction model was established in male, athymic rats by crushing the cavernous nerves and ligating the internal pudendal neurovascular bundles, bilaterally. At the time of defect creation, nonlabeled PSCs were injected into the corpus cavernosum at a concentration of 2.5 × 10⁶ cells/0.2 mL. The phosphate-buffered saline-treated group served as the negative control group, and age-matched rats (age-matched controls) were used as the control group. Erectile function, histomorphological analyses, and Western blot were assessed at 1, 6, and 12 weeks after model creation. The distribution of implanted, dual-labeled PSCs was monitored using an in vivo imaging system (IVIS). Implanted cells were further tracked by detection of mKATE fluorescence in histological sections.

MAIN OUTCOME MEASURE

The main outcome measure includes intracavernous pressure/mean arterial pressure ratio, neural, endothelial, smooth muscle cell regeneration, mKATE fluorescence, and IVIS imaging.

RESULTS

The ratio of intracavernous pressure to mean arterial pressure significantly increased in PSC-injected rats compared with phosphate-buffered saline controls (P < 0.05) at the 6- and 12-week time points, reaching 72% and 68% of the age-matched control group, respectively. Immunofluorescence staining and Western blot analysis showed significant increases in markers of neurons (84.3%), endothelial cells (70.2%), and smooth muscle cells (70.3%) by 6 weeks in treatment groups compared with negative controls. These results were maintained through 12 weeks. IVIS analysis showed luminescence of implanted PSCs in the injected corpora immediately after injection and migration of cells to the sites of injury, including the incision site and periprostatic vasculature by day 1. mKATE fluorescence data revealed the presence of PSCs in the penile corpora and major pelvic ganglion at 1 and 3 days postoperatively. At 7 days, immunofluorescence of penile PSCs had disappeared and was diminished in the major pelvic ganglion.

CLINICAL IMPLICATIONS

Placenta-derived stem cells may represent a future "off-the-shelf" treatment to mitigate against development of erectile dysfunction after radical prostatectomy or other forms of pelvic injury.

STRENGTH & LIMITATIONS

Single dose injection of PSCs after injury resulted in maximal functional recovery and tissue regeneration at 6 weeks, and the results were maintained through 12 weeks. Strategies to optimize adult stem cell therapy might achieve more effective outcomes for human clinical trials.

CONCLUSION

Human PSC therapy effectively restores the erectile tissue and function in this animal model. Thus, PSC therapy may provide an attractive modality to lessen the incidence of erectile dysfunction after pelvic neurovascular injury. Further improvement in tissue regeneration and functional recovery may be possible using multiple injections or systemic introduction of stem cells. Gu X, Thakker PU, Matz EL, et al. Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model. J Sex Med 2020;17:400-411.

A prospective study of erectile dysfunction in men after pelvic surgical procedures and its association with non-modifiable risk factors

Objective

A pelvic surgery can cause erectile dysfunction. The purpose of this study was to evaluate erectile function at various times after pelvic surgery in male patients; to search the non-modifiable risk factors associated with the presence and intensity of sexuality in these patients. This prospective study used the erectile dysfunction IIEF scale.

Results

The study population comprised of 106 male patients who had undergone minor pelvic surgery at least 9 months before and during the 2010–2016 period in the 4th Surgical Clinic. A control group of healthy males (N = 106) who underwent no pelvic surgery matched for age was also used for reference values. The main age of the participants was 66.16 ± 13.07 years old. A history of colectomy was present in 36.8%, 18.9% had undergone sigmoidectomy, and 33% inguinal hernia repair. The percentage of severe erectile function increased from 38.7% before surgery to 48.1% (25% increase) after surgery, at the end of the follow-up period (p < 0.05). In the multivariate analysis model, age emerged as an independent predictor of erectile function (p < 0.001). Age was the most important determinant of the IIEF score, which was aggravated by 25% from the first to the last assessment of patients.

Improved patient-reported functional outcomes after nerve-sparing radical prostatectomy by using NeuroSAFE technique

Purpose: To explore whether prostatectomized men report improved post-operative erectile function and urinary control dependent on the application of intra-operative frozen section examination (NeuroSAFE) during nerve-sparing radical prostatectomies (NS-RPs).Methods: Pre- and post-RP responses to the sexual domain and the urinary incontinence subscale of EPIC-26 were analyzed in 95 and 312 men from a NeuroSAFEGroup (Martini-Klinik, Hamburg, Germany) and a Non-NeuroSAFE Group (Oslo University Hospital, Norway), respectively, undergoing NS-RPs for ≤ cT2 prostate cancer. All patients had intra-prostatic tumors as evaluated by Digital Rectal Examination. Statistical significance in bivariate and multi-variable analyses: p < 0.05.Results: With similar oncological outcomes and not associated with the performance of bilateral or unilateral NS-RP within each group patients from the NeuroSAFE Group had better sexuality outcomes than those from the NonNeuroSAFE Group (p < 0.01). Age and pre-RP sexual function represented significant co-variables. In pre-RP potent men, erectile function was preserved in 74% of men in the NeuroSAFE Group and in 46% in those from the NonNeuroSAFE Group (p < 0.01). Any superior continence-saving effect of NeuroSAFE was limited. The non-randomized small-sized observational study design represents the observations' main limitation.Conclusions: Our study indicates that NeuroSAFE contributes to preservation of post-RP erectile function. If confirmed in a randomized trial the NeuroSAFE should be applied in patients undergoing NS-RP for maximal preservation of post-RP sexual function.

Assessment of Return to Baseline Urinary and Sexual Function Following Primary Focal Cryotherapy for Nonmetastatic Prostate Cancer

BACKGROUND

The oncological outcomes in men with clinically significant prostate cancer following focal cryotherapy are promising, although functional outcomes are under-reported.

OBJECTIVE

To determine the impact of focal cryotherapy on urinary and sexual function, specifically assessing return to baseline function.

DESIGN, SETTING, AND PARTICIPANTS

Between October 2013 and November 2016, 58 of 122 men who underwent focal cryotherapy for predominantly anterior clinically significant localised prostate cancer within a prospective registry returned patient-reported outcome measure questionnaires, which included International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-15) questionnaires.

INTERVENTION

Standard cryotherapy procedure using either the SeedNet or the Visual-ICE cryotherapy system.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary outcome was return to baseline function of IPSS score and IIEF erectile function (EF) subdomain. Cumulative incidence and Cox-regression analyses were performed.

RESULTS AND LIMITATIONS

Probability of returning to baseline IPSS function was 78% at 12 mo and 87% at both 18 and 24 mo, with recovery seen up to 18 mo. For IIEF (EF domain), the probability of returning to baseline function was 85% at 12 mo and 89% at both 18 and 24 mo, with recovery seen up to 18 mo. Only the preoperative IIEF-EF score was associated with a poor outcome (hazard ratio 0.96, 95% confidence interval 0.93-0.999, p =  0.04). The main limitation was that only half of the patients returned their questionnaires.

CONCLUSIONS

In men undergoing primary focal cryotherapy, there is a high degree of preservation of urinary and erectile function with return to baseline function occurring from 3 mo and continuing up to 18 mo after focal cryotherapy.

PATIENT SUMMARY

In men who underwent focal cryotherapy for prostate cancer, approximately nine in 10 returned to their baseline urinary and sexual function. Keeping in mind that level 1 evidence and long-term data are still needed, in men who wish to preserve urinary and sexual function, focal cryotherapy may be considered an alternative treatment option to radical therapy.

Management of erectile dysfunction after prostate cancer treatment: cross-sectional surveys of the perceptions and experiences of patients and healthcare professionals in the UK

OBJECTIVES

Erectile dysfunction (ED) is known to be a common consequence of radical treatment for prostate cancer (PCa) but is often under-reported and undertreated. This study aimed to explore how ED in patients with PCa is managed in real-life clinical practice, from the perspective of patients and healthcare professionals (HCPs).

DESIGN AND SETTING

This is a UK-wide cross-sectional survey of men with ED after treatment for PCa which covered assessment and discussion of erectile function, provision of supportive care and satisfaction with management. Parallel surveys of primary and secondary HCPs were also conducted.

RESULTS

Responses were received from 546 men with ED after PCa treatment, 167 primary (general practitioners and practice nurses) and 94 secondary care HCPs (urologists and urology clinical nurse specialists). Survey findings revealed inadequate management of ED in primary care, particularly underprescribing of effective management options. A fifth of men (21%) were not offered any ED management, and a similar proportion (23%) were not satisfied with the way HCPs addressed their ED concerns. There was poor communication between HCPs and men, including failure to initiate discussions about ED and/or involve partners, with 12% of men not told that ED was a risk factor of PCa treatment. These issues seemed to reflect poor access to effective ED management or services and lack of primary HCP confidence in managing ED, as well as confusion over the roles and responsibilities among both HCPs and men.

CONCLUSIONS

This study confirms the need for better support for men from HCPs and more tailored and timely access to effective ED management after treatment for PCa. A clearly defined pathway is required for the discussion and management of ED, starting from the planning stage of PCa treatment. Improved adherence to ED management guidelines and better education and training for primary care HCPs are areas of priority.

Combined Transplantation of Mesenchymal Stem Cells and Endothelial Progenitor Cells Restores Cavernous Nerve Injury-Related Erectile Dysfunction

BACKGROUND

Whether combined transplantation of mesenchymal stem cells (MSCs) and endothelial progenitor cells (EPCs) is more effective than transplantation of a single cell type in the restoration of erectile function is unknown.

AIM

To investigate the effect of combined transplantation of MSCs and EPCs on restoration of erectile function in rats with cavernous nerve injury (CNI).

METHODS

MSCs were isolated from human bone marrow and EPCs were isolated from human umbilical cord blood. MSCs and EPCs were identified by flow cytometry and in vitro differentiation or immunofluorescence staining. 25 8-week-old male Sprague-Dawley rats were allocated to 1 of 5 groups: sham operation group, bilateral CNI group receiving periprostatic implantation of MSCs plus EPCs, MSCs, EPCs, or phosphate buffered saline (control group). 2 weeks after CNI and treatment, erectile function of rats was measured by electrically stimulating the CN. The penis and major pelvic ganglia were harvested for histologic examinations. RNA and protein levels of neurotrophin factors (vascular endothelial growth factor, nerve growth factor, and brain-derived neurotrophic factor) in mono- or coculture MSCs and EPCs were assessed by real-time polymerase chain reaction and enzyme-linked immunosorbent assay, respectively.

OUTCOMES

Intracavernous pressure and mean arterial pressure were measured to evaluate erectile function. Histologic examinations of the penis and major pelvic ganglia and RNA and protein levels of neurotrophin factors in MSCs and EPCs were performed.

RESULTS

MSCs and EPCs expressed the specified cell markers and exhibited the typical appearance and characteristics. Treatments using MSCs and/or EPCs could increase endothelial and smooth muscle contents of the corpus cavernosum, decrease caspase-3 expression and increase penile neuronal nitric oxide synthase expression, and restore the neural component of the major pelvic ganglia in rats with CNI. Combined transplantation of MSCs and EPCs had a better effect on improving erectile function than single transplantation of MSCs or EPCs. Expression levels of vascular endothelial growth factor and nerve growth factor in coculture MSCs and EPCs were significantly higher than those of primary MSCs or EPCs.

CLINICAL TRANSLATION

Combined transplantation of MSCs and EPCs was more effective in restoring erectile function in CNI-related erectile dysfunction models.

STRENGTHS AND LIMITATIONS

The study, for the 1st time, proved that combined transplantation of MSCs and EPCs was more effective in restoring erectile function in rats with CNI. The rat model might not represent the human condition.

CONCLUSION

Combined periprostatic transplantation of MSCs and EPCs could restore erectile function in rats with CNI more effectively. MSCs might restore CN fibers by secreting neurotrophin factors such as vascular endothelial growth factor and nerve growth factor, and EPCs could enhance the paracrine activity of MSCs. Fang J-f, Huang X-n, Han X-y, et al. Combined Transplantation of Mesenchymal Stem Cells and Endothelial Progenitor Cells Restores Cavernous Nerve Injury-Related Erectile Dysfunction. J Sex Med 2018;15:284-295.

Clinical utility of MRI in the decision-making process before radical prostatectomy: Systematic review and meta-analysis

Context

Magnetic resonance imaging (MRI) is currently the most accurate imaging modality to assess local prostate cancer stage. Despite a growing body of evidence, incorporation of MRI images into decision-making process concerning surgical template of radical prostatectomy, is complex and still poorly understood.

Objective

We sought to determine the value of MRI in preoperative planning before radical prostatectomy.

Materials and methods

Systematic search through electronic PubMed, EMBASE, and Cochrane databases from 2000 up to April 2018 was performed. Only studies that used preoperative MRI in decision-making process regarding extension of resection in patients with prostate cancer, in whom radical prostatectomy was an initial form of treatment were included into analysis. Their quality was scored by Risk Of Bias In Non-Randomized Studies of Interventions system. Meta-analysis was performed to calculate the weighted summary proportion under the fixed or random effects model as appropriate and pooled effects were depicted on forest plots.

Results

The results showed that the preoperative MRI led to the modification of initial surgical template in one third of cases (35%). This occurred increasingly with the rising prostate cancer-risk category: 28%, 33%, 52% in low-, intermediate- and high-risk group, respectively. Modification of neurovascular bundle-sparing surgery based on MRI appeared to have no impact on the positive surgical margin rate. The decision based on MRI was correct on average in 77% of cases and differed across prostate cancer-risk categories: 63%, 75% and 91% in low-, intermediate- and high-risk group, accordingly.

Conclusions

In summary, MRI has a considerable impact on the decision-making process regarding the extent of resection during radical prostatectomy. Adaptation of MRI images by operating surgeons has at worst no significant impact on surgical margin status, however its ability to decrease the positive surgical margin rates remains unconfirmed.

Linking surgical skills to postoperative outcomes: a Delphi study on the robot-assisted radical prostatectomy

OBJECTIVE

To develop an assessment instrument for the evaluation of surgical videos to elucidate the association between surgical skills and postoperative outcomes after a robot-assisted radical prostatectomy (RARP).

DESIGN

A Delphi study consisting of two consecutive online surveys and a consensus group meeting.

SETTING

Urology departments of general, teaching and university hospitals in the Netherlands.

PARTICIPANTS

All Dutch urologists with a specialization in RARP.

RESULTS

Of 18 invited experts, 12 (67%) participated in the first online survey. In the second round, 9 of the 18 invited experts participated (50%). The Delphi meeting was attended by 5 of the 18 (27%) invited experts. The panel identified seven surgical steps with a possible association to postoperative outcomes. The experts also expected an association between adverse postoperative outcomes and the frequency of camera removals, the number of stitches placed, the amount of bleeding, and the extent of coagulation. These factors were incorporated into an assessment instrument.

CONCLUSIONS

Experts in the field of RARP achieved consensus on 7 surgical steps and 4 aspects of the RARP procedure that may be related to adverse postoperative outcomes. The resulting assessment instrument will be tested in future research to determine its validity.

3.0-T multiparametric magnetic resonance imaging modifies the template of endoscopic, conventional radical prostatectomy in all cancer risk categories

INTRODUCTION

We aimed to evaluate the diagnostic performance of 3.0-T multiparametric magnetic resonance imaging (mpMRI) in preoperative staging of prostate cancer (PCa) and its influence on the extent of resection during endoscopic radical prostatectomy (ERP) among cancer risk groups.

MATERIAL AND METHODS

The data of 154 patients with PCa in whom mpMRI was performed prior to ERP between 2011 and 2015 were included. The initial decision whether to perform neurovascular bundle (NVB) sparing surgery was based on EAU guidelines. mpMRI images were reevaluated prior to prostatectomy to modify the surgical template. Imaging was compared with pathological reports to investigate the diagnostic performance of mpMRI.

RESULTS

The surgical template was modified in 69 (44.8%) patients after reevaluation of mpMRI. More preserving NVB sparing was attempted in 17 (11.0%) men, in whom NVB would have been resected if mpMRI had not been available. More aggressive NVB resection was performed in 52 (33.8%) men, in whom innervation would have been spared if basing solely based on guidelines. Among all PCa risk groups mpMRI had an impact on the surgical template with more aggressive surgery in 63.0% and 33.3% of men in the low- and intermediate-risk group, respectively, and more preserving in 21.4% of the high-risk patients. The change in extent of resection was not correlated with a higher risk of positive surgical margins (p = 0.196).

CONCLUSIONS

Preoperative mpMRI exerts a significant impact on decision making concerning the extent of resection during ERP irrespective of the PCa risk group.

Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up

BACKGROUND

Although nerve-sparing robot-assisted radical prostatectomy (NS-RALP) is performed, a large number of patients still experience erectile dysfunction (ED) after surgery.

AIM

To evaluate the efficacy and safety of tadalafil 5 mg once daily (OaD) in ED treatment over 2 years and investigate the cause of vascular ED after NS-RARP.

METHODS

We retrospectively evaluated 95 men who underwent NS-RARP and had a penile rehabilitation treatment with tadalafil 5 mg OaD. They were classified into 3 groups: tadalafil 5 mg OaD for 2 years (group I), tadalafil 5 mg OaD for 1 year (group II), and no tadalafil (group III). All patients in group I underwent penile color duplex ultrasound to evaluate the cause of vascular ED.

OUTCOMES

Patients were surveyed using the abridged 5-item International Index of Erectile Function (IIEF-5).

RESULTS

Statistically significant improvements were observed in group I for all IIEF-5 domain scores (P = .000). There was no statistically significant difference in recovery of erectile function (EF) the 2-year follow-up between groups I and II. Sub-analysis based on NS status showed no difference in recovery of EF. However, group I showed better trends in EF improvement. Those with venogenic ED had poor responses compared with those with arteriogenic ED or unremarkable findings with tadalafil 5-mg OaD treatment (14.2% vs 55.0% vs 53.3%). The overall side effects included hot flushing in 9.5%, headache in 7.1%, and dizziness in 2.3% of patients.

CLINICAL IMPLICATIONS

Long-term usage of tadalafil 5 mg OaD after RARP can be an effective option for penile rehabilitation.

STRENGTHS AND LIMITATIONS

The present study is a retrospective study with a relatively small sample.

CONCLUSIONS

Although the responses of patients with venogenic ED were limited compared with those with arteriogenic ED, tadalafil 5-mg OaD treatment was well tolerated and significantly improved EF up to 2 years after NS-RARP. Kim S, Sung GT. Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up. Sex Med 2018;6:108-114.

Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Post-Prostatectomy Climacturia and Minimal Urinary Incontinence

BACKGROUND

After radical prostatectomy (RP), erectile dysfunction, often necessitating the need for inflatable penile prosthesis (IPP) insertion, and urinary incontinence and climacturia can ensue.

AIM

To assess the efficacy and safety of the mini-jupette, a mesh used to approximate the medial aspects of the 2 corporotomies at the time of IPP insertion, for the management of climacturia and urine leakage in patients with minimal incontinence.

METHODS

We conducted a pilot multicenter study of patients with post-RP erectile dysfunction and climacturia and/or mild urinary incontinence (≤2 pads/day [ppd]) undergoing IPP insertion with concomitant placement of a mini-jupette graft.

OUTCOMES

Pre- and postoperative erectile function, continence and climacturia, and overall surgical outcomes were assessed.

RESULTS

38 patients underwent the mini-jupette procedure. The mean age of the population was 65.3 years (SD = 7.7). 30 had post-RP climacturia and 32 patients had post-RP incontinence (mean = 1.3 ppd, SD = 0.8). 31 patients received Coloplast Titan, 4 received AMS 700 LGX, and 3 received AMS 700 CX IPPs. Mean corporotomy size was 2.9 cm (SD = 1.0). Mean graft measurements were 3.2 cm (SD = 0.9) for width, 3.3 cm (SD = 1.3) for length, and 11.0 cm² (SD = 5.1) for surface area. At a mean follow-up of 5.1 months (SD = 6.9), there were 5 postoperative complications (13.2%) of which 4 required explantation. Climacturia and incontinence were subjectively improved in 92.8% and 85.7%, respectively. Mean ppd decreased by 1.3 postoperatively.

CLINICAL IMPLICATIONS

The Andrianne mini-jupette is a feasible adjunct to IPP placement that can be used for subsets of patients with post-RP climacturia and/or minimal incontinence.

STRENGTHS AND LIMITATIONS

Strengths of this study include the novel nature of this intervention, the multi-institutional nature of the study, and the promising results demonstrated. Limitations include the retrospective nature of the study and the heterogeneity of the techniques and grafts used by different surgeons involved.

CONCLUSION

Longer follow-up and larger patient cohorts are needed to confirm the long-term safety and benefits of this intervention. Yafi FA, Andrianne R, Alzweri L, et al. Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Post-Prostatectomy Climacturia and Minimal Urinary Incontinence. J Sex Med 2018;15:789-796.

Comparison of erectile dysfunction guidelines between the UK (BSSM/NICE) and Europe (EAU)

Erectile dysfunction is a common and often debilitating condition. The National Institute of Clinical Excellence (NICE) and the British Society of Sexual Medicine (BSSM) in the UK and the European Association of the Urology (EAU) have guidelines on the management of ED. This article will look at the similarities of the guidelines commenting where and how they differ.

nNOS-positive minor-branches of the dorsal penile nerves is associated with erectile function in the bilateral cavernous injury model of rats

The changes in neuronal nitric oxide synthases (nNOS) in the dorsal penile nerves (DPNs) are consistent with cavernous nerve (CN) injury in rat models. However, the anatomical relationship and morphological changes between the minor branches of the DPNs and the CNs after injury have never been clearly explored. There were forty 12 week old male Sprague-Dawley rats receiving bilateral cavernous nerve injury (BCNI). Erectile function of intracavernous pressure and mean arterial pressure were measured. The histology and ultrastructure with H&E stain, Masson's trichrome stain and immunohistochemical stains were applied on the examination of CNs and DPNs. We demonstrated communicating nerve branches between the DPNs and the CNs in rats. The greatest damage and lowest erectile function were seen in the 14^th day and partially recovered in the 28^th day after BCNI. The nNOS positive DPN minor branches' number was significantly correlated with erectile function. The sub-analysis of the number of nNOS positive DPN minor branches also matched with the time course of the erectile function after BCNI. We suggest the regeneration of the DPNs minor branches would ameliorate the erectile function in BCNI rats.

DAPK and CIP2A are involved in GAS6/AXL-mediated Schwann cell proliferation in a rat model of bilateral cavernous nerve injury

Purpose

Impotence is one of the major complications occurring in prostate cancer patients after radical prostectomy (RP). Self-repair of the injured nerve has been observed in animal models and in patients after RP. However, the downstream signalling is not well documented. Here, we found that the DAPK/CIP2A complex is involved in GAS6/AXL-related Schwann cell proliferation.

Materials and Methods

The 3 groups were a sham group, a 14-day post-bilateral cavernous nerve injury (BCNI) group and a 28-day post-BCNI group. Erectile function was assessed and immunohistochemistry was performed. The rat Schwann cell RSC96 line was chosen for gene knockdown, cell viability, western blot, immunofluorescence and co-immunoprecipitation assays.

Results

The intracavernosal pressure was low on the 14^th day after BCNI and partially increased by the 28^th day. GAS6 and p-AXL expression gradually increased in the cavernous nerve after BCNI. RSC96 cells incubated with a GAS6 ligand showed increased levels of p-ERK1/2 and p-AKT. Moreover, DAPK and CIP2A.p-AXL and p-DAPK and CIP2A complexes were identified by both immunoblotting and co-immunoprecipitation.

Conclusion

The DAPK/CIP2A complex is involved in GAS6/AXL-related Schwann cell proliferation. CIP2A inhibits PP2A activity, which results in p-DAPK(S308) maintenance and promotes Schwann cell proliferation. CIP2A is a potential target for the treatment of nerve injury after RP.

Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics

INTRODUCTION

Supportive sexual health care is much-needed adjuvant care to oncologic management for men with prostate cancer (PCa).

AIM

To inspire the initiation of biopsychosocial sexual health programming where it does not exist and to inform program enhancement in existing sexual rehabilitation clinics (SRCs).

METHODS

This article reviews the combined 30-year experience of 2 well-established Canadian SRCs for men and their partners after PCa treatments, interwoven with empirical evidence.

MAIN OUTCOME MEASURE

To comprehensively review the biopsychosocial approach to sexual health assessment of men with PCa and their partners to direct the practicalities of running a successful and sustainable SRC.

RESULTS

A full description of the biomedical and psychosocial approaches, inclusive of comprehensive sexual function, the penile rehabilitation controversy, and other medical and relationship issues affecting sexual adjustment, is provided to highlight the relevance of proper assessment and follow-through for sexual adaptation and adjustment. 10 recommendations for a successful SRC are discussed, including the principles behind developing a sustainable business plan, staff acquisition and training, budget, integration of treatment and research priorities, respectful and multidisciplinary approaches to care, and suggestions of visit formats, protocols, and questionnaires. We recommend a phased approach of an SRC into usual care with the option to provide accessible and equitable care to patients not within proximal access of treating institutions.

CONCLUSION

Sexual rehabilitation after treatment for PCa requires a complex treatment process. Providing sustainable sexual rehabilitation programming under the financially strained environment of the Canadian medical system is a challenge; therefore, to provide Canadian patients and their partners with comprehensive cancer care, they deserve a biopsychosocial approach combined with a creative and systematic implementation strategy. Elliott S, Matthew A. Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics. Sex Med Rev 2018;6:279-294.