Urinary Continence and Erectile Function: A Prospective Evaluation of Functional Results after Radical Laparoscopic Prostatectomy

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1 European Urology European Urology 42 (2002) 338±343 Urinary Continence and Erectile Function: A Prospective Evaluation of Functional Results after Radical Laparoscopic Prostatectomy Laurent Salomon a,b,*, Aristotelis G.Anastasiadis b, Ran Katz a, Alexandre De La Taille a, Fabien Saint a, Dimitrios Vordos a, Anthony Cicco a, Andras Hoznek a, Dominique Chopin a, Clement-Claude Abbou a a Department of Urology, Henri Mondor Hospital, S1 av. du Mal-de-Lattre-de-Tasslgny, CreÂteil, France b Department of Urology, College of Physicians and Surgeons, Columbia University, 161 Fort Washington Avenue, Herbert Irving Pavilion, 11th Floor, New York, NY 10032, USA Accepted 31 July 2002 Abstract Objectives: To evaluate prospectively functional results (urinary continence and erectile function) after laparoscopic radical prostatectomy. Methods: From 1998 to 2001, 235 patients underwent laparoscopic radical prostatectomy for localized prostate cancer.all of them completed a con dential, self-administered questionnaire regarding urinary continence and erectile function before, and 1, 3, 6, and 12 months after surgery.results were analyzed separately for day and night for urinary continence and status of neurovascular bundles as well as age for erectile function. Results: To date, 100 consecutive patients have completed all questionnaires.diurnal and nocturnal urinary continence have increased to 90% and 97% one year after surgery.overall, 49.3% of the 77 patients, who were potent preoperatively, and did not receive any form of adjuvant therapy, had erections suf cient for intercourse one year after surgery. Potency rates were 38.4%, 53.8% and 58.8% after no, unilateral, and bilateral nerve bundle preservation, respectively.for younger patients (<60 years) with unilateral and bilateral neurovascular bundle preservation, potency rates were 75% and 83.3%, respectively. Conclusion: One year after laparoscopic radical prostatectomy, urinary continence rate is 90% during the day and 97% during the night.overall potency rates after bilateral preservation of neurovascular bundles are 58.8% and 83.8% for the subgroup of younger patients (<60 years). # 2002 Elsevier Science B.V. All rights reserved. Keywords: Continence; Erectile dysfunction; Laparoscopy; Radical prostatectomy 1. Introduction Radical prostatectomy is a major potentially curative procedure for the treatment of organ con ned prostate cancer.the majority of urologists use the radical retropubic approach, due to familiarity with surgical anatomy, as well as the nerve sparing technique rst described by Walsh et al. [1].The goals of radical prostatectomy are cancer control, urinary continence, * Corresponding author.tel ; Fax: address: aa910@columbia.edu (L. Salomon). and eventually potency with low morbidity.the presentation of men with localized prostate cancer during the past 10±20 years has changed: more men are presenting with localized prostate cancer, low PSA, Gleason score 6 and normal digital examination (clinical T1c stage) [2]. Although many men are willing to trade their sexual life and even their continence for a chance to cure cancer, this does not mean that these functions are unimportant for them [3].Functional results such as postoperative urinary continence and potency are major concerns for many patients.to optimize functional /02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S (02)

2 L. Salomon et al. / European Urology 42 (2002) 338± results, the surgeon should pay attention to meticulous bleeding control from the dorsal vein complex, careful division of the striated sphincter, and avoidance of coagulation in proximity to the neurovascular bundles [4]. Laparoscopic radical prostatectomy addresses important technical modi cations of anatomical radical prostatectomy.in addition to low postoperative morbidity, it also allows a better exposition of the surgical site.the magnifying effect of optical equipment leads to excellent identi cation of structures, resulting in a minimized damage to the striated sphincter and a better sparing of neurovascular structures.laparoscopy offers a signi cantly improved identi cation of details and therefore can potentially improve postoperative rates of both urinary continence and potency. In 1997, Raboy et al.reported the rst case of laparoscopic extraperitoneal radical retropubic prostatectomy, and Schuessler et al.reported nine cases of laparoscopic transperitoneal radical prostatectomy in the same year [5,6].In 1999, Guillonneau and Vallancien reported 65 cases of laparoscopic radical prostatectomy.they suggested that it could become a routine urologic procedure [7].Preliminary results achieved the feasibility of the laparoscopic approach in terms of oncological control in more than 1200 cases reported in the literature [8]. We performed our rst laparoscopic radical prostatectomy successfully in 1998 and since then, we subsequently improved our technique to preserve neurovascular bundles [9].In the present article we report our functional results of laparoscopic radical prostatectomy, which were evaluated in a prospective fashion. 2. Patients and methods From May 1998 to December 2001, 235 consecutive men underwent radical laparoscopic prostatectomy for localized prostate cancer.all patients underwent preoperative physical examinations and serum PSA assays (Hybritech assay, n.l. <4 ng/ml). Ultrasound guided biopsies were performed in each case to con rm diagnosis and Gleason score of positive specimens were noted. Radical laparosopic prostatectomy was performed by the same surgeon.detailed descriptions of the surgical technique and postoperative surgical management have been published previously [9]. The indication for preservation of one or both bundles depended on preoperative (Gleason score of the biopsy, PSA, erectile function of the patient) and intraoperative factors.if all biopsies from one lobe of the prostate were positive, we usually sacri ced the bundle on that side, prioritizing cancer control before sexual function. When a nerve sparing procedure was planned, the dissection was performed using scissors and hemoclips, avoiding coagulation.in order to expose the neurovascular bundle, the periprostatic fascia was incised at the apex and opened retrogradely, pushing the neurovascular bundle laterally.meticulous apical dissection was performed.the dorsal complex was divided, followed by division of the urethra and the rectourethralis muscle.the vesicourethral anastomosis was performed using a 3:0 absorbable suture in a continuous fashion.a drain was left in the retropubic space and the specimen was retrieved in an endoscopic bag.the transurethral catheter was usually removed on the second postoperative day. All radical prostatectomy specimens were analyzed according to the Stanford protocol and pathological stage was noted by the same pathologist, according to the 1997 TNM classi cation.neurovascular bundle status was noted whenever available from the operative report. All patients received a con dential questionnaire regarding their urinary symptoms and their sexual function.this questionnaire was derived from the ICS-male questionnaire [10] (see Appendix A). The participants were asked to complete the questionnaire before, and 1, 3, 6, and 12 months after surgery and to send it to an independent party for collection and data analysis. 3.Results To date, the rst 100 consecutive patients have completed the questionnaires (Table 1) Urinary continence Complete continence was de ned as no pad and/or no urinary leakage.results are shown in Fig.1.The number of patients reporting diurnal continence increased from 45afterone monthofsurgeryto90oneyearaftersurgery. At this time, from the 10 remaining patients, six use no more than one pad a day and four use more than one pad a day.for nocturnal continence, the number of patients increased from 64 one month after surgery to 97 one year after surgery.at this time, from the three remaining patients, two use no more than one pad a night and one uses more than one pad a night Erectile function Patients reporting no erections preoperatively (n ˆ 7), and patients receiving postoperative radiation or hormone therapy (n ˆ 16) were excluded from the study. Table 1 Preoperative characteristics Mean age (years) (46.9±77.1) Mean PSA (ng/ml) (1.3±80) Mean Gleason biopsy score (3±9) Clinical staging T1a-b 3 T1c 70 T2a 24 T2b 3 Pathological staging pt2 74 pt2a 14 pt3b 12 N 3

3 340 L. Salomon et al. / European Urology 42 (2002) 338±343 Fig.1. Urinary continence. Of the remaining 77 patients, 13 had no preservation of neurovascular bundles, 13 had unilateral and 17 had bilateral neurovascular bundle preservation.the status of the neurovascular bundles of the remaining 34 patients were not reported by the surgeon, and therefore not available for analysis. Potency was de ned as the ability to achieve and maintain an erection suitable for sexual intercourse. Patients using vacuum erection devices, pharmacologic injection therapy or transurethral Alprostadil were not included in this group.for the 77 patients, potency rates increased from 16.8% to 49.3% during the rst year after surgery. With 0, 1 and 2 neurovascular bundle preservation, potency rates increased from 7.4%, 15.4% and 23.5% one month after surgery to 38.4%, 53.8% and 58.8% Table 2 Erectile function according to age and status of neurovascular bundle preservation Neurovascular preservation Age (n) Follow-up 1 month, n (%) 3 months, n (%) 6 months, n (%) 1 year, n (%) None (n ˆ 13) <60 years (n ˆ 4) 0 (0) 0 (0) 1 (25) 1 (25) >60 years (n ˆ 9) 1 (11) 2 (22) 2 (22) 4 (44) Unilateral (n ˆ 13) <60 years (n ˆ 4) 1 (25) 2 (50) 2 (50) 3 (75) >60 years (n ˆ 9) 1 (11) 2 (22) 3 (33) 4 (44) Bilateral (n ˆ 17) <60 years (n ˆ 6) 3 (50) 4 (66.6) 5 (83.3) 5 (83.3) >60 years (n ˆ 11) 1 (9) 3 (27) 3 (27) 5 (45) Total (n ˆ 43) <60 years (n ˆ 14) 4 (29) 6 (43) 8 (57) 9 (65) >60 years (n ˆ 29) 3 (10.3) 7 (24.1) 8 (27.5) 13 (44.8)

4 L. Salomon et al. / European Urology 42 (2002) 338± one year after surgery, respectively.of the patients reporting to be potent, 11 used sildena l (3/5 in the group without preservation of the neurovascular bundle, 3/5 in the unilateral and 4/10 in the bilateral preservation group). For patients younger than 60 years with unilateral and bilateral neurovascular bundle preservation, potency rates were 75% and 83.3% one year after surgery, respectively (Table 2). 4. Discussion Evaluation of urinary continence and erectile function can be dif cult, due to subjectivity of the surgeon and the patient, the use of different questionnaires in different centers, and insuf cient data collection or interpretation.physician and patient ratings may not correlate with each other and signi cant differences were noted between physician and patient assessment of clinical domains such as sexual and urinary symptoms as reported by Litwin et al. [11].Much higher postoperative sexual and urinary dysfunction rates reported in recent surveys of patients after radical prostatectomy support that concept: Ojdeby et al.have reported that continence rates assessed by the surgeon were 89%, whereras the results of a self-administered questionnaire in the same population revealed only 51% [12].Mail questionnaires and telephone interviews have also been used to assess functional results after radical prostatectomy [3].However, patient self-reported survey results are probably more re ective of the scope of morbidity in general community practice [10,13]. Similar to Talcott et al., who conducted a pre- and postoperative prospective, multicenter survey in radical prostatectomy patients [14], we think that preoperative incontinence and erectile dysfunction cannot be assessed in a retrospective manner.therefore, we initiated our study prior to surgery.de nition of urinary continence and potency is also variable according to different de nitions [15].We de ne urinary continence as no pad and/or leakage and potency as erections resulting in successful sexual intercourse with or without sildena l.with these de nitions, one year after surgery, continence rates are 90% during day and 97% during night and potency rates are 38.4%, 53.8% and 58.8% for no, unilateral and bilateral neurovascular bundle preservation, respectively. Laparoscopic prostatectomy is a new technique and oncologic control was rst assessed before studying urinary continence and erectile function.similar to results reported in the literature, continence rates in our study were 85% to 97%, 6 and 12 months after surgery (Table 3) [16±19].Early catheter removal due to a continuous suture for urethrovesical anastomosis may play a role in these results. Laparoscopic nerve sparing prostatectomy is performed by incising the lateral pelvic fascia at the bladder neck and dissecting in a retrograde fashion. This maneuver releases the neurovascular bundle laterally and facilitates the dissection of the prostate. Hemostasis is accomplished by hemoclips and monopolar cautery is avoided in order not damage the neurovascular bundle as recommended by Walsh [4]. Guillonneau and Vallancien reported that out of 20 preoperatively potent patients who had bilateral nerve sparing, nine reported sexual intercourse 12 months after surgery [16].TuÈrk et al.reported of 39 patients, which underwent unilateral and ve patients with bilateral nerve preservation.of those, 18 were able to have sexual intercourse and eight needed sildena l [17]. Rassweiler reported that 4 out of 10 patients, who had unilateral nerve preservation, had sexual intercourse with pharmacotherapy [19].In the present study, 10 out of 43 patients who were able to have intercourse, used sildena l.using an extraperitoneal approach, Bollens et al.reported 6 out of 10 patients having sexual intercourse after bilateral nerve preservation [18]. Our continence results are almost identical to those recently published by Walsh and Catalona et al. [20,21].Series using self-administered questionnaires report continence rates between 53% and 78% [10,14], and the overall rate of sexual function at one year in our patients, whose status of the neurovascular bundles is known (55.8%), is comparable to the results of open surgery [21±23].Walsh et al.in nearly the same patient-reported study reported the same results in term of urinary continence and potency [24].However, Table 3 Functional results of laparoscopic radical prostatectomy: review of the literature References n, surgical approach Continence rate (%) Potency rate (%) Guillonneau, 2000 [16] 120 transperitoneal 88.3 (after 6 months) 45 (bilateral preservation) TuÈrk, 2001 [17] 125 transperitoneal 92 (after 9 months) 40 (uni or bilateral preservation) Bollens, 2001 [18] 50 extraperitoneal 85 (after 6 months) 59 (bilateral preservation) Rassweiler, 2001 [19] 180 transperitoneal 97 (after 12 months) 40 (uni or bilateral preservation) Present study, transperitoneal 90 (after 12 months) 58.8 (bilateral preservation)

5 342 L. Salomon et al. / European Urology 42 (2002) 338±343 we have only a 12-month follow-up when compared to the 18 months of follow-up of Walsh's study. As has been demonstrated, preservation of neurovascular bundles, young age of the patient and an experienced surgeon are the main factors associated with the best results regarding erectile function [20± 24].We also nd better results when bilateral preservation is performed and when patients are younger as shown in Table 2.In our study, in men <60 years and with bilateral bundle preservation, the potency rate is 83% one year after surgery.this rate is higher compared to 73% in Walsh's study.the early recovery of potency in a subset of patients may be the result of special attention to careful handling of the bundles and avoidance of stretching of the bundles, which results in neurotmesis. We did not do the same analysis with urinary continence because as Steiner et al. [25], we think that urinary continence depends on anatomical factors and does not correlate with the age of the patient.these rst results, which include our learning curve, should be con rmed in a study with more patients and a longer follow-up period. 5. Conclusion Our rst results demonstrate that one year after laparoscopic radical prostatectomy, urinary continence rates are 90% during the day and 97% during the night.bilateral neurovascular bundle preservation results in an overall potency rate of 53.8%, which is even higher in patients <60 years (83.8%). We continue to evaluate our patients prospectively by a selfadministered questionnaire to evaluate long-term functional results after laparoscopic radical prostatectomy. Appendix A. Questionnaire During the day... Do you leak urine with no apparent reason and without feeling the need to urinate? Sometimes (less than once a week) Often (at least once a day) All the time Under what circumstances does it happen? During intense effort (sport, carrying suitcases, etc.) During moderate effort (climbing stairs, etc.) During the slightest effort (coughing, laughing, etc.) Do you wear pads during the day? As a precaution Not more than one pad per day More than one pad During the night... Do you leak urine during your sleep? Sometimes (less than once a week) Often (at least once a week) All the night Do you use pads at night? As a precaution Not more than one pad per day More than one pad Sexuality Do you desire to have sexual intercourse? Yes No Do you have sexual intercourse? Yes No Do you get erections? Yes, normal erections Yes, not very rigid, but suf cient for full intercourse Yes, but not rigid enough for full intercourse No erections References [1] Walsh PC, Lepor H, Eggleston JD.Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations.prostate 1983;4:473±85. [2] Partin AW, Mangold LA, Lamm DM, Walsh PC, Epstein JI, Pearson JD.Contemporary update of prostate cancer staging nomograms (partin tables) for the new millenium.urology 2001;58:843±8.

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