Preoperative Erectile Function Represents a Significant Predictor of Postoperative Urinary Continence Recovery in Patients Treated With Bilateral Nerve Sparing Radical Prostatectomy

Prediction models for urinary incontinence after robotic-assisted laparoscopic radical prostatectomy: a systematic review

Even though robotic-assisted laparoscopic radical prostatectomy (RARP) is superior to open surgery in reducing postoperative complications, 6-20% of patients still experience urinary incontinence (UI) after surgery. Therefore, many researchers have established predictive models for UI occurrence after RARP, but the predictive performance of these models is inconsistent. This study aims to systematically review and critically evaluate the published prediction models of UI risk for patients after RARP. We conducted a comprehensive literature search in the databases of PubMed, Cochrane Library, Web of Science, and Embase. Literature published from inception to March 20, 2024, which reported the development and/or validation of clinical prediction models for the occurrence of UI after RARP. We identified seven studies with eight models that met our inclusion criteria. Most of the studies used logistic regression models to predict the occurrence of UI after RARP. The most common predictors included age, body mass index, and nerve sparing procedure. The model performance ranged from poor to good, with the area under the receiver operating characteristic curves ranging from 0.64 to 0.98 in studies. All the studies have a high risk of bias. Despite their potential for predicting UI after RARP, clinical prediction models are restricted by their limited accuracy and high risk of bias. In the future, the study design should be improved, the potential predictors should be considered from larger and representative samples comprehensively, and high-quality risk prediction models should be established. And externally validating models performance to enhance their clinical accuracy and applicability.

Impact of postoperative sexual function on health-related quality of life after robot-assisted radical prostatectomy

Background

We investigated potential disparities in health-related quality of life, particularly concerning urinary function, between patients with preserved and those with impaired sexual function after robot-assisted radical prostatectomy (RARP).

Materials and methods

Between December 2012 and April 2020, 704 men underwent RARP in our hospital. This study included 155 patients with a preoperative 5-item International Index of Erectile Function (IIEF-5) of ≥12 points and an assessable IIEF-5 at 12 months postoperatively. Health-related quality of life was assessed using the 8-item Short-Form Health Survey and Expanded Prostate Cancer Index Composite (EPIC) preoperatively and at 3, 6, and 12 months postoperatively. A logistic regression analysis and Wilcoxon rank sum tests were performed.

Results

Patients were grouped according to the median IIEF-5 score 12 months after surgery: those with preserved sexual function (n = 71) and those with impaired sexual function (n = 84). The mental component summary of the 8-item Short-Form Health Survey was better in the group with preserved sexual function at 6 months postoperatively than in the group with impaired sexual function (p < 0.01). In the EPIC, the group with preserved sexual function performed better not only in the sexual domain but also in the urinary domain at all time points compared with the group with impaired sexual function (p < 0.01). In the comparison of the urinary subdomains of the EPIC, there were no significant differences in urinary function or incontinence, but there were significant differences in urinary distress and irritative/obstructive scores (p < 0.01).

Conclusions

Patients with preserved postoperative sexual function after RARP showed better urinary function than those with impaired sexual function. Hence, preserved sexual function is closely associated with urinary function.

Urinary Continence Recovery after Retzius-Sparing Robot Assisted Radical Prostatectomy and Adjuvant Radiation Therapy

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) allows the preservation of the structures advocated to play a crucial role in the continence mechanism. This study aims to evaluate the association between adjuvant radiation therapy (aRT) and urinary continence (UC) recovery after RS-RARP. For the purpose of the current study, all patients submitted to RS-RARP for prostate cancer (PCa) at a single high-volume European institution between January 2010 and December 2021 were identified. Only patients that harbored pT2 stage with positive surgical margins or pT3/pN1 stage with or without positive surgical margins were included in the analyses. Two groups of patients were identified as follows: patients who had undergone aRT and patients submitted to observation (no-aRT patients). As per definition, aRT was delivered within 1-6 months after surgery. After 1:1 propensity score matching, 124 aRT patients were compared with 124 no-aRT patients who continued standard follow-up protocol after surgery. UC recovery was 81 vs. 84% in aRT vs. no-aRT patients (p = 0.7). In multivariable Cox regression analyses, aRT did not reach the independent predictor status for UC recovery at 12 months. In the subgroup analysis including only aRT patients, only the nerve-sparing technique was independently associated with UC recovery at 12 months. Conversely, the type of aRT (IMRT/VMAT vs. 3D-CRT) did not reach the independent predictor status for UC recovery at 12 months. The current study is the first to address the association between aRT and UC recovery in patients treated with RS-RARP for PCa. Based on our data, aRT is not associated with worse UC recovery. In the cohort of patients treated with aRT, the nerve-sparing technique independently predicted UC recovery.

Dynamic contrast enhancement in prostate MRI as predictor of erectile function and recovery after radical prostatectomy

PURPOSE

To analyze routine preoperative prostate MRI to predict erectile function (EF) before and after radical prostatectomy (RP).

METHODS

Patients who underwent RP with an existing preoperative MRI including dynamic contrast-enhanced images and completed International Index of Erectile Function (IIEF-5) questionnaires at baseline and 12 months postoperative. They were divided into four erectile dysfunction (ED) groups according to preoperative IIEF-5 score. The perfusion quality was measured in the peripheral zone of the prostate by the ratio of signal increase 120 s after wash-in of contrast agent (Ratio120) in preoperative MRI and compared between the ED groups.

RESULTS

Ratio120 showed differences among the preoperative ED groups (p = .020) in 97 patients. According to IIEF-5 at 12 months postoperative, 43 patients were dichotomized into "no to mild" (≥17 points) and "moderate to severe" (≤16) ED groups. Ratio120 revealed differences among the postoperative ED groups (128.84% vs. 101.95%; p = .029) and stayed an independent predictor for ED in the multivariable regression analysis (adjusted for age, nerve-sparing and preoperative IIEF-5). ROC curves demonstrated an additional diagnostic benefit.

CONCLUSIONS

Preoperative MRI of the prostate may be used for the prediction of EF and postsurgical recovery after RP. This may serve as important tool in preoperative patient counseling and management of expectations.

Significant association between urethral length measured by magnetic resonance imaging and urinary continence recovery after robot-assisted radical prostatectomy

Introduction

To determine the clinical predictive factors affecting the recovery from postoperative urinary incontinence after robot-assisted radical prostatectomy (RARP).

Materials and methods

We consecutively analyzed 320 patients who underwent RARP between January 2012 and March 2015. The restoration of urinary continence was defined as follows: the use of no pads/no leakage of urine or the use of a safety pad. Preoperative covariates were statistically assessed by multivariate logistic regression analysis to investigate their predict factor to recovery of urinary incontinence. Therefore, in this study, we sought to identify predictors of early urinary continence status in a single-center retrospective study of consecutive patients who underwent RARP.

Results

Continence rates at 1, 3, 6, and 12 months after the catheter was removed were 44%, 71%, 83%, and 93%, respectively. Age, body mass index, and prostate volume had no significant association with urinary continence recovery. In contrast to this, longer preoperative membranous urethral length (MUL) was significantly associated with earlier postoperative continence recovery. Multivariate analysis demonstrated that longer preoperative MUL is significantly associated with continence recovery at 1 month (P = 0.0235).

Conclusion

Approximately 70% of patients achieved urinary continence within 3 months after RARP. Multivariate analysis showed that age, body mass index, and prostate volume had no significant association with urinary continence recovery. Preoperative MUL assessed by magnetic resonance imaging was an independent predictor of early recovery from urinary incontinence after RARP.

A 12-Month Follow-up After a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial

OBJECTIVE

To explore safety in adipose-derived regenerative cells (ADRC) therapy, treating erectile dysfunction (ED).

METHODS

Twenty-one patients with ED after radical prostatectomy, with no signs of recovery using conventional therapy, received a single intracavernous injection of autologous ADRC and were followed for 1 year. Six men were incontinent, and 15 were continent at inclusion. The primary (safety of ADRC therapy) and secondary endpoints (sexual function) were evaluated at 1, 3, 6, and 12 months after ADRC injection by registration of adverse events and validated questionnaires using the international index of erectile function-5 and erection hardness score.

RESULTS

No serious adverse events occurred, but 8 reversible minor events related to the liposuction were noted. Eight out of 15 (53%) patients in the continent group reported erectile function sufficient for intercourse at 12 months. Baseline median international index of erectile function-5 scores (6.0; interquartile range [IQR] 3) were unchanged 1 month after the treatment, but significantly increased after 6 to 7 (IQR 17). This effect was sustained at 12 months (median 8; IQR 14). We did not see any improvements in erectile function in the group of incontinent men or among men with ED prior to radical prostatectomy.

CONCLUSION

Intracavernous injection of ADRC is safe in this phase 1 study with a 12-month follow-up.

Adjuvant and Salvage Radiotherapy after Radical Prostatectomy in Prostate Cancer Patients

CONTEXT

Prostate cancer (PCa) patients found to have adverse pathologic features following radical prostatectomy (RP) are less likely to be cured with surgery alone.

OBJECTIVE

To analyze the role of postoperative radiotherapy (RT) in patients with aggressive PCa.

EVIDENCE ACQUISITION

We performed a systematic literature review of the Medline and EMBASE databases. The search strategy included the terms radical prostatectomy, adjuvant radiotherapy, and salvage radiotherapy, alone or in combination. We limited our search to studies published between January 2009 and August 2016.

EVIDENCE SYNTHESIS

Three randomized trials demonstrated that immediate RT after RP reduces the risk of recurrence in patients with aggressive PCa. However, immediate postoperative RT is associated with an increased risk of acute and late side effects ranging from 15% to 35% and 2% to 8%, respectively. Retrospective studies support the oncologic efficacy of initial observation followed by salvage RT administered at the first sign of recurrence; however, the impact of this delay on long-term control remains uncertain. Hopefully, ongoing randomized trials will shed light on the role of adjuvant RT versus observation±salvage RT in individuals with adverse features at RP. Accurate patient selection based on clinical characteristics and molecular profile is crucial. Dose escalation, whole-pelvis RT, novel techniques, and the use of hormonal therapy might improve the outcomes of postoperative RT.

CONCLUSIONS

Immediate RT reduces the risk of recurrence after RP in patients with aggressive disease. However, this approach is associated with an increase in the incidence of short- and long-term side effects. Observation followed by salvage RT administered at the first sign of recurrence might be associated with durable cancer control, but prospective randomized comparison with adjuvant RT is still awaited. Dose escalation, refinements in the technique, and the concomitant use of hormonal therapies might improve outcomes of patients undergoing postoperative RT.

PATIENT SUMMARY

Postoperative radiotherapy has an impact on oncologic outcomes in patients with aggressive disease characteristics. Salvage radiotherapy administered at the first sign of recurrence might be associated with durable cancer control in selected patients but might compromise cure in others.

Safety and Potential Effect of a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial

BACKGROUND

Prostate cancer is the most common cancer in men, and radical prostatectomy (RP) often results in erectile dysfunction (ED) and a substantially reduced quality of life. The efficacy of current interventions, principal treatment with PDE-5 inhibitors, is not satisfactory and this condition presents an unmet medical need. Preclinical studies using adipose-derived stem cells to treat ED have shown promising results. Herein, we report the results of a human phase 1 trial with autologous adipose-derived regenerative cells (ADRCs) freshly isolated after a liposuction.

METHODS

Seventeen men suffering from post RP ED, with no recovery using conventional therapy, were enrolled in a prospective phase 1 open-label and single-arm study. All subjects had RP performed 5-18 months before enrolment, and were followed for 6 months after intracavernosal transplantation. ADRCs were analyzed for the presence of stem cell surface markers, viability and ability to differentiate. Primary endpoint was the safety and tolerance of the cell therapy while the secondary outcome was improvement of erectile function. Any adverse events were reported and erectile function was assessed by IIEF-5 scores. The study is registered with ClinicalTrials.gov, NCT02240823.

FINDINGS

Intracavernous injection of ADRCs was well-tolerated and only minor events related to the liposuction and cell injections were reported at the one-month evaluation, but none at later time points. Overall during the study period, 8 of 17 men recovered their erectile function and were able to accomplish sexual intercourse. Post-hoc stratification according to urinary continence status was performed. Accordingly, for continent men (median IIEFinclusion = 7 (95% CI 5-12), 8 out of 11 men recovered erectile function (IIEF6months = 17 (6-23)), corresponding to a mean difference of 0.57 (0.38-0.85; p = 0.0069), versus inclusion. In contrast, incontinent men did not regain erectile function (median IIEF1/3/6 months = 5 (95% CI 5-6); mean difference 1 (95% CI 0.85-1.18), p > 0.9999).

INTERPRETATION

In this phase I trial a single intracavernosal injection of freshly isolated autologous ADRCs was a safe procedure. A potential efficacy is suggested by a significant improvement in IIEF-5 scores and erectile function. We suggest that ADRCs represent a promising interventional therapy of ED following prostatectomy.

FUNDING

Danish Medical Research Council, Odense University Hospital and the Danish Cancer Society.

Robot-assisted radical prostatectomy in prostate cancer

Since its introduction in the year 2000, robot-assisted radical prostatectomy (RARP) rapidly diffused, and nowadays roughly 70% of all the radical prostatectomies in the USA are performed using this approach. Interestingly, the broad dissemination of RARP occurred in the absence of comprehensive data coming from prospective randomized trials supporting the superiority of RARP versus the conventional open RP (ORP). Only observations originating from retrospective institutional or large population-based cohorts exist with respect to the comparative effectiveness of the two surgical techniques. What we have learned is that, given an adequate learning curve, RARP leads to better perioperative and long-term functional outcomes compared with ORP, without any compromise to cancer control outcomes. That being said, the substantially higher costs associated with the use of robotics cannot be ignored.

Penile rehabilitation after radical prostatectomy: does it work?

CONTEXT

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

OBJECTIVE

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

How should continence and incontinence after radical prostatectomy be evaluated? A prospective study of patient ratings and changes with time

PURPOSE

We examined prevalence rates, and changes in continence and incontinence before and after radical prostatectomy for prostate cancer by comparing different definitions. We also studied the descriptive validity of the grading system of Ellison et al for post-prostatectomy incontinence and baseline predictors of post-prostatectomy incontinence at 12 months.

MATERIALS AND METHODS

This national prospective study included 844 patients treated with radical prostatectomy between 2005 and 2009. Adverse effects, including urinary dysfunction and bother, were reported by 735 patients (88%) using the EPIC-50 and UCLA-PCI validated questionnaires at baseline and 12-month followup. Linear regression analysis was done to examine baseline predictors and the degree of post-prostatectomy incontinence at followup.

RESULTS

At 12 months after radical prostatectomy 74% of patients reported post-prostatectomy incontinence, of whom 40% used pads daily, 34% reported occasional dribbling without pads and 26% had total urinary control. When defined as total incontinence/no urinary control, severe post-prostatectomy incontinence was reported by 3% of the men but 25% had severe post-prostatectomy incontinence according to the stratification of Ellison et al. Of patients with preoperative incontinence 14% improved postoperatively. Predictors of post-prostatectomy incontinence were age 65 years or greater, not working, sexual dysfunction and incontinence preoperatively. The latter 2 remained the strongest predictors on multivariate analysis. Prostate cancer related variables were not associated with post-prostatectomy incontinence.

CONCLUSIONS

The prevalence of post-prostatectomy incontinence varied considerably according to the definition applied. In our opinion incontinence may be reported as any leakage and not only as pad use with grading done on a symptom scale. Preoperative sexual dysfunction and urinary incontinence were the strongest predictors of post-prostatectomy incontinence at 12-month followup.

A comprehensive review of neuroanatomy of the prostate

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

Men with low preoperative sexual function may benefit from nerve sparing radical prostatectomy

PURPOSE

We determined the effect of nerve sparing radical prostatectomy on sexual and urinary function in men at various levels of pretreatment sexual function.

MATERIALS AND METHODS

Men in the CaPSURE™ (Cancer of the Prostate Strategic Urologic Research Endeavor) database who underwent radical prostatectomy and had baseline and 2-year posttreatment UCLA-PCI sexual function and urinary function scores were selected. Nerve sparing was categorized as bilateral, unilateral or none and the level of pretreatment sexual function was divided into quartiles. The cohort was divided into subgroups of nerve sparing technique and pretreatment sexual function. Differences between sexual function and urinary function among subgroups were determined. A test of interaction was performed between preoperative sexual function and degree of nerve sparing on postoperative sexual function and urinary function scores.

RESULTS

A total of 1,322 patients met the study inclusion criteria. Median patient age was 61 years (range 41 to 79). Bilateral, unilateral and no nerve sparing procedures were performed in 899, 200 and 223 men, respectively. The effects of nerve sparing on sexual function differed among the quartiles of preoperative sexual function (p <0.01). Nerve sparing did not have an effect on the sexual function of men in the lowest quartile of preoperative sexual function score (p = 0.15) but did have a significant beneficial effect on sexual function in the higher 3 quartiles (p = 0.04, p <0.01 and p <0.01, respectively). Alternatively, nerve sparing improved urinary function in men in the lowest quartile of baseline sexual function.

CONCLUSIONS

Nerve sparing radical prostatectomy results in better sexual function outcomes than no nerve sparing in most men except those with little baseline function. Urinary function was positively impacted in all men. Men who are suitable candidates for nerve preservation may benefit from nerve sparing surgery. Poorer baseline sexual function should not exclude these men from such surgery.

[The efficacy of degarelix on LUTS (Lower urinary tract symptoms) relief in patients with prostate cancer]

Hormonal therapy is one of the treatment options for prostate cancer patients. There are many hormonal treatments modality to block the testosterone effect on prostate cancer cell proliferation. Degarelix is an innovative molecule able to antagonize the GnRH receptor with comparable oncological results to GnRH agonist, but with less side effects, avoiding the flare up phase, and better efficacy in LUTS relief. These characteristics of degarelix can impact on the clinical decision making to choose a therapy instead of another.

Postoperative phosphodiesterase type 5 inhibitor administration increases the rate of urinary continence recovery after bilateral nerve-sparing radical prostatectomy

OBJECTIVES

To investigate the effect of phosphodiesterase type 5 inhibitor on urinary continence recovery after bilateral nerve-sparing radical prostatectomy.

METHODS

We analyzed data of 393 open bilateral nerve-sparing radical prostatectomies carried out between 2005 and 2010. Patients who recovered urinary continence within the first month after catheter removal (n = 52) were excluded. This resulted in 341 evaluable patients. Urinary continence recovery was defined as being completely pad free over a period of 24 h. Patients were stratified according to postoperative daily (n = 58; 17%), on-demand (n = 112; 32.8%) and no (n = 171; 50.1%) phosphodiesterase type 5 inhibitor use. The effect of phosphodiesterase type 5 inhibitor use on urinary continence was assessed using the Kaplan-Meier method. Uni- and multivariable Cox regression analyses were used to test the association between phosphodiesterase type 5 inhibitor and urinary continence recovery after adjusting for cofounders.

RESULTS

At a mean follow up of 36.4 months after surgery (median: 33), 288 patients (84.5%) recovered urinary continence after bilateral nerve-sparing radical prostatectomy. Patients who did not use phosphodiesterase type 5 inhibitor after surgery had lower rates of urinary continence recovery at 1- and 2-year follow up as compared with patients taking phosphodiesterase type 5 inhibitor (67.1 vs 86.7% and 76 vs 94.4%, respectively; P < 0.001). After adjusting for all confounders, multivariable analysis showed that phosphodiesterase type 5 inhibitor use, either on demand or daily, had a positive impact on urinary continence recovery (P = 0.03).

CONCLUSIONS

Patients taking phosphodiesterase type 5 inhibitor have higher urinary continence recovery rates as compared with patients left untreated after bilateral nerve-sparing radical prostatectomy. An improvement in sphincteric and pelvic floor blood supply might be responsible for this beneficial effect associated with the use of phosphodiesterase type 5 inhibitor.