Radical prostatectomy, sparing of the seminal vesicles, and painful orgasm

INTRODUCTION

Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health.

AIM

This study aims to investigate the prevalence of PO and to identify potential risk factors.

MAIN OUTCOME MEASURES

A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire.

METHODS

Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency.

RESULTS

The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7-4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)-sparing approach (RR 2.33, 95% CI 1.0-5.3, P = 0.045) and age <60 years were significantly related to the presence of PO (95% CI 0.5-0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO.

CONCLUSIONS

We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population.

Pad use and patient reported bother from urinary leakage after radical prostatectomy

PURPOSE

To better understand clinically significant definitions of urinary incontinence we investigated the relationship between urinary leakage and patient reported bother from urinary leakage.

MATERIALS AND METHODS

A consecutive series of 1,411 men who underwent radical prostatectomy at Karolinska University Hospital, Stockholm, Sweden, from 2002 to 2006 were invited to complete a study specific questionnaire with questions on pad status, urinary leakage and bother from urinary leakage.

RESULTS

Questionnaires were received from 1,179 men with a followup of greater than 1 year (median 2.2). Results showed that even a small amount of urinary leakage resulted in a high risk of urinary bother. Of 775 survivors 46 (6%) reporting 0 pads indicated moderate or much bother compared to 38 of 123 (31%) who reported using a security pad. When comparing the 2 groups, the risk of bother from urinary leakage was more than 5 times higher in the safety pad vs the 0 pad group (RR 5.2, 95% CI 3.5-7.7). As the number of pads increased, we noted a higher bother risk. Cross-tabulation of pad use and urinary leakage revealed wide variation in pad requirements despite the same answer to urinary leakage questions.

CONCLUSIONS

If the definition of continence is based on pad use, for example safety pads, a certain number of men who report moderate or much bother from urinary leakage will be defined as continent. Our results also show that for each stated rate of urinary leakage men prove to have a major variation in the pad requirement.

Orgasm-associated urinary incontinence and sexual life after radical prostatectomy

INTRODUCTION

Involuntary release of urine during sexual climax, orgasm-associated urinary incontinence, occurs frequently after radical prostatectomy. We know little about its prevalence and its effect on sexual satisfaction.

AIM

To determine the prevalence of orgasm-associated incontinence after radical prostatectomy and its effect on sexual satisfaction.

METHODS

Consecutive series, follow-up at one point in calendar time of men having undergone radical prostatectomy (open surgery or robot-assisted laparoscopic surgery) at Karolinska University Hospital, Stockholm, Sweden, 2002-2006. Of the 1,411 eligible men, 1,288 (91%) men completed a study-specific questionnaire.

MAIN OUTCOME MEASURE

Prevalence rate of orgasm-associated incontinence.

RESULTS

Of the 1,288 men providing information, 691 were sexually active. Altogether, 268 men reported orgasm-associated urinary incontinence, of whom 230 (86%) were otherwise continent. When comparing them with the 422 not reporting the symptom but being sexually active, we found a prevalence ratio (with 95% confidence interval) of 1.5 (1.2-1.8) for not being able to satisfy the partner, 2.1 (1.1-3.5) for avoiding sexual activity because of fear of failing, 1.5 (1.1-2.1) for low orgasmic satisfaction, and 1.4 (1.2-1.7) for having sexual intercourse infrequently. Prevalence ratios increase in prostate-cancer survivors with a higher frequency of orgasm-associated urinary incontinence.

CONCLUSION

We found orgasm-associated urinary incontinence to occur among a fifth of prostate cancer survivors having undergone radical prostatectomy, most of whom are continent when not engaged in sexual activity. The symptom was associated with several aspects of sexual life.

Karolinska prostatectomy: A robot-assisted laparoscopic radical prostatectomy technique

OBJECTIVE

The last decade has witnessed an increasing trend towards minimally invasive management of prostate cancer, including laparoscopic and, more recently, robot-assisted laparoscopic prostatectomy. Several different laparoscopic approaches have been continuously developed during the last 5 years and it is still unclear which technique yields the best outcome. We present our current technique of robot-assisted laparoscopic radical prostatectomy.

MATERIAL AND METHODS

The technique described has evolved during the course of >400 robotic prostatectomies performed by the robotic team since the robot-assisted laparoscopic radical prostatectomy program was introduced at Karolinska University Hospital in January 2002.

SURGICAL PROCEDURE

Our procedure comprises several modifications of previously reported ones, and we utilize fewer robotic instruments to reduce costs. An extended posterior dissection is performed to aid in the bladder neck-sparing dissection. In nerve-sparing procedures the vesicles are divided to avoid damage to the erectile nerves. In order to preserve the apical anatomy the dorsal venous complex is incised sharply and is first over-sewn after the apical dissection is completed.

CONCLUSIONS

Our technique enables a more fluent dissection than previously described robotic techniques. Minimizing changes of instruments and the camera not only cuts costs but also reduces inefficient operating maneuvers, such as switching between 30 degrees and 0 degrees lenses during the procedure. We present a technique which in our hands has achieved excellent functional and oncological results.

Bilateral kidney tumors: oncocytoma and adenocarcinoma. A case report

An unusual case of bilateral kidney tumors with two histologically different tumors, one right-sided oncocytoma and one left-sided renal cell carcinoma is described. The morphological features of the two tumors are briefly delineated. The diagnostic dilemma between an oncocytoma and a renal cell carcinoma is discussed.

Acute rejection and angiography in renal transplantation. A prospective study

In a prospective randomized study, 25 recipients of primary cadaveric renal grafts with immediate onset of function were studied. Thirteen patients were submitted to a "base line" angiography of the graft on days 5 to 11 after transplantation, while 12 patients served as controls. HLA compatibility, pretransplant blood transfusions, and recipient age differed only slightly between the two groups. Six of 13 patients in the angiographed group showed clinical evidence of acute rejection within the first 14 days after grafting; of these rejections, two were diagnosed prior to angiography. In the control group, 9 of 12 patients rejected their grafts within the first 2 weeks. Thus, there was no indication that renal angiography in the early post-transplant period precipitated acute rejection crises, as has earlier been suggested.