Nicholas T. Ward

Association of Surgeon Subjective Characterization of Nerve Sparing Quality With Potency Following Laparoscopic Radical Prostatectomy

PURPOSE We assessed whether a surgeon self-graded assessment of neurovascular bundle preservation quality predicted potency following laparoscopic radical prostatectomy. MATERIALS AND METHODS From April 2001 to January 2007 a total of 767 laparoscopic radical prostatectomies were performed by 2 surgeons who graded left and right neurovascular bundle sparing qualities on a scale of 0 to 5. The total number of nerves spared was also recorded. We defined a composite variable, the bilateral sum neurovascular bundle sparing score, to encode 1 independent variable (scale of 0 to 10) for analysis. Multivariate linear regression models were evaluated to assess the significance of the bilateral sum neurovascular bundle sparing score for predicting validated potency outcomes, controlling for significant clinical variables in preoperatively potent men (Sexual Health Inventory for Men 21 or greater). The bilateral sum neurovascular bundle sparing score based model was compared to a model based on the separate number of nerves spared. RESULTS A total of 313 patients were preoperatively potent, of whom 226 (72%), 77 (25%) and 10 (3%) underwent bilateral, unilateral and no neurovascular bundle sparing, respectively. Of the men who underwent bilateral neurovascular bundle sparing 64.3% were engaging in intercourse by 1 year. Regression models indicated that the bilateral sum neurovascular bundle sparing score and the number of nerves spared were highly significant independent positive predictors of postoperative sexual function (p <0.001). The bilateral sum neurovascular bundle sparing score model provided differential prognostic information in the majority group that underwent bilateral nerve preservation. Other independently predictive variables were patient age at surgery, months since surgery and preoperative Sexual Health Inventory for Men 21 to 25 (each p <0.001). CONCLUSIONS Cavernous nerve preservation during laparoscopic radical prostatectomy is not an all or none phenomenon. A surgeon subjective sense of neurovascular bundle sparing quality may aid in accurately characterizing the return of sexual function following laparoscopic radical prostatectomy. Partial nerve preservation may lead to an incremental improvement in the return of sexual function.

The Impact of Prostate Size on Urinary Quality of Life Indexes Following Laparoscopic Radical Prostatectomy

PURPOSE We assessed the effects of prostate size on long-term health related quality of life and functional outcomes after laparoscopic radical prostatectomy. MATERIALS AND METHODS A total of 729 consecutive patients who underwent laparoscopic radical prostatectomy for localized prostate cancer were stratified by pathological prostate gland weight, including group 1--less than 35 gm, group 2--35 to 70 gm and group 3--greater than 70 gm. Urinary health related quality of life was assessed preoperatively and at regular intervals following laparoscopic radical prostatectomy using the validated Expanded Prostate Cancer Index Composite questionnaire. RESULTS A total of 613 evaluable patients were studied with a mean age of 57.7 years, a preoperative prostate specific antigen of 6.0 ng/ml, a median preoperative and postoperative Gleason score of 6, and a mean pathological gland weight of 51.3 gm (range 13.4 to 145.7). Patients with the largest glands had significantly worse baseline urinary function, as demonstrated by Expanded Prostate Cancer Index Composite urinary domain summary (p <0.001) and subscale scores, including scores for urinary bother (p <0.001), urinary irritative/obstructive (p = 0.001) and urinary incontinence (p = 0.03). Patients in group 3 also had significantly older age, a higher body mass index, longer operative time and more blood loss (each p <0.05). Despite preoperative differences and possible confounders all groups approached similar urinary health related quality of life outcomes at all time points postoperatively. At 12 months patients with the largest glands had improved Expanded Prostate Cancer Index Composite urinary irritative/obstructive and urinary bother subscale scores compared to their baseline scores (p <0.05). CONCLUSIONS In laparoscopic radical prostatectomy despite preoperative differences increasing prostatic size is not associated with delayed or worse postoperative urinary health related quality of life. Furthermore, in patients with large glands an improvement in urinary irritative/obstructive and bother symptoms from baseline may be seen 12 months postoperatively.

The Impact of Prostate Size on Perioperative Outcomes in a Large Laparoscopic Radical Prostatectomy Series

PURPOSE To clarify the effects of pathologic prostate specimen weight on perioperative outcomes in laparoscopic radical prostatectomy (LRP), a subject that has recently been analyzed in numerous smaller series. PATIENTS AND METHODS Data from our Institution Review Board-approved database was queried with attention to operative, perioperative, and pathologic outcomes. For analysis, LRP patients were divided into three groups by pathologic specimen weight: <35 g, 35 to 70 g, and >70 g, and outcomes assessed. Outcomes were also analyzed using prostate weight as a continuous variable by multivariate regression. RESULTS Between April 2001 and April 2007, 802 consecutive patients underwent LRP for localized prostate cancer, and complete perioperative data were available for 720 (90%) of these men. Mean age, body mass index (BMI), preoperative prostate-specific antigen (PSA) and postoperative Gleason score were 57.6 years, 26.7 kg/m(2), 5.9 ng/mL, and 6.3, respectively. Mean specimen weight was 51.3 g. When compared with lighter counterparts, patients with the heaviest glands were older (P < 0.01), had a higher PSA level (P < 0.01), and had a higher percentage of pathologically organ-confined disease (P < 0.01). By multivariate regression analysis, increasing prostate weight was associated with longer operative times, more blood loss, longer lengths of stay, and more perioperative complications (all P < 0.05). Of note, smaller glands trended toward a higher rate of positive surgical margins overall (P = 0.07) and in pT(2) disease (P = 0.05), but there was no association between surgical margins and gland size in pT(3) disease (P = 0.27). Increasing BMI was also independently predictive of positive margins regardless of prostate size (P < 0.01). CONCLUSIONS Although perioperative outcomes are generally excellent after LRP irrespective of gland size, a larger prostate size is associated with longer operative time, more blood loss, longer length of stay, and increased complications. Patients with smaller glands and organ-confined disease appear to have a higher rate of positive surgical margins.

Comparison of Validated Instruments Measuring Sexual Function in Men

OBJECTIVES There is no universally accepted instrument to measure sexual function (SF) in men. We compare validated SF measures in a single cohort. METHODS We compare the Sexual Health Inventory for Men (SHIM), Expanded Prostate Cancer Index Composite SF domain (EPIC-SF), and a reconstructed University of California Los Angeles Prostate Cancer Index SF domain (PCI-SF) in 856 men scheduled for radical prostatectomy. We define potency thresholds for the PCI-SF and EPIC-SF. RESULTS Mean age, body mass index, Gleason sum, and PSA were 57 years, 26.7 kg/m(2), 6.3, and 5.9 ng/mL, respectively. Mean instrument scores were as follows: SHIM 20.1; EPIC-SF 65; PCI-SF 71. All instruments were significantly intercorrelated (r = 0.99 for EPIC-SF vs PCI-SF, r = 0.75 for SHIM vs EPIC-SF, r = 0.77 for SHIM vs PCI-SF, all P < .001). The SHIM had the greatest negative skew and ceiling effect (P < .001). Although high scores on either the EPIC-SF or PCI-SF translated reliably to high SHIM scores, the reverse was not true. Subjects who reported no erectile dysfunction (ED) on the SHIM (>or=22) had diverse overall SF, whereas those who scored highly on the EPIC-SF or PCI-SF had both excellent erectile function (potency) and overall SF (including orgasmic function, erectile function, and sexual desire). EPIC-SF scores >or=65 and PCI-SF scores >or=75 define men that are both potent and have good SF. CONCLUSIONS The SHIM is intended as an instrument to assess ED. It is, however, inadequate as a measure of overall SF. The EPIC-SF and PCI-SF capture gradations of both sexual and erectile function and may also be used to define potency more comprehensively.

Defining potency: A comparison of the international index of erectile function short version and the expanded prostate cancer index composite

We read with great interest the recent article by Schroeck et al. Such analyses are invaluable to the study of sexual function outcomes in patients with prostate cancer and facilitate comparisons between datasets. We presented a similar analysis at the 2008 American Urological Association Annual Meeting. However, 72 pretherapy patientsmay be insufficient to provide definitive answers to questions posed by the authors. According to power calculations provided by the Expanded Prostate Cancer Index Composite (EPIC) authors, when assessing changes in domain summary scores, a minimum sample size of 86 patients is required to achieve 90% power.We would assume a similar number of patients should be analyzed when defining clinically meaningful thresholds of the instrument. The additional analyses with 27 post-treatment patients (at various time points after various therapies) interject unnecessary variables into the central underpinnings of the article, which is a comparison of 2 validated instruments. Furthermore, although the majority of respondents had simultaneous questionnaire administration, we believe it preferable to compare solely between simultaneously administered instruments to avoid test-retest variations that are not caused by intrinsic differences between the instruments. Even with contemporaneous administrations of the same instrument, multiple factors contribute to test score changes over time, including test reliability, measurement error, disease fluctuations, and practice effects (the effects when individuals undergo repeated evaluations using the same or similar instruments), among others. In our abstract, we compared the International Index of Erectile Function (IIEF) short form, the EPIC sexual function domain (EPIC-SF), and the University of California-Los Angeles Prostate Cancer Index (UCLAPCI) sexual function domain (UCLA-PCI-SF) in 568 patients who were administered multiple questionnaires simultaneously. It is comforting to note that we produced results similar to those reported in the current study, ie, a median EPIC-SF score of 69.4 (interquartile range [IQR], 55.6-80.6) versus 65.3 (IQR, 47-75), a mean EPIC-SF score in patients who had a perfect score of 25 on the IIEF-short form of 79.7 (range, 52.8-100) versus an unavailable mean EPIC-SF score (range, 61.1-91.7). However, we suggest caution using UCLA-PCI values to dictate cutoff scores for the EPIC-SF because, with the exception of our abstract and 1 Japanese study, no comparative analyses are available. Assumptions of direct value approximations may not be warranted. For example, Namiki et al, using a linking analysis, reported that an EPIC-SF score of 65.3 (the median in the current study) corresponds to a UCLA-PCI-SF score of nearly 80. In our analyses, patients who had mean EPIC-SF scores of 65.3 scored amean of 78.1 on the UCLA-PCI-SF.