Erectile Dysfunction After Robot-Assisted Radical Prostatectomy
Erectile Dysfunction After Robot-Assisted Radical Prostatectomy
With younger and healthier men being diagnosed and treated for localized prostate cancer, postradical prostatectomy erectile dysfunction has become an ever more important matter of debate. However, the lack of a standardized definition for potency and no consensus regarding the optimal instrument for assessing recovery of erectile function after prostatectomy makes comparison among different series extremely difficult. The potential morbidity associated with the open surgical approach has resulted in the search for less invasive surgical options. One such option is robot-assisted radical prostatectomy (RARP) performed with the da Vinci system. In this article we critically review the current outcomes on post-RALP potency rates worldwide and compare the available data with the gold standard open RRP series. A review of the literature was performed for all published manuscripts written in English, comparative and non-comparative, between 2000 and 2009 using the keywords 'robotic radical prostatectomy, 'robot-assisted radical prostatectomy', 'nerve sparing', 'cavernosal nerve' and 'potency outcomes', using the Medline database. Manuscripts were selected according to their relevance to the current topic (i.e., original articles, number of patients in the series and prospective data collection) and incorporated into this review. To date, many large series of RARP are mature enough and have demonstrated that potency outcomes are at least comparable to if not better than open RRP. However, there is still controversy on which form of surgical approach to the neurovascular bundles provides the best results. Prospective multi-institutional studies evaluating outcomes following different techniques need to be designed and results analyzed by an independent third party. Until then, careful patient selection and wise intraoperative clinical judgment should be made when performing nerve-sparing surgery.
Prostate cancer (CaP) is one of the most common cancers worldwide. It is estimated that more than 2 million men are currently living with CaP within the EU. Indeed, in the UK, it is the most common cancer in men, accounting for approximately 24% of all new male cancer diagnoses and it is estimated that this number will continue to rise, probably due to increased awareness of the disease. In the USA, data from the Surveillance, Epidemiology and End Results (SEER) registry indicates that every year younger and healthier men are being diagnosed with localized CaP with an estimated annual percentage increase of 9.5%. Although a number of treatment options are available for this population, radical prostatectomy (RP) remains the gold-standard approach offering the best chances of a long-term cure.
Radical prostatectomy was first described in the early 1900s by Young. However, it was the pioneering work of Walsh et al. on surgical anatomy of the prostate that truly paved the way to the development of the modern RP technique aiming to completely excise the prostate providing optimal cancer control while maintaining urinary continence and sexual potency. Indeed, achieving these three outcomes after RP – so called 'trifecta' – represents how the true success of RP outcomes should be measured. Several large series have reported satisfactory cancer control and continence outcomes after RRP. However, erectile dysfunction (ED) post-RP continues to be a major challenge for most urologists with well recognized high incidence rates.
The etiology and pathophysiology of post-prostatectomy ED is not yet fully understood. However, it appears that injury to the neurovascular bundles (NVBs) during RP occurs secondary to one or more factors, such as excessive traction, use of thermal energy or direct damage during its dissection. The latter usually occurs owing to the inherent difficulty recognizing and visualizing the NVB pathway intraoperatively, leading to its direct transection or incorporation into hemostatic sutures or clips. Indeed, data from large open series recognize that the use of magnification loupes during RRP leads to improved and earlier return of potency. Nonetheless, intraoperative blood loss during RRP is significant, with large series reporting EBL ranging from 500 to 1000 cc. This obscures the operating field with the potential risk of injuring the NVBs. Additionally, RRP is performed in a retrograde fashion with the risk of placing undue traction against the NVBs while the prostate is lifted away from the rectum in order to develop the posterior plane.
The potential morbidity associated with the open surgical approach combined with the increasing demand from younger, healthier patients seeking for optimal cancer control without impairing postoperative quality of life has resulted in the search for less invasive surgical options. One such option is robot-assisted RP (RARP) performed with the da Vinci system (Intuitive Surgical, CA, USA). The da Vinci system combines the advantages of the laparoscopic environment such as superior magnification, closer view to the surgical field and significantly decreased blood loss compared with its open counterpart, with unique features such as 3D vision and instruments maneuverability that mimic the movements made during standard open surgery. These joint features translate into improved visualization and more precise handling and dissection of the tissue, with the potential for improved outcomes when performed by experienced surgeons.
Since the first RARP, performed by Binder and Kramer in 2000, several technical refinements and approaches to nerve preservation have been described aiming to improve outcomes after surgery. Currently, multiple reports from large series are available; however, comparing outcomes between different series is very difficult owing to the lack of a standardized definition used to define return of potency. Additionally, potency rates depend on many factors, such as preoperative erectile function, patient comorbidities, type and extent of nerve sparing (NS), patient's age, frequency of intercourse and the experience of the surgeon.
The aim of this review is to analyze the potency outcomes after RARP currently available in the literature.
Abstract and Introduction
Abstract
With younger and healthier men being diagnosed and treated for localized prostate cancer, postradical prostatectomy erectile dysfunction has become an ever more important matter of debate. However, the lack of a standardized definition for potency and no consensus regarding the optimal instrument for assessing recovery of erectile function after prostatectomy makes comparison among different series extremely difficult. The potential morbidity associated with the open surgical approach has resulted in the search for less invasive surgical options. One such option is robot-assisted radical prostatectomy (RARP) performed with the da Vinci system. In this article we critically review the current outcomes on post-RALP potency rates worldwide and compare the available data with the gold standard open RRP series. A review of the literature was performed for all published manuscripts written in English, comparative and non-comparative, between 2000 and 2009 using the keywords 'robotic radical prostatectomy, 'robot-assisted radical prostatectomy', 'nerve sparing', 'cavernosal nerve' and 'potency outcomes', using the Medline database. Manuscripts were selected according to their relevance to the current topic (i.e., original articles, number of patients in the series and prospective data collection) and incorporated into this review. To date, many large series of RARP are mature enough and have demonstrated that potency outcomes are at least comparable to if not better than open RRP. However, there is still controversy on which form of surgical approach to the neurovascular bundles provides the best results. Prospective multi-institutional studies evaluating outcomes following different techniques need to be designed and results analyzed by an independent third party. Until then, careful patient selection and wise intraoperative clinical judgment should be made when performing nerve-sparing surgery.
Introduction
Prostate cancer (CaP) is one of the most common cancers worldwide. It is estimated that more than 2 million men are currently living with CaP within the EU. Indeed, in the UK, it is the most common cancer in men, accounting for approximately 24% of all new male cancer diagnoses and it is estimated that this number will continue to rise, probably due to increased awareness of the disease. In the USA, data from the Surveillance, Epidemiology and End Results (SEER) registry indicates that every year younger and healthier men are being diagnosed with localized CaP with an estimated annual percentage increase of 9.5%. Although a number of treatment options are available for this population, radical prostatectomy (RP) remains the gold-standard approach offering the best chances of a long-term cure.
Radical prostatectomy was first described in the early 1900s by Young. However, it was the pioneering work of Walsh et al. on surgical anatomy of the prostate that truly paved the way to the development of the modern RP technique aiming to completely excise the prostate providing optimal cancer control while maintaining urinary continence and sexual potency. Indeed, achieving these three outcomes after RP – so called 'trifecta' – represents how the true success of RP outcomes should be measured. Several large series have reported satisfactory cancer control and continence outcomes after RRP. However, erectile dysfunction (ED) post-RP continues to be a major challenge for most urologists with well recognized high incidence rates.
The etiology and pathophysiology of post-prostatectomy ED is not yet fully understood. However, it appears that injury to the neurovascular bundles (NVBs) during RP occurs secondary to one or more factors, such as excessive traction, use of thermal energy or direct damage during its dissection. The latter usually occurs owing to the inherent difficulty recognizing and visualizing the NVB pathway intraoperatively, leading to its direct transection or incorporation into hemostatic sutures or clips. Indeed, data from large open series recognize that the use of magnification loupes during RRP leads to improved and earlier return of potency. Nonetheless, intraoperative blood loss during RRP is significant, with large series reporting EBL ranging from 500 to 1000 cc. This obscures the operating field with the potential risk of injuring the NVBs. Additionally, RRP is performed in a retrograde fashion with the risk of placing undue traction against the NVBs while the prostate is lifted away from the rectum in order to develop the posterior plane.
The potential morbidity associated with the open surgical approach combined with the increasing demand from younger, healthier patients seeking for optimal cancer control without impairing postoperative quality of life has resulted in the search for less invasive surgical options. One such option is robot-assisted RP (RARP) performed with the da Vinci system (Intuitive Surgical, CA, USA). The da Vinci system combines the advantages of the laparoscopic environment such as superior magnification, closer view to the surgical field and significantly decreased blood loss compared with its open counterpart, with unique features such as 3D vision and instruments maneuverability that mimic the movements made during standard open surgery. These joint features translate into improved visualization and more precise handling and dissection of the tissue, with the potential for improved outcomes when performed by experienced surgeons.
Since the first RARP, performed by Binder and Kramer in 2000, several technical refinements and approaches to nerve preservation have been described aiming to improve outcomes after surgery. Currently, multiple reports from large series are available; however, comparing outcomes between different series is very difficult owing to the lack of a standardized definition used to define return of potency. Additionally, potency rates depend on many factors, such as preoperative erectile function, patient comorbidities, type and extent of nerve sparing (NS), patient's age, frequency of intercourse and the experience of the surgeon.
The aim of this review is to analyze the potency outcomes after RARP currently available in the literature.
