Potency after unilateral nerve sparing surgery: a report on functional and oncological results of unilateral nerve sparing surgery

Distribution of neurovascular structures within the prostate gland and their relationship to complications after radical prostatectomy

BACKGROUND

Radical prostatectomy remains the main choice of treatment for prostate cancer. However, despite improvements in surgical techniques and neurovascular sparing procedures, rates of erectile dysfunction, and urinary incontinence remain variable. This is due, at least in part, to an incomplete understanding of neurovascular structures associated with the prostate. The objective of this study was to provide a comprehensive, detailed histological overview of the distribution of nerves and blood vessels within the prostate, facilitating subsequent correlation of prostatic neurovascular structures with patients' clinical outcomes after radical prostatectomy.

METHODS

Neurovascular structures within the prostate were investigated in a total of 309 slides obtained from 15 patients who underwent non-nerve-sparing radical prostatectomy. Immunohistochemical staining was performed to identify and distinguish between parasympathetic and sympathetic nerves, whereas hematoxylin and eosin staining was used to identify blood vessels. The total number, density, and relative position of nerves and blood vessels were established using quantitative morphometry and illustrated using visualization approaches. Patient-specific outcome data were then used to establish whether the internal distribution of nerves and blood vessels within the prostate correlated with the nature and extent of complications after surgery. One-way analysis of variance tests and unpaired t tests were applied to establish statistically significant differences across the measured variables.

RESULTS

Nerves and blood vessels were present across all prostatic levels and regions. However, their number and density varied considerably between regions. Assessment of the precise positioning of neurovascular structures revealed that the majority of nerve fibers were located within the dorsal and peripheral aspects of the gland. In contrast, blood vessels were predominantly located within ventral and dorsal midline regions. The number of intraprostatic nerves was found to be significantly lower in patients who recovered their continence within 12 months of surgery, compared to those whose recovery took 12 months or longer.

CONCLUSION

We report an unexpected disconnect between the localization and positioning of nerve fibers and blood vessels within the prostate. Moreover, individual variability in the density of intraprostatic neurovascular structures appears to correlate with the successful recovery of urinary continence after radical prostatectomy, suggesting that differences in intrinsic neurovascular arrangements of the prostate influence postoperative outcomes.

Open and robotic radical prostatectomy

Open retropubic radical prostatectomy has been the "gold standard" treatment for locally confined prostate cancer (PCa) but in recent years minimal invasive techniques as laparoscopy and robot-assisted prostatectomy have become widely available. The trifecta of the surgical treatment of PCa is cancer control, the preservation of continence, and erectile potency. Over the years the complication rates of radical prostatectomy have become very limited with improved cancer control and better functional results. We review the indications and the surgical technique of radical prostatectomy, be it open or laparoscopic, eventually robot-assisted as well as the pre- and postoperative measures and the surgery-related consequences.

Theranostic Agents for Photodynamic Therapy of Prostate Cancer by Targeting Prostate-Specific Membrane Antigen

Prostatectomy has been the mainstay treatment for men with localized prostate cancer. Surgery, however, often can result in major side effects, which are caused from damage and removal of nerves and muscles surrounding the prostate. A technology that can help surgeons more precisely identify and remove prostate cancer resulting in a more complete prostatectomy is needed. Prostate-specific membrane antigen (PSMA), a type II membrane antigen highly expressed in prostate cancer, has been an attractive target for imaging and therapy. The objective of this study is to develop low molecular weight PSMA-targeted photodynamic therapy (PDT) agents, which would provide image guidance for prostate tumor resection and allow for subsequent PDT to eliminate unresectable or remaining cancer cells. On the basis of our highly negatively charged, urea-based PSMA ligand PSMA-1, we synthesized two PSMA-targeting PDT conjugates named PSMA-1-Pc413 and PSMA-1-IR700. In in vitro cellular uptake experiments and in vivo animal imaging experiments, the two conjugates demonstrated selective and specific uptake in PSMA-positive PC3pip cells/tumors, but not in PSMA-negative PC3flu cells/tumors. Further in vivo photodynamic treatment proved that the two PSMA-1-PDT conjugates can effectively inhibit PC3pip tumor progression. The two PSMA-1-PDT conjugates reported here may have the potential to aid in the detection and resection of prostate cancers. It may also allow for the identification of unresectable cancer tissue and PDT ablation of such tissue after surgical resection with potentially less damage to surrounding tissues. Mol Cancer Ther; 15(8); 1834-44. ©2016 AACR.

Ten-year outcomes of sexual function after radical prostatectomy: results of a prospective longitudinal study

BACKGROUND

The long-term impact of radical prostatectomy (RP) on sexual function (SF) and erectile function (EF) has important implications related to the risk-to-benefit ratio of this treatment.

OBJECTIVE

To determine the long-term effect of RP on male SF and EF over 10 yr of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, longitudinal outcomes study in 1836 men following RP at a university hospital. Men were invited to complete the University of California, Los Angeles, Prostate Cancer Index SF survey at baseline, 3, 6, 12, 24, 96, and 120 mo postoperatively and a survey at 4 and 7 yr postoperatively assessing global changes in their EF over the preceding 2 yr.

INTERVENTION

All men underwent open RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multiple, generalized linear regression models were used to evaluate the association between time following RP and SF and EF scores controlling for age, prostate-specific antigen, Gleason scores, stage, nerve sparing, race, and marital status.

RESULTS AND LIMITATIONS

After an expected initial decline, time-dependent improvements in SF and EF were observed through 2 yr postoperatively. Overall, SF and EF were both generally stable between 2 and 10 yr following RP. The subgroups of younger men and men with better preoperative function were more likely to maintain their EF and SF through 10 yr following RP. The primary limitation is the potential bias attributable to nonresponders.

CONCLUSIONS

The recovery of EF can extend well beyond 2 yr. There is a significant association between younger age and better preoperative function and the likelihood of experiencing improvements beyond 2 yr. Assessing the comparative effectiveness of treatment options for localized prostate cancer must examine SF beyond 2 yr to account for delayed treatment effects and the natural history of SF in the aging male population.

Patients' desire to preserve sexual activity and final decision for a nerve-sparing approach: results from the MIRROR (Multicenter Italian Report on Radical Prostatectomy Outcomes and Research) Study

INTRODUCTION

Preservation of sexual function after surgery represents a major issue for patients undergoing radical prostatectomy (RP).

AIM

To investigate determinants of patients' desire to preserve sexual activity before RP and surgeons' final decision to perform a nerve-sparing RP (NSRP).

METHODS

  Overall, 2,408 prostate cancer patients, candidates to RP, from 136 urologic departments across the Italian territory were evaluated in a multicenter prospective observational study. All patients underwent RP, according to single-center indications and procedures.

MAIN OUTCOME MEASURES

Age, body mass index, previous benign prostatic hyperplasia history, preoperative tumor characteristics, quality of life through the Short Form Health Survey (SF-12), and the University of California Los Angeles Prostate Cancer Index (UCLA-PCI), erectile function through the International Index of Erectile Function (IIEF-5), desire to preserve sexual activity, NS operative outcomes, and surgical margins status were recorded.

RESULTS

Overall, 1,667 were interested to preserve sexual activity. Age, physical component summary of SF12 (PCS-12), sexual function score of UCLA-PCI, and IIEF-5 score were the main determinants of such interest. Only 1,246 patients were suitable for a NSRP according to guidelines. Surgeons performed a non-NSRP (NNSRP) in 1,234 patients, a unilateral NSRP in 318 and a bilateral NSRP in 856. Age, bioptical Gleason score, percentage of positive cores, PCS-12, and patient's desire to preserve sexual activity were the main determinants of final decision for a NSRP. Surgeons performed a NSRP in 424 not suitable and in 121 not interested patients. Positive surgical margins in not suitable patients submitted to NSRP were not higher if compared to that obtained after NNSRP in the same subgroup. Limits include lack of oncological and functional follow-up.

CONCLUSIONS

Most patients are interested to preserve sexual activity. Discrepancies exist among patients' preferences, guidelines' indications, and surgeon's final decision.

Preclinical evidence for the benefits of penile rehabilitation therapy following nerve-sparing radical prostatectomy

Erectile dysfunction following radical prostatectomy remains a frequent problem despite the development of nerve-sparing techniques. This erectile dysfunction is believed to be neurogenic, enhanced by hypoxia-induced structural changes which result in additional veno-occlusive dysfunction. Recently, daily use of intracavernous vasoactive substances and oral use of PDE5-inhibitors have been clinically studied for treatment of postprostatectomy erectile dysfunction. Since these studies showed benefits of “penile rehabilitation therapy,” these effects have been studied in a preclinical setting. We reviewed experimental literature on erectile tissue preserving and neuroregenerative treatment strategies, and found that preservation of the erectile tissue by the use of intracavernous nitric oxide donors or vasoactive substances, oral PDE5-inhibitors, and hyperbaric oxygen therapy improved erectile function by antifibrotic effects and preservation of smooth muscle. Furthermore, neuroregenerative strategies using neuroimmunophilin ligands, neurotrophins, growth factors, and stem cell therapy show improved erectile function by preservation of NOS-containing nerve fibers.

The older cancer survivor

Cancer is an age-related disease, and has increased in prevalence as the population has grown older. Improvements in screening and the availability of better therapeutic options contribute to burgeoning numbers of cancer survivors, who number more than 24 million worldwide. Sixty-one percent of these survivors are at least 65 years old. This review is an attempt to consolidate some of the data available in the area of cancer survivorship, with emphasis on the elderly. Our aim is to provide a better description of the population, elucidate specific physical and psychosocial sequelae secondary to cancer and it's treatment, and better understand how comorbid conditions, functional status, body-weight, and other issues contribute to quality of life, and overall health. This paper also suggests some surveillance guidelines for following elderly cancer survivors and identifies areas that require further research.

Long-term functional and oncological results after retroperitoneal laparoscopic prostatectomy according to a prospective evaluation of 550 patients

The objective of the study was to evaluate the long-term results of retroperitoneal laparoscopic radical prostatectomy (LRP). From 2001 to 2005, 550 consecutive patients underwent a laparoscopic extraperitoneal prostatectomy in our department. Continence and erectile function were analysed prospectively by a self-administrated questionnaire. Mean operating time was 188 min, mean bladder catheterisation time 5.9 days, mean hospital stay 4.6 days Pathological stage was pT2 in 55.8%, pT3a in 29.6%, pT3b in 9.1% and pT4a in 5.4% tumours. Positive surgical margins were 17.9% for pT2, 44.8% for pT3 tumours and 71.4% for pT4a tumours. Five years survival without biochemical progression was 78.8%. After 24 months of follow-up, diurnal continence rate was 91%, and potency rate was 64% when both neurovascular bundles were preserved, 78.6% when the patients were younger than 60 years. LRP is now a standardised procedure. An extraperitoneal approach combines the advantages of a laparoscopic procedure with those of an extraperitoneal approach.

Nerve-sparing radical retropubic prostatectomy: techniques and clinical considerations

There are essentially two ways to accomplish nerve preservation during radical retropubic prostatectomy: the 'apical approach' described by Walsh and the so-called 'lateral approach', a simplified method where the dissection is initially conducted on the portion of the bundles that courses posterolateral to the prostate. Do the different techniques differ in the ability to preserve potency and in the positive surgical margins rate? No previous study has addressed this question. Above all, the preoperative and intraoperative indications to spare or not the nerves remain a matter of debate. The present review is an attempt to elucidate these questions in light of the current literature.