Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice.

BACKGROUND: The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. AIM: To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. METHODS: A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. MAIN OUTCOME MEASURE: The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. RESULTS: A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial. CLINICAL IMPLICATIONS: IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. STRENGTHS & LIMITATIONS: The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. CONCLUSION: ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025-1032.

External validation of a prediction model for penile prosthesis implantation for erectile dysfunction management.

INTRODUCTION: Penile prosthesis implantation (PPI) is the definitive surgical treatment for erectile dysfunction (ED), yet it is often delayed for a variety of reasons. From commercial and Medicare claims data, we previously developed a tool for determining a patient's likelihood of eventually receiving PPI. We validated this instrument's utility by comparing cohorts receiving surgical (PPI) versus non-surgical ED management at a single institution. MATERIAL AND METHODS: The prediction model was based on a logistic regression incorporating claims data on demographics, comorbidities and ED therapy. A risk score is calculated from the model as the product of relative risks for the individual variables. The current validation was a retrospective analysis of ED patients seen at this institution from January to December 2012. Inclusion criteria included ED diagnosis and either first-time PPI or non-surgical treatment (controls). Risk scores for patients receiving PPI were compared to those of non-surgical controls. RESULTS: We established a cohort of 60 PPI patients (mean age 54.4 ± 9.5) and compared them with 120 non-PPI patients (mean age 53.4 ± 11.2 years). The median score of the PPI cohort was 5.7 (IQR 2.8-9.9) versus the non-PPI cohort's 1.8 (IQR 0.9-5.5) (p < 0.0001). The area under the receiver operator characteristic curve for predicting eventual PPI was 0.72 (95% CI, 0.64-0.79) (p < 0.0001). CONCLUSION: The prediction model risk-stratified men who ultimately underwent PPI compared to non-surgically managed controls. This external validation study suggests that the prediction model may be used on an individual patient basis to support a recommendation of PPI for managing ED.

Corporal Burnett "Snake" surgical maneuver for the treatment of ischemic priapism: long-term followup.

PURPOSE: We provide long-term followup on a modification of the Al-Ghorab distal penile corporoglanular shunt surgery for the treatment of ischemic priapism. MATERIALS AND METHODS: We conducted a retrospective review of patients surgically treated for ischemic priapism at The Johns Hopkins Hospital from January 2008 to April 2012 with the Burnett "Snake" maneuver of the Al-Ghorab shunt. Electronic medical records were reviewed to collect demographic information and telephone followup was performed to verify treatment outcomes. Patients completed the SHIM (Sexual Health Inventory for Men) to assess current erectile function. RESULTS: A total of 10 patients were analyzed (age range 31 to 59 years). Mean followup was 6.7 months (range 0.5 to 17). Priapism etiologies were idiopathic (3), trazodone (2), trazodone and cocaine (3), intracavernous injection of trimix (1) and spinal cord injury (1). There were 6 patients who had previously undergone unsuccessful surgical attempts at priapism decompression and mean priapism duration was 75 hours (range 24 to 288). Of the 10 men 8 achieved successful resolution of priapism with no recurrence. There were 2 men with recurrent priapism refractory to all management who were definitively treated with insertion of an inflatable penile prosthesis. Of 9 men 6 had normal erectile function preoperatively, of whom 2 achieved at least partial erectile function postoperatively. Complications were sustained by 2 men, including wound infection with skin necrosis in 1, and an intraoperative urethral injury in the other with subsequent urethrocutaneous fistula formation and wound infection with skin necrosis. CONCLUSIONS: The modified Al-Ghorab corporoglanular shunt using the Burnett snake maneuver is successful in resolving ischemic priapism, particularly in cases refractory to first line management, and in preventing further episodes of priapism.

Combined inflatable penile prosthesis-artificial urinary sphincter implantation: no increased risk of adverse events compared to single or staged device implantation.

PURPOSE: Little data exist on the outcome of combined inflatable penile prosthesis and artificial urinary sphincter insertion for erectile dysfunction and stress urinary incontinence. We assessed patient outcomes for combined vs single device implantation at a single institution. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent inflatable penile prosthesis and artificial urinary sphincter insertion at our hospital from January 2000 to December 2011. A total of 55 combined procedures were performed compared to the single insertion of 336 inflatable penile prostheses and 279 artificial urinary sphincters. RESULTS: The surgical approach consisted of penoscrotal incisions for inflatable penile prostheses and transperineal incisions for artificial urinary sphincter cuff placement with a secondary lower abdominal incision for reservoir placement. Men treated with combined implantation had greater mean age and were at greater risk for prostate cancer diagnosis and treatment, and at lesser risk for Peyronie disease than men who received an inflatable penile prosthesis alone (each p<0.05). Although operative time was significantly longer for the combined procedure than for the inflatable penile prosthesis alone and the AUS alone (mean 218.1 vs 145.9 and 114.7 minutes, respectively, p<0.0001), the rate of device infection, erosion or malfunction was not increased irrespective of combined or staged procedures (p>0.05). CONCLUSIONS: Combined inflatable penile prosthesis-artificial urinary sphincter implantation and staged prosthesis implantation are feasible without an increased risk of adverse outcomes compared to implantation of a single prosthesis. Patients with concomitant erectile dysfunction and stress urinary incontinence should be counseled about the possible advantages of this surgical option, which include a single anesthesia event and faster resumption of sexual activity and urinary control.

Radical cystectomy in patients with preexisting three-piece inflatable penile prosthesis.

INTRODUCTION: Radical cystectomy with urinary diversion is the treatment of choice for muscle-invasive, and certain populations with non-invasive, urothelial carcinoma of the bladder. There have not been any reports to date on patients undergoing this surgery who have had previous placement of an inflatable penile prosthesis. AIM: To present the outcomes of four patients with pre-existing inflatable penile prostheses (IPP) with reservoirs within the space of Retzius who were subsequently treated with radical cystectomy for bladder cancer management. METHODS: After obtaining institutional review board approval, the demographic, clinical, and pathologic data were reviewed in the Johns Hopkins Cystectomy Database for patients who underwent radical cystectomy for bladder cancer from 1994 to 2012. A case series of four patients is presented who had a preexisting IPP and their post-operative course and long-term outcomes are reviewed. RESULTS: All four patients had radical cystectomy and ileal conduit urinary diversion with no intra-operative or post-operative complications. One patient was not sexually active and therefore had the reservoir explanted and not replaced. The other three patients had the reservoir removed prior to bladder extirpation and the tubing capped, with reservoir replacement in the pseudocapsule at the termination of the procedure. In one patient an omental flap was used to ensure separation between the reservoir and ileal conduit. The devices were all functional intra-operatively and on follow-up. CONCLUSIONS: As erectile dysfunction is more commonly being diagnosed and treated with IPP insertion at younger ages, surgeons will increasingly encounter pre-placed abdominal reservoirs when performing pelvic surgery. This case series of four patients undergoing radical cystectomy with prior-placed IPPs reveals that the functionality of the IPP can be preserved while still performing oncologically sound extirpative procedures.

Viberect penile vibratory stimulation system: evaluation of its erectogenic efficacy.

INTRODUCTION: Current non-surgical strategies employed to treat erectile dysfunction (ED) target the vascular component of erection physiology. The Viberect handheld device (Reflexonic, LLC, Chambersburg, PA, USA) is a new FDA-cleared ED treatment, which exploits vibratory stimulation of genital afferent nerves for provoking erections. The aim of this study was to evaluate the clinical feasibility of the Viberect device for the achievement of penile erection and rigidity. MATERIALS AND METHODS: Subjects for this study were five healthy men (mean age 26.4 years) with normal erectile function as measured by responses to the IIEF-EF. The Viberect treatment at 75 Hz with ventral stimulation was initiated without any external visual sexual stimulation. Both objective Rigiscan measurements of rigidity and subjective Erection Hardness Score (EHS) responses were recorded and correlated. Toleration and safety were monitored. RESULTS: Rigiscan demonstrated that 4/5 subjects achieved tumescence episodes beyond 60% total rigidity (considered the minimum required to achieve a non-buckling erection capable of vaginal intromission). According to EHS, the Viberect treatment yielded scores of 4/4 (penis is completely hard and fully rigid) in 2 subjects, 3/4 (penis hard enough for penetration but not completely hard) in 2 and 2/4 (penis is hard but not enough for penetration) in 1. There were no complications, and all subjects felt that Viberect would be a reasonable, practical ED treatment. CONCLUSION: This study provides evidence that Viberect produces a non-invasive, well-tolerated erectogenic effect. These results indicate that penile vibratory stimulation provokes erections via neurostimulatory principles and support further study of this modality in treating men with ED.

Irbesartan promotes erection recovery after nerve-sparing radical retropubic prostatectomy: a retrospective long-term analysis.

UNLABELLED: Study Type--Therapy (retrospective cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Erectile dysfunction following radical prostatectomy (RP) is among the most common and dreaded adverse effects of the surgery. Multiple studies confirm the potential benefit of various drug classes to accelerate the return of erectile function (EF) after RP. There is pre-clinical evidence supporting the use of angiotensin-receptor blockers (ARBs) for this purpose, although this has not been studied in humans. The present study shows that there may be a benefit in the recovery of EF post-RRP in patients taking a daily dose of irbesartan, an ARB, following RRP. In addition, the use of irbesartan may curb the loss of stretched penile length which occurs postoperatively. Further study in the form of prospective, randomized, placebo-controlled clinical trials are necessary to confirm these findings. OBJECTIVE: • To evaluate retrospectively the potential benefit of administering irbesartan, an angiotensin-receptor blocker, to improve erectile function (EF) recovery after nerve-sparing radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: • Before surgery potent patients who underwent nerve-sparing RRP between April and December 2009 elected to start daily oral irbesartan 300 mg on postoperative day 1 (n= 17). A contemporaneously clinically matched cohort consisting of patients who declined irbesartan use served as the control group (n= 12). • Postoperative 'on demand' use of erectile aids (phosphodiesterase type 5 [PDE5] inhibitors and intracavernous injections) was adopted. • Potency was monitored by the administration of International Index of Erectile Function-5 (IIEF-5) questionnaires before surgery and at early (3 months) and long-term (12 and 24 months) postoperative intervals. • Stretched penile length (SPL) was measured both immediately and 3 months after surgery. RESULTS: • EF status was no different between groups at baseline (P > 0.05). • While the IIEF-5 scores at 24 months after surgery were statistically similar between the two groups (control = 15.2 ± 2.0, irbesartan = 14.1 ± 3.1, P = 0.77), at 12 months the IIEF-5 scores of the irbesartan group were significantly higher than those of the control group (14 ± 2.6 vs. 7.2 ± 1.6, P < 0.05). • The proportional loss of SPL after RRP was less in the irbesartan than in the control group at 3 months (-0.9 ± 1.5% vs -5.6 ± 1.5, P < 0.05). CONCLUSION: • Regular irbesartan use after nerve-sparing RRP in patients with normal preoperative erectile function could improve EF recovery after surgery and mitigate early loss of SPL.

Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review.

INTRODUCTION: Erectile dysfunction is a common problem that may be definitively treated with the implantation of an inflatable penile prosthesis (IPP). The preponderance of available data on IPP surgery derives from institutional studies, most notably from academic centers or large single-surgeon series, where the majority of procedures are performed in a hospital setting. Because insurance companies and health systems look to reduce health care costs, IPP surgery in outpatient freestanding ambulatory surgery centers (ASC) is becoming more prevalent. AIM: To review the utility of surgery in an ASC setting and to explore its role in the modern practice of urology, focusing on IPP implantation. METHODS: A critical review was performed of the literature on ambulatory surgery, with specific focus on IPP surgery, using the PubMed database. Key search terms and phrases included erectile dysfunction, penile prosthesis, ambulatory surgery, ambulatory surgery center, outpatient surgery. MAIN OUTCOME MEASURE: The main outcome measure was the use of IPP implantation in an ASC. RESULTS: In contemporary surgical practice, the implementation of ambulatory surgery in free-standing centers is increasing. The principal benefits include reducing cost and improving efficiency. Studies on the modern use of IPPs support the prospect of implantation in an ambulatory setting, which can achieve similar outcomes to surgeries classically performed in the inpatient hospital setting. Novel approaches to anesthesia, surgical, and nursing care have revolutionized IPP surgery so that it can now be safely and effectively performed in the ambulatory setting. CONCLUSION: The role of ambulatory IPP implantation has increased, with the majority of cases being performed outside the hospital. Although there will always be a need for hospital-based surgery, such as significant medical comorbidities, more studies demonstrating the safety and feasibility of ambulatory surgery are needed. For those men who would otherwise be candidates for ambulatory surgery but whose insurance mandates hospital-based treatment, such studies proving utility, safety, and reduced cost could inspire policy change and broaden the ambulatory practice of IPP surgery. Segal RL, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review. Sex Med Rev 2020;8:338-347.

American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism.

These clinical practice guidelines summarize the recommendations of the American Association of Clinical Endocrinologists for the diagnostic evaluation of hyperthyroidism and hypothyroidism and for treatment strategies in patients with these disorders. The sensitive thyroid-stimulating hormone (TSH or thyrotropin) assay has become the single best screening test for hyperthyroidism and hypothyroidism, and in most outpatient clinical situations, the serum TSH is the most sensitive test for detecting mild thyroid hormone excess or deficiency. Therapeutic options for patients with Graves' disease include thyroidectomy (rarely used now in the United States), antithyroid drugs (frequently associated with relapses), and radioactive iodine (currently the treatment of choice). In clinical hypothyroidism, the standard treatment is levothyroxine replacement, which must be tailored to the individual patient. Awareness of subclinical thyroid disease, which often remains undiagnosed, is emphasized, as is a system of care that incorporates regular follow-up surveillance by one physician as well as education and involvement of the patient.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM.

These clinical practice guidelines summarize the recommendations of the American Association of Clinical Endocrinologists for the diagnostic evaluation of hyperthyroidism and hypothyroidism and for treatment strategies in patients with these disorders. The sensitive thyroid-stimulating hormone (TSH or thyrotropin) assay has become the single best screening test for hyperthyroidism and hypothyroidism, and in most outpatient clinical situations, the serum TSH is the most sensitive test for detecting mild thyroid hormone excess or deficiency. Therapeutic options for patients with Graves' disease include thyroidectomy (rarely used now in the United States), antithyroid drugs (frequently associated with relapses), and radioactive iodine (currently the treatment of choice). In clinical hypothyroidism, the standard treatment is levothyroxine replacement, which must be tailored to the individual patient. Awareness of subclinical thyroid disease, which often remains undiagnosed, is emphasized, as is a system of care that incorporates regular follow-up surveillance by one physician as well as education and involvement of the patient.

Management of priapism: an update for clinicians.

Priapism is a prolonged erection that persists beyond or is unrelated to sexual stimulation. It is associated with significant morbidity: psychological, socioeconomic, and physical, including pain and potentially irreversible compromise of erectile function. There are three major types of priapism: ischemic, nonischemic, and stuttering. Establishing the type of priapism is paramount to safely and effectively treating these episodes. Ischemic priapism represents a urological emergency. Its treatment may involve aspiration/irrigation with sympathomimetic injections, surgical shunts, and as a last resort, penile prosthesis implantation. Nonischemic priapism results from continuous flow of arterial blood into the penis, most commonly related to penile trauma. This is not an emergency and may be managed conservatively initially, as most of these episodes are self-limiting. Stuttering priapism involves recurrent self-limiting episodes of ischemic priapism. The primary goal of therapy is prevention, but acute episodes should be managed in accordance with guidelines for ischemic priapism. In this paper we review the diagnosis and treatment of the three priapism variants, as well as discuss future targets of therapy and novel targets on the horizon.

Prediction model for penile prosthesis implantation for erectile dysfunction management.

OBJECTIVE: Penile prosthesis surgery is indicated based on undesirability, contraindication or ineffectiveness of non-surgical options for erectile dysfunction. This definitive treatment is often delayed after initial diagnosis. Our objective was to develop a prediction tool based on a patient's clinical history to determine likelihood of ultimately receiving a penile prosthesis. RESEARCH DESIGN AND METHODS: This retrospective analysis used claims data from Commercial and Medicare supplemental databases. Inclusion criteria were 18 years of age with 1 year of continuous enrollment at the first diagnosis of erectile dysfunction. Patients' demographics, co-morbidities and erectile dysfunction therapy were derived based on enrollment, medical and prescription histories. MAIN OUTCOME MEASURES: The Cox proportional hazards model with stepwise selection was used to identify and quantify (using relative risk) factors associated with a future penile prosthesis implant. Co-morbidities and therapies present prior to the index erectile dysfunction diagnosis were analyzed as fixed covariates. RESULTS: Approximately 1% of the dataset's population (N = 310,303 Commercial, N = 74,315 Medicare, respectively) underwent penile prosthesis implantation during the study period (3928 patients in the overall population: 2405 patients [0.78%] in the Commercial and 1523 patients [2.05%] in the Medicare population). Factors with the greatest predictive strength of penile prosthesis implantation included prostate cancer diagnosis (relative risk: 3.93, 2.29; 95% CI, 3.57-4.34, 2.03-2.6), diabetes mellitus (2.31, 1.23; 2.12-2.52, 1.1-1.37) and previous treatment with first-line therapy (1.39, 1.33; 1.28-1.5, 1.2-1.47) (all P < 0.01). CONCLUSION: The presence and extent of specific medical history factors at the time of erectile dysfunction diagnosis predict an individual's future likelihood of penile prosthesis. Calculating the likelihood of penile prosthesis implantation based on the weight of these factors may assist clinicians with the definition of a care plan and patient counseling. The precision of the model may be limited by factors beyond medical history information that possibly influence the decision to proceed to surgery.

Surgical Management for Peyronie's Disease.

Peyronie's disease is a common debilitating condition for both men and their partners that results in penile deformity and compromises sexual functioning. While there are a myriad of medical therapeutic options, these have not been demonstrated to correct the deformity and restore sexual function definitively. As such, surgery is the mainstay of treatment for this disease, and multiple surgical approaches may be considered depending on disease characteristics, patient co-morbidity, and findings on preoperative diagnostic testing. The purpose of this review is to highlight the different surgical approaches and different procedures within each approach, and to examine important issues for surgeons to consider for administering the best treatment that restores function while reconciling patient expectations.

Current penile-rehabilitation strategies: Clinical evidence.

We review the current strategies used for penile rehabilitation (PR) after a radical prostatectomy, where PR is defined as the attempt to restore spontaneous erectile function so that the patient can generate erections with no need for erectile aids. We searched PubMed for relevant reports, using the keywords 'radical prostatectomy', 'penile rehabilitation', 'phosphodiesterase inhibitors', 'vacuum erection device', 'injection therapy', 'urethral suppository', and 'erectile dysfunction'. In all, 155 articles were identified and reviewed, and had a level of evidence ranging from 1b-4. The use of PR strategies should be based on the patient's goals after a thorough explanation of realistic expectations, and the risks and consequences of the various treatment options. While a multitude of studies suggest a benefit with PR strategies, there are no established, proven regimens. Further research is needed to establish the optimal approaches to PR.

Fibrotic protein expression profiles in penile tissue of patients with erectile dysfunction.

OBJECTIVE: To characterize transforming growth factor beta 1 (TGFß1) and related signaling pathway proteins in a large cohort of human penile tissue (HPT) samples. METHODS: HPT was collected from patients undergoing penile prosthesis implantation for erectile dysfunction (ED) and divided into the following 2 groups: postradical prostatectomy ED (RP-ED; n = 57) and organic ED (O-ED; n = 30). HPT from patients undergoing partial penectomy without ED was used as controls (CON; n = 6). Western blot analysis was performed to investigate the protein expressions of TGFß1, thrombospondin 1 (TSP1; an activator of TGFß1), fibronectin (an extracellular matrix glycoprotein induced by TGFß1), and a family of transcriptional factors activated by TGFß1 (Smad2, phospho-Smad2-serine-465/467 [pSmad2], Smad3, phospho-Smad3-serine-423/425 [pSmad3]). RESULTS: Expressions of TGFß1 and TSP1 were significantly higher in RP-ED (P <.05) and O-ED (P <.05) groups compared with that of the CON group and were not different between either ED groups. Expressions of Smad2, pSmad2, Smad3, pSmad3, and fibronectin were similar among all groups. Within the RP-ED group, a subgroup analysis showed that time from RP to penile prosthesis implantation was related to increased expression of pSmad2 (P <.05), and previous history of intracavernosal injection was related to increased expression of TGFß1 (P <.05). CONCLUSION: Our results demonstrate that TSP1- and TGFß1-dependent fibrotic changes occur in penile tissue in patients with ED regardless of etiology. The unchanged expression of the Smad transcriptional factors may be reconciled by a Smad-independent downstream signaling pathway transmitting TGFß1 signals.

Urinary outcomes are significantly affected by nerve sparing quality during radical prostatectomy.

OBJECTIVE: To assess the effect of nerve sparing (NS) quality on self-reported patient urinary outcomes after radical prostatectomy. METHODS: A total of 102 preoperatively potent men underwent laparoscopic or robotic radical prostatectomy; NS was prospectively graded at surgery using a 0-4 scale/neurovascular bundle. Urinary functional outcomes were measured by validated Expanded Prostate Cancer Index Composite questionnaire at baseline and follow-up time points (1, 3, 6, 9, and 12 months) in 99 men who underwent various degrees of NS. Mixed linear regression was used to analyze the effect of NS quality and other clinical factors on urinary outcomes. RESULTS: Patients with at least 1 neurovascular bundle spared completely, along with its supportive tissues (NS grade 4/4), noted significantly improved Expanded Prostate Cancer Index Composite urinary functional and continence outcomes as early as 1 month postoperatively and up to 12 months. Significantly less urinary bother was also noted in these men by 9-12 months postoperatively. Multivariate analysis revealed that bilateral or unilateral excellent NS (at least 1 bundle graded 4/4), increasing time from surgery, young patient age, and lower body mass index positively and significantly affected urinary functional outcomes, including pad use. Men who received excellent unilateral NS recovered urinary function about as well as men who had both neurovascular bundles spared in similar fashion. CONCLUSION: The quality of NS significantly influences patient-defined urinary functional convalescence. Completely sparing at least 1 neurovascular bundle along with its supportive tissues has a dramatic effect on the recovery of urinary continence and quality of life in preoperatively potent men.