Erectile function recovery after robotic-assisted radical prostatectomy (RARP): long term exhaustive analysis across all preoperative potency categories.

INTRODUCTION: To evaluate erectile function recovery following robotic-assisted radical prostatectomy (RARP) according to preoperative sexual health inventory for men (SHIM) score stratification. MATERIALS AND METHODS: We prospectively collected data on 250 consecutive patients who underwent RARP by a single surgeon between October 2006 and October 2012. Thirty-six patients were excluded because of lack of preoperative SHIM score. All patients had a minimum follow up of 2 years. Patients were divided into four groups according to their preoperative SHIM score: group 1 with normal potency (SHIM 22-25), group 2 with mild ED (SHIM 17-21), group 3 with mild-moderate ED (SHIM 12-16) and group 4 with moderate-severe ED (SHIM 1-11). Patients were followed at 3, 6, 9, 12, 18, 24 months intervals and twice yearly thereafter. SHIM questionnaire and erection hardness scale (EHS) score were collected at each visit. Potency was defined as successful penetration during intercourse (EHS score 3-4) with or without phosphodiesterase type 5-inhibitor (PDE5-I). RESULTS: After exclusion, 214 patients were evaluated. The number of patients in group 1, 2, 3 and 4 were 95, 59, 26 and 34, respectively. At 3, 6, 9, 12, 18, 24 months, SHIM scores and potency rates were statistically different between groups 1 versus 2 versus 3 versus 4 (p < 0.01, at each time point). Patients in each group 1, 2 and 3 showed a statistically significant improvement in potency rates and SHIM scores at consecutive follow up visits up to 24 months (p < 0.01, for each potency group). Potency rates at 24 months for groups 1 to 4 were 83.3%, 54.5%, 50.0%, and 20.7%, respectively (p < 0.001). CONCLUSION: For proper patient counseling and better prediction of erectile function recovery after RARP, it is important to stratify patients according to preoperative SHIM scores. Setting realistic expectations may increase patient satisfaction.

Peyronie's disease: a literature review on epidemiology, genetics, pathophysiology, diagnosis and work-up.

Peyronie's disease (PD), a fibromatous disorder of the tunica albuginea of the penile corpus cavernosum, named after the French physician Francois de la Peyronie, is characterized by pain, plaque formation, penile curvature, and plaque calcification. The epidemiological data on PD is inconsistent, with recent reports stating a prevalence of up to 9%, and the condition affecting men of all ages, from teenagers to septuagenarians. We are just beginning to elucidate the role of genetics as a causative factor for PD. Chromosomal abnormalities and single-nucleotide polymorphisms have been shown to be associated with fibrotic diatheses. Tunical mechanical stress and microvascular trauma are major contributory factors to the pathophysiology of PD. The diagnosis of PD can be made using a combination of clinical history, physical examination and, sometimes, imaging modalities. A better understanding of the molecular pathophysiology of this condition remains paramount for the development of newer and more effective disease-targeted interventions.

Uroflow Stop Test and Potency Recovery: A Surrogate for Pelvic Floor Integrity Post Robotic-Assisted Radical Prostatectomy?

OBJECTIVE: To study the relation between uroflow Stop Test and early recovery of potency following robot-assisted radical prostatectomy (RARP). We recently showed that the ability to completely stop urine flow during voiding, measured objectively by uroflowmetry at the time of catheter removal (uroflow Stop Test) can predict early urinary continence recovery following RARP. MATERIALS AND METHODS: In this prospective observational cohort, data were collected on 108 patients operated by a single surgeon (AEH). Eighty patients had a positive uroflow Stop Test (group one) and 28 had a negative Stop Test (group two). Patients were followed for a minimum of 2 years. Covariates included age, body mass index, international prostate symptom score and sexual health inventory for men scores, prostate-specific antigen, tumor stage, prostate volume, nerve sparing status, and estimated blood loss. RESULTS: Preoperative characteristics were comparable between both groups except nerve sparing and prostate-specific antigen which were statistically higher in group one (P <.05). Early 3- and 6-months recovery of erectile function was significantly higher in group one. Potency rates in group one and two at 1, 3, 6, 9, 12, 18, and 24 months were 25% vs 14.3% (P = .241), 54.5% vs 18.5% (P = .001), 55.4% vs 18.5% (P = .001), 56.4% vs 36% (P = .084), 66.6% vs 50% (P = .141), 65.5% vs 56% (P = .404) and 73.2% vs 57.7% (P = .160) respectively. Uroflow Stop Test was independent predictor of early potency recovery on multivariate regression analysis at 6 months [odds ratio 6.042 (confidence interval 95% 1.496-24.413) P = .012]. CONCLUSION: Uroflow Stop Test is simple and can help predict early potency recovery following RARP.

Novel uroflow stop test at time of catheter removal is a strong predictor of early urinary continence recovery following robotic-assisted radical prostatectomy: a pilot study.

AIM: To study whether the ability to completely stop urinary flow during voiding at time of catheter removal, measured objectively using uroflowmetry, can predict early recovery of urine continence following robotic-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: In this pilot study, 108 patients with a minimum of 2 years follow-up, operated by a single surgeon (AEH) were subjected to an uroflowmetry at the time of urethral catheter removal following RARP. Normal Saline (150 ml) was instilled intravesically prior to catheter removal and patients were instructed to attempt to stop urine flow during voiding in uroflowmeter. Two groups were studied, group one with positive Stop Test (n = 80) and group two with negative Stop Test (n = 28). Covariates included age, BMI, IPSS score, PSA, tumor stage, prostate volume, nerve sparing status, and estimated blood loss. RESULTS: Basic characteristics were not statistically different between both groups. Early continence recovery was significantly higher in group one. Pad-free continence rates in group one and two at 1, 3, 6, 12, 18, and 24 months were 62% vs. 7% (P < 0.001), 85% vs. 28% (P < 0.001), 93% vs. 67% (P 0.001), 93% vs. 82% (P 0.079), 97% vs. 82% (P 0.006), and 97% vs. 85% (P 0.023), respectively. Uroflow Stop Test was the only independent predictor of early urine continence recovery on univariate and multivariate regression analysis [OR 2.87 (95%CI 1.34-4.38, P = < 0.001)]. CONCLUSION: Novel use of uroflowmetry at time of urethral catheter removal is a simple, non-invasive study with independent ability to predict early continence recovery following RARP.

Accuracy of transrectal ultrasonography to evaluate pathologic prostate weight: correlation with various prostate size groups.

OBJECTIVE: To report the accuracy of transrectal ultrasonography (TRUS) to measure prostate size before robotic-assisted radical prostatectomy using the prolate ellipsoid formula and its correlation to the weight of the postoperative prostate specimen, for different prostate size groups. METHODS: Preoperative prostate size estimated by TRUS and the weight of postoperative prostate specimens were collected from 440 men undergoing robotic-assisted radical prostatectomy. Patients were grouped according to preoperative prostate size: <30, 30-60, 60-80, and ≥80 g. To evaluate accuracy, the mean absolute percentage of error was used. The mean percentage of error was used to indicate whether the estimation of TRUS had a tendency to overestimate or underestimate prostate size. The correlation between both measurements was analyzed for each size group. RESULTS: Accuracy of TRUS estimation was associated with increased prostate size. TRUS estimation was more accurate for larger prostates. The mean absolute percentage of error of each group was 38.64% (<30 g), 21.33% (30-60 g), 13.23% (60-80 g), and 14.96% (≥80 g). Correlation followed a similar size-dependent trend, with a stronger r coefficient for larger prostates: 0.174 (<30 g), 0.327 (30-60 g), 0.457 (60-80 g), and 0.839 (≥80 g). Interestingly, smaller prostates were underestimated, whereas larger glands (≥80 g) had a tendency to be overestimated by TRUS. CONCLUSION: This study demonstrates that the accuracy of the prolate ellipsoid formula for TRUS varies according to prostate size. Although this formula is fairly accurate for assessing larger prostates, it shows some limitations for smaller prostates. This must be taken into account when evaluating treatment modalities such as transurethral incision of the prostate and brachytherapy.

Predictors of viable germ cell tumor in postchemotherapeutic residual retroperitoneal masses.

OBJECTIVE: The aim of this study was to identify predictors of viable germ cell tumor (GCT) in postchemotherapeutic residual retroperitoneal masses. MATERIALS AND METHODS: The pertinent clinical and pathologic data of 16 male patients who underwent postchemotherapeutic retroperitoneal lymph node dissection (PC-RPLND) at King Faisal Specialist Hospital and Research Centre between 1994 and 2005 were reviewed retrospectively. It was found that all patients received cisplatin-based chemotherapy for advanced testicular GCT. RESULTS: Out of the 16 male patients, 2 (13%), 8 (50%), and 6 (37%) had viable GCT, fibrosis, and teratoma, respectively. Ten (10) of the patients with prechemotherapeutic S1 tumor markers did not have viable GCT, and two of the six patients who had prechemotherapeutic S2 tumor markers have viable GCT. All tumor marker levels normalized after chemotherapy even in patients with viable GCT. Four patients had vascular invasion without viable GCT. Furthermore, four patients had more than 60% embryonal elements in the original pathology, but only 1 had viable GCT at PC-RPLND. Four of the five patients with immature teratoma had teratoma at PC-RPLND but no viable GCT; however, out of the four patients with mature teratoma, one had viable GCT and two had teratoma at PC-RPLND. Of the two patients with viable GCT, one had 100% embryonal cancer in the original pathology, prechemotherapeutic S2 tumor markers, history of orchiopexy, and no vascular invasion; the other patient had yolk sac tumor with 25% embryonal elements and 40% teratoma in the original pathology, and prechemotherapeutic S2 tumor markers. CONCLUSION: None of the clinical or pathological parameters showed a strong correlation with the presence of viable GCT in PC-RPLND. However, patients with ≥S2 may be at higher risk to have viable GCT. Further studies are needed to clarify this.

Perioperative, oncological and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases.

BACKGROUND: Robotic-assisted radical prostatectomy (RARP) is being increasingly done in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. The objective of this study is to report the longest single surgeon experience in the province of Quebec. METHODS: We collected prospective data from 250 consecutive patients who underwent RARP by a single fellowship trained surgeon (AEH) from October 2006 to October 2012. Mean follow-up was 28 months (range: 1-72). The D'Amico risk stratification distribution was 34% in low-risk, 48% in intermediate-risk and 18% in high-risk groups. RESULTS: The mean operation time (±SD) was 194 ± 60.6 minutes, and estimated blood loss 318 ± 179 mL. The transfusion rate was only 0.4%. All procedures were completed robotically. The mean hospital stay was 1.2 days, and 88% of patients were discharged on postoperative day 1. The mean catheterization time was 7 days (range: 6-13). There were 2% major (Clavien III-IV) and 7.2% minor (Clavien I-II) postoperative complications, and no mortalities. On final pathology, 76% of patients were organ-confined and 70% specimen-confined. Pathological Gleason sum ≥7 accounted for 86%. Return of urinary continence (0-pads) at 3, 6, 12, and 24 months was 73.3%, 83.5%, 92.3%, 96.5%, respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 49.3%, 85%, and 95.3%, respectively. Operative time and positive surgical margin (PSM) in organ-con-fined disease (pT2) decreased significantly after 50 cases. Seventeen patients (6.8%) had no undetectable prostate-specific antigen (PSA) at first visit (PSA <0.1 ng/mL). Of remaining 233 patients, biochemical recurrence (PSA >0.2 ng/mL) was 4.7% (11 patients), and another 3.4% (8 patients) received early salvage radiotherapy (rising PSA, but <0.2 ng/mL). No patients with undetectable PSA required salvage treatments within 6 months postoperatively. CONCLUSIONS: Our results compare favourably with high-volume RARP programs, despite mainly intermediate- to high-risk disease. Initial learning curve was estimated to be 50 cases. Fellowship training was instrumental in achieving adequate functional and oncological outcomes, while maintaining low complications rate.

180 W vs 120 W lithium triborate photoselective vaporization of the prostate for benign prostatic hyperplasia: a global, multicenter comparative analysis of perioperative treatment parameters.

OBJECTIVE: To evaluate the surgical performance of the new Greenlight XPS-180 W laser system (American Medical Systems, Minnetonka, MI) and the effect of prostate volume (PV), in comparison with the former HPS-120 W system, for the treatment of benign prostatic hyperplasia by photo-selective vaporization of the prostate. METHODS: Between July 2007 and March 2012, 1809 patients underwent laser photo-selective vaporization of the prostate (1187 patients with the use of HPS-120 W and 622 patients with the use of XPS-180 W) at 7 international centers. All data were collected prospectively. Comparative analysis was performed between XPS and HPS according to PV measured by transrectal ultrasound. RESULTS: The XPS compared with HPS, allowed significantly reduced laser and operative time (29.6 minutes vs 65.8 minutes and 53 minutes vs 80 minutes, respectively; P <.01 for both). The number of fiber used during the procedures was significantly reduced with the XPS system (1.11 vs 2.28; P <.01), whereas total energy delivered was lower (250.2 kJ vs 267.7 kJ; P = .043). Overall, the mean operative time, mean laser time, and mean energy were all significantly increased according to PV >80 mL vs <80 mL. However, when stratified according to PV, XPS demonstrates significant advantages compared with HPS, regardless of prostate size in all operative parameters (P <.01). CONCLUSION: The new XPS-180 W system exhibits significant advantages in all surgical parameters compared with the HPS-120 W system. Overall, with XPS-180 W and HPS-120 W, mean operative time, laser time, and energy usage increased according to PV. This suggests that preoperative evaluation of PV by transrectal ultrasound should be mandatory.

Antioxidant therapy in male infertility: fact or fiction?

Infertile men have higher levels of semen reactive oxygen species (ROS) than do fertile men. High levels of semen ROS can cause sperm dysfunction, sperm DNA damage and reduced male reproductive potential. This observation has led clinicians to treat infertile men with antioxidant supplements. The purpose of this article is to discuss the rationale for antioxidant therapy in infertile men and to evaluate the data on the efficacy of dietary and in vitro antioxidant preparations on sperm function and DNA damage. To date, most clinical studies suggest that dietary antioxidant supplements are beneficial in terms of improving sperm function and DNA integrity. However, the exact mechanism of action of dietary antioxidants and the optimal dietary supplement have not been established. Moreover, most of the clinical studies are small and few have evaluated pregnancy rates. A beneficial effect of in vitro antioxidant supplements in protecting spermatozoa from exogenous oxidants has been demonstrated in most studies; however, the effect of these antioxidants in protecting sperm from endogenous ROS, gentle sperm processing and cryopreservation has not been established conclusively.

Pattern of management of urologic cancer in Saudi Arabia.

BACKGROUND: To compare the current uro-oncologic practice pattern in Saudi Arabia with the standard of care practice and to identify obstacles in our health care system that prevent offering such a treatment. MATERIALS AND METHODS: We surveyed 247 practicing urologists in Saudi Arabia using a designed questionnaire. This questionnaire contains 19 questions focusing on management of bladder and renal cancers. RESULTS: Of the 247 contacted urologists, 86 completed the questionnaire. Seventy six percent see more than 10 bladder cancer cases/year and 83% used rigid cystoscope for diagnosis under general anesthesia. Eighty two percent perform over 10 bladder tumor resections/year; however, 90% of them perform less than five cystectomies/year, if any. Seventy nine percent had intravesical therapy available at their hospitals and majority of them use it after resection in selected patients. Fifty percent preferred re-resection within 2-4 weeks for T1 and/or G3 tumors and majority of them (86%) perform cystectomy for muscle invasive disease and ninety six percent perform ileal conduit. Thirty four percent see over 10 renal cancers/year. Forty nine percent perform radical nephrectomy for less than 4 cm renal masses and for more than 4 cm, only 9% do laparoscopic nephrectomy while the majority preferred open technique although 77% of the hospitals participated in this survey have a urologist capable of doing laparoscopy. CONCLUSION: A significant number of urologists in Saudi Arabia do not apply some of the well-accepted standard practices in urologic cancer. To improve this, we need to work on our referral system and establish education and training programs to make the urologist familiar with the new modalities of treatment.

Computed tomography angiogram: accuracy in renal surgery.

OBJECTIVES: To determine the sensitivity and specificity of computed tomography angiogram (CTA) in detecting number and location of renal arteries and veins as well as crossing vessels causing uretero-pelvic junction obstruction (UPJO), and to determine if this can be used in decision-making algorithms for treatment of UPJO. METHODS: A prospective study was carried out in patients undergoing open, laparoscopic and robotic renal surgery from April 2005 until October 2006. All patients were imaged using CTA with 1.25 collimation of arterial and venous phases. Each multi-detector CTA was then read by one radiologist and his results were compared prospectively with the actual intra-operative findings. RESULTS: Overall, 118 patients were included. CTA had 93% sensitivity, 77% specificity and 90% overall accuracy for detecting a single renal artery, and 76% sensitivity, 92% specificity and 90% overall accuracy for detecting two or more renal arteries (Pearson chi(2) = 0.001). There was 95% sensitivity, 84% specificity and 85% overall accuracy for detecting the number of renal veins. CTA had 100% overall accuracy in detecting early dividing renal artery (defined as less than 1.5 cm branching from origin), and 83.3% sensitivity, specificity and overall accuracy in detecting crossing vessels at UPJ. The percentage of surgeons stating CTA to be helpful as pre-operative diagnostic tool was 85%. CONCLUSION: Computed tomography angiogram is simple, quick and can provide an accurate pre-operative renal vascular anatomy in terms of number and location of renal vessels, early dividing renal arteries and crossing vessels at UPJ.