Surgical management of male infertility: An overview.

BACKGROUND: The general practitioner is often the first to assess couples with infertility. In up to half of all infertile couples, a male factor may be found as a contributing cause. OBJECTIVE: The aim of this article is to provide a broad understanding of the options available for surgical management of male infertility to assist couples in navigating their treatment journey. DISCUSSION: Treatments may be classified into four categories: surgery for diagnostic purposes, surgery to improve semen parameters, surgery to improve sperm delivery and surgery to retrieve sperm for in vitro fertilisation. Assessment and treatment of the male partner by urologists trained in male reproductive health, working collaboratively within a team, can maximise fertility outcomes.

Psychological, social, and sexual challenges affecting men receiving male infertility treatment: a systematic review and implications for clinical care.

In recent years, social research surrounding the consequences of infertility has increasingly focused on the male perspective; however, a gap exists in the understanding of men's experiences of male infertility treatment. This review aims to synthesize the existing evidence concerning the psychological, social, and sexual burden of male infertility treatment on men, as well as patient needs during clinical care. A systematic search identified 12 studies that are diverse in design, setting, and methods. Psychological evaluations have found that urological surgery may have a lasting impact on infertility-specific stress, and treatment failure can lead to feelings of depression, grief, and inadequacy. Men tended to have an avoidant coping mechanism throughout fertility treatment, and their self-esteem, relationship quality, and sexual functions can be tied to outcomes of treatment. Partner bonds can be strengthened by mutual support and enhanced communication; couple separation, however, has been noted as a predominant reason for discontinuing male infertility treatment and may be associated with difficult circumstances surrounding severe male infertility. Surgical treatments can affect the sexual functioning of infertile men; however, the impact of testicular sperm extraction outcomes appears to be psychologically driven whereas the improvements after microsurgical varicocelectomy are only evident in hypogonadal men. Clinically, there is a need for better inclusion, communication, education, and resource provision, to address reported issues of marginalization and uncertainty in men. Routine psychosocial screening in cases of severe male infertility and follow-up in cases of surgical treatment failure are likely beneficial.

Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy.

BACKGROUND: Prior studies suggest that men with good erectile function shortly after radical prostatectomy (RP) can subsequently have worsened erectile function. AIM: To determine the prevalence and predictors of early erectile function recovery post-RP and of worsening erectile function after initial erectile function recovery. METHODS: We retrospectively queried our institutional database. Men who underwent RP during 2008-2017 and who completed the International Index of Erectile Function erectile function domain both pre-RP and serially post-RP, constituted the population. Functional erections were defined as International Index of Erectile Function (IIEF)-6 erectile function domain scores ≥24. We analyzed factors predicting functional erections at 3 months post-RP as well as factors predicting a decrease in functional erections between 3 and 6 months, defined as ≥2-point drop in the erectile function domain. Multivariable logistic regression models were used to identify predictors of early erectile function recovery and also of subsequent decline. OUTCOMES: Erectile function recovery rates at 3 months post-RP and predictive factors; rates of erectile function decline between 3-6 months and associated predictors. RESULTS: Eligible patients comprised 1,655 men with median age of 62 (IQR 57, 67) years. Bilateral nerve-sparing (NS) surgery was performed in 71% of men, unilateral NS in 19%, and no NS in 10%. Of this population, 224 men (14%; 95% CI 12%, 15%) had functional erections at 3 months post-RP. On multivariable analysis, significant predictors of early erectile function recovery included: younger age (OR 0.93, P < .001), higher baseline erectile function domain score (OR 1.14, P < .001) and bilateral NS (OR 3.81, P = .002). The presence of diabetes (OR 0.43, P = .028) and a former smoking history (OR 0.63, P = .008; reference group: never smoker) was associated with the erectile dysfunction at 3 months post-RP. Of the men with early functional erections, 41% (95% CI 33%, 48%) had a ≥ 2-point decline in erectile function between 3 and 6 months. No factors were identified as predictors for this decline. CLINICAL IMPLICATIONS: Only a small proportion of men have functional erections at 3 months post-RP and a notable number of them will experience a decline in erectile function between 3 and 6 months. STRENGTHS AND LIMITATIONS: Strengths: large patient population and the use of validated questionnaire. LIMITATIONS: single-center retrospective study. CONCLUSION: A minority of men had functional erections 3 months post-RP, about half of whom had a decline in erectile function by month 6. We recommend appropriately counseling post-RP patients on the risk of such a decline in erectile function. Salter CA, Tin AL, Bernie HL, et al. Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy. J Sex Med 2022;19:1790-1796.

Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone.

BACKGROUND: Due to the negative feedback mechanism involved in the hypothalamic-pituitary-gonadal axis, testosterone therapy (TTh) may result in suppression of luteinizing hormone (LH) secretion, but clinical experience demonstrates the level of LH suppression is variable. AIM: We sought to define the relationship between TTh and LH levels, specifically predictors of LH suppression in men on TTh. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients with testosterone deficiency (TD) treated with TTh. Patient demographic and clinical data including vascular risk factor (VRF) status were collected. Serum total T and LH levels before TTh and after ≥3 months (m) were recorded. LH suppression was defined as serum LH level <1.0 IU/ml. MAIN OUTCOME MEASURES: Predictors of LH suppression were searched though a series of logistic regression models assessing suppression status at the final observation, and then a series of Cox proportional hazards models assessing time to first suppression were performed. RESULTS: A total of 227 patients with mean age of 58±14 years at time of TTh initiation were included in our analysis. Just under half of subjects received transdermal T as the only modality (n = 101, 44%), while one third (n = 77, 34%) received intramuscular only, and the remainder (n = 49, 22%) received both modalities during follow-up. The mean baseline LH level was 10 ± 12 IU/ml. The percent of men who had baseline LH level above 1 IU/ml and at any given point of TTh was 84% and 78%, respectively, thus 22% of men had suppressed LH levels on TTh considering the definition of LH <1 IU/ml. Most men (73%) had a suppressed LH level of <1 IU/ml at least once during follow-up. In the final adjusted model for LH suppression, intramuscular route (OR = 2.44), baseline LH (OR = 0.94), estradiol (OR = 1.05) remained significant. CLINICAL IMPLICATIONS: LH suppression profiles may be relevant for dose titration during TTh and perhaps to minimize testicular atrophy. STRENGTHS & LIMITATIONS: A strict definition for TD was applied using LCMS for T measurements and patients had long-term follow-up. CONCLUSION: While 73% of patients had at least one LH <1 IU/ml during TTh, only 22% maintained suppressed throughout the treatment. Miranda EP, Schofield E, Matsushita K, et al. Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone. J Sex Med 2022;19:1359-1365.

Improving interpretation of biopsies during microsurgical testicular sperm exploration in azospermic patients: use of Davidson's fluid.

Histological interpretation of testicular biopsies in the investigation of infertility in men with azoospermia requires adequate tissue fixation to preserve the nuclear and cytoplasmic detail, as well as the architectural organisation of germ cells in different phases of maturation within seminiferous tubules. The aim of the study was to assess the histomorphological quality of testicular biopsies using Davidson's fluid (DF) as fixative and compare it to standard 10% neutral buffered formalin. Concurrent testicular biopsies from the same testis from patients undergoing microsurgical testicular sperm exploration (m-TESE) were separately fixed in DF and formalin and processed for histological examination. Histological parameters including sloughing of cells, cytoplasmic shrinkage of seminiferous tubular cells, nuclear chromatin detail, cytoplasmic graininess and overall clarity of morphological detail were graded on a scale of 0-4 (0, none; 1, minimal; 2, slight; 3, moderate; 4, marked). The effect of DF on biopsy diagnoses was assessed by comparison with corresponding formalin fixed biopsy diagnoses. Eighty-seven testicular biopsies from 27 patients were examined. DF fixation resulted in significantly less luminal sloughing of cells (1.59±1.34 vs 3.44±0.83, p≤0.00001), less cytoplasmic shrinkage of seminiferous tubular cells (1.58±1.11 vs 3.11±1.07, p≤0.00001), better nuclear chromatin detail (3.06±0.91 vs 1.92±0.48, p≤0.00001), less cytoplasmic graininess (2.11±0.96 vs 2.86±0.87, p=0.0014) and better overall clarity of morphological detail than formalin fixation (3.14±0.69 vs 2.14±0.58, p≤0.00001). The diagnostic concordance between DF fixed and formalin fixed biopsies was 90.8%. This study supports the use of DF as a superior alternative fixative to formalin for histological assessment of testicular biopsies.

Detection of chlamydia infection within human testicular biopsies.

STUDY QUESTION: Can Chlamydia be found in the testes of infertile men? SUMMARY ANSWER: Chlamydia can be found in 16.7% of fresh testicular biopsies and 45.3% of fixed testicular biopsies taken from a selection of infertile men. WHAT IS KNOWN ALREADY: Male chlamydial infection has been understudied despite male and female infections occurring at similar rates. This is particularly true of asymptomatic infections, which occur in 50% of cases. Chlamydial infection has also been associated with increased sperm DNA damage and reduced male fertility. STUDY DESIGN, SIZE, DURATION: We collected diagnostic (fixed, n = 100) and therapeutic (fresh, n = 18) human testicular biopsies during sperm recovery procedures from moderately to severely infertile men in a cross-sectional approach to sampling. PARTICIPANTS/MATERIALS, SETTING, METHODS: The diagnostic and therapeutic biopsies were tested for Chlamydia-specific DNA and protein, using real-time PCR and immunohistochemical approaches, respectively. Serum samples matched to the fresh biopsies were also assayed for the presence of Chlamydia-specific antibodies using immunoblotting techniques. MAIN RESULTS AND THE ROLE OF CHANCE: Chlamydial major outer membrane protein was detected in fixed biopsies at a rate of 45.3%. This was confirmed by detection of chlamydial DNA and TC0500 protein (replication marker). C. trachomatis DNA was detected in fresh biopsies at a rate of 16.7%, and the sera from each of these three positive patients contained C. trachomatis-specific antibodies. Overall, C. trachomatis-specific antibodies were detected in 72.2% of the serum samples from the patients providing fresh biopsies, although none of the patients were symptomatic nor had they reported a previous sexually transmitted infection diagnosis including Chlamydia. LIMITATIONS, REASONS FOR CAUTION: No reproductively healthy male testicular biopsies were tested for the presence of Chlamydia DNA or proteins or Chlamydia-specific antibodies due to the unavailability of these samples. WIDER IMPLICATIONS FOR THE FINDINGS: Application of Chlamydia-specific PCR and immunohistochemistry in this human male infertility context of testicular biopsies reveals evidence of a high prevalence of previously unrecognised infection, which may potentially have a pathogenic role in spermatogenic failure. STUDY FUNDING/COMPETING INTEREST(S): Funding for this project was provided by the Australian NHMRC under project grant number APP1062198. We also acknowledge assistance from the Monash IVF Group and Queensland Fertility Group in the collection of fresh biopsies, and the Monash Health and co-author McLachlan (declared equity interest) in retrieval and sectioning of fixed biopsies. E.M. declares an equity interest in the study due to financing of fixed biopsy sectioning. All other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Much more than prescribing a pill - Assessment and treatment of erectile dysfunction by the general practitioner.

BACKGROUND: Erectile dysfunction is a common but often neglected condition. Prevalence increases with age, but is not insignificant in younger men. OBJECTIVE: This article will broadly describe the epidemiology, classification and risk factors of erectile dysfunction. It will also discuss assessment and current treatment modalities, with a particular focus on the unique role of the general practitioner (GP). DISCUSSION: Erectile dysfunction may be classified as vasculogenic, neurogenic, endocrinological, drug-related, psychogenic or mixed. Commonly, erectile dysfunction is a cause of anxiety and even depression. Risk factors, such as smoking and hypertension, and reversible causes, such as hypogonadism or offending medications, should be addressed. At present, oral pharmacotherapy represents the first-line option for most patients with erectile dysfunction. It is of utmost importance to evaluate and treat comorbidities, such as depression, metabolic syndrome and cardiovascular disease, that often accompany erectile dysfunction. Patients will undoubtedly benefit from comprehensive management by a dedicated GP. Occasionally, referral to a urologist, psychologist or sexual health physician may be required.

Urolithiasis - Ten things every general practitioner should know.

BACKGROUND: Upper urinary tract stones are a common problem in Australia, with an incidence of 0.13% per year, and a lifetime prevalence of up to 15% in males and 8% in females. Many of these patients first present to general practitioners (GPs), so a thorough understanding of the diagnosis, treatment and prevention of stone disease is an important part of any GP's arsenal. OBJECTIVE: In this article, we present evidence-based guidelines regarding urolithiasis, from diagnosis, through to conservative and operative management, and prevention, as a reference for GPs and other primary care physicians. DISCUSSION: The majority of urolithiasis cases can be conservatively managed. However, prior to conservative management, adequate imaging must be obtained and emergent conditions must be excluded. Conservative management should not be initiated without a plan in the event the management fails, and adequate analgesia and medical expulsive therapy should be prescribed. Should surgery be necessary, the majority of operations can be performed as minimally invasive day procedures.

Peyronie's disease - Watch out for the bend.

BACKGROUND: Peyronie's disease is a relatively common condition in urological practice, but is still poorly identified and understood in the wider medical community and by most of the public. Identifying the condition and appropriate referral for expert opinion can significantly lessen the physical and psychological effect on patients. OBJECTIVE: The objective of this article is to provide general practitioners with a concise and updated review of Peyronie's disease, with the aim of helping them to provide appropriate advice to their patients. DISCUSSION: Peyronie's disease is an aberrant wound healing process culminating in excess scar formation in the penis, which may cause penile pain, shortening and curvature. It is often accompanied by erectile dysfunction, and can result in progressive and severe impairment of penetrative intercourse. The course of the disorder is divided into active inflammatory and chronic stable phases. Oral therapy is usually of limited efficacy, while penile traction may only be beneficial in motivated patients. Intralesional injections of collagenase were recently introduced as a non-surgical measure to decrease penile curvature. Surgery remains the most effective treatment for Peyronie's disease and is considered the gold standard.

Adult male stress and urge urinary incontinence - A review of pathophysiology and treatment strategies for voiding dysfunction in men.

BACKGROUND: Male urinary incontinence adversely affects health-related quality of life and is associated with significant psychosexual and financial burden. The two most common forms of male incontinence are stress urinary incontinence (SUI) and overactive bladder (OAB) with concomitant urge urinary incontinence (UUI). OBJECTIVE: The objectives of this article are to briefly review the current understandings of the pathophysiological mechanisms in SUI and OAB/UUI, and offer a set of practical, action-based recommendations and treatment strategies. DISCUSSION: The initial evaluation of male urinary incontinence usually occurs in general practice, and the basic work-up aims to identify reversible causes. First-line treatment is conservative management, such as lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder retraining. Treatment options include male slings and artificial urinary sphincter surgery for men with persistent SUI, and medical therapy, intravesical botulinum toxin, sacral neuromodulation or surgery in refractory cases for those with predominant OAB/UUI.

Comparison of transperineal mapping biopsy results with whole-mount radical prostatectomy pathology in patients with localized prostate cancer.

Objective. We sought to evaluate the accuracy of transperineal mapping biopsy (TMB) by comparing it to the pathology specimen of patients who underwent radical prostatectomy (RP) for localized prostate cancer. Methods. From March 2007 to September 2009, 78 men at a single center underwent TMB; 17 of 78 subsequently underwent RP. TMB cores were grouped into four quadrants and matched to data from RP whole-mount slides. Gleason score, tumor location and volume, cross-sectional area, and maximal diameter were measured; sensitivity and specificity were assessed. Results. For the 17 patients who underwent RP, TMB revealed 12 (71%) had biopsy Gleason grades ≥ 3 + 4 and 13 (76%) had bilateral disease. RP specimens showed 14 (82%) had Gleason scores ≥ 3 + 4 and 13 (76%) had bilateral disease. Sensitivity and specificity of TMB for prostate cancer detection were 86% (95% confidence interval [CI] 72%-94%) and 83% (95% CI 62%-95%), respectively. Four quadrants negative for cancer on TMB were positive on prostatectomy, and six positive on TMB were negative on prostatectomy. Conclusion. TMB is a highly invasive procedure that can accurately detect and localize prostate cancer. These findings help establish baseline performance characteristics for TMB and its utility for organ-sparing strategies.

Fertility preservation strategies for male patients with cancer.

With the increasing number of patients surviving cancer, there is increasing interest in long-term quality of life, especially with respect to cancer-related infertility. Although infertility most commonly occurs as the result of treatment with gonadotoxic agents, it can also manifest before treatment has commenced. Current fertility preservation strategies for the postpubertal male patient with cancer focus on sperm cryopreservation before therapy. Sperm acquisition techniques should be discussed with the patient as early as possible, by either an oncologist or a specialist in male reproduction. For patients rendered infertile by cancer treatment who did not cryopreserve sperm beforehand, there are no techniques currently available to restore fertility. For the prepubertal male patient, cryopreservation of sperm is impossible. However, emerging research--primarily in animal models--into promising fertility preservation and restoration strategies might provide a clinical solution in the future. Advances in the protection and cryopreservation of spermatogonial stem cells (SSCs) might translate into clinical options for fertility preservation before treatment. Restoring fertility after treatment might also be possible via SSC autotransplantation or in vitro maturation of SSCs. Before any of these techniques become clinically viable, a number of scientific, logistical and ethical issues will need to be resolved.

Perioperative prevention of penile prosthesis infection: practice patterns among surgeons of SMSNA and ISSM.

INTRODUCTION: Anecdotally, there is great variation in the use of strategies to prevent postoperative penile implant infection. AIM: To evaluate the perioperative practice patterns of surgeons who insert penile prostheses focusing on their respective infection control routines. METHOD: An anonymous Web-based survey was sent to members of the Sexual Medicine Society of North America (SMSNA) and the International Society of Sexual Medicine (ISSM). MAIN OUTCOME MEASURES: Thirty-nine questions were asked pertaining to the strategies used during the pre-, intra-, and postoperative phases of penile implant surgery to prevent infection. RESULTS: One hundred twenty-nine surgeons responded to the survey (SMSNA 84; ISSM 45). Most surgeons considered themselves sexual medicine specialists. More SMSNA respondents had inserted >100 prosthesis (SMSNA 69%, ISSM 50%). Routine urine culture is not performed by 40% and 50% of SMSNA and ISSM members, respectively. Similar percentages of surgeons from each society request a daily preoperative antimicrobial scrub. About two-thirds of ISSM members use razors for the preoperative shave compared with one-third of SMSNA members. Most ISSM surgeons preferred povidone-iodine for hand and skin preparation while most SMSNA surgeons chose this only for skin preparation. Two-thirds of SMSNA members prepared the skin for at least 10 minutes compared with 34% of ISSM surgeons. There were considerable differences in all aspects of antibiotic usage not only between members of both societies but also among individual members of each society. Most surgeons prefer not to place a drain (SMSNA 70%, ISSM 81%). Discharge timing differs between the two groups. CONCLUSIONS: There is great variation in perioperative strategies utilized to prevent penile implant infections including some key differences between surgeons from SMSNA and ISSM. It is unknown if these variations result in changes in the postoperative infection rate; however, the study data may assist in the formation of practice guidelines and form the basis of future prospective studies.

Clomiphene citrate is safe and effective for long-term management of hypogonadism.

OBJECTIVE: To assess the efficacy and safety of long-term clomiphene citrate (CC) therapy in symptomatic patients with hypogonadism (HG). PATIENTS AND METHODS: Serum T, oestradiol and luteinizing hormone (LH) were measured in patients who were treated with CC for over 12 months. Additionally, bone densitometry (BD) results were collected for all patients. Demographic, comorbidity, treatment and Androgen Deficiency in Aging Men (ADAM) score data were also recorded. Comparison was made between baseline and post-treatment variables, and multivariable analysis was conducted to define predictors of successful response to CC. The main outcome measures were predictors of response and long-term results with long-term CC therapy in hypogonadal patients. RESULTS: The 46 patients (mean age 44 years) had baseline serum testosterone (T) levels of 228 ng/dL. Follow-up T levels were 612 ng/dL at 1 year, 562 ng/dL at 2 years, and 582 ng/dL at 3 years (P < 0.001). Mean femoral neck and lumbar spine BD scores improved significantly. ADAM scores (and responses) fell from a baseline of 7 to a nadir of 3 after 1 year. No adverse events were reported by any patients. CONCLUSIONS: Clomiphene citrate is an effective long-term therapy for HG in appropriate patients. The drug raises T levels substantially in addition to improving other manifestations of HG such as osteopenia/osteoporosis and ADAM symptoms.

Novel extraction technique to remove a penile constriction device.

INTRODUCTION: Penile strangulation can be a challenging clinical situation and usually requires prompt treatment. The clinician should be aware of the various techniques to remove such devices. AIM: The aim of this article was to describe a new noninvasive technique, the "pseudo-pulley" method, to remove a penile constriction device. METHODS: During an episode of medication-induced hypersexuality, a 63-year-old man presented to the emergency department with a cast iron locking nut of a vehicle towbar lodged at the base of the patient's penis. RESULTS: The utilization of the "pseudo-pulley" method to remove the constriction device negated the need for more invasive measures. We outline a step-by-step description on this new technique. The patient's recovery was complete and uneventful. CONCLUSION: The current case report describes a noninvasive technique for removing a penile constriction device that does not rely on specialized equipment and industrial drills that can cause iatrogenic injury.

Routine drain placement after partial nephrectomy is not always necessary.

PURPOSE: To our knowledge the benefit of routine drainage after partial nephrectomy has never been investigated, although a drain after partial nephrectomy can be associated with morbidity. We report our initial experience with omitting the drain in select cases of superficial renal cortical tumors. MATERIALS AND METHODS: From a surgery database we identified 512 consecutive open partial nephrectomies performed by a single surgeon between January 2005 and May 2009 using standardized technique. The study group included 75 evaluable patients (14.6%) who did not have a drain placed. Clinical data, surgical information, histological type and postoperative complications within 90 days of the procedure using the modified Clavien system were included in analysis. RESULTS: Median patient age was 64 years (IQR 49, 70) and 56.8% of the patients were male. Median tumor size was 2.0 cm (IQR 1.5, 3.0) and more than 70% were malignant. A total of 38 patients (50.7%) underwent renal artery clamping and cold ischemia with a median clamp time of 30 minutes. The overall complication rate was 13.3% (10 patients). In 4 patients (5.3%) complications were related to an absent drain, including grade I urinary leak, grade II perirenal collection, grade III urinoma requiring percutaneous drainage and grade III urinary leak with urosepsis, respectively. No deaths occurred in this cohort. CONCLUSIONS: Omitting drainage after partial nephrectomy in a select group of patients without collecting system entry is feasible and safe. The decision to place a drain after partial nephrectomy for small renal cortical tumors must be made intraoperatively and should be tailored to each case.

Extended pelvic lymph node dissection in robotic-assisted radical prostatectomy: surgical technique and initial experience.

OBJECTIVES: To describe, and show in the accompanying video segments, a technique for extended pelvic lymph node dissection (ePLND) in robotic-assisted radical prostatectomy (RARP) and report our clinicopathologic and perioperative outcomes. The extent of pelvic lymphadenectomy during radical prostatectomy has not been standardized. However, evidence demonstrates that an ePLND yields a greater number of positive nodes. METHODS: A total of 32 patients with clinically localized prostate cancer underwent RARP with ePLND by a single surgeon (J.C.) between January and August 2008. The template for the ePLND included the obturator, hypogastric, external iliac, and common iliac lymph nodes up to the bifurcation of the aorta. Systematic review and grading of adverse events were performed. RESULTS: The median number of lymph nodes retrieved was 18 (interquartile range [IQR] 12-28). Four patients (12.5%) had lymph node metastases. Of the 4 patients with lymph node metastases, 1 patient (25%) had the involved lymph node exclusively in the common iliac region. Median operative time for the ePLND was 72 minutes (IQR 66-86). Median hospital length of stay was 2.0 days (IQR 2.0-2.8). Graded complications included 13 grade 1 events and 1 grade 2 event, with 1 grade 1 event being considered related to ePLND. No clinically presenting lymphoceles or thrombotic events were encountered. CONCLUSIONS: An ePLND during RARP is technically feasible and appears to have minimal morbidity. It produces a high lymph node yield and may result in improved pathologic staging.

Lymph node dissection during robotic-assisted laparoscopic prostatectomy: comparison of lymph node yield and clinical outcomes when including common iliac nodes with standard template dissection.

OBJECTIVE: To compare the perioperative outcomes of standard pelvic to full-template lymph node (LN) dissection (LND) during robotic-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: The study included 94 patients undergoing RALP with LND between January 2007 and August 2008, by one surgeon. In February 2008 the LND template was modified to include common iliac and medial hypogastric LNs. Clinical and pathological patient characteristics were analysed, including total number of retrieved and positive LNs in each area of dissection, operative duration and complications. RESULTS: Of the 94 patients, 62 underwent standard LND (group 1) and 32 underwent full-template pelvic LND (group 2). The median (mean) number of LNs retrieved in groups 1 and 2 were 12 (13.3) and 17.5 (21.4), respectively. Of the five patients with positive LNs (5%), four were in group 2 (13%); two of these patients had positive LNs in the common iliac dissection, and for one of these patients it was the sole site of involvement. Deep venous thrombosis, pulmonary embolism or transient neuropraxia occurred in six patients (five in group 1 and one in group 2). The median additional operative time for resection of common and internal LNs was 25 min. CONCLUSIONS: LN yield increased and additional sites of LN metastases were identified during full-template pelvic LND during RALP. This modification was not associated with an increased rate of complications. Derived benefits of including additional nodal dissection and the effect on staging accuracy remain to be determined.