What is the definition of a satisfactory erectile function after bilateral nerve sparing radical prostatectomy?

INTRODUCTION: Different cut-offs of the erectile function (EF) domain of the International Index of Erectile Function (IIEF) have been used as definition of postoperative EF recovery. AIM: To test the correlation between patient satisfaction and IIEF-EF domain score cut-offs. MAIN OUTCOME MEASURE: The IIEF was used to evaluate EF and satisfaction before and after bilateral nerve sparing radical prostatectomy (BNSRP). METHODS: The study included 165 consecutive patients treated with retropubic BNSRP at a single institution. All patients had normal preoperative EF (IIEF-EF ≥ 26) and reached an IIEF-EF ≥ 17 following surgery. Complete data included EF, intercourse (IS), and overall satisfaction (OS) assessed by the corresponding domains of the IIEF administered prior and after surgery. Patients were divided into three groups according to the highest IIEF-EF score reached postoperatively, namely 17-21 (group 1), 22-25 (group 2), and ≥ 26 (group 3). One-way analysis of variance was used to compare IIEF-OS and IIEF-IS domain scores at the time the EF end point was reached. The same analyses were repeated separately in those patients with a complete EF recovery after surgery (group 3). RESULTS: Mean preoperative IIEF-OS and IIEF-IS domain score was 8.4, 8.8, 8.7 and 11.6, 11.8, 11.9 in group 1, 2, 3, respectively (all P ≥ 0.3). After a mean follow-up of 26.7 months, mean postoperative IIEF-OS and IIEF-IS domain scores assessed at the time of EF recovery were comparable for patients reaching an IIEF-EF of 22-25 and for patients scoring postoperatively ≥ 26 (8.1, 8.1, and 10.6, 11.4; all P ≥ 0.3). However, mean IIEF-OS and IIEF-IS domain scores of these patients were significantly higher as compared to patients reaching an IIEF-EF domain score < 22 (6.3 and 8.4, respectively; all P ≤ 0.006). Similar results were achieved considering only those patients (group 3) who had complete EF recovery after surgery. CONCLUSIONS: We demonstrated that in preoperatively fully potent patients treated with BNSRP a lower satisfaction is expected when an IIEF-EF cut-off of 17 is used. Conversely, no difference was found using a cut-off of 22 or 26. Therefore, our results support that a cut-off of IIEF-EF ≥ 22 might represent a reliable score for defining EF recovery after BNSRP.

Predicting erectile function recovery after bilateral nerve sparing radical prostatectomy: a proposal of a novel preoperative risk stratification.

INTRODUCTION: No multivariable model is currently available for the prediction of erectile function (EF) recovery after bilateral nerve sparing radical prostatectomy (BNSRP). AIM: The aim of this study was to develop a novel preoperative risk stratification aimed at assessing the probability of EF recovery after BNSRP. MAIN OUTCOME MEASURE: The International Index of Erectile Function (IIEF) was used to evaluate EF after BNSRP. METHODS: This study included 435 patients treated with retropubic BNSRP between 2004 and 2008 at a single Institution. Preoperative data, including age, IIEF, Charlson comorbidity index (CCI), and body mass index (BMI) were available for all patients. Moreover, all patients were assessed postoperatively every 3 months and were asked to complete the IIEF during each visit. Cox regression models tested the association between preoperative predictors (age at surgery, preoperative IIEF-EF domain score, CCI, BMI) and EF recovery. Independent predictors of EF recovery were then used to stratify patients into three groups according to the risk of erectile dysfunction (ED) after surgery: low (age or= 26, CCI or= 70 years or IIEF-EF or= 2; n = 136). Kaplan-Meier curves assessed the time to EF recovery (defined as IIEF-EF score >or= 22). Predictive accuracy of our proposed classification was quantified using the AUC method. RESULTS: Of 435 patients, 242 (55.6%) received phosphodiesterase type 5 inhibitors (PDE5-I) either on demand or every day for a period of 3-6 months. Overall, EF recovery rate was 58% at 3-year follow-up. Patients treated with PDE5-I had significantly higher 3-year EF recovery rate as compared with patients left untreated after surgery (73 vs. 37%; P < 0.001). Except for BMI (P = 0.7), all preoperative covariates showed a significant association with EF recovery (all P

When to perform bone scan in patients with newly diagnosed prostate cancer: external validation of the currently available guidelines and proposal of a novel risk stratification tool.

BACKGROUND: Several guidelines have indicated that in patients with well-differentiated or moderately well-differentiated prostate cancer (PCa), a staging bone scan may be omitted. However, the guidelines recommendations have not yet been externally validated. OBJECTIVE: The aim of the study was to externally validate the available guidelines regarding the need for a staging bone scan in patients with newly diagnosed PCa. Moreover, we developed a novel risk stratification tool aimed at improving the accuracy of these guidelines. DESIGN, SETTING, AND PARTICIPANTS: The study included 853 consecutive patients diagnosed with PCa between January 2003 and June 2008 at a single centre. All patients underwent bone scan using technetium Tc 99m methylene diphosphonate at diagnosis. MEASUREMENTS: The area under the curve (AUC) of the criteria suggested by the guidelines (European Association of Urology, American Urological Association, National Comprehensive Cancer Network, and American Joint Committee on Cancer) to perform a baseline bone scan was assessed and compared with the accuracy of a classification and regression tree (CART) including prostate-specific antigen (PSA), clinical stage, and biopsy Gleason sum as covariates. RESULTS AND LIMITATIONS: The AUC of the guidelines ranged between 79.7% and 82.6%. However, the novel CART model, which stratified patients into low risk (biopsy Gleason ≤7, cT1-T3, and PSA <10 ng/ml), intermediate risk (biopsy Gleason ≤7, cT2/T3, and PSA >10 ng/ml), and high risk (biopsy Gleason >7) was significantly more accurate (AUC: 88.0%) than all the guidelines (all p≤0.002). The limitation of this study resides in its retrospective design. Moreover, the proposed risk stratification tool can be considered only for patients who are candidates for radical prostatectomy until validated in other clinical settings. CONCLUSIONS: This is the first study aimed at externally validating the available guidelines addressing the need for staging baseline bone scans in PCa patients. All guidelines showed high accuracy. However, their accuracy was significantly lower compared with the accuracy of the novel risk stratification tool. According to this tool, staging bone scans might be considered only for patients with a biopsy Gleason score >7 or with a PSA >10 ng/ml and palpable disease (cT2/T3) prior to treatment. However, before recommending its use in clinical practice, our model needs to be externally validated.

Impact of surgical volume on the rate of lymph node metastases in patients undergoing radical prostatectomy and extended pelvic lymph node dissection for clinically localized prostate cancer.

BACKGROUND: Previous trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). OBJECTIVE: To test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. INTERVENTION: All patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. MEASUREMENTS: Univariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs < or =144 ePLNDs) and the rate of lymph node invasion (LNI) after accounting for preoperative (baseline prostate-specific antigen [PSA], clinical stage, biopsy Gleason sum) and postoperative (pathologic stages and Gleason score, surgical margin status) patient characteristics. RESULTS AND LIMITATIONS: Mean number of nodes removed was 19.1 (median, 16; range, 7-63). Mean overall SV was 227 (range, 87-379). Overall, LNI rate was 11.8% (120/1020). No significant differences were found among patients treated by the different surgeons in terms of clinical and pathologic characteristics (all p> or =0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p<0.001, and 15 vs 9.8% of LNI; p=0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI (p=0.007 and p<0.001, respectively). In multivariable models, continuously coded as well as dichotomized SV maintained a significant association with the rate of LNI, after accounting for preoperative (p=0.04 and p=0.009, respectively) as well as for postoperative variables (p=0.03 and p=0.002, respectively). CONCLUSIONS: After adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal.

Topical prilocaine-lidocaine cream combined with peripheral nerve block improves pain control in prostatic biopsy: results from a prospective randomized trial.

OBJECTIVES: To compare pain control results between periprostatic nerve block alone and combined with topical prilocaine-lidocaine cream as local anesthesia of prostate biopsy. METHODS: Three hundred patients were randomized to receive PNB (group 1), topical anesthesia of the anal ring, anal canal, and anterior rectal wall combined with PNB (group 2) and placebo (group 3). Patients were asked to use scale of 0-10 to complete a visual analogue scale questionnaire about pain during probe insertion (VAS1), periprostatic infiltration (VAS2), and cores (VAS3). RESULTS: Pain during probe insertion in group 2 was significantly less than in groups 1 and 3 (VAS1, 0.29 vs. 1.46 and 1.48; p<0.0001). Pain during periprostatic infiltration was also reduced in group 2 compared with group 1 (VAS2, 1.06 vs. 2.39; p<0.0001). Pain control was similar during biopsy in the PNB and combined groups (VAS3, 0.43 vs. 0.37; p=0.77) and was superior to group 3 (VAS3, 3.02; p<0.0001). In younger patients (cut off, median age 67 yr) these differences were still significant between groups 1 and 2 (VAS1, 1.95 vs.0.31; p<0.0001 and VAS2, 2.97 vs. 1,15; p<0.0001), but not in older patients (VAS1, 0.91 vs. 0.28; p=0.06; VAS2, 1.52 vs. 0,92; p=0.06). Vagal symptoms were registered in 36 (12%) patients in all groups. Sepsis occurred in one group 1 patient and in one group 2 patient. Rectal bleeding was observed in one group 2 patient. CONCLUSION: Combined prilocaine-lidocaine cream topically placed with PNB is superior to PNB alone and may be of maximum benefit for younger patients.

Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectional study.

OBJECTIVE: The aim of this study was to determine the prevalence of sexual dysfunctions in women with urinary incontinence and/or lower urinary tract symptoms as compared to a general female population. METHODS: We extensively evaluated 227 consecutive women (mean age 52; age range 19-66) complaining of urinary incontinence (UI) and/or lower urinary tract symptoms (LUTS) with a comprehensive history (including several validated questionnaires), a complete physical examination and a urodynamic multichannel evaluation. Two hundred and sixteen patients were eligible for sexual function investigation because 11 out of 227 (5%) were not interested in dealing with questions regarding their own sexuality and were thus excluded from the final evaluation results. A group of 102 age-matched women (mean age 54; age range 19-63) assessed for a yearly routine gynaecological evaluation and not complaining of urinary symptoms were enrolled as cross-sectional controls and investigated in accordance with the Female Sexual Function Index (FSFI). RESULTS: Sexual dysfunction was diagnosed in 99 out of 216 patients (46%). Of these, 34 (34%) reported hypoactive sexual desire, 23 (23%) reported sexual arousal disorder; 11 patients (11%) complained of orgasmic deficiency, and 44 (44%) suffered from sexual pain disorder (e.g., dyspareunia or non-coital genital pain). Women reporting low sexual desire commonly suffered from stress incontinence (47%). We found that 60% of the women with sexual arousal disorders and 61% of those with sexual pain disorders also complained of recurrent bacterial cystitis. Forty-six percent of those complaining of orgasmic phase difficulties also reported a troublesome urge incontinence. The FSFI values in both groups scored as follows (patients versus controls; median value; p value): desire: 2.0 vs. 3.2 (p<0.01); arousal: 2.8 vs. 3.6 (p=n.s.); lubrication: 3.2 vs. 4.4 (p=0.01); orgasm: 4.1 vs. 4.4 (p=n.s.); sexual satisfaction: 2.7 vs. 4.0 (p<0.01); sexual pain: 1.8 vs. 4.0 (p<0.001). CONCLUSIONS: Women reporting UI or LUTS also complained of sexual dysfunctions in a significantly higher number than a general, healthy female population not complaining of urinary symptoms. Investigation of female sexuality is suggested for these patients.