A prediction model relating the extent of intraoperative fascia preservation to erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy

Fluorescence-guided radical prostatectomy

Robotic-assisted laparoscopic radical prostatectomy represents one of the most common operations in urologic oncology and involves several critical technical steps including pelvic lymph node dissection, cavernous nerve sparing and vesicourethral anastomosis. The quality of performing these steps is linked to functional and oncological outcomes. Indocyanine green [ICG] is a non-radioactive, water-soluble compound which allows for enhanced visualization with near-infrared fluorescence of both anatomical structures and vasculature during complex abdominal operations such as prostatectomy. During the last decade, several investigators have examined the value and role of ICG fluorescence during prostatectomy. In this review, we sought to evaluate the body of evidence for fluorescence-guided robotic prostatectomy as well as assess potential future areas of investigation with this technology.

Development and clinical applicability of MRI-based 3D prostate models in the planning of nerve-sparing robot-assisted radical prostatectomy

The interpretation of conventional MRI may be limited by the two-dimensional presentation of the images. To develop patient-specific MRI prostate-based virtual and three-dimensional (3D)-printed models. To assess the association between 3D imaging and the pathological outcome of RARP specimen. To assess the clinical applicability of 3D models to guide nerve-sparing robot-assisted radical prostatectomy (RARP). We created virtual 3D and 3D-printed 3D models of 20 prostate cancer patients retrospectively. A comparison was made between conventional MRI and 3D-reconstructed images. The concordance between tumour lesion location in 3D models and pathology reporting of RARP specimens was assessed. Seven urologists assessed the side-specific extent of nerve-sparing based on (1) conventional MR images, (2) virtual 3D models, and (3) 3D-printed models. Clinically relevant changes in nerve-sparing and the absolute agreement between observers was analyzed using the Chi-square test and intra-class correlation coefficient (ICC). The index lesion was correctly visualized in 19/20 (95%) 3D models and the expected location of extraprostatic extension was correctly visualized in all 3D models. Clinically relevant changes in the planned extent of nerve-sparing between MRI and virtual 3D models and MRI and 3D-printed models were found in 25% and 26%. The ICC of the planned extent of nerve-sparing between urologists was 0.40 (95% CI 0.28-0.55) for conventional MRI, 0.52 (95% CI 0.39-0.66) for virtual 3D models and 0.58 (95% CI 0.45-0.71) for 3D-printed models. 3D models of the MRI prostate to guide RARP could aid urologists in the planning of nerve-sparing surgery as shown by a higher inter-observer agreement.

Applications of artificial intelligence in the diagnosis and prediction of erectile dysfunction: a narrative review

Despite the high prevalence of erectile dysfunction, patients are reluctant to seek medical advice, which leads to low diagnostic rates in clinical practice. Artificial intelligence has been widely applied in the diagnosis of many diseases and may alleviate the situation. However, the applications of artificial intelligence in erectile dysfunction have not been reviewed to date. Therefore, the assistance from artificial intelligence needs to be summarized. In this review, 418 publications before January 10, 2021, regarding artificial intelligence applications in diagnosing and predicting erectile dysfunction, were retrieved from five databases, including PubMed, EMBASE, the Cochrane Library, and two Chinese databases (WANFANG and CNKI). In addition, the reference lists of the included studies or relevant reviews were checked to avoid bias. Finally, 30 articles were reviewed to summarize the current status, merits, and limitations of applying artificial intelligence in diagnosing and predicting erectile dysfunction. The results showed that artificial intelligence contributed to developing novel diagnostic questionnaires, equipment, expert systems, classifiers by images and predictive models. However, most of the included studies were not subjected to external validations, resulting in doubt on the generalizability. In the future, more rigorously designed studies with high-quality datasets for erectile dysfunction are required.

The detection rate of apical tumour involvement on preoperative MRI and its impact on clinical outcomes in patients with localized prostate cancer

To determine the diagnostic performance of radiological apical tumour involvement (radATI) in preoperative prostate MRI, referenced to pathological ATI (pathATI) at radical prostatectomy specimens. To investigate risk factors for apical positive surgical margins (APSM). A retrospective cohort of consecutive patients with biopsy-proven PCa who underwent MRI and robot-assisted radical prostatectomy between July 2015 and March 2020 was studied (n = 177). Clinical, imaging, pathology, oncology and functional data were retrieved. The diagnostic accuracy of MRI to detect pathATI was analysed. Multivariate logistic regression was used to find independent predictors for APSM. radATI and pathATI was found in 121 (68%) and 161 (91%) patients, respectively. The diagnostic metrics of sensitivity, specificity, PPV, and NPV were 69, 38, 92, and 11%, respectively. APSM were present in 43 (24%) patients. Patients with radATI were more likely to have APSM (37/121 (31%)) than those without radATI (6/56 (11%)) (OR 3.67 [95% CI 1.45-9.31], p = 0.004). This was confirmed in multivariate analysis. Only 2/56 (4%) patients without radATI developed a biochemical recurrence compared to 25/120 (21%) patients with radATI (hazard ratio 6.68 [95% CI 3.03-14.8], p = 0.003). Prostate cancer extends into the apex in the majority of cases. Clinicians are advised to report on the presence or absence of radiological apical tumour involvement as it is an independent risk factor for apical positive surgical margins and is even associated with biochemical recurrence.

Intraoperative visualization of nerves using a myelin protein-zero specific fluorescent tracer

BACKGROUND

Surgically induced nerve damage is a common but debilitating side effect in oncological surgery. With the aim to use fluorescence guidance to enable nerve-sparing interventions in future surgery, a fluorescent tracer was developed that specifically targets myelin protein zero (P0).

RESULTS

Truncated homotypic P0 protein-based peptide sequences were C-terminally functionalized with the far-red cyanine dye Cy5. The lead compound Cy5-P0101-125 was selected after initial solubility, (photo)physical and in vitro evaluation (including P0-blocking experiments). Cy5-P0101-125 (KD = 105 ± 17 nM) allowed in vitro and ex vivo P0-related staining. Furthermore, Cy5-P0101-125  enabled in vivo fluorescence imaging of the Sciatic nerve in mice after local intravenous (i.v.) administration and showed compatibility with a clinical fluorescence laparoscope during evaluation in a porcine model undergoing robot-assisted surgery. Biodistribution data revealed that i.v. administered [111In]In-DTPA-P0101-125 does not enter the central nervous system (CNS).

CONCLUSION

P0101-125 has proven to be a potent nerve-specific agent that is able to target P0/myelin under in vitro, ex vivo, and in vivo conditions without posing a threat for CNS-related toxicity.

Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study

BACKGROUND

Preservation of erectile function is an important postoperative quality of life concern for patients after robot-assisted radical prostatectomy (RARP) for prostate cancer. Although erectile function may recover, many men continue to suffer from erectile dysfunction (ED).

AIM

This study aims to determine whether satisfaction with sexual life improves in patients with ED after RARP and which factors are associated with satisfaction during follow-up.

METHODS

A review was carried out of a prospectively maintained database of patients with prostate cancer who underwent a RARP between 2006 and 2019. The "International Index of Erectile Function" questionnaire was used to describe ED (range 5-25), overall satisfaction with sexual life and sexual desire (range for both: 2-10). Patients with ED due to RARP were compared with those without ED after RARP. Mixed effect model was used to test differences in satisfaction over time. Mann-Whitney U tests and multiple logistic regression were used to assess factors associated with being satisfied at 24 and 36 months.

OUTCOMES

The main outcomes of this study are the overall satisfaction with sexual life score over time and factors which influence sexual satisfaction.

RESULTS

Data of 2808 patients were reviewed. Patients whose erectile function was not known (n = 643) or who had ED at the baseline (n = 1281) were excluded. About 884 patients were included for analysis. They had an overall satisfaction score of 8.4. Patients with ED due to RARP had mean overall satisfaction scores of 4.8, 4.8, 4.9, and 4.6 at 6 mo, 12 mo, 24 mo, and 36 mo. These scores were significantly lower than those of patients without ED at every time point. In multiple regression analysis, higher overall satisfaction score at the baseline and higher sexual desire at 24 and 36 months' follow-up were associated with satisfaction with sexual life at 24 and 36 months' follow-up. No association was found for erectile function.

CLINICAL IMPLICATIONS

Interventions focusing on adjustment to the changes in sexual functioning might improve sexual satisfaction; especially for those men who continue to suffer from ED.

STRENGTHS & LIMITATIONS

Strengths of this study are the large number of patients, time of follow-up, and use of multiple validated questionnaires. Our results must be interpreted within the limits of retrospectively collected, observational data.

CONCLUSION

Satisfaction with sexual life in men with ED due to RARP may take a long time to improve. One could counsel patients that sexual satisfaction is based on individual baseline sexual satisfaction and the return of sexual desire after RARP. Albers LF, Tillier CN, van Muilekom HAM, et al. Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study. J Sex Med 2021;18:339-346.

Sexual function recovery after robot-assisted radical prostatectomy: Outcomes from an Italian referral centre and predicting nomogram

Aims of this study were to assess sexual recovery after robotic-assisted radical prostatectomy (RARP) and to build a nomogram predicting 1-year sexual function. From May 2015 to July 2016, all patients eligible for RARP at our institution were invited to enter the study. The Expanded Prostate cancer Index Composite (EPIC) questionnaire was administered pre-operatively, then at 45 days, and at 3, 6, 9, and 12 months post-operatively. According to sexual function scores, patients were divided into four classes. Multivariate analysis was used to investigate the influence of patient- and disease-related features on sexual recovery. A total of 643 patients were included. Age was associated with baseline potency (p < .0001). Bioptic Gleason score (GS; p = .0002), American Society of Anesthesiologists (ASA) score ( = .002ASA Physical Status Classification System ) and Charlson Comorbidity Index (CCI; p = .02) were negatively associated with potency. Baseline sexual function was associated with potency recovery. A nomogram resulted from fitting a proportional odds logistic model for ordinal outcomes, with 1-year sexual function as a dependent variable and baseline sexual potency, age, body mass index (BMI), clinical stage, biopsy GS, initial prostate-specific antigen (iPSA), ASA score, and CCI as predictors. After further validation, this nomogram could be a useful tool for the pre-operative counselling.