Erectile dysfunction in robotic radical prostatectomy: Outcomes and management

Abstract

Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 2014 to identify studies comparing RALP with open retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy, modified RALP techniques and treatment options and management for ED following radical prostatectomy. RALP demonstrates adequate potency rates without compromising oncologic benefit, with observed benefit for potency rates compared with RRP. Additionally, specific surgical technical modifications appear to provide benefit over traditional RALP. Phosphodiesterase-5 inhibitors (PDE5I) demonstrate benefit for ED treatment compared with placebo. However, long-term benefit is often lost after use. Other therapies have been less extensively studied. Additionally, correct patient identification is important for greatest clinical benefit. RALP appears to provide beneficial potency rates compared with RRP; however, these effects are most pronounced at high-volume centers with experienced surgeons. No optimal rehabilitation program with PDE5Is has been identified based on current data. Additionally, vacuum erection devices, intracavernosal injections and other techniques have not been well validated for post RALP ED treatment.

A Predictive Preoperative and Postoperative Nomogram for Postoperative Potency Recovery after Robot-Assisted Radical Prostatectomy

“…Traditional IIEF-15 and EPIC questionnaires are long and cumbersome to administer and currently most of the literature uses SHIM score in the preoperative setting and postoperative erection suitable for intercourse in the postoperative setting to categorize patients with ED post-RARP. 13 We developed two nomograms, one to be used in the preoperative period and one in the immediate postoperative period. As recommended by Royston et al, we used several statistical tools for internal and external validation; CIF curves at different levels of the prognostic index and different levels of the single prognostic factors, hazard ratios across risk groups, ROC curves and AUCs, calibration plots 20 while the other 2 used only calibration plots in their validation.…”

“…The primary end point of EF is defined as the ability to penetrate and satisfactorily complete intercourse with or without PDE5 inhibitor usage in more than half of the attempts. 12,13…”

“…The primary end point of EF is defined as the ability to penetrate and satisfactorily complete intercourse with or without PDE5 inhibitor usage in more than half of the attempts. 12,13 The Clavien-Dindo grading system was used to evaluate the perioperative and postoperative complications within 30 days after surgery. 14 Regular followup data were collected prospectively every 3 months in the first year, every 6 months in the second year, and then yearly.…”

A novel intraoperative physician-assigned grading score to predict postoperative return of potency at 1 year after robotic-assisted laparoscopic prostatectomy

“…Whelan et al demonstrated that RALP provides better potency outcomes than an open radical prostatectomy but only in high-volume centers with experienced surgeons. [ 9 ] Consequently, our patient pool was chosen from a single high-volume center, operated by the same surgeon who has done >250 RALP's per year for the last 10 years. In a larger reported series, Ficarra et al summarized that the incidence of erectile function recovery after RALP at 1 year was 70% (54%–90%).…”

“…[ 2 ] Evidence points toward some factors as being associated with better outcomes, such as high-volume centers, bilateral nerve sparing, absence of lateral traction and bleeding, ideal plane of dissection, athermal technique, and a single experienced surgeon. [ 3 4 5 6 7 8 9 ] However, what is lacking is a standardized measurable intraoperative method of scaling and grading the nerve sparing, taking into consideration all these factors simultaneously to enable physicians to preemptively predict the potency outcome postoperatively.…”