Christof van der Horst

Recovery of erectile function after nerve-sparing radical prostatectomy: improvement with nightly low-dose sildenafil.

To evaluate the effect of low‐dose sildenafil for rehabilitating erectile function after nerve‐sparing radical prostatectomy (NSRP), as the delay to recovery of erectile function after NSRP remains under debate.

Functional Outcome Following Photoselective Vaporisation of the Prostate (PVP): Urodynamic Findings Within 12 Months Follow-Up

OBJECTIVES We determined the impact of potassium-titanyl-phosphate (KTP) laser therapy of the prostate on urodynamic results, voiding function, quality of life, and sexual function. DESIGN, SETTING, AND PARTICIPANTS Forty-five patients complaining of symptomatic benign prostatic hyperplasia (BPH) and urodynamically proven obstructive voiding were included in the prospective study. Follow-up exams were repeated 3 mo and 12 mo after the treatment. INTERVENTION All patients underwent photoselective 80-Watt KTP laser vaporisation of the prostate performed by two experienced surgeons. MEASUREMENTS Disease-specific quality of life and sexual function were assessed using the International Prostate Symptom Score (IPSS) and International Inventory of Erectile Function (IIEF). Video-urodynamics were carried out to determine changes in pressure flow and bladder function. RESULTS AND LIMITATIONS The average preoperative prostate volume was 47.63 ml (range 30-75 m). The mean preoperative PSA-value, which had been 3.5 ng/ml (range 0.13-7 ng/ml) initially, dropped by 34.2% after 3 mo and 37.1% after 12 mo. Despite transient micturition complaints (40%), all patients showed significant improvement in the IPSS in urinary peak flow and detrusor pressure at peak flow. The mean post-void residual urine volume decreased, while erectile function and libido scores remained unaffected by the procedure according to the IIEF. Detrusor contractility was also not affected in any of the patients. The single-centre study design and small number of patients may have limited the study results. CONCLUSIONS KTP laser therapy of the prostate achieves significant improvements both symptomatically as well as with respect to objective micturition parameters. The procedure leads to a functional deobstruction of the lower urinary tract with steady improvement results throughout the follow up period.

Nocturnal tumescence: a parameter for postoperative erectile integrity after nerve sparing radical prostatectomy.

PURPOSE The exact process and time required for rehabilitation of erectile function after nerve sparing prostatectomy remain unclear to date. Different theories of the pathophysiology of postoperative erectile dysfunction are currently being discussed. In a prospective study we performed recordings of nocturnal penile tumescence and rigidity during the acute phase after nerve sparing radical prostatectomy, ie in the first night after removal of the catheter, to assess the organic penile integrity. MATERIALS AND METHODS In 27 patients with local prostate carcinoma who had been sexually active before the intervention, we performed unilateral or bilateral nerve sparing radical prostatectomy. Preoperative sexual function of all patients was evaluated by the International Index of Erectile Function-5 questionnaire. On the day of catheter removal (postoperative day 7 to 14) an NPTR recording was performed on the following night with an erectometer (RigiScan). RESULTS All patients had a preoperative IIEF score greater than 18. After removal of the catheter 25 of 27 patients (93%) showed 1 to 5 nocturnal rigidity increases by greater than 70% for at least 10 minutes. In a control group of 4 patients who underwent radical prostatectomy without nerve sparing, no nocturnal erections were recorded. CONCLUSIONS NPTR recording during the acute phase after nerve sparing radical prostatectomy showed residual erectile function as early as the first night after catheter removal. These results are significant for selecting adequate pharmacological treatment for optimal therapy and rehabilitation of satisfactory erections and sexual function. In cases of early nocturnal tumescence, application of a PDE5 inhibitor can support successive organ rehabilitation. However, if tumescence does not occur, penile injection therapy is recommended.

Interobserver variation in grading and staging of squamous cell carcinoma of the penis in relation to the clinical outcome.

To examine interobserver variations in assessing grade and stage of penile squamous cell carcinoma (SCC).

Unilateral vs bilateral sacral neuromodulation in pigs with formalin-induced detrusor hyperactivity

To investigate the efficacy of unilateral vs bilateral sacral neuromodulation (SNM) under standard experimental conditions by stimulating the dorsal sacral roots in pigs with formalin‐induced detrusor hyperactivity.

Lymph-node metastases in intermediate-risk squamous cell carcinoma of the penis

To evaluate the metastatic risk of pT1 G2 squamous cell carcinoma (SCC) of the penis.

Penile Carcinoma (pT1 G2): Surveillance or Inguinal Lymph Node Dissection?

Background: Due to the low incidence of squamous cell penile cancer and lack of well-designed studies, controversies persist over the therapeutic approach in patients with pT1 G2 carcinoma. Patients and Methods: Between 1992 and 2003, 16 patients with T1 squamous penile cancer were treated in our institution either by surveillance or by inguinal lymph node dissection (ILND). Results: A total of 8 primary lesions were classified as pT1 G2 carcinoma with 4 tumors developing early or delayed inguinal metastatic disease. Conclusions: The natural behavior of pT1 G2 squamous penile carcinoma and its metastatic potential has been underestimated in recent literature. Since morbidity after early ILND has markedly decreased and its superiority over delayed ILND has been shown, we advocate the early modified inguinal lymph node dissection until strong prognostic factors for positive inguinal lymph nodes have been validated.

Management of recurrent post-prostatectomy incontinence after previous failed retrourethral male slings

OBJECTIVE Our objective was to establish the feasibility of combining 2 minimally invasive procedures in patients with failed primary treatment (male sling) in post-prostatectomy incontinence (PPI) patients. METHODS From January 2007 to July 2008, 40 men with PPI were implanted with a suburethral tape (2 patients with Seratim, 3 with I-Stop and 35 with Advance). The median preoperative pad count was 4 (range 2-10). Prior to sling placement, 6 patients had undergone ProACT implantation. Of these, 4 patients required explantation due to balloon migration and 2 patients had their balloons kept in situ, with the balloons deflated. RESULTS Twenty-five patients were socially continent at this time. Fifteen patients (37.5%) did not improve or their improvement was not significant. These patients had a preoperative pad count between 7 and 10. Two of these patients had prostate adjustable continence therapy (ProACT) systems still in place. By gradually filling the balloons to 3 mL, both of these patients achieved complete continence, which was maintained at a mean follow-up of 8.5 months. Three patients with prior pelvic irradiation received an artificial urinary sphincter and achieved continence at mean follow-up of 8.3 months. The remaining 10 patients received a ProACT system in addition to the already implanted sling. After appropriate healing and filling of the balloons (average balloon volume 5 mL), all 10 patients reached complete continence; they were pad-free at a mean follow-up of 6 months (range 3-9). CONCLUSIONS The combination of ProACT and a suburethral tape was demonstrated to be a possible treatment option in recurrent or persistent PPI.

Should being aged over 70 years hinder penile prosthesis implantation

To assess the satisfaction profiles following penile prosthesis surgery in patients with erectile dysfunction (ED) in their seventh decade of life.

Functional Impact of the Rhabdosphincter Branch of the Pelvic Nerve on the Membranous Urethra in Comparison to That of the Pudendal Nerve in Male Rabbits

Introduction: The innervation of the membranous urethra (MU) is still under debate. We analysed the functional effects of electrostimulation of the rhabdosphincter branch of the pelvic nerve (RBP) on the MU in a standardized male rabbit model, paying attention both to the efferent and the possible afferent effects of stimulation. Material and Methods: Six male rabbits (chinchilla bastards) were included in this study. Pudendal nerve branches as well as pelvic nerve branches were exposed bilaterally in all animals. Randomized electrostimulation trials of both the pudendal nerve fibres and the RBP were carried out using a biphasic signal (0.3 mA, 200 μs). The stimulation frequency ranged from 10 to 40 Hz in a randomized pattern. Changes in MU pressure were measured urodynamically. The pressure changes occurring as a result of stimulation were compared in both nerve structures. At the end of the stimulation trial, the RBP and the pudendal nerve were dissected at different positions before repeating the stimulation and the MU pressure recording. Results: The mean MU baseline pressure without stimulation was 24 cm H2O (range 21–27) in all animals. During unilateral pudendal stimulation, the mean pressure response rose by highly significant values (p < 0.005) compared to baseline. The pressure response was frequency dependent. Stimulation of the RBP resulted in a small but significant change of the MU pressure in the lower frequency range (10 and 20 Hz) (p > 0.05). On performing stimulation at higher frequencies, there was no significant difference from baseline. The pressure response of the MU during stimulation of the intact RBP did not differ significantly from the response after dissection of the RBP. However, after dissecting the pudendal nerve, the MU pressure response to RBP stimulation was diminished. Conclusion: Our results confirm the primacy of the pudendal nerve in the innervation of the MU. Stimulation of the RBP, however, may produce an afferent signal which is transmitted to the pudendal nerve, thus resulting in a pressure increase of the MU and contributing towards continence. We showed the importance of the RBP to maintain full urinary continence in rabbits. Our results suggest that substantially higher continence rates can be achieved through a nerve-sparing procedure in radical prostatectomy. Nerve-sparing radical prostatectomy incidentally also protects the RBP from injury.