Objectives• To clarify the role of phosphodiesterase type 5 (PDE5) inhibitors in post-prostatectomy penile rehabilitation (PPPR).• To compare nightly and on-demand use of PDE5 inhibitors after nerve-sparing minimally invasive radical prostatectomy (RP). Patients and Methods• We conducted a single-institution, double-blind, randomized controlled trial of nightly vs on-demand 50-mg sildenafil citrate after nerve-sparing minimally invasive RP. • A total of 100 preoperatively potent men, aged <65 years, with scores on the Erectile Function domain of the International Index of Erectile Function (IIEF-EF) ≥26, underwent nerve-sparing surgery.• The patients were randomized to either nightly sildenafil and on-demand placebo (nightly sildenafil group), or on-demand sildenafil and nightly placebo (on-demand sildenafil group; maximum on-demand dose six tablets/month) for 12 months. Patients then underwent a 1-month washout period. • Validated measures of erectile function (IIEF-EF score and the Expanded Prostate Cancer Index Composite [EPIC])were compared between treatment groups over the entire 13-month time course, using multivariable mixed linear regression models. Results• The treatment groups were well matched preoperatively (mean age 54.3 vs 54.6 years, baseline IIEF-EF score 29.4 vs 29.3, for the nightly vs the on-demand sildenafil groups, respectively).• No significant differences were found in erectile function between treatments (nightly vs on-demand sildenafil) at any single timepoint after RP, after adjusting for potential confounding factors.• When evaluated over all timepoints simultaneously, no significant effects of treatment group (nightly vs on-demand sildenafil) were found on recovery of potency, as assessed by absolute IIEF-EF scores (P = 0.765), on percentage of men returning to an IIEF-EF score >21 (P = 0.830), or on IIEF-EF score recovery to a percentage of baseline value (P = 0.778).• When evaluated over all timepoints simultaneously, no significant effects of treatment group were found on secondary endpoints such as assessment of potency (including EPIC item 59 response 'erections firm enough for intercourse'), attempted intercourse frequency or confidence. Conclusions• Erectile recovery up to 1 year after RP does not differ between previously potent men who use sildenafil nightly compared to on-demand. • This trial does not support chronic nightly sildenafil as being any better than on-demand sildenafil for use in penile rehabilitation after nerve-sparing minimally invasive RP.

No abstract

Cavernous nerve preservation during laparoscopic radical prostatectomy is not an all or none phenomenon. A surgeon subjective sense of neurovascular bundle sparing quality may aid in accurately characterizing the return of sexual function following laparoscopic radical prostatectomy. Partial nerve preservation may lead to an incremental improvement in the return of sexual function.

Objectives To evaluate operative and pathologic outcomes of laparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in men with progressive changes in BMI category. Methods A single-surgeon series of 1,023 LRP and RARP (mostly extraperitoneal) patients was considered, of whom 987 were evaluable. Results were stratified by World Health Organization BMI category. Multivariable linear and logistic regression was used to model operating time (OT), length of stay (LOS), positive surgical margins (PSM), and noncurable cancer. Results A total of 57% (563/987) of patients were overweight and 19.6% (193/987) were obese: 152 (15.4%) BMI 30 to <35 (class I obesity), 28 (2.8%) BMI 35 to <40 (class II), and 13 (1.3%) BMI ≥ 40 (class III). There were no differences in estimated blood loss, complications, PSM, pathologic stage, or biochemical recurrence across BMI categories (6.0-month median follow-up). However, pelvic lymph node dissection was more commonly omitted and nerve-sparing score was inferior in obese men. On multivariable analysis, higher BMI was a significant predictor of longer OT. Conclusions Obese men can safely undergo LRP or RARP, though the ability to perform excellent nerve-sparing appears to decrease with increasing obesity. Nevertheless, obese men may expect perioperative and early oncologic outcomes comparable to those of normal weight men without an increased risk of perioperative complications.

Methods and materials: Twenty-five men with known prostate cancer scheduled for radical prostatectomy were preoperatively imaged with both LoTRUS (5 MHz) and HiTRUS (21 MHz). Dynamic cine loops and still images for each modality were saved and subjected to blinded review by a radiologist looking for hypoechoic foci ~5 mm in each sextant of the prostate. Following prostatectomy, areas of prostate cancer ~ 5 mm on pathologic review were anatomically correlated to LoTRUS and HiTRUS findings. The accuracy of LoTRUS and HiTRUS to visualize prostate cancer in each sextant of the prostate and to identify high-grade and locally advanced disease was assessed. The McNemar test was used to compare sensitivity and specificity and paired dichotomous outcomes between imaging modalities.Results: Among 69 sextants with pathologically identified cancerous foci at radical prostatecomy, HiTRUS visualized 45 and missed 24, whereas LoTRUS visualized 26 and missed 43. Compared with LoTRUS, HiTRUS demonstrated improved sensitivity (65.2% vs. 37.7%) and specificity (71.6% vs. 65.4%). HiTRUS's agreement with pathologic findings was twice as high as LoTRUS (P = 0.006). HiTRUS provided a nonsignificant increase in visualization of high-grade lesions (84% vs. 60%, P = 0.11).Conclusions: HiTRUS appears promising for prostate cancer imaging. Our initial experience suggests superiority to LoTRUS for the visualization of cancerous foci, and supports proceeding with a clinical trial in the biopsy setting.