Ejaculatory Hood Sparing versus Standard Laser Photoselective Vaporization of the Prostate: Sexual and Urodynamic Assessment through a Double Blinded, Randomized Trial.

PURPOSE: In a preliminary clinical trial we assessed the efficacy of ejaculatory hood sparing GreenLight™ Laser prostate photoselective vaporization to preserve antegrade ejaculation and urodynamic relief of obstruction compared to standard GreenLight prostate photoselective vaporization. MATERIALS AND METHODS: Standard prostate photoselective vaporization was classically performed in 24 patients. Ejaculatory hood sparing vaporization was performed with preservation of the paracollicular and supracollicular tissue proximal to the verumontanum in 25 patients. Patients were assessed at baseline, and 1, 3, 6 and 12 months postoperatively using the Ej-MSHQ (Ejaculatory Domain of Male Sexual Health Questionnaire) and the IIEF-15 (International Index of Erectile Function-15). The I-PSS (International Prostate Symptom Score), uroflowmetry and post-void residual urine volume were reported at each followup visit. A standard urodynamic study was performed at 6 months. RESULTS: Antegrade ejaculation was reported in 85% and 31.6% of patients after hood sparing and standard prostate vaporization, respectively (p=0.001). A significant reduction in the EJ-MSHQ score was reported after standard vaporization at 6 and 12 months (each p <0.001) with no significant difference after hood sparing vaporization (p=0.18 and 0.078, respectively). The median EJ-MSHQ score was 28.5 (range 1 to 33) and 27 (range 1 to 33) for hood sparing vaporization, and 9.5 (range 1 to 35) and 9 (range 0 to 33) for standard vaporization at 6 (p=0.005) and 12 months (p <0.001), respectively. Each group showed a decline in the mean total IIEF-15 score at 1 year but it was statistically significant only after standard vaporization (p=0.001). All urinary outcome measures revealed comparable significant improvement at all followups. Postoperative urodynamic assessment demonstrated a significant comparable decrease in the Bladder Outlet Obstruction Index from a median of 64 (range 21 to 207) to 23.5 (range 10 to 53) after hood sparing vaporization (p=0.005) and from 87 (range 38 to 186) to 19.5 (range 7 to 51) after standard vaporization (p=0.001). At 1 year the overall re-treatment rate was comparable in the 2 groups (p=0.26). CONCLUSIONS: In well informed, sexually interested patients ejaculatory hood sparing GreenLight prostate photoselective vaporization is feasible and effective treatment of small to moderate sized benign prostatic hyperplasia with a superior sexual function related outcome. Short-term relief of obstruction is objectively comparable to that of standard prostate photoselective vaporization.

Robot assisted laparoscopic prostatectomy in 2013.

Robot assisted laparoscopic prostatectomy has surpassed open radical prostatectomy as the most common surgical approach for radical prostatectomy in the United States. In this article we briefly describe the evolution of this minimally invasive technique. The current diagnostic approaches of multiparametric magnetic resonance imaging and fusion biopsy used in preoperative workup of the patients are discussed, followed by a description of risk stratified a thermal nerve sparing approach with total anatomical reconstruction. Finally we present a critical appraisal of the published oncological, continence and potency outcomes.

[Rage against the machine -- necessity of robotic assisted prostatectomy]. / Die Macht der Maschinen - Notwendigkeit der roboterassistierten Prostatektomie.

During the last decade urologists have faced a dramatic increase in robotic surgery. Despite the exceptional acceptance of this technique there is a complete lack of evidence for the equi-efficacy or superiority of this technique compared to open or laparoscopic prostatectomy. There is now an increasing body of evidence for the evaluation of robotic assisted prostatectomy. Robotic assisted prostatectomy is a safe procedure. The rate of technical failure is small. The rate of surgical complications is comparable with that of open or conventional laparoscopic prostatectomy. Similar to the conventional laparoscopic prostatectomy there is a trend for a minor blood loss and a smaller transfusion rate compared to the retropubic approach. In recent meta-analyses there is no advatage regarding the oncological or functional outcome for robotic prostatectomy. Neither the rate of positive surgical margins nor the rate of biochemical recurrence favours robotic prostatectomy. Regarding functional outcome some publications describe better results for urinary and sexual function for robotic surgery. Careful evaluation of these data reveals a low level of evidence due to a strong bias in favour of robotic surgery. In contrast, recent analysis of "Medicare" data reveal a considerable poorer urinary function after robotic prostatectomy compared to open retropubic prostatectomy. The Urological Board of the Helios Hospital Group does not recommend the use of a robotic device for radical prostatectomy.

Cavernosal nerve preservation during robot-assisted radical prostatectomy is a graded rather than an all-or-none phenomenon: objective demonstration by assessment of residual nerve tissue on surgical specimens.

OBJECTIVE: To demonstrate the existence of different degrees of nerve sparing (NS) (graded NS) by comparing the surgeon's intent of NS with the residual nerve tissue on prostatectomy specimens. METHODS: We performed a prospective study of 133 consecutive patients who underwent robot-assisted radical prostatectomy in January and February of 2011. The surgeon graded the amount of NS intraoperatively independently for either side as follows: 1, no NS; 2, <50% NS; 3, 50% NS; 4, 75% NS; and 5, ≥ 95% NS. A pathologist who was unaware of the surgeon's score measured the area of residual nerve tissue on the posterolateral surface of the prostate. RESULTS: A greater NS score correlated significantly with a decreasing area of residual nerve tissue on the prostatectomy specimens (P < .001). Overall, the area of residual nerve tissue on the prostatectomy specimens was significantly different among the NS groups (P < .001). On specific intergroup analysis, significant differences were found in the area of residual nerve tissue on the prostatectomy specimens between the greater NS groups: NS score 3 versus 4, median 13 mm(2) (interquartile range [IQR] 7-23) versus 3 mm(2) (IQR 0-8; P = .01); NS score 4 versus 5, median 3 mm(2) (IQR 0-8) versus 0.5 mm(2) (IQR 0-2; P = .001). CONCLUSION: Subjective NS classification using the surgeon's intraoperative perception correlated significantly with the area of residual nerve tissue on the prostatectomy specimens determined by the pathologist. It is possible to intentionally tailor the amount of NS performed at surgery. This finding demonstrates that NS is a graded rather than an all-or-none phenomenon that can even go beyond the traditional concept of complete, partial, or no NS.

2D and 3D T2-weighted MR sequences for the assessment of neurovascular bundle changes after nerve-sparing radical retropubic prostatectomy with erectile function correlation.

The aim of this study was to assess the capability of a 3D isotropic MRI T2-weighted sequence (3D T2 ISO) in the depiction of changes of neurovascular bundles (NVBs) after bilateral nerve-sparing radical retropubic prostatectomy (RRP). Furthermore, our aim was also to introduce a new MRI classification score of the NVB alteration patterns using the International Index Erectile Function Five-Item (IIEF-5) score as standard of reference. Fifty-three consecutive patients were postoperatively submitted to two MR examinations, including both 2D TSE T2-weighted (2D T2) and 3D T2 ISO sequences. Image findings were scored using a relative five-point classification and correlated with the postoperative IIEF-5 score. Radiologists attributed 13.2% of patients to class 0, 11.3% to class I, 34% to class II, 24.5% to class III, and 16.9% to class IV. With 3D T2 ISO images, the same radiologists determined 43.3% class 0, 32% class I, 11.4% class II, 7.5% class III, and 5.7% class IV. In all cases, the correlation and regression analysis between the 3D T2 ISO and IIEF-5 score resulted in higher coefficients values. The 3D sequence correlated most closely with patients' grading of erectile function.

Follow up of men post-prostatectomy: who is responsible?

INTRODUCTION: Men living with prostate cancer represent a large, at-risk population deserving access to comprehensive follow-up services stemming from chronic aspects of living with the disease. Current research about the quality and accessibility of prostate cancer follow-up services is limited. OBJECTIVE: The purpose of this study was to describe the patient, provider, and health plan characteristics speculated to influence prostate cancer follow-up care. METHOD: A cross-sectional descriptive study of men living with prostate cancer, treated by radical prostatectomy within the past 3 to 5 years was conducted. Subjects were surveyed regarding follow-up care, type of providers visited, current health status, late-term effects, health behaviors, and health plan requirements. Data obtained analyzed associations among patient, provider, and health plan characteristics in relation to the use of post-prostatectomy follow-up services. RESULTS: Post-prostatectomy, all men participated in follow-up visits to a cancer care provider (urologist) and were monitored for recurrence by prostate-specific antigen (PSA) testing. Fewer men had rectal examinations performed. For nearly half of the men, the general medical provider duplicated the PSA test, indicating a lack of coordination among providers. Almost all men had health insurance; no subjects identified barriers to care because of health plan rules or out-of-pocket expenses. Persistent late effects included urinary incontinence (60%) and erectile dysfunction (71.9%). No significant associations were found among patient, provider, and health plan characteristics to their utilization. CONCLUSIONS: In this study, men living with prostate cancer post-prostatectomy received ongoing follow-up health care, some of which was duplicated. Most experienced late adverse effects and many had other health problems. Nurses are uniquely positioned to assume a central role in promoting access to comprehensive, non- duplicative post-prostatectomy follow-up care. Additionally, nurses can provide effective counseling, advocacy, and education for men living with prostate cancer.

Early prostate cancer: hedonic prices model of provider-patient interactions and decisions.

PURPOSE: To determine the relative influence of treatment features and treatment availabilities on final treatment decisions in early prostate cancer. METHODS AND MATERIALS: We describe and apply a model, based on hedonic prices, to understand provider-patient interactions in prostate cancer. This model included four treatments (observation, external beam radiotherapy, brachytherapy, and prostatectomy) and five treatment features (one efficacy and four treatment complication features). We performed a literature search to estimate (1) the intersections of the "bid" functions and "offer" functions with the price function along different treatment feature axes, and (2) the treatments actually rendered in different patient subgroups based on age. We performed regressions to determine the relative weight of each feature in the overall interaction and the relative availability of each treatment modality to explain differences between observed vs. predicted use of different modalities in different patient subpopulations. RESULTS: Treatment efficacy and potency preservation are the major factors influencing decisions for young patients, whereas preservation of urinary and rectal function is much more important for very elderly patients. Referral patterns seem to be responsible for most of the deviations of observed use of different treatments from those predicted by idealized provider-patient interactions. Specifically, prostatectomy is used far more commonly in young patients and radiotherapy and observation used far more commonly in elderly patients than predicted by a uniform referral pattern. CONCLUSIONS: The hedonic prices approach facilitated identifying the relative importance of treatment features and quantification of the impact of the prevailing referral pattern on prostate cancer treatment decisions.

Erectile dysfunction following radical retropubic prostatectomy: epidemiology, pathophysiology and pharmacological management.

Radical prostatectomy has been the time-honoured and standard treatment option for prostate cancer. Erectile dysfunction (ED) is one of the common quality-of-life issues following radical prostatectomy. The recovery of potency following radical prostatectomy varies from 16% to 86%. Although major modifications in surgical technique appear to be promising, the reported ED rates are still high. The time period required for the recovery of erectile function after surgery varies from 6 to 24 months. During this period of neuropraxia lack of natural erections produces cavernosal hypoxia. This cavernosal hypoxia has been implicated as one of the most important factors in the pathophysiology of ED. Cavernosal hypoxia predisposes to cavernosal fibrosis, ultimately producing venous leak and long-term ED. Interruption of this cascade of events has been the major challenge for physicians. Physicians have several options available for the treatment of ED. However, oral treatment options have quickly become established as first-line treatment options. Sildenafil has been most extensively studied in the radical prostatectomy population. In patients who do not respond to oral therapy alone, standard treatment options (intracavernosal injections, vacuum constriction devices and intraurethral alprostadil) are useful. Use of penile prostheses is one of the oldest treatment options available for the treatment of ED but is used only as a last resort. Initial attempts to promote the earlier recovery of erectile function appear to be promising. However, further confirmatory studies are essential. The roles of gene transfer and growth factors are still in experimental stages. In this review we discuss the epidemiology, pathophysiology and treatment options available for ED following radical prostatectomy.

Male sexuality after cancer treatment--needs for information and support: testicular cancer compared to malignant lymphoma.

Testicular cancer (TC) as well as malignant lymphoma (ML), both have nowadays an excellent prognosis. However, both types of cancer may be diagnosed at young adulthood and patients may experience sexual concerns. In this article the need for information and support concerning sexuality will be explored, and the traumatic impact of cancer diagnosis with respect to this will be considered. A total of 264 patients with testicular cancer, median age 36 (S.D. 9.7) years, and 50 patients with malignant lymphoma, median age 42 (S.D. 11.7) years returned a questionnaire concerning sexual functioning; four items assessed the need for information or support concerning sexuality, at diagnosis and at follow-up. It appeared that more than half of the patients with testicular cancer reported a lack of information and support concerning sexuality during treatment; 67% of them still had a need for information at follow-up. These rates were significantly lower for patients with malignant lymphoma. Especially patients with testicular cancer who suffered sexual dysfunction reported extremely high needs for information and support. According to these findings it can be concluded that more attention should be paid to the doctor-patient communication with respect to sexual concerns in general, and especially where it concerns patients with testicular cancer.

Erectile function after radical prostatectomy.

The early detection of prostate cancer through the use of prostate-specific antigen screening has resulted in the performance of many more radical prostatectomy procedures as a curative treatment for this disease. Many patients who are candidates for this procedure already suffer from erectile dysfunction, and the incidence of inadequate erections following radical prostatectomy is certainly high. Nerve-sparing procedures during performance of this operation are encouraged as the incidence of erectile dysfunction is lower if one or both nerves are spared. If the patient is already impotent before the procedure, medical treatments with oral agents, intraurethral compounds, or intracorporally injected medications may be more effective with the nerves intact. Early institution of medical therapy, specifically intracorporal injections, after 2 months postoperatively has resulted in a higher incidence of spontaneous return of erections at 1 year. Vacuum erection devices may be successful in restoring erections but extensive practice in their use is necessary, and they may be unappealing to many patients. A penile prosthesis will restore erections if the patient is so motivated for implantation of such a device. These are expensive and require invasive surgery, but satisfaction rates among patients and partners who have used them have been in the range of 85%, the highest satisfaction rate among all of the treatments of erectile dysfunction.