Robot assisted radical prostatectomy in fit older patients compared to a standard population: Clinical characteristics, surgical, oncological and functional outcomes.

INTRODUCTION: To compare robotic assisted radical prostatectomy (RARP) in well-selected older patients with clinically localized prostate cancer, compared to a younger population. Primary endpoint was perioperative outcomes comparison and secondary endpoint were oncological and functional outcomes comparison to a younger population. METHODS: Single tertiary center cohort of consecutive patients treated with RARP (2017-2020) with retrospective analysis. Patients were classified by age in two groups: <75: control group (CG) and ≥75: study group (SG). Patients aged ≥75 had a comprehensive geriatric assessment (CGA) and only patients classified Balducci ≤2 were admitted to surgery. RESULTS: Two hundred and sixty-nine patients were included, 56 in SG and 213 in CG. Median follow-up was 9.8 months. Univariate analysis showed no statistically significant (SS) difference between the groups for patients' characteristics (PSA, digital rectal examination -DRE- and biopsy Gleason Score), perioperative data (operative time, hospitalization length, transfusions rate, immediate complications, Clavien-Dindo complications, 30-days re-interventions and 30-days re-hospitalisation), oncological (TNM, margins, extraprostatic extension, postoperative PSA, BCR, metastases, overall survival -OS- and cancer specific survival -CSS-) and functional outcomes. Median perioperative blood loss was lower in the SG: 200.00 cc IQR [100.00, 300.00] vs 200.00cc IQR [100.00, 400.00] in the CG (P<0.05). A multivariate regression considering age>75, DRE, GS, PSA, cardiovascular history and diabetes showed none of variables associated with early BCR. Limitations are retrospective design, small number of patients and short follow-up. CONCLUSIONS: RARP shows similar perioperative, oncologic and functional outcomes for older patients selected by a CGA when compared to younger patients. The SG shows a minor perioperative bleeding. LEVEL OF EVIDENCE: IV.

[Artificial urinary sphincter in patients with urinary incontinence after High Intensity Focused ultrasound]. / Sphincter urinaire artificiel chez les patients présentant une incontinence urinaire après High Intensivity Focused Ultrasound Therapy.

INTRODUCTION: Urinary incontinence after High Intensity Focused ultrasound (HIFU) is a poorly documented issue. To our knowledge, no study has evaluated the outcomes of artificial urinary sphincter (AUS) after HIFU. The aim of this study was to evaluate the functional outcomes of AUS for post-HIFU urinary incontinence. METHODS: The charts of all male patients who underwent an AUS implantation between 2004 and 2020 in 13 centers were reviewed retrospectively. Only men with a history of HIFU were included. The primary endpoint was social continence at 3 months defined as wearing 0 to 1 pad per day. RESULTS: Out of 1318 procedures, nine men were implanted with an AUS after HIFU including four men with an history of pelvic irradiation: 3 pelvic radiation therapy and 1 prostatic brachytherapy. The patients were divided into two groups, 5 in the HIFU group without a history of pelvic irradiation, 4 patients in the HIRX group with a history of pelvic irradiation. The median age was 74 years (IQR 71-76). There was no perioperative complication. The median follow-up was 47.5 (IQR 25-85.5) months. Social continence at 3 months was 75% in the total cohort: 80% in the HIFU group and 67% in the HIRX group. CONCLUSION: AUS implantation may provide satisfactory long-term functional outcomes in the treatment of stress urinary incontinence resulting from HIFU. Larger series are needed to confirm these findings. LEVEL OF EVIDENCE: 4.

[Medico-economic evaluation of the impact of measures to adapt to the switch to surgery robot-assisted in urology]. / Évaluation médico-economique de l'impact de mesures d'adaptation au virage de la chirurgie robot-assistée en urologie.

INTRODUCTION: The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery. METHOD: We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison. RESULTS: Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year. CONCLUSIONS: Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term. LEVEL OF EVIDENCE: 3.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]. / Évaluation des mesures de triages de la première vague pandémique Covid-19 pour sélectionner les patients à opérer pour cancers et urgences urologiques.

INTRODUCTION: Faced with the first wave of Covid-19 pandemic, guidelines for surgical triage were developed to free up healthcare resources. The aim of our study was to assess clinical characteristics and surgical outcomes of triaged patients during the first Covid-19 crisis. METHOD: We conducted a cohort-controlled, non-randomized, study in a University Hospital of south-eastern France. Data were collected prospectively from consecutive patients after triage during the period from March 15th to May 1st and compared with control data from outside pandemic period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications and data from cancer and non- cancer subgroups were assessed. RESULTS: After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 y.o (IQR: 56-75 y.o), sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery. No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid- era patients. CONCLUSIONS: Surgery after triage during the first Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be life threatening. LEVEL OF EVIDENCE: 3.

[Assessment of a post-emergency pathway with early urological regulation]. / Analyse d'un modèle de circuit court post-urgence avec une régulation précoce urologique.

INTRODUCTION: Urological emergencies represent 7 % of the outpatients at the emergency department (ED). We assessed the effect of setting up a post-emergency consultation (CPU) after deferred urological medical regulation. METHODS: All patients admitted to the ED in a university center over the period December 2017 to July 2018 and for whom a CPU was scheduled were included. The regulation concerned the date of CPU and supplementary exams. The main outcome was the ability to provide an efficient response according to a predefined grid of specific solutions. RESULTS: One hundred and twenty-eight patients were included. The median age was 57 years (18-97). Efficacy of the CPU was 76 %. This rate was lower in no-show patients or consulting for rare and complex motives (47 %, n=60). The no-show were not reachable on the first call in 51.6 % of cases, with a similar age and motives distribution to the others. Only 6,9 % (n=128) of all consultants (n=1863) had been referred to the CPU by emergency physicians. The decision was a second consultation in 70 % (48), a new exam in 10 % (7), deferred emergency surgery in 12 % (8) and finally 18 % (12) of no follow-up. CONCLUSION: CPU following early regulation by a urologist provides an effective response in 76 % of situations. Assessment of "no-shows" helped to identify groups at risk. LEVEL OF EVIDENCE: III.

Endoscopic robot-assisted C7 nerve root retrophalangeal transfer from the contralateral healthy side: A cadaver feasibility study.

Controlateral C7 nerve root transfer in brachial plexus palsy requires a nerve graft and large incisions. This study investigated the feasibility of transferring the right C7 to the left C7 nerve root, without a graft, via a minimally invasive retropharyngeal approach. After installation of 6 trocars of 1cm diameter in the supraclavicular space, a Da Vinci SI® robot was placed. After locating the right brachial plexus, the C7 root was sectioned flush with the clavicle, transferred behind the pharynx and sutured to the left C7 root severed at the foramen level. The duration of the procedure was 2h40min. No technical difficulties were encountered. The hypothesis of this work was verified since it was possible to carry out a transfer of the right C7 root on the left C7 root by direct retropharyngeal suture without graft and by a minimally invasive technique.

A porcine model for robotic training harvest of the rectus abdominis muscle.

Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.

[Elastography shows promise in testicular cancer detection]. / Apport de l'élastographie en temps réel pour la caractérisation des masses testiculaires.

PURPOSE: Elastography is a novel imaging technology that shows promise in the identification of anatomic structures. The widespread use of ultrasound for screening testicular tumors in patients with cancer risk factors highlights unclassified testicular micronodules. We investigated the ability of elastography to accurately diagnose testicular nodules. MATERIAL: Patients with clinical testicular nodules were assigned to undergo elastography in a prospective study. The imaging was carried out by a single radiologist using a static elastography unit with a 9-14MHz frequency linear transducer, to identify hardness score, loss of architecture of testicular parenchyma, and surrounding effect. When orchidectomy was required, the corresponding specimens were subjected to hematoxylin and eosin staining for histologic correlation. RESULTS: We imaged 34 testicular lesions: 26/34 (76%) malignant tumors and 8/34 (24%) non-tumor lesion including 4 hematomas, 3 orchitis and 1 ischemia. Se, Sp, PPV and NPV of hardness in elastography in differentiating between malignant and benign tissue was found to be 96.2%, 37.5%, 83%, and 75%, respectively. Further, for recognizing cancer, the loss of architecture of the testicular parenchyma detecting in elastography was 92.3%, 75%, 92.3%, and 75%, respectively, and the surrounding effect was 84.6%, 87.5%, 95.6% and 63.6%, respectively. CONCLUSION: Elastography may be a promising tool at diagnosing testicular tumor when the loss of architecture and the surrounding effect were present. Further studies are needed to evaluate whether the utility of elastography is worth pursuing to identify of unclassified testicular micronodules. LEVEL OF EVIDENCE: 3.

[Salvage HIFU after radiotherapy and salvage radiotherapy after HIFU in locally recurrent prostate cancer: Retrospective analysis of morbidity]. / Traitements de rattrapage par HIFU après radiothérapie première et par radiothérapie après HIFU première dans la récidive locale du cancer de prostate: analyse rétrospective de la toxicité

OBJECTIVES: To evaluate the toxicity of therapeutic sequences High Intensity Focused Ultrasound (HIFU)-salvage radiotherapy (HIFU-RT) or radiotherapy-salvage HIFU (RT-HIFU) in case of locally recurrent prostate cancer. MATERIALS AND METHODS: Nineteen patients had a local recurrence of prostate cancer. Among them, 10 patients were treated by HIFU-RT and 9 patients by RT- HIFU (4 by external beam radiotherapy [EBR] and 5 by brachytherapy [BRACHY]). Urinary side effects were assessed using CTCAE v4. RESULTS: At the time of the initial management, the median age was 66.5 years (53-72), the median PSA was 10.8ng/mL (3.4-50) and the median initial Gleason score was 6.3 (5-8). Median follow-up after salvage treatment was 46.3 months (2-108). Thirty percent of the patients in the HIFU-RT group and 33.3 % of the patients in the RT-HIFU group, all belonging to the sub-group BRACHY-HIFU, had urinary complication greater than or equal to grade 2. Among all the patients, only 1 had grade 1 gastrointestinal toxicity. CONCLUSION: BRACHY-HIFU sequence seems to be purveyor of many significant urinary side effects. A larger database is needed to confirm this conclusion.

[Ipsilateral dual kidney transplantation: a monocentric experience about 15 cases and literature review]. / Bi-transplantation rénale par abord ipsilatéral: expérience d'un centre à propos de 15 patients opérés consécutivement et revue de la littérature.

OBJECTIVE: Our study aimed to support the viability of the concept of Ipsilateral Dual Kidney Transplantation (DKT) by presenting our initial experience and proposing a review of the literature in this subject. METHODS: Fifteen ipsilateral DKT were performed at Nice University Hospital between August 2010 and March 2012. We have described our skin incision preferences, the vascular anastomoses, and the uretero-vesical reimplantation. We have analyzed the operative duration, the cold ischemia time (CIT) of both transplants, the blood transfusion volume, the intraoperative and postoperative complications, the time to diuresis recovery, the hospital stay, and the kinetics of the creatinine clearance until the third postoperative month. We have compared our results with those of the literature. RESULTS: The average CIT of the first transplant (T1) was 17.5 ± 3.3 hours, and that of the second (T2) was 18.4 ± 3.3 hours. The mean operating time was 234 ± 67 minutes. Patients received an average of 2 units of blood during surgery [0-4] and 1.8 units in the postoperative period [0-15]. The complications rate was 26.7% and included an intraoperative T2 artery thrombosis and 3 postoperative complications consistent with a hematoma, a T2 ureteric necrosis and a T2 venous thrombosis. Two transplants were lost (6.7%) and one death (6.7%) was reported on day 40. The average length of hospital stay was 20.9 ± 7.8 days. The mean creatinine clearance values were 12.6 mL/min at D2, 35.6 mL/min at D7, 44.9 mL/min on discharge, and 48.2 mL/min at D90. CONCLUSION: Our results supported the viability of the dual kidney transplantation concept. Furthermore the ipsilateral approach shortened the procedure and limited the surgical trauma by preserving the contralateral iliac fossa, without compromising renal function recovery or increasing morbidity.

[Cosmetic surgery of the male genitalia]. / Chirurgie cosmétique de l'appareil génital masculin.

OBJECTIVES: To describe the indications and results of techniques to change the appearance of the penis for aesthetic reasons. Provide recommendations concerning cosmetic surgery of the male genitalia. MATERIAL AND METHODS: We have selected from Medline Database, articles published between 1990 and 2011. Forty articles have been selected excluding papers reporting populations less than five cases per type of procedure. RESULTS: There is no consensus on the size below which it is justifiable to accept or attempt to modify the size of the penis. Length of the penis in maximal tension less than 9.5 cm or 10 cm in erection can be considered as an acceptable limit, in a patient who suffers from it. The assessment of men asking for penile enlargement must include a psychosexological or psychiatric evaluation, looking for a dysmorphophobia or another psychiatric condition. Penile extenders under medical control must be the first-line treatment option for patient seeking penile lenghtening procedure when justified. In case of failure, three techniques can be used alone or in combination: penile lengthening by section of the suspensory ligaments and suprapubic skin advancement, lipectomy of Mons pubis and scrotal webbing section. The results are modest, the rate of complications significant and satisfaction low. Girth enlargement techniques by injection of autologous fat give inconsistent aesthetic results and satisfaction rates are low. All other techniques remain experimental. CONCLUSIONS: Cosmetic surgery of the penis is associated with a high risk of forensic exposure and surgery should be only proposed after a multidisciplinary consensus, followed by a time of reflection given to the patient after full disclosure. Applications for the purpose of reconstruction surgery after trauma or consequences of cancer treatment are justified.

The emerging role of connexin 43 in testis pathogenesis.

Direct intercellular communication is mediated by gap junctions and their constitutive proteins, the connexins, which are organized in a hexameric arrangement forming a channel between adjacent cells. Connexins are essential for cell homeostasis and are also involved in many physiological processes such as cell growth, differentiation and death. Spermatogenesis is a sophisticated model of germ cell proliferation, differentiation, survival and apoptosis, in which one connexin isoform, connexin 43, plays an essential role as evidenced by the targeted genetic deletion of Cx43 gene. A controlled balance of germ cell growth is a prerequisite to maintain either normal level of spermatozoa necessary for fertility and/or to limit an uncontrolled and anarchic germ cell proliferation, a major risk for germ cell tumor cell development. In the present review, we highlight the emerging role of connexins in testis pathogenesis, specifically in two intimately interconnected human testicular diseases: azoospermia with impaired spermatogenesis and testicular germ cell tumors, whose incidence increased during the last decades. This review proposes the gap junction protein connexin 43 as a new potential cancer diagnostic and prognostic marker, as well as a promising therapeutic target for testicular diseases.

[Photovaporisation of the prostate using KTP laser in patients on antithrombotics. About a restrospective study of 120 cases]. / Photovaporisation prostatique avec le laser KTP chez les patients sous traitement antithrombotique. À propos d'une étude rétrospective sur 120 cas.

UNLABELLED: Antithrombotic (AT) medications are more and more prescribed, so complicating the surgery of benign prostatic hyperplasia (BPH). KTP laser is an alternative to the transurethral resection of the prostate thanks to its haemostatic properties. OBJECTIVES: To study the functional outcomes and complications of KTP 80W laser treatment in patients taking AT, comparing with patients without AT (nAT). PATIENTS AND METHODS: A single-center retrospective study has been conducted in the department of Urology of Nice Teaching Hospital, in patients with uncomplicated symptomatic BPH, treated with the KTP 80W laser treatment, between November 2005 and October 2009. The cohort was divided into two matched groups AT/nAT. In the AT group patients, treatment with aspirin and vitamin K antagonist (VKA) were maintained, whereas clopidogrel was discontinued. The urinary flowmetry, measurement of residual urine, International Prostate Symptom Score (IPSS) and question 8 of the IPSS score were analyzed. The duration of intervention, the amount of laser energy delivered, duration of catheterization and postoperative hospitalization, and the rate of blood transfusion have been evaluated. Clavien classification was used to characterize the postoperative complications. RESULTS: A total of 120 patients were included in two groups (50 AT/70 nAT), with a median follow-up of 24 months. The two study groups were comparable except for age which was significantly higher in patients on AT (P=0.001). The average duration of operation, of catheterization and hospital stay were significantly longer in patients receiving AT. Seven complications were reported in the AT group versus three complications in the nAT. No significant difference was reported on the evaluation of voiding parameters and IPSS score. CONCLUSION: Photovaporisation of the prostate using KTP 80W laser treatment provided functional outcomes comparable in patients on AT and untreated patients, with minimal risk of complication.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center.

INTRODUCTION: Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations. METHOD: We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum. RESULTS: Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. CONCLUSION: As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

RET gene mutations are not involved in the origin of human testicular seminoma.

Testicular germ cell cancers are the most common solid malignancies in young men, but their pathogenesis remains undetermined although some epidemiological data have implicated both environmental and genetic factors. Glial cell-derived neurotrophic factor (GDNF) is secreted by Sertoli cells, and promotes germ stem cell proliferation by activating RET, a tyrosine kinase receptor. Over-expression of GDNF in adult transgenic mice induces the development of testicular tumours that mimic human seminoma, the most frequent testicular germ cell tumour. Activating mutations of RET were previously reported in several types of cancer, including thyroid, pituitary, adrenal and melanoma cancer. Both mouse experimental model and clinical studies suggested that mutations or selective polymorphisms of RET might be associated with human seminoma. To verify this hypothesis, we conducted this study in a French University Hospital and carried out an association study using tissue samples from 66 paraffin-embedded seminoma tumours. The most frequently mutated exons of the RET proto-oncogene were sequenced to identify mutations or selective polymorphisms. No somatic mutations were identified. The polymorphic variants frequencies did not differ from those in a control Caucasian population. Human classical seminoma that occurs in young men does not appear to be linked with mutations or relevant polymorphisms of RET.

Reg I protein in healthy and seminoma human testis.

Regenerating gene (Reg), encodes a secretory protein with growth and differentiation stimulating effects mostly in digestive tissues. Overexpression of Reg proteins and specifically of Reg I, one member of the Reg family, is associated with several human diseases and cancers. In the present study we analyzed the expression of Reg I in normal rodent and human testes where germ cells normally proliferate and differentiate into spermatozoa, and in seminoma testis, the most common cancer of young men. Western blot analyses demonstrated the presence of a specific band at 19 kDa in human and rodent testis extracts. Immunofluorescence and deconvolution microscopy demonstrated that Reg I was present within the seminiferous tubules in both Sertoli and germ cells. By using a Sertoli cell line we demonstrated that Reg I was localized at the plasma membrane even in the absence of contact between neighboring cells and appeared before the tight junction associated protein ZO-1 was revealed at this location. Reg I was strongly expressed in human seminoma testis tissue and in a human tumor germ cell line where the immunoreactive signal was mainly detected at the plasma membrane level. These data showing for the first time the weak presence of Reg I in the normal testis and its strong expression in the testis cancer suggest a potential role of Reg I in normal and neoplastic germ cell proliferation.

Unilateral testicular tumour associated to congenital adrenal hyperplasia: Failure of specific tumoral molecular markers to discriminate between adrenal rest and leydigioma.

Testicular adrenal rest tumours are frequently associated with congenital adrenal hyperplasia (CAH). These ACTH-dependent tumours cannot be easily distinguished histologically from Leydig-cell tumours. We report the case of a 30-year-old man who was explored for infertility, azoospermia and unilateral testicular tumour. High levels of 17-OH progesterone and ACTH, low cortisol and undetectable gonadotropins levels, associated to bilateral adrenal hyperplasia, led to the diagnosis of CAH by 21-OH deficiency with a composite heterozygoty. The testicular tumour was first considered as adrenal rest. However, histological analysis of this unilateral painful tumour showed a steroid-hormone-secreting cell proliferation with atypical and frequent mitosis. To discriminate between a benign adrenal rest tumour and a possible malignant leydigioma, tumoral expression of specific gene products was analyzed by RT-PCR. No 11-beta-hydroxylase nor ACTH receptor mRNAs could be found in the tumour, which did not behave like usual adrenal rest cells. For this unilateral testicular tumour, the lack of adrenal-specific markers associated with a high rate of mitosis and pleiomorphism supported a leydigian origin with malignant potential. However, lack of tumoral LH-R mRNA expression and a tumour-free 3-year follow-up led us to retain the diagnosis of adrenal rest tumour with loss of adrenal gene expression and progressive autonomous behaviour.

[The treatments of localized prostate cancer: the impact on sexuality]. / Retentissement sur la sexualité des traitements du cancer de la prostate.

Nowadays, taking into account the sexuality is an essential component of the management of prostate cancer patients. This implies the necessity for providing accurate, clear and transparent information about the potential adverse effects on the sexual functioning for each proposed treatment. This information is not only given to the patient, but also to his female partner. The association of extended radical prostatectomy (without preservation of neurovascular bundles) and androgen suppression therapy will be proposed for men with locally advanced prostate cancer at high-risk for recurrence. The impact of such combined management regarding sexual functioning is high in terms of erection and sexual interest. Early pharmacological treatment of erectile dysfunction (within the three months following surgical treatment) with phosphodiesterase 5 inhibitors or intracavernous injections will allow an optimal recovery of a certain quality of erection. Moreover, monotherapy with bicalutamide will be associated with significant advantage in terms of sexual interest. The sexuality after treatment will certainly be different but will be accomplished.