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Sexual function after robotic prostatectomy

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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.

Sexual dysfunction associated with radical...

However, erectile dysfunction ED remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of Sexual function after robotic prostatectomy versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 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. 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. Prostate cancer CaP remains the most common malignancy in men in the United States. The functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options and management of ED following RALP are examined in this paper.

A systematic review using the Medline database was performed in March Humans, English and gender Sexual function after robotic prostatectomy. Articles were screened using abstracts and those selected underwent full review. Two hundred and thirty-three articles were obtained.

Anatomy of Sexual Function

All abstracts were reviewed. Given the numerous articles available for such a broad subject matter, those that are included in this article were determined to be most critical to the subject matter. After a thorough review of the articles obtained, 23 articles addressing ED following RALP were included in this review as outlined in Table 1.

Men who undergo Dr. Samadi's...

Improved surgical precision and reduced complication rates have provided hope that RALP provides greater potency rates with preservation of oncologic outcomes. A meta-analysis by Ficarra et al. The Mulhall "Sexual function after robotic prostatectomy" were developed to better assess the validity of reported ED rates following radical prostatectomy RP.

When comparing multiple studies, it is easier to compare the results if a greater number of these criteria are met.

A recent meta-analysis Sexual function after robotic prostatectomy Moran et al. Independent predictors of potency were age HR 2. The potency rates were Further studies have shown that age OR 0. However, this is in contrast to data reporting Several attempts Sexual function after robotic prostatectomy modified RALP techniques have been performed and the results are shown in Table 2. In a technique where O 2 tissue monitoring allowed intraoperative surgical modification for reduced traction, benefit was noted.

The Veil of Aphrodite technique was developed to provide the greatest nerve sparing NS possible. Although most studies broadly classify patients who have undergone nerve sparing radical prostatectomy NSRPthe NS technique is not an all-or-none technique. After a thorough review, 17 articles were determined to be most relevant for clinical application of treatment of ED post-RALP. The purpose of penile rehabilitation has been proposed to prevent alterations of the smooth muscle of the corpora cavernosa, limit venous leak development and maximize the chances of returning to pre-operative erectile function.

Study design and primary outcomes of long-term, randomized control trials evaluating PDE5Is for penile rehabilitation after RP. Compliance with therapy is important as potency recovery may require 1 year or more. Seventy-seven men were prospectively followed after NS RALP and enrolled in a penile rehabilitation program with sildenafil or tadalafil three times weekly.

Pre-operative ED and long-term compliance were independent predictors of potency. Active surveillance AS is frequently employed for the management of CaP. Several animal models have demonstrated histological and functional benefit with PDE5Is in animal studies.

Currently, three large, randomized, double-blind, placebo-controlled studies evaluating PDE5Is as penile rehabilitation following Sexual function after robotic prostatectomy have been performed. Additionally, a randomized control trial without placebo evaluating sildenafil was also performed. Trial designs and primary outcomes are outlined in Table 3. However, the study was terminated prematurely after the interim review showed response rates less than expected compared with the rates of spontaneous recovery in the literature.

Vardenafil on-demand was also superior to vardenafil nightly for SEP-3 success rates However, superior SEP-1 and -2 success rates were observed after open-label therapy for both formulations of tadalafil.

Significantly less penile shrinkage was noted in the tadalafil nightly group versus placebo at 9 months 2.

Physical and Psychological Effects of...

VED benefit was first demonstrated in several markers of inflammation, fibrosis and erectile function in animal models. Other results with VED use have been less conclusive. A study of 28 men post-unilateral nerve sparing or BNSRP randomized patients to receive penile rehabilitation with VED starting at 1 or 6 months post-operatively. However, there was no difference in the spontaneous erection rates or ESI rate.

Prostaglandin E1 PGE1 causes erection via vasodilation and smooth muscle relaxation to expand the corpora. A study of medicated urethral system for erections MUSE therapy randomized men following BNSRP to intraurethral alprostadil or nightly sildenafil 50 mg for 1 months, 1 month DFW and open-label sildenafil mg for 1 month.

Psychological factors Sexual function after robotic prostatectomy an important role for sexual function after RALP. A study randomized 52 men to receive early post-operative pelvic-floor biofeedback weekly for 3 months or a control group with verbal instructions to contract the pelvic floor.

IPP remains the most definitive surgical treatment for ED refractory to oral or other therapies. However, it should only be used as a last resort, as, once installed, IPP is the only means by which erection can be achieved and natural erections are no longer attainable. CaP will continue to remain a serious and prevalent disease that requires RP for treatment. Although current robotic techniques are improving, there is still clear evidence that ED will be encountered for men choosing to undergo RALP.

All men should be counseled that potency return could take up to 1 year or more. The risk stratification proposed by Briganti et al. There is evidence that certain surgical techniques Sexual function after robotic prostatectomy at high-volume centers lead to more promising results.

Nerve sparing techniques have been confirmed to be superior to non-nerve sparing techniques. Unilateral nerve sparing should be considered when bilateral nerve sparing is not feasible for oncologic control. Additionally, although NS techniques are superior, it is evident that the degree of NS leads to different post-operative potency rates.

Keywords: Erectile dysfunction, robotic radical...

Although retrograde[ 21 ] and intraoperative cooling[ 22 ] have demonstrated benefit in potency recovery, these are single-center studies. Although traction-free Sexual function after robotic prostatectomy have been proposed to reduce neuropraxia, results between studies have been conflicting.

However, similar to traction-free techniques, athermal studies have produced conflicting results. Additionally, the use Sexual function after robotic prostatectomy validated questionnaires has been inconsistent. A firmer definition of potency would allow for greater comparison in future studies. The retrospective population study from Barry[ 16 ] should be interpreted with caution as a non-validated questionnaire was used to assess potency. Patients were not matched for pre-operative erectile function, age, comorbidities or other factors.

Although the evidence from animal models suggests that PDE5Is can help prevent and provide recovery from ED,[ 34353637 ] this has not always translated to humans. Additionally, the psychological effect of not receiving treatment during DFW might result in a regression of erectile function.

Furthermore, there have been no studies comparing the effect of different PDE5Is with each other. Although, theoretically, they have the same mechanism of action, different half-lives may contribute to the different results observed in on-demand or daily PDE5I use.

After Robot Assisted Radical Prostatectomy

There is likely benefit to compare different PDE5Is in future trials. Additionally, there is a lack of consistency in use of placebo, DFW, trial length, inclusion criteria, degree of NS technique, use of robotic or open technique and, maybe most notably, potency definition. Current evidence suggests that PDE5Is can play a role in penile rehabilitation, although the dosing, frequency and PDE5I used cannot be recommended based on current data.

VEDs have increasingly been used in penile rehabilitation programs. When counseling a patient Sexual function after robotic prostatectomy RALP, it is necessary to explain that recovery of erectile function can take up to 1 year, if not greater. Therefore, it is important to identify the patients that will be willing to complete a rehabilitation program to provide the greatest clinical benefit.

However, these data lack prospective randomized control studies. Although benefit is demonstrated during use of PDE5Is compared with placebo, it is often lost after use. Subsequently, no optimal rehabilitation program with PDE5Is has been developed. It is important to identify patients who will most likely recover erectile function for patient education. Although the future is promising with improved robotic techniques, an optimal robotic technique has not been identified.

Additionally, no definitive recommendations regarding a penile rehabilitation program can be made without further Sexual function after robotic prostatectomy.

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