Current practice patterns in the perioperative management of patients undergoing radical cystectomy: Results from a global survey.

OBJECTIVE: To determine current practice patterns and adherence to various components of enhanced recovery after surgery in cystectomy (ERAC) protocol for peri-operative management of radical cystectomy patients through a global survey. METHODS: A survey containing 25 questions and addressing 15 of the 22 items of the ERAC protocol was developed and disseminated through Email to the urologists with recent bladder cancer publications. The mailing list was generated by retrieving Email-ids of corresponding authors of articles using the keyword "cystectomy" in Scopus from January 2018 to October 2020. RESULTS: The survey was completed by 443 respondents across the globe. About 51.5% of respondents used some form of bowel preparation. A minority used carbohydrate loading (29.8%) and Alvimopan (13.3%). A short duration of nil by mouth was practised by 28.9%. For antibiotic prophylaxis, 51.7% used one, and 42% used two antibiotics. Duration of antibiotics was 24 hours, 48 hours, and >48 hours for 47.6%, 16.9%, and 35.4%, respectively. For peri-operative analgesia, 43.6% used non-steroidal anti-inflammatory drugs, 9.3% opioids and 40.6% combination of both. Pharmacological thrombo-prophylaxis was routinely used by 74.7% respondents. There was significant variability in ERAC and non-ERAC components according to region of practice; The open surgical approach was most commonly used in Africa (92%), whereas it was the robotic approach in North America (or America?) (41%). The use of bowel preparation was higher in Asia (58%) and Africa (65%). Alvimopan use was more common in North America (58%). Most used 1 or 2 prophylactic antibiotics but the duration was shorter (<24 hours) in the Americas and European (58%-83%) compared to Asia and Africa (15%-35%). CONCLUSION: There is high variability in the use of different ERAC components. Other than the timely removal of the abdominal drain and the use of thromboprophylaxis, the overall adherence of ERAC components is low.

The UroLift® System for lower urinary tract obstruction: patient selection for optimum clinical outcome.

INTRODUCTION: The minimally invasive UroLift® System procedure in moderate-to-severe benign prostate hyperplasia (BPH) refractory to medical treatment may be superior over other prostate procedures regarding its preserved sexual function post-operatively. We aimed to optimise patient selection criteria for the UroLift® System. MATERIAL AND METHODS: Fifty-one men that underwent UroLift® System surgery were retrospectively reviewed over >24 months. We evaluated the efficacy and safety of UroLift® System, pre-operatively and at three, six, 12, and 24 months post-operatively, assessing the International Prostate Symptom Score (IPPS), urinary flow rates (Qmax), post void residual (PVR) bladder scan volumes and the International Index of Erectile Function (IIEF). Adverse events were assessed by Clavien-Dindo Classification. RESULTS: The 51 men undergoing UroLift® System had a success rate of 92.2% over 2 years, with improvements in Qmax, IPSS and PVR. IIEF was preserved in all cases. Adverse events were Clavien-Dindo grade 1, most commonly mild-to-severe dysuria (19.6%), and resolved spontaneously. Four patients failed to improve. CONCLUSION: Patient-related selection criteria to optimise the UroLift® System clinical outcomes include age, Qmax, PVR urine, median lobe, PSA levels, prostate volume, IPSS and IIEF scores. The UroLift® System is safe and effective in moderate-to-severe BPH refractory to pharmacological treatments and avoids retrograde ejaculation.

Telementoring of Surgeons: A Systematic Review.

BACKGROUND: Telementoring is a technique that has shown potential as a surgical training aid. Previous studies have suggested that telementoring is a safe training modality. This review aimed to review both the technological capabilities of reported telementoring systems as well as its potential benefits as a mentoring modality. METHODS: A systematic review of the literature, up to July 2017, was carried out in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study quality was assessed using the Oxford Levels of Evidence proforma. Data were extracted regarding technical capabilities, bandwidth, latency, and costs. Additionally, the primary aim and key results were extracted from each study and analyzed. RESULTS: A total of 66 studies were identified for inclusion. In all, 48% of studies were conducted in general surgery; 22 (33%), 24 (36%), and 20 (30%) of studies reported telementoring that occurred within the same hospital, outside the hospital, and outside the country, respectively. Sixty-four (98%) of studies employed video and audio and 38 (58%) used telestration. Twelve separate studies directly compared telementoring against on-site mentoring. Seven (58%) showed no difference in outcomes between telementoring and on-site mentoring. No study found telementoring to result in poorer postoperative outcomes. CONCLUSIONS: The results of this review suggest that telementoring has a similar safety and efficacy profile as on-site mentoring. Future analysis to determine the potential benefits and pitfalls to surgical education through telementoring are required to determine the exact role it shall play in the future. Technological advances to improve remote connectivity would also aid the uptake of telementoring on a larger scale.

Expression of ribosomal proteins in normal and cancerous human prostate tissue.

Few quantifiable tissue biomarkers for the diagnosis and prognosis of prostate cancer exist. Using an unbiased, quantitative approach, this study evaluates the potential of three proteins of the 40S ribosomal protein complex as putative biomarkers of malignancy in prostate cancer. Prostate tissue arrays, constructed from 82 patient samples (245 tissue cores, stage pT3a or pT3b), were stained for antibodies against three ribosomal proteins, RPS19, RPS21 and RPS24. Semi-automated Ox-DAB signal quantification using ImageJ software revealed a significant change in expression of RPS19, RPS21 and RPS24 in malignant vs non-malignant tissue (p<0.0001). Receiver operating characteristics curves were calculated to evaluate the potential of each protein as a biomarker of malignancy in prostate cancer. Positive likelihood ratios for RPS19, RPS21 and RPS24 were calculated as 2.99, 4.21, and 2.56 respectively, indicating that the overexpression of the protein is correlated with the presence of disease. Triple-labelled, quantitative, immunofluorescence (with RPS19, RPS21 and RPS24) showed significant changes (p<0.01) in the global intersection coefficient, a measure of how often two fluorophore signals intersect, for RPS19 and RPS24 only. No change was observed in the co-localization of any other permutations of the three proteins. Our results show that RPS19, RPS21 or RPS24 are upregulated in malignant tissue and may serve as putative biomarkers for prostate cancer.

Pharmacological Treatment of Post-Prostatectomy Incontinence: What is the Evidence?

Urinary incontinence is a common and debilitating problem, and post-prostatectomy incontinence (PPI) is becoming an increasing problem, with a higher risk among elderly men. Current treatment options for PPI include pelvic floor muscle exercises and surgery. Conservative treatment has disputable effects, and surgical treatment is expensive, is not always effective, and may have complications. This article describes the prevalence and causes of PPI and the current treatment methods. We conducted a search of the PUBMED database and reviewed the current literature on novel medical treatments of PPI, with special focus on the aging man. Antimuscarinic drugs, phosphodiesterase inhibitors, duloxetine, and α-adrenergic drugs have been proposed as medical treatments for PPI. Most studies were small and used different criteria for quantifying incontinence and assessing treatment results. Thus, there is not enough evidence to recommend the use of these medications as standard treatment of PPI. To determine whether medical therapy is a viable option in the treatment of PPI, randomized, placebo-controlled studies are needed that also assess side effects in the elderly population.

Is robotic-assisted radical cystectomy (RARC) with intracorporeal diversion becoming the new gold standard of care?

BACKGROUND: Totally intracorporeal robotic-assisted radical cystectomy (RARC) has perceived difficulties compared to open radical cystectomy (ORC). As the technique is increasingly adopted around the world, the benefits of RARC with intra- or extracorporeal urinary diversion or ORC for the patients are still unclear. In this article, we consider the current evidence for this issue. METHODS: We assessed two questions through using expert opinion and the medical literature: (A) Is RARC better than ORC for removing the cancer surgery and outcome? (B) Is RARC better than ORC for the urinary diversion? OUTCOMES: (A) RARC is better than ORC for shorter length of stay, blood loss and complication rates. (B) Intracorporeal orthotopic neobladder may have a significant physiological and surgical benefit to the patient recovery. CONCLUSIONS: RARC with total intracorporeal reconstruction has potential benefits to the patient. We recommend that all surgeons document patient-related outcome measures, urodynamics and enhanced recovery protocols for cystectomy patients to help us understand the real improvements within bladder cancer surgery and reconstruction.

Targets of Wnt/ß-catenin transcription in penile carcinoma.

Penile squamous cell carcinoma (PeCa) is a rare malignancy and little is known regarding the molecular mechanisms involved in carcinogenesis of PeCa. The Wnt signaling pathway, with the transcription activator ß-catenin as a major transducer, is a key cellular pathway during development and in disease, particularly cancer. We have used PeCa tissue arrays and multi-fluorophore labelled, quantitative, immunohistochemistry to interrogate the expression of WNT4, a Wnt ligand, and three targets of Wnt-ß-catenin transcription activation, namely, MMP7, cyclinD1 (CD1) and c-MYC in 141 penile tissue cores from 101 unique samples. The expression of all Wnt signaling proteins tested was increased by 1.6 to 3 fold in PeCa samples compared to control tissue (normal or cancer adjacent) samples (p<0.01). Expression of all proteins, except CD1, showed a significant decrease in grade II compared to grade I tumors. High magnification, deconvolved confocal images were used to measure differences in co-localization between the four proteins. Significant (p<0.04-0.0001) differences were observed for various permutations of the combinations of proteins and state of the tissue (control, tumor grades I and II). Wnt signaling may play an important role in PeCa and proteins of the Wnt signaling network could be useful targets for diagnosis and prognostic stratification of disease.

Key papers in prostate cancer.

Prostate cancer is the most common cancer and second leading cause of death in men. The evidence base for the diagnosis and treatment of prostate cancer is continually changing. We aim to review and discuss past and contemporary papers on these topics to provoke debate and highlight key dilemmas faced by the urological community. We review key papers on prostate-specific antigen screening, radical prostatectomy versus surveillance strategies, targeted therapies, timing of radiotherapy and alternative anti-androgen therapeutics. Previously, the majority of patients, irrespective of risk, underwent radical open surgical procedures associated with considerable morbidity and mortality. Evidence is emerging that not all prostate cancers are alike and that low-grade disease can be safely managed by surveillance strategies and localized treatment to the prostate. The question remains as to how to accurately stage the disease and ultimately choose which treatment pathway to follow.

Quality of life and satisfaction with information after radical prostatectomy, radical external beam radiotherapy and postoperative radiotherapy: a long-term follow-up study.

AIMS AND OBJECTIVES: To assess patients' symptoms, quality of life and satisfaction with information three to four years after radical prostatectomy, radical external beam radiotherapy and postoperative radiotherapy and to analyse differences between treatment groups and the relationship between disease-specific, health-related and overall quality of life and satisfaction with information. BACKGROUND: Radical prostate cancer treatments are associated with changes in quality of life. Differences between patients undergoing different treatments in symptoms and quality of life have been reported, but there are limited long-term data comparing radical prostatectomy with radical external beam radiotherapy and postoperative radiotherapy. DESIGN: A cross-sectional survey design was used. METHODS: The study sample included 143 men treated with radical prostatectomy and/or radical external beam radiotherapy. Quality of life was measured using the 12-item Short Form Health Survey and the 50-item Expanded Prostate Cancer Index Composite Instrument. Questions assessing overall Quality of life and satisfaction with information were included. Descriptive statistics and interference statistical methods were applied to analyse the data. RESULTS: Radical external beam radiotherapy was associated with less urinary incontinence and better urinary function. There were no differences between the groups for disease-specific quality of life sum scores. Sexual quality of life was reported very low in all groups. Disease-specific quality of life and health-related quality of life were associated with overall quality of life. Patients having undergone surgery were more satisfied with information, and there was a positive correlation between quality of life and patient satisfaction. CONCLUSION: Pretreatment information and patient education lead to better quality of life and satisfaction. This study indicates a need for structured, pretreatment information and follow-up for all men going through radical prostate cancer treatment. RELEVANCE TO CLINICAL PRACTICE: Long-term quality of life effects should be considered when planning follow-up and information for men after radical prostate cancer treatment. Structured and organised information/education may increase preparedness for symptoms and bother after the treatment, improve symptom management strategies and result in improved quality of life.

Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT).

BACKGROUND: The potential rehabilitative and protective effect of phosphodiesterase type 5 inhibitors (PDE5-Is) on penile function after nerve-sparing radical prostatectomy (NSRP) remains unclear. OBJECTIVE: The primary objective was to compare the efficacy of tadalafil 5mg once daily and tadalafil 20mg on demand versus placebo taken over 9 mo in improving unassisted erectile function (EF) following NSRP, as measured by the proportion of patients achieving an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score ≥ 22 after 6-wk drug-free washout (DFW). Secondary measures included IIEF-EF, Sexual Encounter Profile question 3 (SEP-3), and penile length. DESIGN, SETTING, AND PARTICIPANTS: Randomised, double-blind, double-dummy, placebo-controlled trial in men ≤ 68 yr of age with adenocarcinoma of the prostate (Gleason ≤ 7) and normal preoperative EF who underwent NSRP at 50 centres from nine European countries and Canada. INTERVENTIONS: 1:1:1 randomisation to 9 mo of treatment with tadalafil 5mg once daily, tadalafil 20mg on demand, or placebo followed by a 6-wk DFW and 3-mo open-label tadalafil once daily (all patients). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Logistic regression, mixed-effects model for repeated measures, and analysis of covariance, adjusting for treatment, age, and country, were applied to IIEF-EF scores ≥ 22, SEP-3, and penile length. RESULTS AND LIMITATIONS: Four hundred twenty-three patients were randomised to tadalafil once daily (n=139), on demand (n=143), and placebo (n=141). The mean age was 57.9 yr of age (standard deviation: 5.58 yr); 20.9%, 16.9%, and 19.1% of patients in the tadalafil once daily, on demand, and placebo groups, respectively, achieved IIEF EF scores ≥ 22 after DFW; odds ratios for tadalafil once daily and on demand versus placebo were 1.1 (95% confidence interval [CI], 0.6-2.1; p=0.675) and 0.9 (95% CI, 0.5-1.7; p=0.704). At the end of double-blind treatment (EDT), least squares (LS) mean IIEF-EF score improvement significantly exceeded the minimally clinically important difference (MCID: ΔIIEF-EF ≥ 4) in both tadalafil groups; for SEP-3 (MCID ≥ 23%), this was the case for tadalafil once daily only. Treatment effects versus placebo were significant for tadalafil once daily only (IIEF-EF: p=0.016; SEP-3: p=0.019). In all groups, IIEF-EF and SEP-3 decreased during DFW but continued to improve during open-label treatment. At month 9 (EDT), penile length loss was significantly reduced versus placebo in the tadalafil once daily group only (LS mean difference 4.1mm; 95% CI, 0.4-7.8; p=0.032). CONCLUSIONS: Tadalafil once daily was most effective on drug-assisted EF in men with erectile dysfunction following NSRP, and data suggest a potential role for tadalafil once daily provided early after surgery in contributing to the recovery of EF after prostatectomy and possibly protecting from penile structural changes. Unassisted EF was not improved after cessation of active therapy for 9 mo. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01026818.

Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.

Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery. OBJECTIVES: The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group. EVIDENCE ACQUISITION: A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated. EVIDENCE SYNTHESIS: Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery. CONCLUSIONS: ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.

Quantitative analysis of BTF3, HINT1, NDRG1 and ODC1 protein over-expression in human prostate cancer tissue.

Prostate carcinoma is the most common cancer in men with few, quantifiable, biomarkers. Prostate cancer biomarker discovery has been hampered due to subjective analysis of protein expression in tissue sections. An unbiased, quantitative immunohistochemical approach provided here, for the diagnosis and stratification of prostate cancer could overcome this problem. Antibodies against four proteins BTF3, HINT1, NDRG1 and ODC1 were used in a prostate tissue array (> 500 individual tissue cores from 82 patients, 41 case pairs matched with one patient in each pair had biochemical recurrence). Protein expression, quantified in an unbiased manner using an automated analysis protocol in ImageJ software, was increased in malignant vs non-malignant prostate (by 2-2.5 fold, p<0.0001). Operating characteristics indicate sensitivity in the range of 0.68 to 0.74; combination of markers in a logistic regression model demonstrates further improvement in diagnostic power. Triple-labeled immunofluorescence (BTF3, HINT1 and NDRG1) in tissue array showed a significant (p<0.02) change in co-localization coefficients for BTF3 and NDRG1 co-expression in biochemical relapse vs non-relapse cancer epithelium. BTF3, HINT1, NDRG1 and ODC1 could be developed as epithelial specific biomarkers for tissue based diagnosis and stratification of prostate cancer.

Nano- and microrobotics: how far is the reality?

There has been an explosion in the development of microscopic and miniaturized technology over the past decade and we have long awaited their arrival and integration into clinical practice. We have now reached the stage where promises are beginning to be delivered. This article reviews their place in modern medicine and looks toward the future. Miniature camera robots (microrobots) provide a mobile viewing platform, enhancing a surgeon's view. Nanorobots have arisen from the fictional world of the 'Fantastic Voyage' and are finally approaching clinical application. As the targeting and drive forces are further developed, these vehicles could be realistically used for delivery of agents for diagnosis and therapies. These new robots have the potential to further evolve the robotic armamentarium for surgeons.

Microrobot assisted laparoscopic urological surgery in a canine model.

PURPOSE: Robotic technologies have had a significant impact on surgery. We report what is to our knowledge the first use of microrobots to perform laparoscopic urological surgery in a canine model. MATERIALS AND METHODS: Nonsurvival laparoscopic radical prostatectomy and radical nephrectomy were performed using microrobotic camera assistance. Following the administration of general anesthesia miniature camera robots were inserted in the insufflated abdomen via a 15 mm laparoscopic port. These microrobots were mobile, controlled remotely to desired locations and provided views of the abdominal cavity, assisting the laparoscopic procedures. Additional ports and laparoscopic instruments were placed in the abdomen using the views provided by these microrobots. RESULTS: One dog underwent laparoscopic prostatectomy and another underwent laparoscopic nephrectomy. The 2 procedures were completed successfully. Microrobots provided additional views from several angles, aiding in the performance of the procedures. CONCLUSIONS: Miniature camera robots (microrobots) provide a mobile viewing platform. With added functionality these new robots have the potential to further evolve the robotic armamentarium for surgeons.

Page kidney phenomenon presenting as acute renal failure after partial nephrectomy: a case report and review of the literature.

BACKGROUND: The Page kidney phenomenon, whilst a known condition, is in itself a rare entity. This report illustrates a case following partial nephrectomy which presented as post-operative renal failure. CASE PRESENTATION: The authors present a case of renal cell carcinoma in a solitary kidney that after partial nephrectomy resulted in a subcapsular haematoma formation and acute renal failure. CONCLUSION: The condition of Page kidneys are typically described in young patients after trauma. However, with the increasing usage of surgical interventions, post-operative bleeding can result in a compression-induced necrosis.

The cost of radical prostatectomy: retrospective comparison of open, laparoscopic, and robot-assisted approaches.

New technologies are regularly being used for surgical treatment of prostate cancer, however the cost associated is often a secondary issue. We assessed the operative costs incurred by using the daVinci robot assisted prostatectomy (RAP) method compared to pure laparoscopic radical prostatectomy (LRP) and open radical prostatectomy (ORP). We retrospectively analyzed three techniques of radical prostatectomies: ORP, LRP, and RAP (n = 70, 57, 106, respectively). The mean patient age was 53.6, 57.6, and 60 with a mean preoperative prostate specific antigen (PSA) of 7.2, 8.4, and 6.6, respectively. The mean Gleason score was 6. Operative cost was measured for each patient. Charts were reviewed to assess individual patients postoperative requirements, and hospital length of stay (LOS). Intraoperative data show costs to be higher with the RAP and LRP compared to open surgery. Average total operating room (OR) costs per case were $5410, $3876, and $1870 for RAP, LRP, and open prostatectomy, respectively. However when comparisons are made in the postoperative period with regard to LOS, there is a significant advantage of the RAP and LRP groups over open surgery (P < 0.05). Intraoperative costs are highest for RAP. Both LRP and RAP are associated with a shorter hospital stay.

Surgical case order does not affect outcomes during robot-assisted radical prostatectomy.

Fatigue has been implicated in medical errors. There has not been any report in the surgical literature addressing the impact of case order on patient outcomes. The purpose of this study was to determine whether the order of robot-assisted radical prostatectomy (RARP) has an influence on surgical outcomes. All patients undergoing RARP by a single surgeon (J.V.J.) on days during which there were three consecutive RARP cases were divided into three groups based on case order. They were compared with respect to pre-operative, intra-operative, and post-operative parameters. Complications were classified as surgical (bladder neck contracture, urinary tract infection, post-operative bleeding) or medical (deep venous thrombosis, myocardial infarction, C. difficile colitis) and compared between the groups. A total of 381 patients were evaluated, 127 in each group. The median start time for group 1 was 0732 hours (range 0722-0900 hours), group 2 was 1108 hours (range 1008-1344 hours), and group 3 was 1458 hours (range 1258-1742 hours). Patient age, body mass index, pre-operative PSA, pre-operative Gleason score, and clinical stage were all similar amongst the groups. The total operative time was equivalent, as was the estimated blood loss. Prostate volume and pathologic Gleason score showed no significant changes between groups. Pathologic stage showed a slight trend toward increasing percentages of T3 disease with increasing group number (group 1 = 17%, group 2 = 19%, and group 3 = 24%). Positive margin rates were lowest in group 3 (11.8% for group 1, 12.6% for group 2, and 3.9% for group 3). Complication rates were equivalent at 5-7% overall (2-6% surgical complications, 2-4% medical). Three patients from each group had PSA recurrence. With an experienced surgical team, three RARP procedures may be performed in 1 day without significant variation in surgical outcomes among the cases.

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate ED, 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.