Assessment of the functional role of accessory pudendal arteries in erection by transrectal color Doppler ultrasound

Anatomical Fundamentals and Current Surgical Knowledge of Prostate Anatomy Related to Functional and Oncological Outcomes for Robotic-Assisted Radical Prostatectomy

Context

Meticulous knowledge about the anatomy of the prostate and surrounding tissue represents a crucial and mandatory requirement during radical prostatectomy for reliable oncological and excellent replicable, functional outcomes. Since its introduction two decades ago, robotic-assisted laparoscopic radical prostatectomy (RALP) has evolved to become the predominant surgical approach in many industrialized countries.

Objective

To provide and highlight currently available literature regarding prostate anatomy and to help in improving oncological and functional outcomes in RALP.

Methods/Evidence Acquiring

PubMed database was searched using the following keywords: "robotic-assisted radical prostatectomy," "anatomy," "neurovascular bundle," "nerve," "periprostatic fascia," "pelvis," "sphincter," "urethra," "urinary incontinence," and "erectile dysfunction." Relevant articles and book chapters were critically reviewed and if eligible, they were included in this review.

Results

New evidence in regards to prostatic anatomy and surgical approaches in RALP has been reported in recent years. Besides detailed anatomical studies investigating the meticulous structure of the fascial structures surrounding the prostate and neurovascular bundle preservation, debate about the optimal RALP approach is still ongoing, inspired by recent publications presenting promising functional outcomes following modifications in surgical approaches.

Conclusions

This review provides a detailed overview of the current knowledge of prostate anatomy, its surrounding tissue, and its influence on key surgical step development for RALP.

Inflatable penile prosthesis in the radical prostatectomy patient: a review

In the population of patients with prostate cancer, survivorship has come to the forefront of continuity-of-care. In addition to urinary control, erectile function is a significant issue after radical pelvic surgery. Penile prosthesis surgery remains an excellent option for restoring erectile function to those for whom more conservative measures have failed. This review article outlines the anatomical, surgical and post-operative consideration involved in the placement of a penile prosthesis in this special patient population.

Sexual Function after Surgery for Prostate or Bladder Cancer

Background

Compromised sexual function is often a side effect for patients following radical surgical procedures for bladder or prostate cancer.

Methods

The authors review the classification and physiology of sexual function and dysfunction. Moreover, they explain the possible pathophysiology directly resulting from surgery, and they discuss several approaches available to address these problems.

Results

Options for male sexual dysfunction, primarily erectile dysfunction resulting from radical prostatectomy or surgery for bladder cancer, range from patient education to penile prosthesis implantation. Female sexual dysfunction caused by surgical intervention for bladder cancer includes problems with libido, arousal, orgasm, and dyspareunia. Treatment options for women can include sex therapy, hormonal therapy, and preventive strategies. However, no consensus has been established on the most effective agents and time points to treat male or female sexual dysfunction following radical cystectomies or prostatectomies. The chronic intermittent treatment of erectile dysfunction following radical prostatectomy has been commonly referred to as penile rehabilitation.

Conclusions

Additional research is needed to obtain further data concerning sexual dysfunction in both men and women following radical pelvic surgeries. Modification of surgical techniques, the use of various treatment modalities for sexual dysfunction, and the development of new agents will help to successfully minimize or prevent damage and restore normal sexual function after local surgical therapy for prostate or bladder cancer in the future.

Prognostic value of penile colour doppler ultrasonography for recovering erectile function after radical prostatectomy

OBJECTIVE

To analyse the predictive utility of penile colour Doppler ultrasonography after the injection of vasoactive agents for recovering erectile function after radical prostatectomy.

MATERIAL AND METHODS

A retrospective study was conducted on patients with erectile dysfunction after radical prostatectomy who were treated with intracavernous injections of prostaglandins E1 between January 1, 2006 and December 31, 2012. The study included patients with no history of erectile dysfunction prior to the surgery and who did not respond to medical treatment. Colour Doppler was performed on all patients after the intracavernous injection. A peak systolic velocity ≥30cm/sec and an end diastolic velocity ≤5cm/sec were considered normal haemodynamic values. We assessed the result of the treatment during the follow-up using the International Index of Erectile Function-5.

RESULTS

We included 197 patients. The mean age was 60.8 (±6.3). The pathological diagnosis for all patients was adenocarcinoma, 74.1% of which were confined to the organ (T1-T2/Nx-N0). Treatment with injections after the surgery was started after a mean duration of 6.8 months (+3.5). The Doppler ultrasonography results were normal for 53 patients (26.9%). During the follow-up, 113 patients (57.4%) maintained functional erections; 55 of these patients (28%) did not require injections. Normal Doppler ultrasonography results were associated with a favourable response to treatment (p<.01).

CONCLUSIONS

The prostaglandin E1 test will help provide a diagnosis in erectile dysfunction for patients who have undergone prostatectomies. The test helps provide information on the vascular condition of the penis and useful prognostic information for the follow-up of these patients.

[Functional results and treatment of functional dysfunctions after radical prostatectomy]

OBJECTIVE

To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer.

MATERIAL AND METHOD

Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta.

RESULTS

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach.

CONCLUSION

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.

Is there a rationale for penile rehabilitation following radical prostatectomy?

Erectile function recovery after radical prostatectomy (RP) is an increasingly prominent quality-of-life outcome following surgery. Following RP many men, despite the advent of cavernous nerve-sparing surgical technique, have moderately or significantly impaired erectile function (EF). The term penile rehabilitation (PR) is used to define interventions that maintain the health of erectile tissue in the context of nervous, vascular, and structural tissue injury. The goal of PR is to regain, as closely re-approximate, preoperative erectile function. PR is based on an increasing volume of preclinical and clinical data, but conclusive evidence of efficacy has not been established, and therefore the concept of PR remains controversial. The optimal PR regimen has not been established, but all strategies rely on one or more erectile dysfunction treatments to be administered on a regular basis regardless of actual use for sexual activity. This review highlights recent studies and evidence related to PR.

What is the origin of the arterial vascularization of the corpora cavernosa? A computer-assisted anatomic dissection study

The purpose of this study was to identify the microscopic arterial vascularization of the corpora cavernosa (CC) of the penis using computer-assisted anatomic dissection (CAAD), determine the contribution of the different penile arteries towards this vascularization, detail the nature of cavernospongiosum shunts, and locate the anastomoses between these different arteries. Tissue specimens were taken from five donors who donated their bodies to science. The specimens were fixed in 10% formalin and sliced into a series of five 5-μm sections at intervals of 200 μm. The first section was stained with hematoxylin-eosin or Masson's trichrome and the second with anti-protein S100. The cavernous artery of the penis is not the only source of arterial vascularization of the CC. In four of the five cases studied, we found two to four perforating branches arising from the dorsal arteries of the penis that join up with the cavernous artery of the penis or that are solely responsible for the vascularization of the distal third of the penis. The bulbo-urethral and urethral arteries are situated outside of the tunica albuginea of the corpus spongiosum on their lateral and dorsal sides. The anastomoses do not occur between the cavernous artery of the penis and the corpus spongiosum but between the cavernous artery of the penis and the urethral artery on the surface of the tunica albuginea. All of these arteries are accompanied by nerve branches. The CC were found to be vascularized by both cavernous and dorsal arteries of the penis. Intrapenile vascularization is organized around four arterial axes, which are anastomosed by multiple neurovascular shunts.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Preoperative detection and localization of accessory pudendal artery with contrast-enhanced MR angiography

PURPOSE

To evaluate the diagnostic performance of contrast material-enhanced magnetic resonance (MR) angiography for preoperative detection and localization of accessory pudendal arteries (APAs) in patients with prostate cancer.

MATERIALS AND METHODS

This prospective study was approved by the institutional review board, and informed consent was obtained. Between July 2007 and December 2010, 127 patients underwent contrast-enhanced MR angiography following prostate MR imaging at 3.0 T before robot-assisted laparoscopic radical prostatectomy (RALP). APAs were defined as any arteries located in the periprostatic region and anastomosed with the common penile artery or its branches; they were then subclassified into lateral and apical APAs. For detecting and localizing APAs, MR angiograms were evaluated prospectively by one reader and retrospectively by two independent blinded readers. Diagnostic performance was determined on a per-patient basis by using surgical findings as the reference standard. In addition, the origin of APAs identified at both surgery and contrast-enhanced MR angiography was determined by consensus of two retrospective readers. Interreader agreements were assessed by using k statistics.

RESULTS

At surgery, 19 APAs (seven right apical, three left apical, four right lateral, and five left lateral) were detected in 16 patients, and 16 of these APAs were localized in 13 patients at preoperative contrast-enhanced MR angiography. Prospectively, sensitivity, specificity, and accuracy of contrast-enhanced MR angiography for the localization of APAs were 81.3%, 93.7%, and 92.1%, while retrospectively they were 87.5%, 91.9%, and 91.3% for reader 2 and 75.0%, 90.1%, and 88.2% for reader 3, respectively. Overall interreader agreement was substantial (k = 0.795). Nine and seven APAs originated from the obturator artery and the inferior vesical artery, respectively.

CONCLUSION

Contrast-enhanced MR angiography can be used for the preoperative detection of APAs in patients with prostate cancer.

Evolution in the concept of erection anatomy

PURPOSE

To review and to summarize the literature on anatomy and physiology of erection in the past three decades, especially the work done in our institution.

METHODS

A search of the PubMed database was performed using keywords erection, anatomy and erectile dysfunction (ED). Relevant articles were reviewed, analyzed and summarized.

RESULTS

Penile vascularisation and innervation vary substantially. Internal pudendal artery is the major source of penile blood supply, but a supralevator accessory pudendal artery that may originate from inferior vesical or obturator or external iliac arteries is not uncommon. Section of this artery during radical prostatectomy (RP) may adversely affect postoperative potency. Anastomoses between the supra and the infralevator arterial pathways are frequent. The cavernous nerves (CNs) contain parasympathetic and sympathetic nerve fibers and these nerves lie within leaves of the lateral endopelvic fascia. Anastomoses between the CNs and the dorsal nerve of the penis are common. Nitric oxide released from noradrenergic, noncholinergic neurotransmission of the CN and from the endothelium is the principal neurotransmitter-mediating penile erection. Interactions between pro-erectile and anti-erectile neurotransmitters are not completely defined. Finally, medial preoptic area and paraventricular nucleus are the key structures in the central control of sexual function and penile erection.

CONCLUSIONS

The surgical and functional anatomy of erection is complex. Precise knowledge of penile vascularisation and innervation facilitates treatment of ED especially after RP.

[Neurological and vascular preservation during laparoscopic radical prostatectomy]

The objective of the cavernous nerve preservation is to avoid injury of the unmyelinated nerve fibers and arteries destined to the corpora cavernosa. Dissection anatomical plans could be inter or extra fascial allowing complete or partial neurovascular bundle preservation. The technique is chosen according to the carcinological evaluated risk and anatomical characteristics. Accessory pudendal arteries preservation must be performed when such an artery is identified in order to improve the chance of recovery of spontaneous erections.

The incidence and anatomy of accessory pudendal arteries as depicted on multidetector-row CT angiography: clinical implications of preoperative evaluation for laparoscopic and robot-assisted radical prostatectomy

Objective

To help preserve accessory pudendal arteries (APAs) and to ensure optimal postoperative sexual function after a laparoscopic or robot-assisted radical prostatectomy, we have evaluated the incidence of APAs as detected on multidetector-row CT (MDCT) angiography and have provided a detailed anatomical description.

Materials and Methods

The distribution of APAs was evaluated in 121 consecutive male patients between February 2006 and July 2007 who underwent 64-channel MDCT angiography of the lower extremities. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex. We also subclassified APAs into lateral and apical APAs. Two radiologists retrospectively evaluated the origin, course and number of APAs; the final APA subclassification based on MDCT angiography source data was determined by consensus.

Results

We identified 44 APAs in 36 of 121 patients (30%). Two distinct varieties of APAs were identified. Thirty-three APAs (75%) coursed near the anterolateral region of the prostatic apex, termed apical APAs. The remaining 11 APAs (25%) coursed along the lateral aspect of the prostate, termed lateral APAs. All APAs originated from the internal obturator artery and iliac artery or a branch of the iliac artery such as the inferior vesical artery. The majority of apical APAs arose from the internal obturator artery (84%). Seven patients (19%) had multiple APAs.

Conclusion

APAs are more frequently detected by the use of MDCT angiography than as suggested by previous surgical studies. The identification of APAs on MDCT angiography may provide useful information for the surgical preservation of APAs during a laparoscopic or robot-assisted radical prostatectomy.

A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy

CONTEXT

Detailed knowledge of the anatomy of the prostate and adjacent tissues is mandatory during radical prostatectomy to ensure reliable oncologic and functional outcomes.

OBJECTIVE

To review critically and to summarize the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control, erectile function, and urinary continence.

EVIDENCE ACQUISITION

A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis, and sphincter. Relevant articles and textbook chapters were reviewed, analyzed, and summarized.

EVIDENCE SYNTHESIS

Anatomy of the prostate and the adjacent tissues varies substantially. The fascia surrounding the prostate is multilayered, sometimes either fused with the prostate capsule or clearly separated from the capsule as a reflection of interindividual variations. The neurovascular bundle (NVB) is situated between the fascial layers covering the prostate. The NVB is composed of numerous nerve fibers superimposed on a scaffold of veins, arteries, and variable amounts of adipose tissue surrounding almost the entire lateral and posterior surfaces of the prostate. The NVB is also in close, cage-like contact to the seminal vesicles. The external urethral sphincter is a complex structure in close anatomic and functional relationship to the pelvic floor, and its fragile innervation is in close association to the prostate apex. Finally, the shape and size of the prostate can significantly modify the anatomy of the NVB, the urethral sphincter, the dorsal vascular complex, and the pubovesical/puboprostatic ligaments.

CONCLUSIONS

The surgical anatomy of the prostate and adjacent tissues involved in radical prostatectomy is complex. Precise knowledge of all relevant anatomic structures facilitates surgical orientation and dissection during radical prostatectomy and ideally translates into both superior rates of cancer control and improved functional outcomes postoperatively.

Anatomy and preservation of accessory pudendal arteries in laparoscopic radical prostatectomy

OBJECTIVE

The incidence of laparoscopically diagnosed accessory pudendal arteries (APAs) varies depending on how proactive the surgeon is to find them. Their preservation depends on their calibre and location. Our objective was to provide a detailed description of how to identify, dissect, and preserve APAs during laparoscopic radical prostatectomy (LRP).

METHODS

Between January 2003 and January 2005, we treated 377 men with LRP; 325 met inclusion criteria for this study. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudally towards the anterior perineum, other than cavernous arteries, corona mortis, and satellite arteries to the superficial and deep vascular complex. Two distinct varieties of APAs were identified: (1) lateral APAs course along the lateral aspect of the prostate and branch off any of the terminal branches of the hypogastric artery; and (2) apical APAs emerge through the levator ani fibres near the apical region of the prostate and most likely branch off the pudendal artery or corresponds to an aberrant course of the pudendal artery itself. We present a video depicting the laparoscopic anatomy of APAs and the technique to preserve them.

RESULTS

Ninety-six of 325 men (30%) were found to have 125 separate APAs. Using the depicted surgical technique, we were able to preserve 83% of all APAs. Forty-nine of 55 lateral APAs (89%) and 55 of 70 apical APAs (79%) were preserved. Thirty-five of 38 large-calibre APAs (92%) and 70 of 87 small-calibre APAs (80%) were spared. The side-specific incidence of PSMs were 3% and 6% when APAs were preserved and not preserved, respectively (p=0.5).

CONCLUSIONS

APAs are frequently identified during laparoscopic prostatectomy. Their preservation is feasible in LRP without increasing the risk of causing a PSM. It is reasonable to integrate APA preservation as part of the modern radical prostatectomy, although their role in functional outcomes still needs to be prospectively established.

Sexual function before and after radical retropubic prostatectomy: A systematic review of prognostic indicators for a successful outcome

OBJECTIVES

Erectile dysfunction is common after surgery for prostate cancer. Potency rates after radical retropubic prostatectomy (RRP) vary widely among different studies. Since the introduction of the nerve-sparing technique potency rates have increased. Erectile function recovery rates for selected groups of patients are high. However, studies from community practices have shown less favourable outcomes after RP.

METHODS

We have performed a systematic review of the literature concerning sexual function after RRP and focused on prognostic indicators for a successful sexual outcome.

RESULTS

Most important prognostic factors for the return of potency after RRP are preservation of the neurovascular bundles, age of the patient and sexual function before the operation. Neurogenic and vasculogenic factors seem to play an important role in the aetiology of the erectile dysfunction after surgery. The role of preserving the accessory pudendal artery is not certain, although some investigators found significant hemodynamic changes after sacrificing the accessory pudendal artery. Colour Doppler ultrasound studies in combination with intracavernous injection of vasoactive drugs or after PDE-5 inhibitors administration has shown to be a reliable test for vascular factors.

CONCLUSIONS

After bilateral nerve-sparing RRP sexual potency is preserved in 31-86% of sexually active men with organ-confined disease. The aetiology of impotence following RRP is multifactorial, but neurogenic factors seem to play a major role. Vascular factors may be of importance in selective cases. Colour Doppler ultrasound appears to be the most reliable, non-invasive diagnostic test for erectile dysfunction after RRP in patients who do not respond to pharmacotherapy.

Recognition and preservation of accessory pudendal arteries during laparoscopic radical prostatectomy

OBJECTIVES

To determine the incidence of, and ability to preserve, accessory pudendal arteries (APAs) in patients undergoing laparoscopic radical prostatectomy (LRP). The incidence of APAs is not well established. Preservation of APAs may be important for the maintenance of erectile function after prostatectomy. Data are limited regarding the ability to preserve APAs during laparoscopic surgery.

METHODS

At the beginning of each of 70 consecutive laparoscopic radical prostatectomies performed at my institution, a purposeful search for APAs was performed during dissection of the space of Retzius. The operative findings were systematically dictated, and video documentation was obtained whenever possible. In every case in which APAs were identified, an attempt was made to spare them.

RESULTS

Of the 70 patients, 18 (25.7%) were identified as having 23 APAs on the left (n = 8), right (n = 5), or both (n = 5) sides. Documentation and the technique of preservation are detailed in the accompanying video. In all but 1 case, APAs were identified at the initial exploration. APAs were preserved in 78.3% of cases. Of 10 preoperatively potent, sexually active men undergoing bilateral nerve-sparing surgery, all had preservation of APAs.

CONCLUSIONS

The incidence of APAs in this consecutive series of LRP was 25.7%. Preservation of the APAs was successful in 78.3% of those with APAs found. Although occasionally the anatomy may not permit vascular preservation, vigilant examination and strategic laparoscopic dissection allow APAs to be successfully spared in most cases.

ANATOMY OF ACCESSORY PUDENDAL ARTERIES IN LAPAROSCOPIC RADICAL PROSTATECTOMY

PURPOSE

The incidence of accessory pudendal arteries (APAs) varies from 4% to 70% depending on the means used to identify them. We provide a detailed laparoscopic anatomical description of their appearance, location and identification rate based on our series of radical prostatectomies.

MATERIALS AND METHODS

The distribution of APAs was prospectively recorded in 285 consecutive patients between October 2002 and November 2004. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum, other than cavernous arteries, corona mortis and satellite arteries to the superficial and deep vascular complex.

RESULTS

We identified 92 APAs in 72 of 285 patients (25%). Two distinct varieties of APAs were identified. In 10% of patients an APA coursed along the lateral aspect of the prostate, termed lateral APA, and in 13% an APA emerged through the levator ani fibers near the apical region of the prostate, termed apical APA. Five patients (1.7%) were found to have apical and lateral APAs.

CONCLUSIONS

APAs are more frequent than previously reported in the surgical literature. To our knowledge apical APAs have never been reported previously. The visualization and accessibility advantages of laparoscopy may account for a higher intraoperative APA identification rate. Their roles in continence and potency remain to be determined.

The Use of an Erectogenic Pharmacotherapy Regimen Following Radical Prostatectomy Improves Recovery of Spontaneous Erectile Function

PURPOSE

It has been suggested that postradical prostatectomy (RP) erectile function outcomes are improved by early use of erectogenic medications. This analysis was designed to assess the ability of a post-RP vasoactive drug program to improve long-term spontaneous erectile function.

METHODS

Men with functional preoperative erections who underwent RP were challenged early postoperatively with oral sildenafil. Nonresponders were switched to intracavernosal injection therapy (ICI). Patients were instructed to inject three times a week. Only patients who presented within 6 months post RP, who completed the International Index of Erectile Function (IIEF) questionnaire on at least three separate occasions after surgery, and who had been followed for at least 18 months were included. Data from men who were committed to rehabilitation were compared with those of men who did not follow the protocol but continued to be followed serially following RP.

RESULTS

There were 58 patients in the rehabilitation (R) group and 74 in the nonrehabilitation (NR) group. No differences existed in mean patient age, comorbidity profile, intraoperative nerve sparing status, or postoperative erectile hemodynamics between the two groups. At 18 months post RP, there were statistically significant differences between the two groups in the percentage of patients who were capable of having medication-unassisted intercourse (R=52% vs. NR=19%, P<0.001); mean erectile rigidity (R=53+/-21% vs. NR=26+/-43%, P<0.01); mean IIEF erectile function (EF) domain scores (R=22+/-6 vs. NR=12+/-14, P<0.01); the percentage of patients with normal EF domain scores (R=22% vs. NR=6%, P<0.01); the percentage of patients responding to sildenafil (R=64% vs. NR=24%, P<0.001); the time to become a sildenafil responder (R=9+/-4 vs. NR=13+/-3 months, P=0.02); and the percentage of patients responding to ICI (R=95% vs. NR=76%, P<0.01).

CONCLUSIONS

The data generated from this nonrandomized study indicate that a pharmacologic penile rehabilitation protocol results in higher rates of spontaneous functional erections and erectogenic drug response after RP.

Épidémiologie et physiopathologie de la dysfonction érectile

Erectile dysfunction (ED) is a common condition with a significant deleterious effect on the quality of life. The prevalence rate of ED is about 20-45% and its incidence in western countries has been evaluated from 25 to 30 cases per 1000 person year. Risk factors of ED are ageing, diabetes, and cardiovascular, uro-genital, psychiatric and any chronic diseases. Smoking, hormonal factors and some drugs may be associated with ED. Modifications of risk factors must be initiated before the age of 50 to prevent ED occurrence. Two thirds of men with ED report embarrassment when discussing this problem with a physician and less than 25% ask for medical advice. As a symptom of endothelial dysfunction, ED may be considered a premonitory sign of coronary or peripheral vascular disease and diabetes.

Preservation of accessory pudendal arteries during radical retropubic prostatectomy: surgical technique and results

INTRODUCTION

Our institution previously described a surgical technique for preservation of accessory pudendal arteries at radical retropubic prostatectomy. Since then, we have expanded our experience. We now report our refinements in the surgical technique, illustrated with video, and the influence of accessory artery preservation on the recovery of sexual function after radical retropubic prostatectomy (RRP).

TECHNICAL CONSIDERATIONS

Between 1987 and 2003, 2399 potent men underwent RRP. Of the 2399 men, 84 (4%) were identified with accessory pudendal arteries. Of the 84 men, 52, who underwent bilateral nerve-sparing surgery, were available for evaluation. We identified a control population, without accessory pudendal arteries, who were matched for age, stage, and neurovascular bundle status. Potency was defined as the ability to achieve unassisted intercourse with or without the use of sildenafil. In a Cox proportional hazards model, the effect of artery preservation increased the likelihood of potency more than twofold (relative risk 2.65; 95% confidence interval 1.11 to 6.32; P = 0.028). Kaplan-Meier analysis showed a significantly shorter median time to regain potency among those with artery preservation, 6 versus 12 months (P = 0.020).

CONCLUSIONS

Preservation of accessory pudendal arteries may favorably influence the recovery of sexual function and interval to recovery after RRP.

Potency after unilateral nerve sparing surgery: a report on functional and oncological results of unilateral nerve sparing surgery

The objective of the study was to evaluate unilateral nerve sparing prostate surgery. Patient files of men who underwent unilateral nerve sparing radical prostatectomy were analyzed retrospectively after a minimum follow-up period of 18 months. Of 46 patients who received unilateral nerve sparing surgery, 14 (30.4%) regained full potency after surgery. In 92.9% of these patients, recovery occurred within a period of 18 months. Age is the single most important factor in the recuperation of potency after unilateral nerve sparing surgery. Most of the patients (84.8%) reported the ability to achieve orgasm. Of eight patients with positive section margins, two had positive section margins at the spared side only. Unilateral nerve sparing surgery remains a feasible treatment option for prostate cancer.

Is there an optimal time for intracavernous prostaglandin E1 rehabilitation following nonnerve sparing radical prostatectomy? Results from a hemodynamic prospective study

PURPOSE

Previous studies have shown that early intracavernous prostaglandin E1 injection may reduce significantly the incidence of veno-occlusive dysfunction before spontaneous erections recover after nerve sparing radical prostatectomy. We identify the more convenient postoperative timing for successful intracavernous injection rehabilitation in a series of patients who underwent nonnerve sparing radical prostatectomy.

MATERIALS AND METHODS

A total of 73 patients with a normal preoperative International Index of Erectile Function score were randomly allocated to undergo dynamic color Doppler ultrasound study 20 mg. prostaglandin E1 at 1, 2 to 3, 4 to 6 and 7 to 12 months postoperatively, respectively. In all cases the peak systolic velocity, end diastolic velocity and resistance index were evaluated at 5, 10 and 20 minutes after injection.

RESULTS

Of the patients 36 received the intracavernous injection within the first 3 months (group 1) and 37 received it at 4 to 12 months (group 2). A significantly higher proportion of group 1 patients had grade 3 erection compared with group 2. Peak systolic velocity less than 30 cm. per second in at least 1 cavernosal artery was recorded in 22.2% of group 1 patients and 51.3% of group 2 (p >0.05).

CONCLUSIONS

Intracavernous injections after nonnerve sparing radical prostatectomy produce valid erectile responses in a significantly higher proportion of patients when started within month 3 after the operation. Injection given in postoperative month 1 gives the best response rate but with significant complications and poor patient compliance. Arteriogenic and venogenic factors seem to be involved with failure.

Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function

PURPOSE

Despite the advent of nerve sparing radical prostatectomy some men experience erectile dysfunction. Many of these men have vasculogenic erectile impairment in the form of arterial insufficiency or venous leakage. Recent data imply that early postoperative injection therapy may decrease the rate of erectile dysfunction. We defined hemodynamic patterns in patients who underwent bilateral nerve sparing radical prostatectomy to assess the chronology of venous leakage development and explore the correlation of hemodynamic profiles with the return of functional erection 12 months postoperatively.

MATERIALS AND METHODS

Patients with excellent preoperative erectile function who underwent bilateral nerve sparing surgery and had no pharmacological support for erectile dysfunction in the initial 12 months after surgery received vascular evaluation at presentation. Vascular evaluation involved cavernosometry or penile ultrasonography. Patients were then interviewed again at least 12 months postoperatively to assess the ability to achieve sexual intercourse.

RESULTS

Our study group comprised 96 men with a mean age plus or minus standard deviation of 54 +/- 12 years who met all inclusion criteria. All patients had pathologically proved organ confined disease. Mean time to the initial postoperative presentation was 6 +/- 5 months. Patients were divided into 4 groups according to the time of vascular studies postoperatively, namely less than 4 to 8, 9 to 12 and greater than 12 months. Normal vascular status, arterial insufficiency and venous leakage were diagnosed in 35%, 59% and 26% of the group, respectively. No difference in the incidence of arterial insufficiency was noted in the 4 time groups. Time postoperatively was significantly associated with the incidence of venous leakage (14% at less than 4 months and 35% at between 9 and 12). In regard to the correlation of the vascular diagnosis with the return to functional erection 47% of the normal, 31% of the arteriogenic and 9% of the venous leakage group achieved sexual intercourse 12 months postoperatively.

CONCLUSIONS

These data imply that the longer the duration of erectile dysfunction after radical prostatectomy, the greater the risk of venous leakage. Furthermore, it appears that the prognosis for the return of functional erection is worst when venous leakage is present.