Impacting Factors for Recovery of Erectile Function Within 1 Year Following Robotic-Assisted Laparoscopic Radical Prostatectomy

Outcomes of health-related quality of life after open, laparoscopic, or robot-assisted radical prostatectomy in China

Purpose

To compare the outcomes of health-related quality of life (HRQOL) in patients undergoing open (ORP), laparoscopic (LRP), or robot-assisted (RARP) radical prostatectomy.

Patients and methods

We retrospectively analyzed 347 men with clinically localized prostate cancer treated with ORP (n=97), LRP (n=71), or RARP (n=179) by high-volume surgeons in our institution between January 2014 and December 2016. The primary endpoint was HRQOL including urinary incontinence and erectile dysfunction.

Results

One year after surgery, 15.9% of men reported moderate to severe urinary incontinence (ORP 16.5%, LRP 15.4%, and RARP 15.7%), with only 4.6% using pads. There were no statistically significant differences in the ratios of no pad usage and urinary incontinence bother after 12 months postoperatively among the three groups. However, 67.7% of the men reported moderate to severe erectile dysfunction (ORP 66%, LRP 66.1%, and RARP 69.3%) 12 months after surgery. There was no statistically significant difference in the international index of erectile function-5 (IIEF-5) postoperatively among the different surgical groups. In the univariate and multivariate analyses, age at surgery, preoperative IIEF-5, and neurovascular bundle preservation were the risk factors for moderate to severe sexual bother. Interestingly, 16.1% of men with an erection hardness score of grade 3-4 were hesitant to become sexually active postoperatively.

Conclusion

ORP, LRP, and RARP have similar early HRQOL outcomes with respect to urinary incontinence and erectile dysfunction. In contrast to urinary continence, erectile dysfunction is still a serious concern for patients who undergo radical prostatectomy.

Evaluation of periprostatic neurovascular fibers before and after radical prostatectomy by means of 1.5 T MRI diffusion tensor imaging

OBJECTIVE

To evaluate if diffusion tensor imaging (DTI) is able to detect changes of periprostatic neurovascular fibers (PNFs) before and after radical prostatectomy (RP), and if these changes are related to post-surgical urinary incontinence and erectile dysfunction.

METHODS

22 patients (mean age 62.6 years) with biopsy-proven prostate cancer underwent 1.5 T DTI before and after RP. The number, fractional anisotropy (FA) values and length of PNFs before and after RP were compared using Student's t-test. Each patient filled out two questionnaires before and after RP, one for the evaluation of urinary continence (ICIQ-SF) and one for the evaluation of erectile function (IIEF-5). The ratios of the number, FA values and length of PNFs before and after RP (DTI B-A RATIOs) and the ratios between the scores obtained before and after RP for both ICIQ-SF and IIEF-2 (ICIQ-SF B-A RATIOs and IIEF-2 B-A RATIOs) were calculated to perform the Kendall's τ-test between them.

RESULTS

There was a statistically significant decrease of the number of PNFs after RP at base, midgland, and apex (p < 0.01) and of FA values at midgland (p < 0.05), with positive statistically significant correlation between the DTI B-A RATIOs of the number of PNFs and IIEF-2 B-A RATIOs (p < 0.05, ρ = 0.47).

CONCLUSION

DTI was able to detect that the decrease of the number of the PNFs after RP was statistically related to the post-surgical erectile dysfunction (p < 0.05). Advances in knowledge: This work demonstrates that: (1) 1.5 T MRI DTI is able to detect the decrease of the number and of the FA of PNFs after prostatectomy; (2) the decrease of the number of PNFs after prostatectomy is related with the post-surgical erectile dysfunction; (3) 1.5 T MRI DTI has demonstrated to be a reproducible technique in detecting the changes of the PNFs induced by RP, with high interobserver agreement.

Exploratory Decision-Tree Modeling of Data from the Randomized REACTT Trial of Tadalafil Versus Placebo to Predict Recovery of Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy

BACKGROUND

Understanding predictors for the recovery of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) might help clinicians and patients in preoperative counseling and expectation management of EF rehabilitation strategies.

OBJECTIVE

To describe the effect of potential predictors on EF recovery after nsRP by post hoc decision-tree modeling of data from A Study of Tadalafil After Radical Prostatectomy (REACTT).

DESIGN, SETTING, AND PARTICIPANTS

Randomized double-blind double-dummy placebo-controlled trial in 423 men aged <68 yr with adenocarcinoma of the prostate (Gleason ≤7, normal preoperative EF) who underwent nsRP at 50 centers from nine European countries and Canada.

INTERVENTION

Postsurgery 1:1:1 randomization to 9-mo double-blind treatment with tadalafil 5mg once a day (OaD), tadalafil 20mg on demand, or placebo, followed by a 6-wk drug-free-washout, and a 3-mo open-label tadalafil OaD treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Three decision-tree models, using the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score at the end of double-blind treatment, washout, and open-label treatment as response variable. Each model evaluated the association between potential predictors: presurgery IIEF domain and IIEF single-item scores, surgical approach, nerve-sparing score (NSS), and postsurgery randomized treatment group.

RESULTS AND LIMITATIONS

The first decision-tree model (n=422, intention-to-treat population) identified high presurgery sexual desire (IIEF item 12: ≥3.5 and <3.5) as the key predictor for IIEF-EF at the end of double-blind treatment (mean IIEF-EF: 14.9 and 11.1), followed by high confidence to get and maintain an erection (IIEF item 15: ≥3.5 and <3.5; IIEF-EF: 15.4 and 7.1). For patients meeting these criteria, additional non-IIEF-related predictors included robot-assisted laparoscopic surgery (yes or no; IIEF-EF: 19.3 and 12.6), quality of nerve sparing (NSS: <2.5 and ≥2.5; IIEF-EF: 14.3 and 10.5), and treatment with tadalafil OaD (yes and no; IIEF-EF: 17.6 and 14.3). Additional analyses after washout and open-label treatment identified high presurgery intercourse satisfaction as the key predictor.

CONCLUSIONS

Exploratory decision-tree analyses identified high presurgery sexual desire, confidence, and intercourse satisfaction as key predictors for EF recovery. Patients meeting these criteria might benefit the most from conserving surgery and early postsurgery EF rehabilitation. Strategies for improving EF after surgery should be discussed preoperatively with all patients; this information may support expectation management for functional recovery on an individual patient level.

PATIENT SUMMARY

Understanding how patient characteristics and different treatment options affect the recovery of erectile function (EF) after radical surgery for prostate cancer might help physicians select the optimal treatment for their patients. This analysis of data from a clinical trial suggested that high presurgery sexual desire, sexual confidence, and intercourse satisfaction are key factors predicting EF recovery. Patients meeting these criteria might benefit the most from conserving surgery (robot-assisted surgery, perfect nerve sparing) and postsurgery medical rehabilitation of EF.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01026818.

Racial Disparities in Sexual Dysfunction Outcomes After Prostate Cancer Treatment: Myth or Reality?

Among diverse subject areas in the field of prostate cancer management, treatment-related sexual dysfunction complications persist today as a significant potential problem for all men receiving treatment for this disease. The conjecture that African-American men are disproportionately affected by this problem among ethnic groups is not trivial and warrants attention in view of the possibility that its risk profile, whether real or perceived, may influence clinical management decisions impacting survival outcomes in this high-prostate cancer-risk population. A literature review was performed to define the occurrence and significance of sexual dysfunction after prostate cancer treatment in African-American men, with an emphasis on clinically localized treatment. Data retrieved from population-based as well as single-center investigations are conflicting with regard to the extent and quality of life relevance of sexual dysfunction following prostate cancer treatments in African-American men, relative to that of ethnically different counterparts. Some reports suggest a relatively greater trend in African-American men than other ethnic groups toward obtaining clinical management for sexual dysfunction and experiencing psychosocial effects from it, lending additional support for the possibly greater effect of this problem in African-American men. Although further studies are needed to define sexual dysfunction after prostate cancer treatment and ascertain its bother and impact on quality of life in African-American men, survivorship care that encompasses sexual dysfunction management should proceed with appropriate attention given to cultural, educational, and psychosocial variables.

Comprehensive analysis of sexual function outcome in prostate cancer patients after robot-assisted radical prostatectomy

PURPOSE

The recovery of potency following radical prostatectomy is complex and has a very wide range. In this study, we analyzed in detail the precise pattern of recovery of potency following robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

Prospectively collected database of patients with a minimum follow-up of 1 year after RARP were evaluated retrospectively. Of 503 patients identified, 483 patients completed the sexual health inventory for men (SHIM) preoperatively and postoperatively every 3 months for the first 12 months. Overall potency, usage of phosphodiesterase type-5 (PDE-5) inhibitors, and return to baseline erectile function were evaluated. Potency was defined as having erection that is sufficient for sexual intercourse more than 50% of attempts, while quality potency was defined as being potent without the use of PDE-5 inhibitors.

RESULTS

Preoperatively, the overall potency and quality potency rate were 67.1% and 48.1%, respectively. Postoperatively, the overall potency rate was 61.4%, while the quality potency rate was 37.2%. In multivariate regression analysis, independent predictors of potency recovery were young age (<60), preoperative potency status, and bilateral preservation of neurovascular bundles (NVBs). In men with SHIM>21, the overall potency and quality potency rate were 79.7% and 41.2%, respectively. More importantly, only 21.4% of the men with normal erection preoperatively (SHIM>21) returned to baseline erectile function (SHIM>21) 12 months after surgery.

CONCLUSIONS

This study indicates that young age (<60), preoperative potency, and bilateral preservation of NVBs were positive predictors of potency recovery following RARP. However, an overwhelming majority of men experience a deterioration in the overall quality of erection after RARP.

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.

Diffusion tensor magnetic resonance tractography of the prostate: feasibility for mapping periprostatic fibers

OBJECTIVE

To evaluate the feasibility of diffusion tensor imaging (DTI) tractography of the prostate for mapping of periprostatic neurovascular anatomy.

METHODS

Eight men with prostate cancer scheduled to undergo nerve-sparing robot-assisted radical prostatectomy (RARP) underwent endorectal multiparametric magnetic resonance imaging (MRI) of the prostate with DTI. Tract mapping was accomplished by positioning spherical regions of interest contiguously along the prostatic capsule at the prostatic apex, midgland, and base.

RESULTS

DTI tractography of the prostate effectively visualized periprostatic fiber tract anatomy. There was no significant correlation between total tract number and prostate size, however (Spearman's coefficient = 0.33, P = .42). Variation in tract distribution existed. The total fiber mass was highest in the lower prostate hemisphere at the base of the prostate (mean = 36.9 vs 21.1, P = .0004) and in the upper hemisphere at the apex (mean = 41.6 vs 57.9, P = .006).

CONCLUSION

DTI tractography successfully visualized fiber tracts around the prostate. Gold standard anatomic correlation is needed.

Use of multiparametric MR with neurovascular bundle evaluation to optimize the oncological and functional management of patients considered for nerve-sparing radical prostatectomy

INTRODUCTION

To obtain the best results with radical prostatectomy, either from an oncological or a functional point of view, a correct selection of cases and planning of surgery are crucial. Multiparametric magnetic resonance imaging (MRI) promises to make it a successful imaging tool for improving many aspects of prostate cancer management.

AIM

The aim of this study is to evaluate whether a modern multiparametric MRI can help either to better select prostate cancer cases for a nerve-sparing radical prostatectomy or to improve the functional evaluation related to neurovascular bundles preservation.

MAIN OUTCOME MEASURES

The effect of preoperative MRI on neurovascular bundle management was examined for the frequency and the appropriateness of changes of the surgical plane on the basis of MRI indications.

METHODS

In a prospective study, 125 consecutive patients with biopsy proven prostate cancer who were scheduled to undergo bilateral nerve-sparing surgery. All patients included into the study were submitted to a preoperative multiparametric MRI. On the basis of MRI evaluation, patients were divided into two groups. Patients in group A were then submitted to a bilateral nerve-sparing (NS) radical prostatectomy (RP), whereas patients in group B were submitted to unilateral NS or non-NS RP.

RESULTS

In group A, the confirmation from the MRI study to perform a bilateral NS procedure was appropriate in 70 of 73 cases (95.9%), whereas in group B, the surgical plan was appropriate in 28 of 32 cases (87.5%). On the contrary, MRI findings suggested a change in the initial surgical plan (group B) for 32 of 105 cases (30.5%). Of these 32 cases in group B, MRI suggested to perform a unilateral NS procedure in 21 of 32 cases (65.6%) and a non-NS procedure in 11 of 32 cases (34.4%).

CONCLUSIONS

Multiparametric MRI analysis can significantly improve the standard selection and management of prostate carcinoma cases considered for an NS RP.

Increasing the dose of vardenafil on a daily basis does not improve erectile function after unilateral nerve-sparing radical prostatectomy

INTRODUCTION

Several treatment regimens for rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) are currently discussed. The optimal and most cost-effective therapy is still not found yet.

AIM

To evaluate the effect of vardenafil, a PDE5 inhibitor, dose escalation on recovery of EF after unilateral nsRP.

METHODS

Thirty-six sexually active patients received a unilateral nsRP. All patients completed an International Index of Erectile Function-5 items (IIEF-5) questionnaire concerning EF preoperatively. Group 1 (N = 12 patients) received vardenafil 5 mg/day vs. group 2 (N = 12) who received vardenafil 10 mg/day at night beginning the day of catheter removal. A control of 12 patients underwent follow-up without PDE5 inhibitors.

MAIN OUTCOME MEASURE

The IIEF-5 was the primary end point. IIEF-5 questionnaires were completed at baseline, 3, 6, and 12 months after nsRP.

RESULTS

In group 1 (5 mg/day vardenafil) the IIEF-5 score decreased from a preoperative 22.4 mean score to 4.2 at 3 months, 8.9 at 6 months, and 13.4 mean score at 12 months after nsRP vs. preoperative 22.8, 4.1 at 3 months, 7.9 at 6 months, and 12.8 mean score at 12 months in group 2 (10 mg/day vardenafil). In the control group the preoperative IIEF-5 mean score of 21.9 decreased to 3.8 at 3 months, 6.1 at 6 months, and 8.9 at 12 months. Statistical evaluation showed significant difference in IIEF-5 score and time to recovery of EF between groups 1 and 3 and between groups 2 and 3 (P < 0.01). No statistical differences were found between groups 1 and 2.

CONCLUSIONS

Daily low-dose vardenafil lead to significant improvement of recovery of EF. In this study doubling the dosage did not improve the recovery of EF further.