Recovery of Sexual Potency

As for continence, objective evaluation of postoperative erectile dysfunction encounters a number of difficulties:

1. Absence of a consensual definition of sexual potency in the studies

2. Various methods of evaluation

3. Difficulties of evaluation

4. Variable follow-up

The definition of sexual potency varies according to the adopted criteria, such as erection without intercourse (i.e., return of erection) or erection firm enough for intercourse. Moreover, the frequency as well as quality of sexual activity has been recorded (66).

The most successful tool to evaluate erectile dysfunction proved to be the abridged, five-item version of the International Index of Erectile Function (67).

Hara et al. were able to demonstrate its applicability when comparing the quality of life after open and laparoscopic radical prostatectomy. They found a significant impairment of sexual function by surgery with no difference between the laparoscopic or open approach (68). Additionally, the quality of erection should be classified according the international classification (E1-5) distinguishing between tumescence (E2-3) and rigidity (E4-5).

The methods of evaluation of sexual potency are also very heterogeneous including clinical interview by the surgeon, interview by another physician, or a self-administered questionnaire (Table 15). The additional use of oral, intraurethral, or intracorporeal therapy of erectile dysfunction, particularly in the early postoperative phase (i.e., intracorporeal injection therapy to expedite recovery of erection) makes it difficult to compare the various series. In laparoscopic radical prostatectomy with the

TABLE 15 ■ Laparoscopic versus Open Radical Prostatectomy-Recovery of Potency After Bilateral Preservation

Author (Ref.)

N

Mean age (yr)

Evaluation

(%)

Laparoscopic radical prostatectomy

Türk et al.(28)

58

60.2

Physician

12

38.5

Eden(57)

58

62.2

Physician

18

64.0

Salomon et al. (40)

17

63.8

Questionnaire

12

58.8

Roumeguere et al. (52)

26

62.5

Questionnaire

12

65.3

Artibani et al. (69)

9

64.3

Physician

6

55.5

Rassweiler (present

219

64.0

Questionnaire

12

61.0

series)

Open radical prostatectomy

Geary et al. (49)

69

64.1

Physician

18

31.2

Talcott et al. (59)

19

61.5

Questionnaire

12

79.0

Catalona et al. (59)

798

63.0

Physician

18

68.0

Huland et al. (62)

366

n.a.

Questionnaire

12

56.0

Stanford et al. (54)

1291

62.9

Questionnaire

18

44.0

Walsh 2000

64

57.0

Questionnaire

18

86.0

Roumeguere et al.

33

63.9

Questionnaire

12

54.5

In summary, there are no significant differences between the laparoscopic or open approach concerning the recovery of potency (34-67% vs. 31-79%), if one excludes the selected series of Walsh with a mean age of 57 years.

Early outcomes have indicated that once the learning curve is established, transperitoneal laparoscopic radical prostatectomy is at least equivalent to open radical prostatectomy in terms of early oncologic outcomes continence and potency rates, and operation times.

Heilbronn technique, our results of erectile response during sexual intercourse with or without using intracavernosal injection in patients who underwent bilateral and unilateral nerve sparing are given in Table 16. Moreover, in contrast to urinary continence, spontaneous sexual potency is difficult to assess objectively (65). Rigiscan studies may provide insight into the organic basis of postradical prostatectomy erectile dysfunction, but are not yet a routine part of evaluation (71).

Follow-up again represents an important parameter in this evaluation. While a large number of series have demonstrated the possibility of late recovery, most studies are limited to a relatively short follow-up. There is a consensus that the assessment of recovery of sexual function requires a follow-up of at least 18 months (71). According to this, Litwin et al. (72) found little additional recovery in the sexual domains after 18-24 months. Although the nerves are optimally preserved during nerve-sparing surgery, they usually are damaged by direct trauma or by stretch injury during intraoperative retraction. This is reflected again by the study of Hara et al. (68), showing a significant impairment of sexual life by surgery without any difference between laparoscopy and open prostatectomy. These damaged nerves need time to heal. Restoration of the neuron occurs from the point of injury to the target organ at a rate of 1 mm per day.

Like for recovery of continence, several authors have published some technical steps that may improve the results of nerve-sparing surgery, such as the use of water-jet dissection, the early detachment of the neurovascular bundle before division of the urethra to avoid any traction on the neurovascular bundle or monopolar coagulation close to the bundles and the tip of the seminal vesicles, and the preservation of the accessory pudendal arteries (70,73-75).

Other factors influencing the operative results have also been considered: the quality of erections before surgery, patient's age, and the type of surgery. It is very important whether the surgeon is able to preserve both or only one neurovascular bundle. In our previously published review, we focused mainly on the results of bilateral nerve sparing (Table 15). The long-term outcome of sural nerve-grafting (which has also been realized laparoscopically) still remains an open question (70-73). All comparative analyses should also focus on the selection of patients (i.e., less than 65 years, potent, with sexual interest, low-stage, low-grade tumor) in the different series. Some authors postulate that nerve-sparing surgery should only be limited to patients aged less than 60 or even 55 years (76).

In summary, there are no significant differences between the laparoscopic or open approach concerning the recovery of potency (34-67% vs. 31-79%), if one excludes the selected series of Walsh with a mean age of 57 years (Table 15).

Again, laparoscopic surgery enables the transformation of all technical variations proposed for open radical prostatectomy, but despite all efforts could not yet significantly improve potency rates in comparison to open surgery. Conclusively, not the approach but the experience of the surgeon still remains one of the most essential factors to improve the recovery of potency. The cases of failed recovery of potency are mainly attributed to associated factors such as age or concomitant morbidity of the patient.

Early outcomes have indicated that once the learning curve is established, transperitoneal laparoscopic radical prostatectomy is at least equivalent to open radical prostatectomy in terms of early oncological outcomes continence and potency rates, and operation times.

TABLE 16 ■ Erectile Response after Laparoscopic Radical Prostatectomy via the Heilbronn Technique

Laparoscopic radical prostatectomy

Penetration +/-PDE5-inhibitor a

Penetration +/-CIb

Bilateral nerve-sparing (%) 27/41 (65.9) Unilateral nerve-sparing (%) 19/43 (44.2) No nerve-sparing (%) 14/135 (10.4)

aPhosphodiessterase type V selective inhibitor. bIntracorporeal injection.

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