Optimizing postoperative sexual function after radical prostatectomy

Improving early urinary continence recovery after radical prostatectomy by applying a sutureless technique for maximal preservation of the intrapelvic urethra: A 17-year single-surgeon experience

BACKGROUND

There is a growing concern about postsurgical outcomes of radical prostatectomy, especially in the younger population and patients with earlier tumor stages. Here, we present our 17 years' experience of sutureless vesico-urethral alignment after radical prostatectomy with a focus on postoperative functional urinary outcomes.

METHODS

Data of 784 patients who underwent radical prostatectomy during 2001-2017 were evaluated retrospectively. Before surgery, patients' demographic information, pathologic stage, margin of surgery, prostate-specific antigen, and Gleason score were obtained. Then, serum prostate-specific antigen level, urinary continence, potency, and other functional outcomes of surgery were recorded after each postoperative visit.

RESULTS

The mean age (±standard deviation) of patients was 61.3 (±6.30) years. The median (IQ_25-75) duration of follow-up was 30 (12-72) months. Full continence was achieved in 90% and 95.9% of patients at 3 and 6 months post surgery and 96.4% of the patients were continent at the last follow-up visit. Bladder neck stricture occurred in 167 patients (21.3%). During the follow-up period, none of the patients complained of total incontinence and at the last visit, 36.6% of patients reported potency. The frequency of grade 2 continence was significantly higher in patients with high-stage tumors (T3/T4), high Gleason score (⩾8), high preoperative serum prostate-specific antigen (>20 ng/dL), and positive margin of surgery. Potency had a significant relationship with age, stage of the disease, and preoperative prostate-specific antigen.

CONCLUSION

Maximal sparing of intrapelvic urethral length through sutureless vesico-urethral alignment technique results in excellent early urinary continence recovery after radical prostatectomy. A more advanced tumor stage (T1/T2), a higher Gleason score, high preoperative prostate-specific antigen, as well as positive surgical margin are risk factors of postoperative incontinence in patients who undergo radical prostatectomy.

Is active surveillance an appropriate approach to manage prostate cancer patients with Gleason Score 3+3 who met the criteria for active surveillance?

OBJECTIVE

Prostate cancer is one of the common malignant tumors in men worldwide. Nowadays it seems that Gleason Score 3+3 may not need definite treatment and some of the experts even ignore it as a cancer but we should be aware that in some patients with Gleason Score 3+3 there is a higher risk for harboring higher-grade cancer. We had done this study to evaluate patients with prostate cancer with Gleason Score 3+3 to determine the value of tumor volume in these cases.

MATERIAL AND METHODS

From September 2010 to October 2017, radical prostatectomy was done for 123 sequential patients with localized prostate cancer in two referral centers of Shahid Beheshti Medical University, Tehran, Iran, and 42 cases with Gleason Scores 3+3 which who were candidates for active surveillance were included in the study.

RESULTS

Thirty of 42 (71.4%) patients had significant tumor volumes (≥0/5 cm3). When tumor volume was less than 0.5 cm3, none of the patients had extra prostatic tumor extension. In patients with tumor volume greater than 0.5 cm3, two cases (6.6%) had extra prostatic extension, 4 cases (13.3%) had positive margins, four cases (13.3%) reactive lymph nodes and 16 cases (53.3%) perineural invasion.

CONCLUSION

We suggest that some patients with Gleason Score 3+3 have tumor volume >0.5 cm3 who are considered having significant cancer pathology and active surveillance may not be appropriate approach to manage all cases with Gleason Score 3+3.

A comparison of time taken to return to baseline erectile function following focal and whole gland ablative therapies for localized prostate cancer: A systematic review

OBJECTIVES

To systematically review erectile function (EF) outcomes following primary whole gland (WG) and focal ablative therapies for localized prostate cancer to ascertain whether the treatment modality or intended treatment volume affects the time taken to recover baseline EF.

METHOD AND MATERIALS

A systematic review was performed according to the preferred reporting items for systematic review and meta-analysis statement. Inclusion criteria were men with localized prostate cancer treated with primary, ablative therapy. Primary outcome was the return to baseline EF measured with objective, validated symptoms scores. Secondary outcome was use of phosphodiesterase inhibitors or erectile aids. Meta-analysis was not performed owing to heterogenous outcome measures.

RESULTS

Of 222 articles identified in February 2017, 55 studies which reported EF after ablative therapy were identified but only 17 used validated outcome measures and met inclusion criteria. WG cryotherapy was used in 2 studies, WG high-intensity focused ultrasound (HIFU) in 5, focal cryotherapy in 2, focal HIFU in 3, focal phototherapy or laser therapy in 4, vascular-targeted photodynamic therapy in 3, and irreversible electroporation in 2. WG cryotherapy was associated with a significant decline in EF at 6 months with minimal improvement at 36 months. Baseline IIEF-15 of patients undergoing focal HIFU fell 30 points at 1 month but returned to baseline by 6 months. The remaining focal therapies demonstrated minimal or no effect on EF, but the men in these studies had small foci of disease. The review is limited by lack of randomized studies and heterogenous outcome measures.

CONCLUSIONS

Most studies assessing the outcomes of focal therapy on sexual function were not of high quality, used heterogenous outcomes, and had relatively short follow up, highlighting the need for more robustly designed studies using validated patient reported outcome measures  for comparison. However, FT in general resulted in less effect on EF than WG ablation.

Comparisons of regular and on-demand regimen of PED5-Is in the treatment of ED after nerve-sparing radical prostatectomy for Prostate Cancer

Phosphodiesterase type-5 inhibitors (PDE5-Is) have been recommended as first line therapy for erectile dysfunction for patients received nerve-sparing radical prostatectomy for prostate cancer. We examed the efficiency of PDE5-Is and considered the optimal application. Systematic search of PubMed, Embase and the Cochrane Library was performed to identify all the studies. We identified 103 studies including 3175 patients, of which 14 were recruited for systematic review. Compared with placebo, PDE5-Is significantly ameliorated the International Index of Erectile Function-Erectile Function domain score (IIEF) scores (MD 4.89, 95% CI 4.25-5.53, p < 0.001). By network meta-analysis, sildenafil seems to be the most efficiency with a slightly higher rate of treatment-emergent adverse events (TEATs), whereas tadalafil had the lowest TEATs. In terms of IIEF scores, regular regimen was remarkably better than on-demand (MD 3.28, 95% CI 1.67-4.89, p < 0.001). Regular use was not associated with higher proportion of patients suffering TEATs compared with on-demand (RR 1.02, 95% CI 0.90-1.16, p = 0.72). Compared with placebo, PDE5-Is manifested significantly improved treatment outcomes. Overall, regular regimen demonstrated statistically pronounced better potency than on-demand. Coupled with the comparable rate of side effects, these findings support the regular delivery procedure to be a cost-effective option for patients.

Improvement in sexual function after robot-assisted radical prostatectomy: A rehabilitation program with involvement of a clinical sexologist

INTRODUCTION

To prospectively evaluate if the inclusion of a clinical sexologist in a penile and sexual rehabilitation program improves sexual function one year after prostate cancer surgery.

MATERIAL AND METHODS

Twelve months after da Vinci Radical Prostatectomy (dVRP) for prostate cancer, 28 fully potent (IIEF-5 >21) and sexually active men (ages 47-69 years, mean 61) who, in 2008, were enrolled in a prospectively monitored penile rehabilitation program (reference group) were compared with 79 fully potent (IIEF-5 >21) and sexually active men (ages 45-74 years, mean 61) enrolled in 2009 (study group); whose program differed by the inclusion of evaluation and treatment by a clinical sexologist.

RESULTS

Twelve months after dVRP, seventeen patients in the reference group (61%) were sexually active with regular penetrating sexual activity compared to sixty-six (84%) in the study group (p = 0.02). These findings were independent of whether they had undergone a nerve sparing or non-nerve sparing procedure. Almost 94% (74 patients) in the study group had at some time been able to perform penetrating sexual activity; 14 patients required additional visits to the clinical sexologist beyond the routine follow-up, 9 for short-term cognitive behavior therapy.

CONCLUSIONS

Inclusion of a clinical sexologist in a penile and sexual rehabilitation program appears to improve the ability to have regular sexual activity with penetrating sex one year after da Vinci Robotic Radical Prostatectomy.

Pelvic magnetic resonance imaging angioanatomy of the arterial blood supply to the penis in suspected prostate cancer patients

PURPOSE

To describe the internal pudendal artery (IPA) and accessory pudendal artery (APA) detected by magnetic resonance (MR) angiography to help surgeons to find and preserve them during radical prostatectomy (RP).

MATERIALS AND METHODS

Constrast-enhanced MR 3.0 T angiography of the pelvis were performed in 111 male patients suspected diagnosis of prostate cancer (PCa), and describe the penile arterial blood supply.

RESULTS

There are three patterns of the arterial blood supply to the penis (IPA and/or APA) accounting for 51.4%, 46.8% and 1.8% of cases, respectively. About the accessory pudendal artery (APA): 54/111 (48.6%) patients had APA with five different branching patterns, they were type I (APA bilateral symmetry): 17 (31.5%); type II (APA bilateral asymmetry): 1 (1.9%); type III (APA unilateral lateral): 13 (24%); type IV (APA unilateral apical): 21 (38.9%); type V (APA unilateral mix): 2 (3.7%). APA origin were from inferior epigastric artery (IEA): 7 (9.5%); from inferior vesical artery (IVA): 32 (43.2%); from obturator artery (OA): 35 (47.3%).

CONCLUSION

A precise angioanatomic evalutation of arteries destined to the penis by MR angiography pre-operation for male pelvic organs will help surgeons to preserve them and contributes to reduce the erectile dysfunction after these procedures.

Development of UK recommendations on treatment for post-surgical erectile dysfunction

AIM

To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted.

RESULTS

Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies.

CONCLUSION

Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

Systematic review and meta-analysis of the use of phosphodiesterase type 5 inhibitors for treatment of erectile dysfunction following bilateral nerve-sparing radical prostatectomy

Prostate cancer is relatively common cancer occurring in males. Radical prostatectomy (RP) is the most effective treatment for a localized tumor but erectile dysfunction (ED) is common complication, even when bilateral nerve-sparing RP (BNSRP) is performed. Clinical trials have shown varied effectiveness of phosphodiesterase type-5 inhibitors (PDE5-Is) for treatment of post-BNSRP ED, but there remains controversy over the application of this treatment and no formal systematic review and meta-analysis for the use of PDE5-Is for this condition has been conducted. This review was to systematically assess the efficacy and safety of oral PDE5-Is for post-BNSRP ED. A database search was conducted to identify randomized controlled trials (RCTs). The comparative efficacy of treatments was analyzed by fixed or random effect modeling. Erectile function was measured using the International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP) question-2, 3 and the Global Assessment Question (GAQ). The rate and incidence of adverse events (AEs) were determined. The quality of included studies was appraised using the Cochrane Collaboration bias appraisal tool. Eight RCTs were included in the analyses. PDE5-Is were effective for treating post-BNSRP ED compared to placebo when erectile function was determined using the IIEF score [mean difference (MD) 5.63, 95% confidence interval (CI) (4.26-6.99)], SEP-2 [relative risk (RR) 1.63, 95% CI (1.18-2.25) ], SEP-3 [RR 2.00, 95% CI (1.27-3.15) ] and GAQ [RR 3.35, 95% CI (2.68-4.67) ]. The subgroup analysis could find a trend that longer treatment duration, higher dosage, on-demand dosing, sildenafil and mild ED are associated with more responsiveness to PDE5-Is. PDE5-Is were overall well tolerated with headache being the most commonly reported AE. Our data provides compelling evidence for the use of PDE5-Is as a primary treatment for post-BNSRP ED. However, further studies are required to optomize usage parameters (such as dosage and duration of treatment).