A survey of patient expectations regarding sexual function following radical prostatectomy

Is early continence recovery related to the length of spared urethra? A prospective multicenter study comparing preoperative MRI and histologic specimen measurements after robotic radical prostatectomy

BACKGROUND

Urinary incontinence (UI) is a common complication after radical prostatectomy, significantly affecting patients' quality of life. This study aimed to correlate the length of preserved urethra in robotic radical prostatectomy (RALP) patients with short-term urinary continence rates within 90 days post-surgery.

METHODS

A prospective multicentric study enrolled 190 prostate adenocarcinoma patients undergoing RALP. Using preoperative magnetic resonance imaging (mpMRI), urethral length was measured from the external urethral sphincter to the bladder neck. After surgery, histological measurements of the removed urethra were compared to the preoperative mpMRI data. Patients were categorized into two groups at the three-month follow-up based on urinary continence assessed through Urodynamic Study (UDS): Group A (94 patients without UI) and Group B (96 patients with UI).

RESULTS

Results revealed a significant difference in mean UI recovery time (Group A: 12.35 days, SD: 3.09 vs. Group B: 93.86 days, SD: 34.8, p < 0.0001). A ROC curve identified a 16.5% cut-off value (p < 0.000, sensitivity 87.5%, specificity 91.8%). Both groups showed a significant negative correlation between preserved urethral percentage and UI recovery time (Group A: r -0.655, p < 0.0001; Group B: r -0.340, p: 0.017). Group A had an average of 21.52% preserved urethra, while Group B had 13.86% (p < 0.0001). At one-year follow-up, 93.2% overall patients reported urinary continence without pads.

CONCLUSIONS

This study emphasizes the positive correlation between preserved urethra percentage in RALP and early urinary continence recovery, highlighting its surgical significance.

Evaluation of sexual function after robot-assisted radical prostatectomy: A farewell to IIEF questionnaire

Longevity with localized prostate cancer (PCa) has been achieved, and the contribution of robot-assisted radical prostatectomy (RARP) to cancer control is evident. The next step to investigate in the treatment of localized PCa is improvement of the quality of life (QOL) after RARP. Erectile dysfunction has been considered a major surgical complication, and patient satisfaction after RARP has not improved despite the development of nerve preservation and penile rehabilitation. To comprehensively understand sexual dysfunction after RARP, we must investigate other complications with regard to sexual health, including low sexual desire, disturbed orgasmic function (i.e., anejaculation, orgasm intensity, painful orgasm, and climacturia), shortening of penile length, penile curvature (Peyronie's disease) and unique psychological alterations after the diagnosis of PCa, which are neglected side effects after prostatectomy. In this context, routine evaluation of erectile function by the International Index of Erectile Function only is not sufficient to understand patients' difficulties. A questionnaire is just one way of enabling patients to evaluate their pre- and postoperative concerns; listening to patients face-to-face is warranted to detect symptoms. Understanding the relationship between symptoms and preserved nerve localization can ultimately provide an individualized nerve-sparing procedure and improve patient satisfaction after RARP. In combination with psychological counseling, including the partner and medical treatment, such as testosterone replacement, it is time to reconsider ways to improve sexual dysfunction after RARP.

Development and Validation of Dynamic Multivariate Prediction Models of Sexual Function Recovery in Patients with Prostate Cancer Undergoing Radical Prostatectomy: Results from the MUSIC Statewide Collaborative

Background

Radical prostatectomy (RP) is the most common definitive treatment for men with intermediate-risk prostate cancer and is frequently complicated by erectile dysfunction.

Objective

To develop and validate models to predict 12- and 24-month post-RP sexual function.

Design, setting, and participants

Using Michigan Urological Surgery Improvement Collaborative (MUSIC) registry data from 2016 to 2021, we developed dynamic, multivariate, random-forest models to predict sexual function recovery following RP. Model factors (established a priori) included baseline patient characteristics and repeated assessments of sexual satisfaction, and Expanded Prostate Cancer Index Composite 26 (EPIC-26) overall scores and sexual domain questions.

Outcome measurements and statistical analysis

We evaluated three outcomes related to sexual function: (1) the EPIC-26 sexual domain score (range 0–100); (2) the EPIC-26 sexual domain score dichotomized at ≥73 for “good” function; and (3) a dichotomized variable for erection quality at 12 and 24 months after RP. A gradient-boosting decision tree was used for the prediction models, which combines many decision trees into a single model. We evaluated the performance of our model using the root mean squared error (RMSE) and mean absolute error (MAE) for the EPIC-26 score as a continuous variable, and the area under the receiver operating characteristic curve (AUC) for the dichotomized EPIC-26 sexual domain score (SDS) and erection quality. All analyses were conducted using R v3.6.3.

Results and limitations

We identified 3983 patients at 12 months and 2494 patients at 24 months who were randomized to the derivation cohort at 12 and 24 months, respectively. Using baseline information only, our model predicted the 12-month EPIC-26 SDS with RMSE of 24 and MAE of 20. The AUC for predicting EPIC-26 SDS ≥73 (a previously published threshold) was 0.82. Our model predicted 24-month EPIC-26 SDS with RMSE of 26 and MAE of 21, and AUC for SDS ≥73 of 0.81. Inclusion of post-RP data improved the AUC to 0.91 and 0.94 at 12 and 24 months, respectively. A web tool has also been developed and is available at https://ml4lhs.shinyapps.io/askmusic_prostate_pro/.

Conclusions

Our model provides a valid way to predict sexual function recovery at 12 and 24 months after RP. With this dynamic, multivariate (multiple outcomes) model, accurate predictions can be made for decision-making and during survivorship, which may reduce decision regret.

Patient summary

Our prediction model allows patients considering prostate cancer surgery to understand their probability before and after surgery of recovering their erectile function and may reduce decision regret.

Width of spared neurovascular bundle after robot-assisted laparoscopic prostatectomy in patients with prostate cancer: is it a reliable factor for predicting postoperative sexual outcome?

Purpose

To investigate the relationship between the width of spared neurovascular bundle (NVB) measured during robot-assisted laparoscopic prostatectomy and postoperative sexual outcomes.

Methods

Patients with localized prostate cancer with erectile hardness score ≥2 (N = 105) who underwent NVB-sparing robot-assisted laparoscopic prostatectomy were included. Patients were divided into three groups [first (Q1) vs. second and third (Q2-3) vs. fourth (Q4) quartile] according to width of spared NVB measured with a flexible ruler after prostate removal. Preoperative and postoperative sexual function was evaluated according to erectile hardness score and Expanded Prostate Cancer Index Composite questionnaires.

Results

The proportion of patients with postoperative erectile hardness score ≥2 at postoperative 6 months was as follows: 38.9% (Q1), 48.6% (Q2–3), and 83.3% (Q4) (P = 0.016). The preoperative/postoperative 6-month sexual function score was 40.7/16.9 (Q1), 48.1/19.0 (Q2–3), and 51.2/28.1 (Q4). Postoperative sexual function was significantly associated with preoperative sexual function in Q4 (P = 0.006) and Q2–3 (P = 0.030) but not in Q1. On multivariate analysis, the width of spared NVB was a significant predictor for postoperative 6-month erectile hardness score ≥2. Limitation includes selection bias and short follow-up duration.

Conclusions

Not only the performance but also the degree and quality of NVB sparing thought to be important for postoperative sexual function. Measurement of the width of NVB during surgery could be an easy intraoperative method for assessing the quality of NVB sparing.

Individual risk prediction of urinary incontinence after prostatectomy and impact on treatment choice in patients with localized prostate cancer

AIMS

Individualized information about the risk of incontinence after prostatectomy could help patients in shared decision-making.

METHODS

We compared a historical control cohort (n = 254; between June 2016 and 2017) that received standardized information about the risk of incontinence after robot-assisted radical prostatectomy (RARP) with a prospective patient cohort (n = 254; between June 2017 and May 2018) that received individualized information of the chance of recovery of incontinence within 6 months postoperatively based on the continence prediction tool (CPRED). We measured switch in treatment choice, health-related quality of life (QoL) in both cohorts and the accuracy of the CPRED tool.

RESULTS

Patients in the individualized information group with RARP as initial preference switched more often to another treatment than patients who received standardized information (16% vs. 5%; p = 0.001). Patients in the individualized information group with a high risk of incontinence and with RARP as initial preference switched more often to other treatments than patients in intermediate/low risk of incontinence (35% vs. 9.8%; p = 0.001). Patients with a low risk of incontinence choosing RARP after individualized information were less likely to use more than one diaper a day at any time postoperative (p = 0.001) compared to men with an intermediate/high incontinence risk. Overall QoL was worse in patients with incontinence than patients with continence 6 and 12 months after RARP (respectively; p < 0.0001 and p = 0.007).

CONCLUSION

Personalized information about the risk of incontinence after RARP makes more patients reconsidering their initial treatment preference. The CPRED correlated strongly with continence outcome after RARP and is a useful tool for shared decision-making.

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

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

Comparison of Satisfaction With Penile Prosthesis Implantation in Patients With Radical Prostatectomy or Radical Cystoprostatectomy to the General Population

Introduction

Penile prosthesis implantation is a widely used treatment option for erectile dysfunction. Data is limited with regard to patient satisfaction with a penile prosthesis following radical prostatectomy/cystoprostatectomy vs patients with erectile dysfunction of other etiologies.

Aim

To examine patient satisfaction with penile prosthesis implantation and determine if a difference in satisfaction exists in post-prostatectomy/cystoprostatectomy patients vs patients with erectile dysfunction of other etiologies. We hypothesize that etiology does not affect satisfaction.

Methods

A total of 164 patients underwent penile prosthesis implantation at our institution between August 2017 and December 2019, with 102 patients completing a validated 14 item questionnaire, Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), at 6 months postoperation. Demographics, surgical characteristics, and erectile dysfunction etiology were recorded. Patients were assigned to one of 2 groups: postprostatectomy/postcystoprostatectomy erectile dysfunction or other etiologies. The study group was further analyzed between radical prostatectomy or radical cystoprostatectomy.

Main Outcome Measures

Satisfaction based on key EDITS questions with postradical prostatectomy/cystoprostatectomy vs patients with erectile dysfunction of other etiologies.

Results

Responses to 3 questions were analyzed: overall satisfaction, expectations met in the past 4 weeks, and confidence in the ability to participate in sexual activity. Chi-square analysis was performed to determine the difference in responses. No difference was seen in overall satisfaction (P = .96), expectations (P = .78), or confidence (P = .78) between groups. On subgroup analysis, there was no difference in reported overall satisfaction (P = .47) or confidence (P = .080) between postprostatectomy and postcystoprostatectomy patients. Postprostatectomy and postcystoprostatectomy patients differed in whether the penile prosthesis implantation met expectations (P = .033). Postprostatectomy patients reported a mean score of 3.5/4 compared to postcystoprostatectomy patients, who reported a mean of 3.0/4.

Conclusions

Our analysis suggests that key erectile function scores are not significantly different between postprostatectomy/postcystoprostatectomy patients compared to other etiologies. The difference in measures between postprostatectomy and postcystoprostatectomy patients is not significant or of unclear significance.

Registration # of clinical trial: HSC-MS-19-0320

Howell S, Palasi S, Green T, et al. Comparison of Satisfaction With Penile Prosthesis Implantation in Patients With Radical Prostatectomy or Radical Cystoprostatectomy to the General Population. Sex Med 2021;9:100300.

Neglected side effects to curative prostate cancer treatments

In this narrative review we summarize neglected side effects of curative intended treatment for prostate cancer. They include climacturia, arousal incontinence (AI), orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia), ejaculatory dysfunction, and morphological penile alterations in the form of shortening and deformity. Even though they have not received as much interest as erectile dysfunction (ED) or urinary incontinence, these side effects have been shown to negatively impact patient's quality of life. They are common and rates of climacturia after radical prostatectomy (RP) range from 20% and 45%, less after external beam radiation therapy (EBRT). Decreased orgasmic sensation ranges from 3.9% to 60% after RP and between 36-57% after EBRT. Dysorgasmia ranges from 9.5-15% for both RP and EBRT. Anejculation after EBRT ranges from 11-71% and rates of penile shortening are reported between 0 and 100%. There are no internationally validated questionnaires that adequately asses these side effects. This is necessary if we are to align patient and partner expectations properly and consequently manage them optimally. Neglected side effects should be discussed with patients and their partners preoperatively, as they are associated with bother and may lead to patient's avoiding sexual activity.

Impact of Retzius-sparing Versus Standard Robotic-assisted Radical Prostatectomy on Penile Shortening, Peyronie's Disease, and Inguinal Hernia Sequelae

Background

Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) has improved urinary function compared with standard robotic-assisted radical prostatectomy (S-RARP). As RS-RARP spares the dorsal vascular complex, pelvic fascia, and anterior abdominal fascia, it may also lower the incidence of “neglected” postprostatectomy sequelae such as penile shortening, Peyronie’s disease, and inguinal hernias.

Objective

To determine whether there are patient-perceived differences in penile shortening, Peyronie’s disease, and inguinal hernia rates among men undergoing RS-RARP versus S-RARP.

Design, setting, and participants

Researchers uninvolved in clinical care and blinded to surgical approach surveyed 60 RS-RARP versus 57 S-RARP men with validated patient-reported items to assess penile shortening, Peyronie’s disease, and inguinal hernia sequelae following surgery.

Intervention

RS-RARP versus S-RARP.

Outcome measurements and statistical analysis

Univariate differences between the two cohorts were analyzed using Student t test. Logistic regression was used to analyze variables associated with postoperative penile shortening. Cox proportional hazards models were used to assess the risk of developing Peyronie’s disease and inguinal hernia postoperatively.

Results and limitations

RS-RARP was associated with less patient-reported penile shortening (41.7% vs 64.9%, p = 0.012), Peyronie’s disease (0% vs 8.7%, p = 0.020), and inguinal hernia (0.0% vs 13.0%, p = 0.004). In adjusted analyses, RS-RARP (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09–0.63, p = 0.004) was associated with lower odds of penile shortening, while a higher body mass index was associated with increased odds of penile shortening (OR 1.13, 95% CI 1.01–1.26, p = 0.037). RS-RARP was not associated with a decreased risk of Peyronie’s disease on Cox proportion hazard model; however, these models are limited due to a limited number of events in our cohort. Limitations include retrospective design, patient-reported outcomes, and small cohorts.

Conclusions

RS-RARP is associated with less patient-reported penile shortening and may decrease the risk of Peyronie’s disease and postoperative inguinal hernia development. These new findings add to research, showing improved urinary continence and quality of life following RS-RARP; however, a prospective study is needed to validate these findings.

Patient summary

Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment, which has shown improved postoperative urinary control compared with the standard technique, likely due to preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia.

Effects of nerve-sparing procedures on bowel function after robot-assisted radical prostatectomy: A longitudinal study

BACKGROUND

This study aimed to evaluate rectal pain and bowel function of the patients following robot-assisted radical prostatectomy (RARP).

METHODS

We divided 296 patients who underwent RARP into two groups depending on the intervention: NS (nerve-sparing) group (bilateral NS, unilateral NS and bilateral partial NS) and non-NS group (unilateral partial NS, bilateral non-NS). Bowel function was assessed using the Extended Prostate Cancer Index Composite for 24 months after RARP.

RESULTS

The bowel function score and rectal urgency at 1-6 months after RARP were more significantly impaired in the non-NS group than in the NS group (p < 0.05). In a multivariate analysis of factors affecting the bowel function score at 6 months after RARP, only NS procedure had a significant effect.

CONCLUSIONS

In the initial period after RARP, bowel symptoms were significantly impaired. This impairment was affected by the degree of NS. These results could guide patients in their decision to choose RARP.

[Benign prostatic hyperplasia surgery and patient's information: What do patients understand and remember?]

INTRODUCTION

Preoperative information is a key to adherence to treatment for the patients, but may be misunderstood because of its density and complexity. The aim of this study was to assess comprehension and satisfaction of patients about preoperative information of benign prostatic hyperplasia (BPH) surgery. Factors influencing patient understanding were also studied.

PATIENTS AND METHODS

It was a monocentric study on questionnaires including every patients planned for BPH surgery, whatever the surgical technique. A survey was sent at patient's home after the preoperative consultation.

RESULTS

One hundred and six of 210 patients (50,5 %) returned the questionnaire. 38,68 % (n=41) found the quality of information excellent (9 or 10 out of 10), and 45,28 % (n=48) found the quality of information good (7 or 8 out of 10). The main recalled complications were retrograde ejaculation (39.6 %, n=42/106), and bleeding (29,2 %, n=31/106). 57.6 % of patients (n=61) remembered receiving the written information sheet of the French Association of Urology. 5.7 % (n=6) hesitated having the procedure. Only patient's age was significantly associated with difference of comprehension (p<0.005).

CONCLUSION

Information given before a BPH surgery seems satisfactory although it was poorly understood, notably about complications. Providing complete oral information, insisting on complications, and giving the written information sheet are essential for a good doctor-patient relationship and a forensic serenity.

LEVEL OF EVIDENCE

3.

Ejaculatory and Orgasmic Dysfunction Following Prostate Cancer Therapy: Clinical Management

The majority of sexual health research has focused on erectile dysfunction following prostate cancer treatment. Ejaculatory and orgasmic dysfunction are significant side effects following the treatment of prostate cancer. Orgasmic dysfunction covers a range of issues including premature ejaculation, anorgasmia, dysorgasmia, and climacturia. This review provides an overview of prevalence and management options to deal with orgasmic dysfunction. A Medline Pubmed search was used to identify articles relating to these problems. We found that orgasmic dysfunction has a very large impact on patients’ lives following prostate cancer treatment and there are ways for physicians to treat it. Management of patients’ sexual health should be focused not only on erectile dysfunction, but on orgasmic dysfunction as well in order to ensure a healthy sexual life for patients and their partners.

Sexual function recovery after robot-assisted radical prostatectomy: Outcomes from an Italian referral centre and predicting nomogram

Aims of this study were to assess sexual recovery after robotic-assisted radical prostatectomy (RARP) and to build a nomogram predicting 1-year sexual function. From May 2015 to July 2016, all patients eligible for RARP at our institution were invited to enter the study. The Expanded Prostate cancer Index Composite (EPIC) questionnaire was administered pre-operatively, then at 45 days, and at 3, 6, 9, and 12 months post-operatively. According to sexual function scores, patients were divided into four classes. Multivariate analysis was used to investigate the influence of patient- and disease-related features on sexual recovery. A total of 643 patients were included. Age was associated with baseline potency (p < .0001). Bioptic Gleason score (GS; p = .0002), American Society of Anesthesiologists (ASA) score ( = .002ASA Physical Status Classification System ) and Charlson Comorbidity Index (CCI; p = .02) were negatively associated with potency. Baseline sexual function was associated with potency recovery. A nomogram resulted from fitting a proportional odds logistic model for ordinal outcomes, with 1-year sexual function as a dependent variable and baseline sexual potency, age, body mass index (BMI), clinical stage, biopsy GS, initial prostate-specific antigen (iPSA), ASA score, and CCI as predictors. After further validation, this nomogram could be a useful tool for the pre-operative counselling.

Predicting trajectories of recovery in prostate cancer patients undergone Robot-Assisted Radical Prostatectomy (RARP)

OBJECTIVE

To identify trends of patients' urinary and sexual dysfunctions from a clinical and psychological perspective and understand whether sociodemographic and medical predictors could differentiate among patients following different one-year longitudinal trajectories.

METHODS

An Italian sample of 478 prostate cancer patients undergone Robot-Assisted Radical Prostatectomy completed the EPIC-26 survey between July 2015 and July 2016 at the pre-hospitalization (T0), 45 days (T1) and 3 (T2), 6 (T3), 9 (T4), and 12 months (T5) after surgery. Sociodemographic and clinical characteristics (age, BMI, diabetes, nerve-sparing procedure) were also collected. Latent Class Growth Analysis was conducted separately for sexual dysfunction and urinary incontinence EPIC-26 subscales. The association between membership in the two longitudinal trajectories of urinary and sexual dysfunctions was assessed by considering Chi-square test and its related contingency table.

RESULTS

People who have a high level of urinary incontinence at T1 are likely to have a worse recovery. Age, BMI and pre-surgical continence may affect the level of incontinence at T1 and the recovery trajectories. Patients with low and moderate sexual problems at T1 can face a moderate linear recovery, while people with high level of impotence immediately after surgery may take a longer period to solve sexual dysfunctions. Age and the pre-surgical sexual condition may impact the recovery. Finally, a great proportion of patients reported both steady problems in sexual function and constant high levels of urinary incontinence over time.

CONCLUSIONS

This study highlights different categories of patients at risk who may be important to know in order to develop personalized medical pathways and predictive models in a value-based healthcare.

Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature

INTRODUCTION

The sexual problem after radical prostatectomy (RP) that has received the most focus in the current literature is erectile dysfunction. However, there are orgasmic complications that encompass orgasm-associated urinary incontinence (climacturia), anorgasmia, changes in orgasmic sensation, and painful orgasm (dysorgasmia). Although the body of research is still growing, there remains a need for physician and patient awareness of these potentially problematic complications.

AIM

To review the prevalence and management options for different orgasmic dysfunctions after RP.

METHODS

A Medline PubMed search was used to identify articles related to orgasmic dysfunction, including climacturia, dysorgasmia, anorgasmia, and altered sensation after RP.

MAIN OUTCOME MEASURE

Rates and types of orgasmic dysfunction after RP.

RESULTS

Orgasmic dysfunction encompasses a series of conditions that affect men after RP. These include climacturia, dysorgasmia, anorgasmia, and altered sensation. Although the etiologies and management options remain uncertain, their effect on the sexual health of patients is not negligible.

CONCLUSION

To provide proper counseling to patients, physicians should be aware of the prevalence of orgasmic side effects after RP. Post-prostatectomy sexual recovery should be focused not only on penile erectile function but also on a satisfactory and healthy sexual life for patients and their partners. Clavell-Hernández J, Martin C, Wang R. Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature. Sex Med Rev 2018;6:124-134.

Healthcare utilization in men with poorer sexual and urinary function recovery following robot-assisted radical prostatectomy

PURPOSE

Robotic radical prostatectomy focuses on oncologic cure, urinary continence and sexual function recovery. However, little is known about the effect of declines in urinary continence and sexual function on healthcare utilization. We aim to identify these factors.

MATERIALS AND METHODS

From March 2011 to September 2013, all men undergoing robotic prostatectomy within our healthcare system were enrolled. Men completed the expanded prostate cancer index composite-26 survey at the time of diagnosis and 90 days post-operatively. Patients were stratified according to change in scores in the sexual function and urinary incontinence domains. Patient, treatment and post-op utilization patterns were examined for association with the extent of decline in sexual function and urinary continence. Multivariate linear regression was used to identify factors independently associated with decline in continence and sexual function.

RESULTS

A total of 411 men who completed the baseline survey and at 90 days postoperatively were included. On multivariate linear regression, younger age (p < 0.01), higher preoperative sexual function (< 0.01), single marital status (p = 0.04) and more post-surgery email contacts (p = 0.04) were associated with higher declines in sexual function. For continence, no family history of prostate cancer (p = 0.01), higher baseline continence (p < 0.01) and more post-surgery physical therapy visits (p < 0.01) were associated with higher declines.

CONCLUSIONS

Patients with the poorest quality of life outcomes at 90 days post-operatively were more likely to seek care via email and physical therapy encounters related to sexual function and urinary incontinence, respectively. This suggests that maximizing post-treatment quality of life can potentially reduce healthcare utilization.

Influence of multinerve-sparing, robot-assisted radical prostatectomy on the recovery of erection in Japanese patients

Purpose

To evaluate in Japanese patients their sexual function after robot‐assisted radical prostatectomy (RARP) and to investigate the influence of the multinerve‐sparing (NS) grade on their sexual function.

Methods

In total, 225 patients were reviewed with localized prostate cancer who underwent RARP at the authors' institution. They underwent RARP >3 months ago, without pre‐ and posthormone therapy and salvage radiation. Self‐administered International Index of Erectile Function (IIEF) questionnaires were used for assessment preoperatively and 1–48 months postoperatively. In all, 129 patients were evaluated with the preoperative IIEF‐Question 1 and who achieved a score of ≥2 by being divided into five NS groups. The recovery rates of erection (postoperative IIEF‐Question 1 score of ≥2) were calculated by using the Kaplan–Meier analysis.

Results

Seventy‐four percent of all the patients had not attempted sexual intercourse, but 60% had felt sexual desire at 24 months postoperatively. In those patients with a preoperative erection, the recovery rate of erection was 58% at 24 months after the RARP. Across the five NS groups, as the procedure was more nerve‐sparing, the recovery rate of erection became significantly higher. The postoperative effects on erection in the bilateral and unilateral NS groups were significantly superior to those in the other NS groups.

Conclusion

In Japanese patients, erection after a RARP is improved with multiNS grade procedures.

Orgasmic Function after Radical Prostatectomy

PURPOSE

We examined postprostatectomy orgasmic function and assessed for potential predictors.

MATERIALS AND METHODS

Between 2005 and 2013, 499 men underwent radical prostatectomy and completed quality of life questionnaires prospectively before surgery and at regular postoperative intervals. We used mixed effects logistic regression models to evaluate average differences in followup measures and interactions with time.

RESULTS

At a median followup of 36 months orgasmic function was worse, stable or improved in 300 (60.1%), 152 (30.5%) and 47 men (9.4%), respectively. Orgasmic function recovery plateaued at 15 to 21 months. High postoperative orgasmic function was positively associated with younger age (50 years or younger vs 51 to 60 OR 3.40, 95% CI 1.56-7.41), nerve sparing (bilateral OR 7.11, 95% CI 2.55-19.77, modified 4.34, 95% CI 1.38-13.58 and unilateral OR 3.93, 95% CI 1.17-13.16), erectile function (OR 4.67, 95% CI 3.32-6.57) and sexual desire (OR 5.51, 95% CI 3.95-7.68) but negatively associated with lower urinary tract symptoms (OR 0.58, 95% CI 0.41-0.82) and urinary incontinence (OR 0.38, 95% CI 0.25-0.56). Although robotic status did not influence orgasmic function in the overall cohort, it was associated with faster recovery on subgroup analysis of 356 patients with long followup. On another subgroup analysis of 235 men with long followup and poor erectile function the association of high preoperative orgasmic function and bilateral nerve sparing with high orgasmic function persisted, suggesting an independent effect on orgasmic function apart from that on erectile function.

CONCLUSIONS

Orgasmic function recovery after radical prostatectomy is a lengthy process. Predictors of orgasmic function include preoperative orgasmic function, age, nerve sparing status, erectile function, sexual desire and urinary control and function.

Orgasmic Dysfunction after Radical Prostatectomy

In addition to urinary incontinence and erectile dysfunction, several other impairments of sexual function potentially occurring after radical prostatectomy (RP) have been described; as a whole, these less frequently assessed disorders are referred to as neglected side effects. In particular, orgasmic dysfunctions (ODs) have been reported in a non-negligible number of cases, with detrimental impacts on patients' overall sexual life. This review aimed to comprehensively discuss the prevalence and physiopathology of post-RP ODs, as well as potential treatment options. Orgasm-associated incontinence (climacturia) has been reported to occur in between 20% and 93% of patients after RP. Similarly, up to 19% of patients complain of postoperative orgasm-associated pain, mainly referred pain at the level of the penis. Moreover, impairment in the sensation of orgasm or even complete anorgasmia has been reported in 33% to 77% of patients after surgery. Clinical and surgical factors including age, the use of a nerve-sparing technique, and robotic surgery have been variably associated with the risk of ODs after RP, although robust and reliable data allowing for a proper estimation of the risk of postoperative orgasmic function impairment are still lacking. Likewise, little evidence regarding the management of postoperative ODs is currently available. In general, physicians should be aware of the prevalence of ODs after RP, in order to properly counsel all patients both preoperatively and immediately post-RP about the potential occurrence of bothersome and distressful changes in their overall sexual function.

Prostate Cancer Detection Using Composite Impedance Metric

Prostate cancer (PCa) recurrences are often predicted by assessing the status of surgical margins (SM)- positive surgical margins (PSM) increase the chances of biochemical recurrence by 2-4 times which may lead to PCa recurrence. To this end, an electrical impedance acquisition system with a microendoscopic probe was employed in an ex-vivo study of human prostates. This system measures the tissue bioimpedance over a range of frequencies (1 kHz to 1MHz), and computes a number of Composite Impedance Metrics (CIM). A classifier trained using CIM data can be used to classify tissue as benign or cancerous. The system was used to collect the impedance spectra from 14 excised prostates, which were obtained from men undergoing radical prostatectomy, for a total of 23 cancerous and 53 benign measurements. The data revealed statistically significant (p < 0.05) differences in the impedance properties of the benign and tumorous tissues, and among the measurements taken on the apical, base, and lateral surface of the prostate. Further, in the leave-one-patient-out cross validation, a maximum predictive accuracy of 90.79% was achieved by combining high frequency CIM phase data to train a support vector machine classifier with a radial basis function kernel. The observations are consistent with the physiology and morphology of benign and malignant prostate tissue. CIMs were found to be an effective tool in distinguishing benign from cancerous tissues.

Postprostatectomy Erectile Dysfunction: A Review

In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis.