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Alanazi G, Alsubaie N, Nabi G, Gillingwater TH, Alashkham A. Distribution of neurovascular structures within the prostate gland and their relationship to complications after radical prostatectomy. Prostate 2024; 84:491-501. [PMID: 38173273 DOI: 10.1002/pros.24667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Radical prostatectomy remains the main choice of treatment for prostate cancer. However, despite improvements in surgical techniques and neurovascular sparing procedures, rates of erectile dysfunction, and urinary incontinence remain variable. This is due, at least in part, to an incomplete understanding of neurovascular structures associated with the prostate. The objective of this study was to provide a comprehensive, detailed histological overview of the distribution of nerves and blood vessels within the prostate, facilitating subsequent correlation of prostatic neurovascular structures with patients' clinical outcomes after radical prostatectomy. METHODS Neurovascular structures within the prostate were investigated in a total of 309 slides obtained from 15 patients who underwent non-nerve-sparing radical prostatectomy. Immunohistochemical staining was performed to identify and distinguish between parasympathetic and sympathetic nerves, whereas hematoxylin and eosin staining was used to identify blood vessels. The total number, density, and relative position of nerves and blood vessels were established using quantitative morphometry and illustrated using visualization approaches. Patient-specific outcome data were then used to establish whether the internal distribution of nerves and blood vessels within the prostate correlated with the nature and extent of complications after surgery. One-way analysis of variance tests and unpaired t tests were applied to establish statistically significant differences across the measured variables. RESULTS Nerves and blood vessels were present across all prostatic levels and regions. However, their number and density varied considerably between regions. Assessment of the precise positioning of neurovascular structures revealed that the majority of nerve fibers were located within the dorsal and peripheral aspects of the gland. In contrast, blood vessels were predominantly located within ventral and dorsal midline regions. The number of intraprostatic nerves was found to be significantly lower in patients who recovered their continence within 12 months of surgery, compared to those whose recovery took 12 months or longer. CONCLUSION We report an unexpected disconnect between the localization and positioning of nerve fibers and blood vessels within the prostate. Moreover, individual variability in the density of intraprostatic neurovascular structures appears to correlate with the successful recovery of urinary continence after radical prostatectomy, suggesting that differences in intrinsic neurovascular arrangements of the prostate influence postoperative outcomes.
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Affiliation(s)
- Ghazi Alanazi
- Anatomy, Edinburgh Medical School: Biomedical Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- College of Science and Health Professions, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Kingdom of Saudi Arabia
| | - Najah Alsubaie
- Department of Computer Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
| | - Ghulam Nabi
- Division of Cancer Research, University of Dundee, Dundee, UK
| | - Thomas H Gillingwater
- Anatomy, Edinburgh Medical School: Biomedical Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
| | - Abduelmenem Alashkham
- Anatomy, Edinburgh Medical School: Biomedical Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Görgen ARH, Burttet LM, Cachoeira ET, Knijnik PG, Brum PW, de Oliveira Paludo A, Cabral RD, Rosito TE, Berger M, Pavlovich CP, Neto BS. Association of nerve-sparing grading in robotic radical prostatectomy and trifecta outcome. World J Urol 2022; 40:2925-2930. [DOI: 10.1007/s00345-022-04196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/15/2022] [Indexed: 11/24/2022] Open
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Shim JS, Tae JH, Noh TI, Kang SH, Cheon J, Lee JG, Patel VR, Kang SG. Toggling Technique Allows Retrograde Early Release to Facilitate Neurovascular Bundle Sparing During Robot-Assisted Radical Prostatectomy: A Propensity Score-Matching Study. J Korean Med Sci 2022; 37:e6. [PMID: 34981681 PMCID: PMC8723890 DOI: 10.3346/jkms.2022.37.e6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Ji Sung Shim
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Tae
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Tae Il Noh
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seok Ho Kang
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jun Cheon
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jeong Gu Lee
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Vipul R Patel
- Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA
| | - Sung Gu Kang
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, Korea.
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Martini A, Cumarasamy S, Haines KG, Tewari AK. An updated approach to incremental nerve sparing for robot-assisted radical prostatectomy. BJU Int 2019; 124:103-108. [PMID: 30575261 DOI: 10.1111/bju.14655] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To update the algorithm for performing incremental nerve sparing (NS) using our multiparametric magnetic resonance imaging (mpMRI)-based nomogram. PATIENTS AND METHODS We applied the coefficients of the nomogram to the observations extracted from our population of patients who underwent robot-assisted radical prostatectomy between February 2014 and October 2015 and who received preoperative mpMRI. The information considered were PSA level, highest side-specific biopsy Gleason grade group, highest ipsilateral percentage core involvement with the highest Gleason grade group, and extracapsular extension (ECE) on mpMRI. The nomogram-derived probability [P (%)], after internal validation, was used as the independent variable on a classification tree to identify the most significant thresholds for ECE prediction. Incremental NS was performed as follows: Grade 1 NS: intrafascial dissection between the peri-prostatic veins and the pseudocapsule of the prostate; Grade 2 NS: inter-fascial dissection along the peri-venous plane; Grade 3 NS: inter-fascial dissection through the outer compartment of the lateral prostatic fascia; Grade 4 NS: extrafascial dissection. RESULTS Data from 561 patients were considered, and 829 prostatic lobes with biopsy-documented tumour were analysed. Overall, 142 lobes presented ECE that was focal in 27 (19%) cases. The classification tree identified four risk categories. In the low- [P (%) ≤10], intermediate- [P (%) 10-21], high [P (%) 21-73] and very-high-risk [P(%) >73] groups, the ECE rates were 3.3%, 16%, 61.6% and 90%, respectively. Amongst those, ECE was focal in 41.7%, 31.7%, 7.9% and 0%, respectively. CONCLUSION We suggest that Grade 1 NS (intrafascial) should be performed in the low-risk group. The inter-fascial approach, namely grades 2 and 3 NS, should be performed in the intermediate- and high-risk categories, respectively. Grade 4 NS (extrafascial) should be performed in the very-high-risk group. The current algorithm yields a better accuracy than the previous one; however, prospective validation is warranted.
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Affiliation(s)
- Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shivaram Cumarasamy
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenneth G Haines
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashutosh K Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Avulova S, Zhao Z, Lee D, Huang LC, Koyama T, Hoffman KE, Conwill RM, Wu XC, Chen V, Cooperberg MR, Goodman M, Greenfield S, Hamilton AS, Hashibe M, Paddock LE, Stroup A, Resnick MJ, Penson DF, Barocas DA. The Effect of Nerve Sparing Status on Sexual and Urinary Function: 3-Year Results from the CEASAR Study. J Urol 2017; 199:1202-1209. [PMID: 29253578 DOI: 10.1016/j.juro.2017.12.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Nerve sparing contributes to the recovery of sexual and urinary function after radical prostatectomy but it may be ineffective in some patients or carry the risk of a positive surgical margin. We evaluated sexual and urinary function outcomes according to the degree of nerve sparing in patients with prostate cancer treated with radical prostatectomy. MATERIALS AND METHODS The CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study is a prospective, population based, observational study of men diagnosed with localized prostate cancer in 2011 to 2012. Patient reported sexual and urinary functions were measured using the 26-item Expanded Prostate Index Composite at baseline within 6 months after diagnosis, and 6, 12 and 36 months after enrollment. Study inclusion criteria included radical prostatectomy as primary treatment, documentation of nerve sparing status and absent androgen deprivation therapy. Nerve sparing status was defined as none, unilateral or bilateral according to the operative report. RESULTS The final analytical cohort included 991 men. The 11 men treated with unilateral nerve sparing and the 75 treated with a nonnerve sparing procedure were grouped together. In the multivariable model there was a significant difference in the sexual function score 3 years after radical prostatectomy in the bilateral nerve sparing group compared with the unilateral and nonnerve sparing group (6.1 points, 95% CI 2.0-10.3, p = 0.004). This was more pronounced in men with high baseline sexual function (8.23 points, 95% CI 1.6-14.8, p = 0.014) but not in those with low baseline function (4.0 points, 95% CI -0.6-8.7, p = 0.090). Similar effects were demonstrated on urinary incontinence scores. CONCLUSIONS Bilateral nerve sparing resulted in better sexual and urinary function outcomes than unilateral or nonnerve sparing but the difference was not significant in men with low baseline sexual function.
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Affiliation(s)
- Svetlana Avulova
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Daniel Lee
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karen E Hoffman
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Ralph M Conwill
- Office of Patient and Community Education, Patient Advocacy Program, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xiao-Cheng Wu
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Vivien Chen
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Matthew R Cooperberg
- Department of Urology, University of California-San Francisco Medical Center, San Francisco, California
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sheldon Greenfield
- Center for Health Policy Research and Department of Medicine, University of California-Irvine, Irvine, California
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mia Hashibe
- Department of Family and Preventive Medicine and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Lisa E Paddock
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Antoinette Stroup
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Patel VR, Sandri M, Grasso AAC, De Lorenzis E, Palmisano F, Albo G, Coelho RF, Mottrie A, Harvey T, Kameh D, Palayapalayam H, Wiklund P, Bosari S, Puliatti S, Zuccolotto P, Bianchi G, Rocco B. A novel tool for predicting extracapsular extension during graded partial nerve sparing in radical prostatectomy. BJU Int 2017; 121:373-382. [PMID: 28941058 DOI: 10.1111/bju.14026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To create a statistical tool for the estimation of extracapsular extension (ECE) level of prostate cancer and determine the nerve-sparing (NS) approach that can be safely performed during radical prostatectomy (RP). PATIENTS AND METHODS A total of 11 794 lobes, from 6 360 patients who underwent robot-assisted RP between 2008 and 2016 were evaluated. Clinicopathological features were included in a statistical algorithm for the prediction of the maximum ECE width. Five multivariable logistic models were estimated for: presence of ECE and ECE width of >1, >2, >3, and >4 mm. A five-zone decision rule based on a lower and upper threshold is proposed. Using a graphical interface, surgeons can view patient's pre-treatment characteristics and a curve showing the estimated probabilities for ECE amount together with the areas identified by the decision rule. RESULTS Of the 6 360 patients, 1 803 (28.4%) were affected by non-organ-confined disease. ECE was present in 1 351 lobes (11.4%) and extended beyond the capsule for >1, >2, >3, and >4 mm in 498 (4.2%), 261 (2.2%), 148 (1.3%), 99 (0.8%) cases, respectively. ECE width was up to 15 mm (interquartile range 1.00-2.00). The five logistic models showed good predictive performance, the area under the receiver operating characteristic curve was: 0.81 for ECE, and 0.84, 0.85, 0.88, and 0.90 for ECE width of >1, >2, >3, and >4 mm, respectively. CONCLUSION This novel tool predicts with good accuracy the presence and amount of ECE. Furthermore, the graphical interface available at www.prece.it can support surgeons in patient counselling and preoperative planning.
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Affiliation(s)
- Vipul R Patel
- Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA
| | - Marco Sandri
- Data Methods and Systems Statistical Laboratory, University of Brescia, Brescia, Italy
| | - Angelica A C Grasso
- Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Policlinico, University of Milan, Milan, Italy
| | - Elisa De Lorenzis
- Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Policlinico, University of Milan, Milan, Italy
| | - Franco Palmisano
- Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Policlinico, University of Milan, Milan, Italy
| | - Giancarlo Albo
- Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Policlinico, University of Milan, Milan, Italy
| | - Rafael F Coelho
- Department of Urology, Instituto do Cancer, Universidade de Sao Paulo Faculdade de Medicina Hospital das Clinicas, Sao Paulo, SP, Brazil
| | - Alexander Mottrie
- Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium.,OLV Vattikuti Robotic Surgery Institute, Melle, Belgium
| | - Tadzia Harvey
- Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA
| | - Darian Kameh
- Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA
| | - Hariharan Palayapalayam
- Global Robotics Institute, Florida Hospital-Celebration Health Celebration, University of Central Florida School of Medicine, Orlando, FL, USA
| | - Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Silvano Bosari
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Policlinico, University of Milan, Milan, Italy
| | - Stefano Puliatti
- Department of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S. Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Paola Zuccolotto
- Big & Open Data Innovation Laboratory, University of Brescia, Brescia, Italy
| | - Giampaolo Bianchi
- Department of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S. Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bernardo Rocco
- Department of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S. Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy
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Pavlovich CP, Rocco B, Druskin SC, Davis JW. Urinary continence recovery after radical prostatectomy - anatomical/reconstructive and nerve-sparing techniques to improve outcomes. BJU Int 2017; 120:185-196. [PMID: 28319318 DOI: 10.1111/bju.13852] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In an editorial board-moderated debate format, two experts in prostate cancer surgery are challenged with presenting the key strategies in radical prostatectomy that improve urinary functional outcomes. Dr Bernardo Rocco was tasked with arguing the facts that support the anatomical preservation and reconstruction steps that improve urinary continence. Drs Christian Pavlovich and Sasha Druskin were tasked with arguing the facts supporting neurovascular bundle and high anterior release surgical planes that improve urinary continence. Associate Editor John Davis moderates the debate, and outlines the current status of validated patient questionnaires that can be used to evaluate urinary continence, and recent work that allows measuring what constitutes a 'clinically significant' difference that either or both of these surgical techniques could influence. A review of raw data from a publication from Dr Pavlovich's team demonstrates how clinically relevant differences in patient-reported outcomes can be correlated to technique. A visual atlas is presented from both presenting teams, and Dr Davis demonstrates further reproducibility of technique. A linked video on this concept is available as a supplementary file.
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Affiliation(s)
- Christian P Pavlovich
- Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bernardo Rocco
- Ospedale Policlinico e Nuovo Ospedale Civile, S. Agostino Estense, University of Modena and Reggio Emilia, Modena, Italy
| | - Sasha C Druskin
- Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hyndman ME, Bivalacqua TJ, Mettee LZ, Su LM, Trock BJ, Pavlovich CP. Nightly sildenafil use after radical prostatectomy has adverse effects on urinary convalescence: Results from a randomized trial of nightly vs on-demand dosing regimens. Can Urol Assoc J 2016; 9:414-9. [PMID: 26788231 DOI: 10.5489/cuaj.3169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This is a report on urinary function results from a randomized trial of nightly versus on-demand sildenafil after nerve-sparing radical prostatectomy (RP), a secondary objective. We analyzed the effects of these sildenafil administration schemes on urinary health-related quality of life after RP. METHODS In total, 100 potent men were equally randomized to nightly and on-demand sildenafil 50 mg after minimally-invasive RP for 1 year. Health-related quality of life questionnaires were administered at various postoperative intervals. Urinary function was assessed using appropriate expanded prostate cancer index composite (EPIC) subscales. Analyses of covariance and linear mixed-effects modeling were used to compare the effects of treatment over time on urinary recovery, controlling for age, nerve-sparing score, and time from surgery. RESULTS The nightly (n = 50) and on-demand (n = 50) sildenafil groups were well-matched at baseline. Nightly sildenafil patients had worse EPIC urinary bother and urinary irritative/obstructive subscale scores at 3 and 6 months after RP, even after controlling for multiple variables. On mixed-model analyses, the differences between groups for these EPIC subscales (4.9 and 2.5, respectively) were greater than documented thresholds for clinical significance. Increasing nerve-sparing score was associated with improvements in EPIC urinary summary, bother, incontinence, and function scores; time from surgery was associated with improvements in all EPIC urinary health-related quality of life subscales. CONCLUSIONS In this specific population and drug dose, we found that on-demand short-acting phosphodiesterase-5 inhibitor (PDE5i) dosing may be more effective after RP to maximize early urinary health-related quality of life. In preoperatively potent men, nightly sildenafil 50 mg impaired urinary health-related quality of life more than on-demand use in the early months after nerve-sparing RP, independent of effects on urinary continence.
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Affiliation(s)
- Matthew Eric Hyndman
- Department of Surgery, Division of Urology, Southern Alberta Institute of Urology, University of Calgary, Calgary, AB
| | - Trinity J Bivalacqua
- James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
| | - Lynda Z Mettee
- James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
| | - Li-Ming Su
- University of Florida College of Medicine, Gainesville, FL
| | - Bruce J Trock
- James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
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Kang SG, Schatloff O, Haidar AM, Samavedi S, Palmer KJ, Cheon J, Patel VR. Does surgeon subjective nerve sparing score predict recovery time of erectile function following robot-assisted radical prostatectomy? J Sex Med 2015; 12:1490-6. [PMID: 25689342 DOI: 10.1111/jsm.12844] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION During robot-assisted radical prostatectomy (RARP), the quality of nerve sparing (NS) was usually classified by laterality of NS (none, unilateral, and bilateral) or degree of NS (none, partial, and full). Recently, side-specific NS have been more frequently performed, but previous NS grading system might not reflect the differential NS in each side. AIM Herein, we assessed whether a subjective NS score (NSS) incorporating both degree of NS and NS laterality can predict the time to potency recovery following RARP. METHODS Data were analyzed from 1,898 patients who had left and right neurovascular bundle sparing quality scores and at least one year of follow-up after RARP was performed between January 2008 and October 2011. MAIN OUTCOME MEASURES Cox proportional hazard method analyses were used to determine predictive factors for early recovery. Multivariate linear regression models were used to assess subjective NSS in an effort to predict time to potency recovery. Subjective NSSs were compared to a model based on the three grades according to laterality and degree. RESULTS Time to potency recovery showed a statistically significant difference in favor of higher NSS by the Cox proportional hazard regression analysis (NSS 0 vs. NSS 5-6, 7-8, and 9-10; P < 0.01). The regression model indicated that the statistical significance of the subjective NSS covering the differential NS is not different from that of the conventional three-grade scales, while it has a higher R(2). The regression equation with subjective NSS was as follows: Log (Time) = 5.163 - (0.035 × SHIM Score) + 0.028 Age - (0.101 × Subjective NSS). CONCLUSION The subjective NSS can reflect NS degree for each side based on the visual cues. Regression model can be used to help inform the patient about the time to postoperative potency regain, which is an important patient concern following RARP.
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Affiliation(s)
- Sung Gu Kang
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Oscar Schatloff
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA.,University of Central Florida School of Medicine, Orlando, FL, USA
| | - Abdul Muhsin Haidar
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA.,University of Central Florida School of Medicine, Orlando, FL, USA
| | - Srinivas Samavedi
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA.,University of Central Florida School of Medicine, Orlando, FL, USA
| | - Kenneth J Palmer
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA.,University of Central Florida School of Medicine, Orlando, FL, USA
| | - Jun Cheon
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Vipul R Patel
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA.,University of Central Florida School of Medicine, Orlando, FL, USA
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Podnar S, Vodušek DB. Sexual dysfunction in patients with peripheral nervous system lesions. HANDBOOK OF CLINICAL NEUROLOGY 2015; 130:179-202. [PMID: 26003245 DOI: 10.1016/b978-0-444-63247-0.00011-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Peripheral nervous system (PNS) disorders may cause sexual dysfunction (SD) in patients of both genders. These disorders include mainly polyneuropathies (particularly those affecting the autonomic nervous system (ANS)) and localized lesions affecting the innervation of genital organs. Impaired neural control may produce a malfunction of the genital response consisting of loss of genital sensitivity, erectile dysfunction, loss of vaginal lubrication, ejaculation disorder, and orgasmic disorder. In addition, there is often a loss of desire which actually has a complex pathogenesis, which goes beyond the mere loss of relevant nerve function. In patients who have no manifest health problems - particularly men with erectile dysfunction - one should always consider the possibility of an underlying polyneuropathy; in patients with SD after suspected denervation lesions of the innervation of genital organs within the lumbosacral spinal canal and in the pelvis, clinical neurophysiologic testing may clarify the PNS involvement. SD can alter self-esteem and lower patients' quality of life; opening up a discussion on sexual issues should be a part of the management of patients with PNS disorders. They may greatly benefit from counseling, education on coping strategies, and specific treatments.
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Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia.
| | - David B Vodušek
- Division of Neurology, University Medical Center Ljubljana, and Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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11
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Krishnan R, Katz D, Nelson CJ, Mulhall JP. Erectile function recovery in patients after non-nerve sparing radical prostatectomy. Andrology 2014; 2:951-4. [PMID: 25270277 DOI: 10.1111/andr.282] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 09/03/2014] [Indexed: 01/07/2023]
Abstract
Few studies have looked at erectile function recovery (EFR) rates in men undergoing non-nerve sparing resection during radical prostatectomy (RP). Existing studies show great variation in EFR rates owing to multiple factors that minimize their utility in counselling RP patients. We investigated the EFR rate and its predictors in unilateral cavernous nerve resection and bilateral cavernous nerve resection patients 24 months after RP. We conducted a population-based, prospective cohort study of 966 patients who underwent RP at a tertiary cancer centre from 2008 to 2012. Cavernous nerve condition was evaluated on a 4-point nerve sparing score and assigned to one of three groups: bilateral sparing, unilateral resection (UNR) and bilateral nerve resection (BNR). EF was assessed pre-RP and 24-30 months post-op using a validated 5-point patient-reported scale (1 = fully rigid; 5 = no tumescence). EFR was defined as a post-op EF grade of 1-2. Statistical analysis included descriptive statistics, anova, chi-square, Fisher's exact test and logistic regression. Mean baseline EF was 1.84 ± 1.3 and 2.74 ± 1.5 for UNR and BNR patients respectively. Thirty-three percent of UNR patients and 13% of BNR patients exhibited EFR. Age, baseline EF were predictors of EFR. Multivariable analysis showed baseline EF was a significant predictor of EFR at 24 months for UNR. For BNR patients, pre-RP EF was the only factor predictive of EFR. Patients undergoing nerve resection still have a significant chance of achieving true EFR, with UNR surgery patients showing more potential for improvement than patients undergoing BNR surgery. Age and baseline EFR characterize recovery prospects in these two groups. Physicians should thus measure and account for baseline EF in addition to age and the degree of nerve resection when advising patients about expectations for successful EF following RP.
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Affiliation(s)
- R Krishnan
- Division of Urology, Sexual and Reproductive Medicine Program, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Sundi D, Reese AC, Mettee LZ, Trock BJ, Pavlovich CP. Laparoscopic and robotic radical prostatectomy outcomes in obese and extremely obese men. Urology 2013; 82:600-5. [PMID: 23859532 PMCID: PMC3758791 DOI: 10.1016/j.urology.2013.05.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/01/2013] [Accepted: 05/05/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the operative and pathologic outcomes of laparoscopic radical prostatectomy and robot-assisted radical prostatectomy in men with progressive changes in body mass index (BMI) category. MATERIALS AND METHODS A single-surgeon series of 1023 laparoscopic radical prostatectomy and robot-assisted radical prostatectomy (mostly extraperitoneal) patients was considered. Of these patients, 987 were evaluable. Results were stratified by the World Health Organization BMI category. Multivariate linear and logistic regression analysis was used to model the operating time, length of stay, positive surgical margins, and noncurable cancer. RESULTS Of the 987 patients, 563 (57%) were overweight and 193 (19.6%) were obese. Of the 193 obese patients, 152 (15.4%) had a BMI of 30 to <35 kg/m(2) (class I obesity), 28 (2.8%) a BMI of 35 to <40 kg/m(2) (class II), and 13 (1.3%) a BMI of ≥40 kg/m(2) (class III). No differences were found in the estimated blood loss, complications, PSM, pathologic stage, or biochemical recurrence across the BMI categories (6-month median follow-up). However, pelvic lymph node dissection was more commonly omitted and the nerve-sparing score was inferior in the obese men. On multivariate analysis, a higher BMI was a significant predictor of a longer operating time. CONCLUSION Obese men can safely undergo laparoscopic radical prostatectomy or robot-assisted radical prostatectomy, although the ability to perform excellent nerve sparing appears to decrease with increasing obesity. Nevertheless, obese men can expect perioperative and early oncologic outcomes comparable to those of normal weight men without an increased risk of perioperative complications.
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Affiliation(s)
- Debasish Sundi
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Pavlovich CP, Levinson AW, Su LM, Mettee LZ, Feng Z, Bivalacqua TJ, Trock BJ. Nightly vs on-demand sildenafil for penile rehabilitation after minimally invasive nerve-sparing radical prostatectomy: results of a randomized double-blind trial with placebo. BJU Int 2013; 112:844-51. [PMID: 23937708 DOI: 10.1111/bju.12253] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To clarify the role of phosphodiesterase type 5 (PDE5) inhibitors in post-prostatectomy penile rehabilitation (PPPR). To compare nightly and on-demand use of PDE5 inhibitors after nerve-sparing minimally invasive radical prostatectomy (RP). PATIENTS AND METHODS We conducted a single-institution, double-blind, randomized controlled trial of nightly vs on-demand 50-mg sildenafil citrate after nerve-sparing minimally invasive RP. A total of 100 preoperatively potent men, aged <65 years, with scores on the Erectile Function domain of the International Index of Erectile Function (IIEF-EF) ≥26, underwent nerve-sparing surgery. The patients were randomized to either nightly sildenafil and on-demand placebo (nightly sildenafil group), or on-demand sildenafil and nightly placebo (on-demand sildenafil group; maximum on-demand dose six tablets/month) for 12 months. Patients then underwent a 1-month washout period. Validated measures of erectile function (IIEF-EF score and the Expanded Prostate Cancer Index Composite [EPIC]) were compared between treatment groups over the entire 13-month time course, using multivariable mixed linear regression models. RESULTS The treatment groups were well matched preoperatively (mean age 54.3 vs 54.6 years, baseline IIEF-EF score 29.4 vs 29.3, for the nightly vs the on-demand sildenafil groups, respectively). No significant differences were found in erectile function between treatments (nightly vs on-demand sildenafil) at any single timepoint after RP, after adjusting for potential confounding factors. When evaluated over all timepoints simultaneously, no significant effects of treatment group (nightly vs on-demand sildenafil) were found on recovery of potency, as assessed by absolute IIEF-EF scores (P = 0.765), on percentage of men returning to an IIEF-EF score >21 (P = 0.830), or on IIEF-EF score recovery to a percentage of baseline value (P = 0.778). When evaluated over all timepoints simultaneously, no significant effects of treatment group were found on secondary endpoints such as assessment of potency (including EPIC item 59 response 'erections firm enough for intercourse'), attempted intercourse frequency or confidence. CONCLUSIONS Erectile recovery up to 1 year after RP does not differ between previously potent men who use sildenafil nightly compared to on-demand. This trial does not support chronic nightly sildenafil as being any better than on-demand sildenafil for use in penile rehabilitation after nerve-sparing minimally invasive RP.
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Affiliation(s)
- Christian P Pavlovich
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Teloken PE, Mulhall JP. Erectile Function Following Prostate Cancer Treatment: Factors Predicting Recovery. Sex Med Rev 2013; 1:91-103. [PMID: 27784588 DOI: 10.1002/smrj.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Patrick E Teloken
- Department of Urology, Sir Charles Gaidner Hospital, Perth, Australia
| | - John P Mulhall
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy. Prostate Cancer 2013; 2013:810715. [PMID: 23862066 PMCID: PMC3703796 DOI: 10.1155/2013/810715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/22/2013] [Accepted: 06/05/2013] [Indexed: 11/20/2022] Open
Abstract
Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.
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Schatloff O, Kameh D, Giedelman C, Samavedi S, Abdul-Muhsin H, Coelho RF, Kang SG, Palmer KJ, Patel VR. Proposal of a method to assess and report the extent of residual neurovascular tissue present in radical prostatectomy specimens. BJU Int 2013; 112:E301-6. [DOI: 10.1111/bju.12038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Oscar Schatloff
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
| | - Darian Kameh
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
| | - Camilo Giedelman
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
| | - Srinivas Samavedi
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
| | - Haidar Abdul-Muhsin
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
| | | | - Sung Gu Kang
- Department of Urology; Korea University School of Medicine; Seoul; Korea
| | - Kenneth J. Palmer
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
| | - Vipul R. Patel
- Global Robotics Institute; Florida Hospital Celebration Health; Celebration; FL; USA
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Retrograde versus antegrade nerve sparing during robot-assisted radical prostatectomy: which is better for achieving early functional recovery? Eur Urol 2012; 63:169-77. [PMID: 23092543 DOI: 10.1016/j.eururo.2012.09.051] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 09/19/2012] [Indexed: 11/17/2022]
Abstract
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.
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Schatloff O, Chauhan S, Kameh D, Valero R, Ko YH, Sivaraman A, Coelho RF, Marquinez J, Palmer KJ, Patel VR. Cavernosal nerve preservation during robot-assisted radical prostatectomy is a graded rather than an all-or-none phenomenon: objective demonstration by assessment of residual nerve tissue on surgical specimens. Urology 2012; 79:596-600. [PMID: 22386406 DOI: 10.1016/j.urology.2011.11.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 11/20/2011] [Accepted: 11/20/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate the existence of different degrees of nerve sparing (NS) (graded NS) by comparing the surgeon's intent of NS with the residual nerve tissue on prostatectomy specimens. METHODS We performed a prospective study of 133 consecutive patients who underwent robot-assisted radical prostatectomy in January and February of 2011. The surgeon graded the amount of NS intraoperatively independently for either side as follows: 1, no NS; 2, <50% NS; 3, 50% NS; 4, 75% NS; and 5, ≥ 95% NS. A pathologist who was unaware of the surgeon's score measured the area of residual nerve tissue on the posterolateral surface of the prostate. RESULTS A greater NS score correlated significantly with a decreasing area of residual nerve tissue on the prostatectomy specimens (P < .001). Overall, the area of residual nerve tissue on the prostatectomy specimens was significantly different among the NS groups (P < .001). On specific intergroup analysis, significant differences were found in the area of residual nerve tissue on the prostatectomy specimens between the greater NS groups: NS score 3 versus 4, median 13 mm(2) (interquartile range [IQR] 7-23) versus 3 mm(2) (IQR 0-8; P = .01); NS score 4 versus 5, median 3 mm(2) (IQR 0-8) versus 0.5 mm(2) (IQR 0-2; P = .001). CONCLUSION Subjective NS classification using the surgeon's intraoperative perception correlated significantly with the area of residual nerve tissue on the prostatectomy specimens determined by the pathologist. It is possible to intentionally tailor the amount of NS performed at surgery. This finding demonstrates that NS is a graded rather than an all-or-none phenomenon that can even go beyond the traditional concept of complete, partial, or no NS.
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Affiliation(s)
- Oscar Schatloff
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, Florida 34747, USA.
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Anatomic Grading of Nerve Sparing During Robot-Assisted Radical Prostatectomy. Eur Urol 2012; 61:796-802. [DOI: 10.1016/j.eururo.2011.12.048] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 12/23/2011] [Indexed: 11/23/2022]
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Lavery HJ, Levinson AW, Brajtbord JS, Samadi DB. Candidacy for active surveillance may be associated with improved functional outcomes after prostatectomy. Urol Oncol 2011; 31:187-92. [PMID: 21795076 DOI: 10.1016/j.urolonc.2010.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 11/19/2010] [Accepted: 11/22/2010] [Indexed: 10/17/2022]
Abstract
OBJECTIVE In an effort to curb overtreatment, active surveillance (AS) has grown in popularity as an option for men with low-risk prostate cancer. We evaluated the histopathologic and functional outcomes of patients who qualified for AS, but opted for robotic-assisted laparoscopic prostatectomy (RALP), and compared them to non-AS candidates. METHODS An institutional database of 1,477 RALP performed by a single surgeon was queried for AS candidates, defined as PSA <10 ng/mL, biopsy Gleason score ≤6 with a minimum of 10 biopsy cores, <3 positive cores with <50% tumor volume in a single core and clinical stage ≤T2a. RESULTS Of the 352 patients who would have qualified for AS, 159 (45%) were upgraded: 143 (41%) to Gl 3 + 4, 16 (4.5%) to 4 + 3, zero to Gleason 8 or higher. Seventeen (4.8%) patients were upstaged to pT3. AS candidates were younger and had more favorable tumor characteristics, but similar preoperative functional status. Bilateral nerve sparing was performed on 96% of AS candidates vs. 86% of non-AS candidates (P < 0.001). After 12 months of follow-up in patients who received bilateral nerve sparing, continence was higher in the AS cohort (98% vs. 92%, P < 0.001) but potency was equivalent (87% in each, P = 0.89). On multivariable analysis, candidacy for AS was independently associated with improved continence, but not potency. CONCLUSIONS In addition to having the expected favorable histopathologic features, AS candidates who desire definitive therapy have a high likelihood of achieving excellent functional outcomes, perhaps superior to non-AS candidates, following RALP.
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Affiliation(s)
- Hugh J Lavery
- Department of Urology, The Mount Sinai Medical Center, New York, NY 10022, USA.
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Choi WW, Freire MP, Soukup JR, Yin L, Lipsitz SR, Carvas F, Williams SB, Hu JC. Nerve-sparing technique and urinary control after robot-assisted laparoscopic prostatectomy. World J Urol 2010; 29:21-7. [DOI: 10.1007/s00345-010-0601-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 09/28/2010] [Indexed: 11/24/2022] Open
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Moskovic DJ, Alphs H, Nelson CJ, Rabbani F, Eastham J, Touijer K, Guillonneau B, Scardino PT, Mulhall JP. Subjective characterization of nerve sparing predicts recovery of erectile function after radical prostatectomy: defining the utility of a nerve sparing grading system. J Sex Med 2010; 8:255-60. [PMID: 20727065 DOI: 10.1111/j.1743-6109.2010.01972.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Radical prostatectomy (RP) is a common technique for managing prostate cancer. Concern regarding functional outcomes in patients prompted the development of nerve sparing to improve recovery of erectile function. AIM To assess if a cumulative nerve damage grading system is a more precise predictor of recovery of erectile function as compared to the current "all-or-none" grading system. METHODS Baseline demographic, medical history, and International Index of Erectile Function (IIEF)-erectile function domain (EFD) scores were collected. At the time of RP, patients were assigned a nerve sparing score (NSS) by their surgeon for each neurovascular bundle (left and right) to assess the quality of intraoperative nerve sparing (1-complete preservation, 4-complete resection). Patients completed IIEF questionnaires at 24 months after RP. MAIN OUTCOME MEASURES Group comparisons and multiple regression analyses were used to test the association between the NSS and IIEF-EFD scores for patients with preoperative EFD scores ≥ 24. RESULTS A total of 173 patients were included in this analysis. Mean age for patients was 59, and 62% of patients had at least one comorbidity. Baseline EFD scores were comparable between all NSS assignments. At 24 months, EFD scores were reduced by 7.2, 11.6, 13.9, and 15.4 points for patients with NSS grades of 2, 3, 4, and 5-8, respectively (P < 0.01). Multivariate analysis demonstrated lower NSS predicted recovery of erectile function at 24 months (P = 0.001), as did age (P = 0.001) and baseline EFD score (P = 0.02). CONCLUSION Our data support the adoption of a subjectively assigned NSS to more precisely predict erectile function outcomes and suggest that even minor nerve trauma significantly impairs the recovery of erectile function after procedures classically regarded as having achieved bilateral nerve sparing. Further studies are needed to identify the optimal NSS system.
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Affiliation(s)
- Daniel J Moskovic
- Urology Service, Department of Psychiatry and Behavioral Services, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
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Wagner L, Faix A, Cuzin B, Droupy S. Dysfonctions sexuelles après prostatectomie totale. Prog Urol 2009; 19 Suppl 4:S168-72. [DOI: 10.1016/s1166-7087(09)73367-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ferrini MG, Kovanecz I, Sanchez S, Umeh C, Rajfer J, Gonzalez-Cadavid NF. Fibrosis and loss of smooth muscle in the corpora cavernosa precede corporal veno-occlusive dysfunction (CVOD) induced by experimental cavernosal nerve damage in the rat. J Sex Med 2009; 6:415-28. [PMID: 19138364 PMCID: PMC2756287 DOI: 10.1111/j.1743-6109.2008.01105.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Corporal veno-occlusive dysfunction (CVOD), which usually is associated with a loss of smooth muscle cells (SMC) and an increase in fibrosis within the corpora cavernosa, can be induced by an injury to the cavernosal nerves. The corporal tissue expresses inducible nitric oxide synthase (iNOS), presumably as an antifibrotic and SMC-protective response. AIMS We studied the temporal relationship in the corpora between the expression of iNOS, other histological and biochemical changes, and the development of CVOD, after bilateral cavernosal nerve resection (BCNR) in the rat. METHODS Rats underwent either BCNR or sham operation. Cavernosometry was performed 1, 3, 7, 15, 30, and 45 days (N = 8/groups) after surgery. Penile tissue sections were subjected to Masson trichrome staining for SMC and collagen, and immunodetection for alpha smooth muscle actin, iNOS, neuronal NOS (nNOS), endothelial NOS (eNOS), proliferating cell nuclear antigen (PCNA), and terminal transferase dUTP nick end labeling (TUNEL). Quantitative western blot analysis was done in homogenates. MAIN OUTCOME MEASURES Time course on the development of fibrosis and CVOD. RESULTS Following BCNR, CVOD was detectable 30 days later, and it became more pronounced by 45 days. In contrast, the SMC/collagen ratio in the BCNR corpora was reduced at 7 days and bottomed at 30 and 45 days, due in part to the reduction of SMC, presumably caused by an increase in apoptosis peaking at 3 days. PCNA also peaked at 3 days, but then decayed. nNOS was reduced early (3-7 days) and disappeared at 30 days, whereas eNOS was not affected. iNOS was induced at day 3, and steadily increased peaking at 30 days. CONCLUSIONS CVOD develops in the BCNR rat as a result of the early loss of corporal SMC by the neuropraxia-induced apoptosis, which the initial cell replication response cannot counteract, followed by fibrosis. The time course of iNOS induction supports the antifibrotic role of iNOS.
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Affiliation(s)
- Monica G Ferrini
- Charles Drew University, Department of Medicine, Los Angeles, CA 90059, USA.
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