Feasibility and acceptability of couple counselling and pelvic floor muscle training after operation for prostate cancer.

BACKGROUND: Radical prostatectomy is often followed by long-lasting erectile dysfunction and urinary incontinence, with adverse effects on the quality of life and intimate relationship of patients and partners. We developed the ProCan intervention to ameliorate sexual and urological dysfunction after radical prostatectomy and examined its feasibility, acceptability and changes in sexual function. MATERIAL AND METHODS: Between May 2014 and October 2014, seven couples attending the Department of Urology, Rigshospitalet, were included 3-4 weeks after radical prostatectomy in the ProCan intervention, which consists of up to six couple counselling sessions, group instruction in pelvic floor muscle training (PFMT), up to three individual PFMT sessions and a DVD home training program. We examined its feasibility on the basis of the recruitment rate, adherence to and acceptability of the intervention, the response rate and changes in erectile and sexual functioning measured on the International Index of Erectile Function at baseline and at eight and 12 months. RESULTS: The recruitment rate was 14%. One couple withdrew, six couples attended 1-4 counselling sessions, and all patients attended PFMT until continence was achieved. The response rate on outcomes was 85% for patients and 71% for partners. The couples reported that counselling improved their sex life but it did not improve their ability to talk openly about sex. Most patients found that the physiotherapist improved their motivation and the quality and intensity of PFMT. Erectile dysfunction improved from severe at baseline to moderate at eight months' follow-up, and mean sexual functioning improved from 18.4 to 37.1 points at eight months' follow-up, but decreased slightly to 31.4 at 12 months. CONCLUSION: Our results suggest that the recruitment procedure should be adapted and minor revisions are needed in the intervention. The key components, couple counselling and PFMT, were well accepted and achievable for the patients.

Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study.

OBJECTIVES: To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP). To describe risk factors associated with prostate cancer mortality. PATIENTS AND METHODS: Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011. Survival was described using Kaplan-Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files. Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson-Aalen estimates. Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score. RESULTS: The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP. In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively. The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confide3nce interval [CI] 13.2-17.7) and 6.6% (95% CI 4.9-8.2) respectively. CONCLUSIONS: We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer. The main limitation of the study was the relatively short follow-up. Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

Changes in preoperative characteristics in patients undergoing radical prostatectomy--a 16-year nationwide analysis.

BACKGROUND: The Danish attitude for diagnosis and treatment of early localized prostate cancer (PCa) has historically been conservative. Denmark introduced radical prostatectomy (RP) as the last of the Nordic countries in 1995. However, a rapid increment in the Danish incidence of PCa is indicative of a shift in attitude with increasing opportunistic PSA testing. This had led to an increasing number of RPs being performed in Denmark. The objective of this study was to analyze changes in preoperative characteristics over time for the complete cohort of 6489 men who underwent RP between 1995 and 2011. Our hypothesis was that an increasing amount of men undergo RP for lower risk PCa. MATERIAL AND METHODS: All patients operated from 1995 to 2011 were identified via patient files and registries. Changes over time in age at surgery, preoperative PSA, clinical T-category, biopsy Gleason score (GS), and D'Amico classification are described. Tests for statistically significant changes were performed. RESULTS: Median age increased from 61.4 to 64.8 years (p < 0.0001) during the 16-year period. Median PSA declined from 11.5 to 7.9 ng/ml (p < 0.0001). Distribution of biopsy GS changed significantly, especially after 2005. Biopsy GS = 7 was found in 20.2% of the patients in 2005 compared to 57.1% in 2011. The proportion of T1 disease increased from 32% to 56%. Significant changes in percentage of patients according to the D'Amico classification were found. After 2005 the proportion of intermediate-risk patients increased significantly. The proportion of patients age 70 or above increased from 2% to 13% in the period studies. CONCLUSION: Significant preoperative stage- and Gleason grade migration was found in this complete Danish nationwide cohort of patients undergoing RP during the past 16 years. This effect is most likely attributed to an increasing use of PSA as marker for early prostate cancer diagnosis in Denmark and new international guidelines for Gleason grading and scoring.

Couple Counseling and Pelvic Floor Muscle Training for Men Operated for Prostate Cancer and for Their Female Partners: Results From the Randomized ProCan Trial.

INTRODUCTION: Patients with prostate cancer (PC) who undergo radical prostatectomy (RP) experience impaired sexual and urinary function. AIM: To compare the effect of early couple counseling and pelvic floor muscle training (PFMT) with usual care for sexual and urinary dysfunction after RP. METHODS: The ProCan study was a randomized controlled trial (RCT) with two parallel treatment arms and 1:1 allocation. Between January 2016 and December 2017, candidates for RP were invited to a longitudinal questionnaire study and provided baseline measures before surgery. Patients who underwent RP, had a female partner, and were sexually active were invited to the ProCan RCT. Couples who provided informed consent were allocated to usual care or usual care and up to six couple counseling sessions, up to three instructions in PFMT and a video home-training program. All couples filled in follow-up questionnaires at 8 and 12 months and non-participants provided 12 months' follow-up. Linear mixed-effect models and 95% confidence intervals were used to measure effects of the intervention. MAIN OUTCOME MEASURE: Primary outcome was erectile function, measured with The International Index of Erectile Function, at 8 and 12 months follow-up. Secondary outcomes were sexual and urinary function and use of treatment for erectile dysfunction (ED) by patients; sexual function in female partners; and relationship function, health-related quality of life, anxiety, depression, and self-efficacy in both patients and female partners. RESULTS: Thirty-five couples were randomized. No significant effect of the intervention was found on erectile function at 8 months (estimated difference in change, 1.41; 95% CI; -5.51 ; 8.33) or 12 months (estimated difference in change, 0.53; 95% CI; -5.94; 6.99) or in secondary outcomes, except for significantly increased use of ED treatment at 8 months. CONCLUSION: We found no effect of early couple counseling and PFMT, possibly because of the limited number of participants. Karlsen RV, Bidstrup PE, Giraldi A, et al. Couple Counseling and Pelvic Floor Muscle Training for Men Operated for Prostate Cancer and for Their Female Partners. Results From the Randomized ProCan Trial. Sex Med 2021;9:100350.

Length of life gained with surgical treatment of prostate cancer: A population-based analysis.

OBJECTIVE: The aim of this study was to analyse relative survival, excess mortality and gain in life expectancy in men who underwent radical prostatectomy (RP) for localized prostate cancer (PCa) between 1995 and 2011 in Denmark. MATERIAL AND METHODS: The study population comprised the complete cohort of 6489 men who underwent RP between 1995 and 2011. Risk of mortality was calculated using a competing risk model. Relative survival, excess mortality rate (EMR) and gain in life expectancy in men undergoing RP were calculated using a matched cohort Danish population based on date of birth and date of surgery. RESULTS: During follow-up 328 patients died, 109 (33.2%) of PCa and 219 (66.8%) of other causes. The cumulative incidence of PCa mortality was 5.8% [95% confidence interval (CI) 4.4, 7.2] after 10 years. Relative survival was significantly above 1.0 for RP patients, except for high-risk patients. EMR was -9.34 (95% CI -10.56, -8.13) after 10 years, i.e. nine men would die in excess of the general population. Overall, the gain in life expectancy in men undergoing RP compared with the general population was 0.41 years. CONCLUSION: This population-based study demonstrated that the gain in life expectancy with RP compared with the general population in Denmark is minimal.

Early biochemical recurrence, urinary continence and potency outcomes following robot-assisted radical prostatectomy.

OBJECTIVE: The aim of this study was to describe recovery of urinary continence and potency and report oncological and functional outcomes using the survival, continence and potency (SCP) system for patients undergoing robot-assisted radical prostatectomy (RARP). MATERIAL AND METHODS: From 2009 to 2012, 232 patients underwent RARP. Self-reported continence, erection sufficient for intercourse (ESI) and scores on the five-item version of the International Index of Erectile Function-5 (IIEF-5) were registered by questionnaire and physician's interview preoperatively and at 3, 6 and 12 month follow-up, and subsequently on a yearly basis. Continence was defined as 0 pads, and potency as ESI or IIEF-5 greater than 17 with or without the aid of phosphodiesterase type 5 inhibitors. Oncological success was defined as absence of biochemical failure (BF) [prostate-specific antigen (PSA) ≥ 0.2 ng/ml]. The SCP system was used to evaluate combined oncological and functional outcomes. RESULTS: In total, 184 patients were followed for more than 1 year. The 12 month BF-free survival rate was 97.7%. Median time to regain continence was 6.2 months; 12 months postoperatively 79.9% used 0 pads/day. Of patients with preoperative ESI, 77.6% (67.9-86.1) and 34.4% (24.1-47.5) maintained ESI 12 months postoperatively after bilateral and unilateral nerve-sparing surgery (NS), respectively. NS (p < 0.0001), increasing prostate volume (p = 0.014) and lower age (p < 0.0001) were positively associated with recovery of potency. Using the SCP system and defining potency as ESI, functional and oncological success 12 months after surgery was achieved in 69 out of 135 (51.1%) preoperative continent and potent patients who underwent unilateral or bilateral NS, and did not require adjuvant treatment; when defining potency as IIEF greater than 17, this figure was 45 out of 108 (41.7%). As expected, the proportions were significantly higher for bilateral than for unilateral NS (p ≤ 0.0014). CONCLUSION: RARP provides good early BF-free survival, continence and potency recovery rates for patients eligible for NS.

Active surveillance can reduce overtreatment in patients with low-risk prostate cancer.

INTRODUCTION: The incidence of prostate cancer in Denmark rose approximately 50% from 2000 to 2009 in parallel with the introduction of prostate-specific antigen (PSA)-testing. Available evidence indicates a significant overtreatment of patients with low-risk prostate cancer. Active surveillance has been proposed as an observation strategy to reduce overtreatment and limit curatively intended therapy to those patients who need it. We reported the first Danish results from an active surveillance cohort. MATERIAL AND METHODS: A total of 167 patients were prospectively followed in an active surveillance programme. RESULTS: The median follow-up was 3.4 years (1.1-9.5). At entry the median age was 65 years (51-73), 94% had a Gleason score ≤ 6, 87.4% had a PSA ≤ 10 ng/ml and 99% ≤ cT2a. Ten patients progressed on digital rectal examination, 40 patients progressed due to a short PSA doubling time, and 34 patients progressed on re-biopsy. A total of 59 patients discontinued active surveillance. The estimated five-year probability of remaining on active surveillance was 60.0% (95% confidence interval 50.9-69.1%). CONCLUSION: Active surveillance as a management strategy for patients with clinically localized, low-risk prostate cancer is accepted by patients, seems feasible and can reduce overtreatment. However, long-term follow-up data are lacking and considerable uncertainties about optimal selection and progression criteria remain. FUNDING: The authors received financial support from the IMK Almene Fond. TRIAL REGISTRATION: not relevant.

Robot-assisted radical prostatectomy is a safe procedure.

INTRODUCTION: We present our departmental experience with robot-assisted radical prostatectomy and describe complications and early results for the first 239 consecutive patients. MATERIAL AND METHODS: A total of 239 patients were planned to undergo robot-assisted radical prostatectomy performed with a DaVinci robot. Final histopathology and pre- and perioperative parameters were registered. Furthermore, early and late complications were recorded according to the Clavien-Dindo classification. RESULTS: Robot-assisted radical prostatectomy was completed in 232 patients (97.1%). The median duration of surgery decreased significantly from initially 4.6 h in the first quartile to 3.1 h in the last quartile (p < 0.001). Overall, the median perioperative blood loss was 300 ml (range: 25-1,000 ml). The median admission time was one day (range: 1-5 days), and the median duration of bladder catheterization was eight days (range: 6-149 days). In total, 88 post-operative complications were observed in 73 patients (31.5%). A total of 70 complications appeared within 30 days of surgery, whereas 18 occurred later. Among the early complications, the majority (57.1%) were minor (Clavien-Dindo grade ≤ II); however, overall 2.6% suffered an early grade ≥ IIIb complication. Overall, the margin-positive rate was 29.3% decreasing from 43.1% in the first quartile to 24.7% in the last three quartiles (p = 0.008). CONCLUSION: Robot-assisted laparoscopic radical prostatectomy is a safe procedure with minimal blood loss, short hospitalization and short time catheter post-operatively. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Men with spinal cord injury have a smaller prostate than men without.

OBJECTIVE: To compare prostate volume and number of ejaculations in men with and without spinal cord injury (SCI). MATERIAL AND METHODS: A total of 31 men aged > or =30 years who had suffered from SCI at the age of 15-30 years >5 years previously were investigated and compared with 31 age-matched controls. Prostate size was measured using transrectal ultrasound and compared between groups. Hormonal status was examined by measuring the levels of prostate-specific antigen, testosterone, prolactin, estradiol and sex hormone-binding globulin. Questions were asked concerning ejaculatory function. RESULTS: Median prostate size was 20.4 cm(3) (range 9.9-39.7 cm(3)) in the SCI group and 25.7 cm(3) (range 14.5-39.1 cm(3)) in the control group (p=0.002). Testosterone levels were within normal ranges, but a significant difference between the groups was seen (p<0.001). The free androgen index did not differ significantly between the groups. No significant differences in other hormone levels were demonstrated. The control group ejaculated a median of eight times per month (range 1-28 times). Eight men with SCI ejaculated without assistance a median of twice per month (range <1-12 times) (p=0.028). Nine men with SCI achieved ejaculations with penile vibratory stimulation a median of once per month (range <1-4 times) (p=0.004). Fourteen men had either not ejaculated at all or very seldom following the injury. CONCLUSIONS: Men with SCI have a smaller prostate than those without. Further investigations are necessary to elucidate whether the reduced number of ejaculations they experience and the neurological damage contribute to this.