Modified technique for neurovascular bundle preservation during radical prostatectomy: association between technique and recovery of erectile function

Relationships between erectile dysfunction, prostate cancer treatment type and inflatable penile prosthesis implantation

PURPOSE

The prevalence of erectile dysfunction (ED) and the utilization of inflatable penile prosthesis (IPP) among prostate cancer patients are understudied. The aim of the study was to examine the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort.

MATERIALS AND METHODS

We identified a retrospective cohort of Surveillance, Epidemiology, and End Results (SEER)-Medicare patients diagnosed with locoregional prostate cancer between 2006 and 2011 and treated with surgery or radiation. Chi-square tests were used to detect significant differences in ED rates as well as use of IPP among the subset with ED. Multivariable logistic regression was used to examine factors associated with the use of IPP.

RESULTS

Among 31,233 patients in our cohort, 10,334 (33.1%) received prostatectomy and 20,899 (66.9%) received radiation. ED within 5 years was significantly more common in the prostatectomy group relative to those the radiation group (65.3% vs. 33.8%, p<0.001). In the subset of 13,812 patients with ED, the radiation group had greater median time to ED diagnosis compared to the prostatectomy group (346 vs. 133 days, p<0.001). IPP implantation was more frequent for prostatectomy patients than for radiation patients (3.6% vs. 1.4%, p<0.001). Cancer treatment type, race, and marital status were significantly associated with IPP utilization.

CONCLUSIONS

ED is highly prevalent among prostate cancer patients, and IPP implantation is be underutilized. ED rates, time to ED diagnosis and utilization of IPP differed significantly by prostate cancer treatment type.

Different Nerve-Sparing Techniques during Radical Prostatectomy and Their Impact on Functional Outcomes

Simple Summary

Optimum preservation of potency and continence after radical prostatectomy (RP) are equally important surgical endpoints as cancer control itself. Nerve-sparing technique during RP has a major impact to both oncological and functional outcomes of the procedure and various different techniques have been developed aiming to optimize its outcomes. This literature review aims to summarize all different nerve-sparing techniques applied during RP from its first description from Patrick C. Walsh to its newer trends. The review underlines that optimum nerve-sparing expands far beyond recognising and preserving the anatomical integrity of the neurovascular bundles. It also emphasises that nerve-sparing is a field under constant development, with new technologies entering continuously the nerve-sparing field corresponding to the evolving open, laparoscopic and robotic-assisted RP approaches.

Abstract

The purpose of this narrative review is to describe the different nerve-sparing techniques applied during radical prostatectomy and document their functional impact on postoperative outcomes. We performed a PubMed search of the literature using the keywords “nerve-sparing”, “techniques”, “prostatectomy” and “outcomes”. Other potentially eligible studies were retrieved using the reference list of the included studies. Nerve-sparing techniques can be distinguished based on the fascial planes of dissection (intrafascial, interfascial or extrafascial), the direction of dissection (retrograde or antegrade), the timing of the neurovascular bundle dissection off the prostate (early vs. late release), the use of cautery, the application of traction and the number of the neurovascular bundles which are preserved. Despite this rough categorisation, many techniques have been developed which cannot be integrated in one of the categories described above. Moreover, emerging technologies have entered the nerve-sparing field, making its future even more promising. Bilateral nerve-sparing of maximal extent, athermal dissection of the neurovascular bundles with avoidance of traction and utilization of the correct planes remain the basic principles for achieving optimum functional outcomes. Given that potency and continence outcomes after radical prostatectomy are multifactorial endpoints in addition to the difficulty in their postoperative assessment and the well-documented discrepancy existing in their definition, safe conclusions about the superiority of one technique over the other cannot be easily drawn. Further studies, comparing the different nerve-sparing techniques, are necessary.

Have urinary function outcomes after radical prostatectomy improved over the past decade?

BACKGROUND

Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one such procedure that has seen multiple advances over the past decade. The objective of this study was to leverage RP as an index case to determine whether practice changes over time produced observable improvements in patient-reported outcomes.

METHODS

This study analyzed patients undergoing RP by experienced surgeons at a tertiary care center with prospectively maintained patient-reported outcome data from 2008 to 2019. Four patient-reported urinary function outcomes at 6 and 12 months after RP were defined with a validated instrument: good urinary function (domain score ≥ 17), no incontinence (0 pads per day), social continence (≤1 pad per day), and severe incontinence (≥3 pads per day). Multivariable logistic regressions evaluated changes in outcomes based on the surgical date.

RESULTS

Among 3945 patients meeting the inclusion criteria, excellent urinary outcomes were reported throughout the decade but without consistent observable improvements over time. Specifically, there were no improvements in good urinary function at 12 months (P = .087) based on the surgical date, and there were countervailing effects on no incontinence (worsening; P = .005) versus severe incontinence (improving; P = .003). Neither approach (open, laparoscopic, or robotic), nor nerve sparing, nor membranous urethral length mediated changes in outcomes.

CONCLUSIONS

In a decade with multiple advances in surgical and postoperative care, there was evidence of improvements in severe incontinence, but no measurable improvements across 3 other urinary outcomes. Although worsening disease factors could contribute to the stable observed outcomes, a more systematic approach to evaluating techniques and implementing patient selection and postoperative care advances is needed.

LAY SUMMARY

Although there have been advances in radical prostatectomy over the past decade, consistent observable improvements in postoperative incontinence were not reported by patients. To improve urinary function outcomes beyond the current high standard, the approach to studying innovations in surgical technique needs to be changed, and further development of other aspects of prostatectomy care is needed.

Prevalence of post-prostatectomy erectile dysfunction and a review of the recommended therapeutic modalities

Radical prostatectomy (RP) represents one of the most commonly used first-line treatment modalities in men with localized prostate cancer. One of the most feared post-surgical complications is erectile dysfunction (ED), usually caused by direct damage to the cavernous nerves or due to neuropraxia. Penile rehabilitation is an emerging concept that was proposed to stimulate and accelerate recovery of erectile function after RP. The goal is to improve blood flow to the penis, increasing cavernous oxygenation and avoiding fibrosis. The most common used modalities include oral phosphodiesterase type 5 inhibitors (PDE5-I), vacuum erection devices (VEDs), intracorporeal injection (ICI) therapy, medicated urethral system for erections (MUSE), and a combination of these treatments. For those patients with severe ED, ED refractory to medical therapy and/or seeking long term reliable results, the penile prosthesis implant remains an excellent alternative. We conducted a broad review of post-prostatectomy ED prevalence with different techniques and the success rates of the different therapeutic approaches.

How to Deal with Interval-Censored Data Practically while Assessing the Progression-Free Survival: A Step-by-Step Guide Using SAS and R Software

We describe how to estimate progression-free survival while dealing with interval-censored data in the setting of clinical trials in oncology. Three procedures with SAS and R statistical software are described: one allowing for a nonparametric maximum likelihood estimation of the survival curve using the EM-ICM (Expectation and Maximization-Iterative Convex Minorant) algorithm as described by Wellner and Zhan in 1997; a sensitivity analysis procedure in which the progression time is assigned (i) at the midpoint, (ii) at the upper limit (reflecting the standard analysis when the progression time is assigned at the first radiologic exam showing progressive disease), or (iii) at the lower limit of the censoring interval; and finally, two multiple imputations are described considering a uniform or the nonparametric maximum likelihood estimation (NPMLE) distribution. Clin Cancer Res; 22(23); 5629-35. ©2016 AACR.

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.

Robot-assisted radical prostatectomy: inching toward gold standard

Robot-assisted radical prostatectomy (RARP) offers excellent and lasting oncologic control. Technical refinements in apical dissection, such as the retroapical approach of synchronous urethral transection, and adoption of real-time frozen section analysis of the excised prostate during RARP have substantially reduced positive surgical margin rates, particularly in high-risk disease patients. Furthermore, precision offered by the robotic platform and technical evolution of radical prostatectomy, including enhanced nerve sparing (veil), have led to improved potency and continence outcomes as well as better safety profile in patients undergoing surgical therapy for prostate cancer.

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.

Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial

OBJECTIVE

To examine the effect of penile vibratory stimulation (PVS) in the preservation and restoration of erectile function and urinary continence in conjunction with nerve-sparing radical prostatectomy (RP).

PATIENTS AND METHODS

The present study was conducted between July 2010 and March 2013 as a randomized prospective trial at two university hospitals. Eligible participants were continent men with an International Index of Erectile Function-5 (IIEF-5) score of at least 18, scheduled to undergo nerve-sparing RP. Patients were randomized to a PVS group or a control group. Patients in the PVS group were instructed in using a PVS device (FERTI CARE(®) vibrator). Stimulation was performed at the frenulum once daily by the patients in their own homes for at least 1 week before surgery. After catheter removal, daily PVS was re-initiated for a period of 6 weeks. Participants were evaluated at 3, 6 and 12 months after surgery with the IIEF-5 questionnaire and questions regarding urinary bother. Patients using up to one pad daily for security reasons only were considered continent. The study was registered at http://clinicaltrials.gov/ (NCT01067261).

RESULTS

Data from 68 patients were available for analyses (30 patients randomized to PVS and 38 patients randomized to the control group). The IIEF-5 score was highest in the PVS group at all time points after surgery with a median score of 18 vs 7.5 in the control group at 12 months (P = 0.09), but the difference only reached borderline significance. At 12 months, 16/30 (53%) patients in the PVS group had reached an IIEF-5 score of at least 18, while this was the case for 12/38 (32%) patients in the control group (P = 0.07). There were no significant differences in the proportions of continent patients between groups at 3, 6 or 12 months. At 12 months 90% of the PVS patients were continent, while 94.7% of the control patients were continent (P = 0.46).

CONCLUSION

The present study did not document a significant effect of PVS. However, the method proved to be acceptable for most patients and there was a trend towards better erectile function with PVS. More studies are needed to explore this possible effect further.

Advances in Robotic-Assisted Radical Prostatectomy over Time

Since the introduction of robot-assisted radical prostatectomy (RALP), robotics has become increasingly more commonplace in the armamentarium of the urologic surgeon. Robotic utilization has exploded across surgical disciplines well beyond the fields of urology and prostate surgery. The literature detailing technical steps, comparison of large surgical series, and even robotically focused randomized control trials are available for review. RALP, the first robot-assisted surgical procedure to achieve widespread use, has recently become the primary approach for the surgical management of localized prostate cancer. As a result, surgeons are constantly trying to refine and improve upon current technical aspects of the operation. Recent areas of published modifications include bladder neck anastomosis and reconstruction, bladder drainage, nerve sparing approaches and techniques, and perioperative and postoperative management including penile rehabilitation. In this review, we summarize recent advances in perioperative management and surgical technique for RALP.

Penile rehabilitation after radical prostatectomy: what the evidence really says

The pathophysiology of erectile dysfunction after radical prostatectomy (RP) is believed to include neuropraxia, which leads to temporarily reduced oxygenation and subsequent structural changes in penile tissue. This results in veno-occlusive dysfunction, therefore, penile rehabilitation programmes focus on tissue oxygenation. Animal studies support the use of phosphodiesterase type 5 inhibitors (PDE5Is) after cavernous nerve damage but results from human studies are contradictory. The largest study to date found no long-term effect of either daily or on-demand PDE5I administration after RP compared with placebo. The effects of prostaglandin and vacuum erection devices are questionable and high-quality studies are lacking. Better documentation for current penile rehabilitation and/or better rehabilitation protocols are needed. One must be careful not to repeat the statement that penile rehabilitation improves erectile function after RP so many times that it becomes a truth even without the proper scientific backing.

Erectile Function Following Prostate Cancer Treatment: Factors Predicting Recovery

Prostate cancer represents the most common nonskin malignancy encountered in men, and the excellent long-term survival achieved in the majority of patients has allowed more attention to be given to the side effects associated with its treatment. Erectile function is one of the main concerns of patients when considering treatment options for prostate cancer. Not surprisingly, post-treatment sexual function is closely related to outcome satisfaction and has long-lasting effects on quality of life. Radical prostatectomy is currently the most commonly employed therapy for prostate cancer. Conflicting rates of erectile dysfunction have been reported after surgery, owing not only to different surgical techniques but also because of dissimilar patient populations and definitions. Providing accurate information to individual patients in regards to their chances of recuperating the ability to have intercourse after treatment is important not only because it allows patients to make informed decisions but also because it has the potential to reduce treatment dissatisfaction. This article mainly focuses on discussing predictors of erectile function after radical prostatectomy. Patient factors, surgical aspects, including comparisons between open, laparoscopic, and robotic approaches, and postoperative management issues that impact sexual outcomes are evaluated. Prediction models combining multiple factors are described. The definition and chronology of erectile function recovery and impact of sexual function on quality of life after surgery are also discussed. Teloken PE and Mulhall JP. Erectile function following prostate cancer treatment: Factors predicting recovery. Sex Med Rev 2013;1:91-103.

Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy

INTRODUCTION

Prostate cancer is common, and, thus, more men are being treated surgically. Long-term functional outcomes are of significant importance to the patient and their partners. Erectile function (EF) preservation (rehabilitation) has gained significant traction worldwide, despite the absence of definitive evidence supporting its use.

AIM

To review the effectiveness of specific pharmacological therapies and other erectogenic aids in the treatment of post-radical prostatectomy (RP) erectile dysfunction.

METHODS

A systematic literature review of original peer-reviewed manuscripts and clinical trials reported in Medline.

MAIN OUTCOME MEASURE

This review focused on the evaluation of interventions that aimed to improve EF recovery following RP.

RESULTS

Although well documented in animal models, studies supporting the rehabilitation with phosphodiesterase type 5 inhibitors in humans are scarce. Daily sildenafil has been used in trials (only one randomized placebo-controlled trial) with a significant improvement in erection recovery when compared to placebo or no rehabilitation but with a low return to baseline rates (27% vs. 4% placebo). Nightly vardenafil vs. on demand vs. placebo has been studied in the Recovery of Erections: INtervention with Vardenafil Early Nightly Therapy trial with no difference in erection recovery following RP. Intracavernosal injections, although widely used and attractive from a rehabilitation standpoint, does not yet have definitive supporting its role in rehabilitation. Vacuum erection devices use following RP has been reported, but there are no data to support its role as monotherapy. Intraurethral alprostadil was also studied vs. sildenafil in a multicenter, randomized, open-label trial, and no superiority was found.

CONCLUSIONS

At this time, we are unable to define what represents the optimal rehabilitation program in regard to strategies utilized, timing of intervention, or duration of treatment.

Defining the impact of vascular risk factors on erectile function recovery after radical prostatectomy

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Erectile function recovery after radical prostatectomy is affected by surgical technique and patient factors. Age and preoperative erectile function are the 2 patient factors that have been consistently shown to impact postoperative erectile function. The presence of vascular risk factors preoperatively seems to negatively impact erectile function recovery after radical prostatectomy independently from age, preoperative erectile function and surgical technique.

OBJECTIVE

To examine whether vascular risk factors (VRFs) affect erectile function (EF) recovery after radical prostatectomy (RP).

PATIENTS AND METHODS

From our prospective database we identified patients with clinically localised prostate cancer who had undergone RP and had preoperative information on EF and VRFs (hypertension, hypercholesterolaemia, diabetes mellitus, coronary artery disease [CAD], and cigarette smoking), surgeon-graded nerve-sparing status, and EF data collected between 24 and 30 months after RP.

RESULTS

In all, 984 patients were included in the analyses. The frequency of the VRFs was as follows: hypertension (38%), hypercholesterolaemia (36%), diabetes mellitus (7%), CAD (5%), and cigarette smoking (37%). On univariate analysis, EF between 24 and 30 months was associated with age (r = 0.37, P < 0.001), EF before RP (r = 0.41, P < 0.001), NSS (r = 0.35, P < 0.001), and VRFs (0-2 vs >3 VRFs; r = 0.15, P = 0.003). On multivariable analysis all variables remained statistically significant, and accounted for 28% of the total variance in EF between 24 and 30 months after RP.

CONCLUSIONS

The presence of VRFs seems to adversely affect EF recovery after RP independently of other factors. This observation might be useful for improving patient counselling before treatment and to support the development of new treatment strategies for erectile dysfunction after RP.

Surgical management of neurovascular bundle in uterine fibroid pseudocapsule

The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.

Neurovascular bundle in fibroid pseudocapsule and its neuroendocrinologic implications

The myoma pseudocapsule is a surgical-anatomical entity surrounding the fibroid that separates the myoma from normal uterine tissue. The myoma pseudocapsule has a delicate vascular network rich with neurotransmitters analogous to the neurovascular bundle surrounding the prostate. The pseudocapsule neurovascular bundle is extremely important during myomectomy to promote uterine myometrial healing and, consequently, for uterine reproductive function. New advancements in surgery, including the use of laparoscopic myomectomy by an intracapsular technique and magnification of the myoma pseudocapsule to enhance visualization are comparable to the dissection during a radical prostatectomy. Fibroid detachment occurring inside the pseudocapsule causes less bleeding, spares the neurovascular bundle and promotes better uterine healing. The maintenance of myometrial integrity after laparoscopic myomectomy maintains uterine function and therefore improves reproductive outcomes, including labor.

Penile rehabilitation after prostate cancer treatment: outcomes and practical algorithm

The number of patients diagnosed with prostate cancer was estimated to be 192,000 in 2009 according to the American Cancer Society. The prevalence of reported erectile dysfunction after radical prostatectomy has significant variance. Among the studies in which the nerve-sparing status was described, erectile function recovery adequate for sexual intercourse was achieved in 50% of patients. This article reviews the animal and human studies in this field and provides a useful penile rehabilitation algorithm.

Erectile dysfunction after radical prostatectomy: treatment options

Erectile dysfunction is a common problem after radical prostatectomy, with almost all men experiencing this complication for at least a short period after such surgery. There is evidence that early use of phosphodiesterase type 5 inhibitors, intracavernous vasoactive drugs, intraurethral alprostadil or vacuum devices can improve the recovery of postoperative erectile function. The same therapeutic modalities can be used to treat erectile dysfunction after radical prostatectomy. Physicians must be active and counsel patients and partners to improve adherence to penile rehabilitation or erectile dysfunction treatment.

The role and structure of a postradical prostatectomy penile rehabilitation program

Erectile dysfunction (ED) is common after radical prostatectomy (RP). ED has a negative impact on health-related quality of life. Penile rehabilitation is defined as the use of any drug or device at or after RP to maximize erectile function recovery. The purpose of penile rehabilitation is the prevention of corpus cavernosal smooth muscle structural alterations not only to maximize the chances of a man having recovery of functional erections but also returning him to his preoperative erectile function level. Appreciating the value of penile rehabilitation requires understanding five concepts: the pathophysiology of ED after RP, cavernosal oxygenation, venous leak, and both the animal and human data supporting this strategy. This paper gives an overview of these factors and attempts to give a common-sense, practical guide to a rehabilitation program.

Critical appraisal of robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

To perform a contemporary critical appraisal of robotic-assisted radical prostatectomy (RaRP) through a review of the recent literature.

RECENT FINDINGS

Most studies of RaRP are observational and report perioperative, functional and short-term oncological outcomes. RaRP is associated with less blood loss and blood transfusion than open radical prostatectomy (ORP), has a positive margin rate of 9.4-20.9%, potency rate of 79.2-80.4% at 1 year and a continence rate of 90.2-97% at 1 year. Costs of the da Vinci system remain a limitation of this technique.

SUMMARY

RaRP has shown rapid dissemination over the past few years in the US urological community. However, prospective randomized clinical trials with long-term follow-up of RaRP, ORP and laparoscopic radical prostatectomy are still necessary.

Trends in radical prostatectomy

The surgical treatment of prostate cancer ideally removes the entire cancer, avoids excessive blood loss or serious perioperative complications, and results in complete recovery of continence and potency. To achieve this, the surgeon must excise sufficient periprostatic tissue to cure the cancer while preserving the cavernosal nerves required for erectile function and the neuromusculature required for normal urinary and bowel function. Here we will examine recent trends in radical prostatectomy, focusing on surgical technique.