1. Disfunzione erettile dopo prostatectomia radicale
TUTTO DA RIFARE?
Andrea Salonia, MD, PhD, FECSM
Università Vita-Salute San Raffaele
Direttore, URI-Urological Research Institute
Divisione di Oncologia Sperimentale/Unità di Urologia, IRCCS Ospedale San Raffaele

2. THE SUSPICION-DIAGNOSIS-TREATMENT MODEL
Salonia A & Montorsi F, ESSM 2012

3. Preop normal Erectile Function: 101/234 (43%)
Salonia A, et al. Eur Urol, 50: , 2006 3

4. “BACK TO BASELINE” CONCEPT
Clinical experience suggests that patients view EF recovery as getting back to their baseline erectile functioning without the use of medication
“BACK TO BASELINE” CONCEPT
Mulhall JP, et al. J Sex Med, 7: , 2010

5. The vast majority of patients will regain Erectile function sufficient to engage in intercourse following LRP
Only a fraction, however, will return to their preoperative level of sexual function
Levinson AW, et al. World J Urol, 29:29-34, 2011

6. Brajtbord JS, et al. J Urol, 192:396-401, 2014

7. 50% 34% 23% 26% SCANDINAVIAN PROSPECTIVE STUDY
(vs AGE-MATCHED HEALTHY CONTROLS)
50%
34%
23%
26%
Johansson et al. Lancet Oncol, 12:91–99, 2011

8. Nubra Valley, Ladakh, 2006

9. Efficacy of Sildenafil Citrate in Men With Erectile Dysfunction Following Radical Prostatectomy: A meta-analysis
Overall response rates (and 95% CI) to sildenafil treatment after RP
35%
Montorsi F, et al. J Sex Med 2:658-67, 2005

10. p<0.0001
Montorsi F, et al, J Urol 172: , 2004 10

11. Safety and efficacy of vardenafil for the treatment of men with erectile dysfunction after radical retropubic prostatectomy
p<0.0001
Brock G et al. J Urol, 170: , 2003 11

12. 298 men with ED ≥ 6 mo after RP treated with avanafil on demand (100 or 200mg) vs placebo for 30 wk
After 12 weeks there were
significantly greater increases in SEP2 and SEP3 and change in mean IIEF-EF domain score with 100 and 200 mg avanafil vs placebo (p:0.01)
Mulhall JP, et al. J Urol 2013;189:

14. TADALAFIL 20mg: 12 compresse

15. ACCEPTANCE OF RATE: ONLY 51%!!!!
TX group characteristics throghout the 18-mo FU
ACCEPTANCE OF RATE: ONLY 51%!!!!
OVERALL DISCONTINUATION RATE: 72.6%
Salonia A, et al. Eur Urol 53: , 2008 15

16. 1 out of 5 patients discontinued the treatment
Polito M, et al. BJU Int, 110:E954-7, 2012

17. SURGICAL TECHNIQUE

18. Moncada I, et al.. World J Urol, 33:1031-8, 2015

19. REACTT – Tadalafil OaD contributes to the recovery of EF after RP
Time to recovery
25 % of patients achieved IIEF-EF ≥ 22 within 5.8 months with TAD OaD, 9.0 months for TAD PRN, and 9.3 months for placebo
The use of tadalafil OaD can significantly shorten the time to EF-recovery post-nsRP compared with placebo
Moncada I, et al. World J Urol, 33:1031-8, 2015

20. Functional & topographic anatomy of the prostate: what has changed?
Walz J, et al. Eur Urol , 57:179-92, 2010
Salonia A, et al. Eur Urol, 62:261-72, 2012

21. Systematic review and meta-analysis on functional outcomes after RARP
The advent of robotic surgery in urology and especially in Pca rise questions about the efficacy of this new technique in terms of oncological and especially of functional outcomes compared to open surgery
In this meta-analysis reporting functional outcomes after RALP the median time to UC was 1.6 mo after RARP compared to 4.3 mo after RRP
With a significant advantage in favor of RARP
The prevalence of ED according to different definitions was 47.8% after RRP and 24.2% after RARP
The cumulative analysis showed a statistically significant advantage in favor of RARP (OR: 2.84; 95% CI, 1.48–5.43; p = 0.002)
Ficarra V, et al, Eur Urol, 62: , 2012

22. PCa treatment – Robotic vs Open surgery
The vast majority of data regarding EF recovery comes from RCTs including mainly patients treated with ORP
Is robotic surgery changing the landscape in terms of rates and recovery from sexual dysfunction after RP?
Do we need to reconceptualized penile rehabilitationin a new patient setting?
So our question was: does
Capogrosso P & Salonia A, ESSM 2015; AUA2015; SIA2015; SIU2015

23. ORGASMIC DYSFUNCTION AFTER ROBOT-ASSISTED VERSUS OPEN RADICAL PROSTATECTOMY
Cox-regression analysis assessing predictors of recovery from climacturia
Predictors
p value HR
95% CI
Age
0.39
1.01
0.98 – 1.03
Type of surgery
RRP vs RALP
0.00
2.86
2.04 – 4.02
IIEF-EF≥22 recovery
0.18
1.91
0.40 – 2.60
UC recovery
0.48
1.31
0.74 – 4.02
Nerve sparing status
None vs monolateral
None vs bilateral
0.72
0.97
1.22
2.08
0.67 – 1.76
0.33 – 3.28
And at multivariate analysis type of surgery, EF and UC recovery and bilateral ns were associated to a faster recovery from climacturia
Capogrosso P, et al. Eur Urol, 2015

24. Kaplan-Meier curves predicting recovery from CLIMACTURIA in the overall population (1) and within treatment groups (2)
The log-rank test indicates the statistically significant difference across each group (p<0.01)
Kaplan-Meier curves predicting recovery from PAINFUL ORGASM in the overall population (a) and within treatment groups (b).
The log-rank test indicates a non statistically significant difference across each group (p=0.3)
Capogrosso P, et al. Eur Urol, 2015

25. - patients undergoing a bilateral NS procedure
ORGASMIC DYSFUNCTION AFTER ROBOT-ASSISTED VERSUS OPEN RADICAL PROSTATECTOMY
These findings showed that one third of patients submitted to RP reported climacturia
Recovery from climacturia was greater and faster following RARP than RRP, in
- patients undergoing a bilateral NS procedure
- patients who recovered satisfactory erectile functioning and urinary continence
In conclusion
Capogrosso P, et al. Eur Urol, 2015

26. SUM-UP
Baseline EF concept
Neglected side effects
Neglected patients needs
Pills & Nota 75
Overall worldwide change in surgical approach has promote significant overall worldwide modifications in patients characteristics