1. Ateş Kadıoğlu, MD, FECSM Professor of ,Urology University of Istanbul
Sexual dysfunction in male cancer survivors: The role of surgical treatment 
Ateş Kadıoğlu, MD, FECSM
Professor of ,Urology
University of Istanbul

2. Introduction
PCa remains the most common solid organ nondermatologic cancer in men
Siegel RL et al CA Cancer J Clin 2016

3. Prostate cancer
Radical prostatectomy (RP) is demonstrated to be the only surgical approach associated with improved patient survival in comparison to conservative management
Postoperative ED remains a troublesome issue for patients and physicians, with a wide range of reported incidence from 6% to 68%
Salonia A et al J Sex Med 2017

4. Post-RP ED Neuronal injury Vascular injury
Post-RP ED has been described as neurogenic, arterogenic, venogenic, or their combination
Neuronal injury
Vascular injury
ED can occur as a consequence of neuropraxia caused by traction, compression, and coagulation The neuropraxia causes Wallerian degeneration of the neural structures. It leads to the denervation of the corpora cavernosa and the consequent loss of nocturnal EF activity, with penile hypoxia and fibrosis that can finally result in veno-occlusive dysfunction responsible for ED
Arterogenic ED may be the transection of the accessory pudendal arteries (APA), which could lead to penile hypoxia independently of the status of the cavernosal nerves
Salonia A et al J Sex Med 2017

5. Method Open radical prostatectomy (ORP)
Laparoscopic radical prostatectomy (LRP)
Robot-assisted radical prostatectomy (RARP)

6. Techniques
Extrafascial
Interfascial
Intrafascial

7. Surgical technique A cumulative meta-analysis of studies
LRP
ORP
RALP
Potency rates
(after 48 months)
58-74%
49-74%
60-100%
Potency rates
Extrafascial
Interfascial
Intrafascial
Potdevin L 2009 --
67%(at 9 m)
91%(at 9 m)
Shikanov S 2009
40% (at 12 m)
64% (at 12 m)
İhsan-Tasci A 2015
64.3%(at 12m)
66.6%(at 12m)
68.1%(at12m)
Xylinas et al. showed that the robot-assisted intrafascial approach provided early satisfactory functional results with respect to postoperative potency (60% of the patients had postoperative erections after 1 month)
However, conflicting data exists on this topic and no clear statement can be made at this time.
Randomized controlled studies are needed for accurate results
Kadioglu A et al Transl Androl Urol 2015

8. Predictors
Briganti et al. preoperative risk stratification determinants:
Cardiac risk factors,
Age
EF.
Three groups:
low (age ≤65 years, IIEF-EF ≥26, CCI ≤1),
intermediate (age years or IIEF-EF 11-25, CCI ≤1),
high risk (age ≥70 years or IIEF-EF ≤10 or CCI ≥2).
EF recovery rate (at 12 months)
82%
57%
29%
Briganti A et al Eur Urol 2013

9. PDE5is
Rehabilitation and treatment are better than leaving the erectile tissue to its unassisted fate;
Treatment with on-demand or daily PDE5Is is better than doing nothing for the patient and his partner, although the baseline condition is rarely recoverable
(LE = 1, GR = A).
Salonia A et al J Sex Med 2017

10. PDE5is The advantage of a specific drug compared another
Daily versus on-demand protocol superiority has not been demonstrated
(LE = 3, GR = C).
EF recovery, within months (6-48 months) after RP.
Salonia A et al J Sex Med 2017

11. Sexual Rehabilitation After Treatment For Prostate Cancer
PDE5is
Penile prostheses
Intracavernosal injection
Vacuum erection device
Intra-urethral alprostadil

12. Penile Prostheses
The surgical placement of a penile prosthesis is widely used for ED, particularly in men unresponsive to medical management.
Interestingly, according to the SEERMedicare database only 0.8% of patients who chose a penile implant were after PCa therapy

13. Cardiovascular disease:19.6%, Peyronie’s disease:8.9%
N:1019 IPP, 983 AMS 700
Etiology of ED;
RP:%28,
Diabetes :21.6%,
Cardiovascular disease:19.6%,
Peyronie’s disease:8.9%
Post-RP ED is the most common cause of patients who is candidate PPI
Henry GD et al J Urol 2015

14. Diabetes and metabolic syndrome (group A):84 patients
Laparoscopic radical prostatectomy (group B):96 patients
AMS 700 CX or Coloplast Titan OTR
1 year after the implant,
Mean IIEF ± 2.7.
EDIT score ± 20.7
No statistically significant difference between the two groups
Antonini G et al Int J Impot Res 2015

15. Comparison of efficacy and satisfaction profile between tadalafil, ICI and PPI treatment
IIEF score
Megas 2012 N
Preoperative
12 months
18 months
24 months
Tadalafil 20mg 29
24 ± 1.7
14 ± 2.4
14.1 ± 2.5
14.3 ± 2.5
PPI 25
23.8 ± 1.6
26.4 ± 1.3
26.5 ± 1.2
26.7 ± 1.3 P
0.725
<0.001
Kucuk EV 2016 N
Improvement in IIEF-5 score, mean ± SD
EDITS score for patients, mean ± SD
Tadalafil 20mg
132
6.2 ± 1.5
70.7 ± 3.4
Tadalafil 5mg
106
6.7 ± 1.5
72.5 ± 4.5
ICI 96
8.4 ± 3.2
60.3 ± 6.3
PPI 22
12.4 ± 1.3
78.2 ± 11.3

16. Simultaneous placement of PPI with radical prostatectomy.
Complication
Intercourse initiate
EDITS
EORTC
Total score
Khoudary KP 1997
RP+IPP 50
4(8%) revision no infection
8 w (17 of 45 patients)
RP alone 72
Ramsawh HJ 2005
1 removed PPI --
81.03
9.58 42
54.86 (<0.001)
13.71 (=0.014)
Men who chose simultaneous placement of a penile prosthesis with RP reported greater overall QOL, erectile function and more frequent sexual contact than a comparison group of men who underwent RP alone.
Simultaneous placement of a penile prosthesis during radical prostatectomy provides early return to sexual function, with no apparent increase in morbidity.

17. Alternative reservoir placement
Previous pelvic surgery alters the surgical planes and makes injury more likely.
To minimize the risk of adverse outcomes, alternative sites for abdominal reservoir placement have been described.
Alternative reservoir placement sites include:
intrabdominal,
submuscular,
lateral retroperitoneal placement via second incision,
subcutaneous placement via second incision

21. Classic reservoir shape Ectopic reservoir shape
Device Enhancements
Name
Classic reservoir shape
Ectopic reservoir shape
AMS
Conceal
Spherical
Like a pancake
Coloplast
Cloverleaf
Standart
Flattened

22. Surgical Technique Enhancements
PTF Reservoir Insertion
For men with no prior history of significant pelvic surgery, along (80-mm) nasal speculum is used to perforate the transversalis fascia in a downward fashion.
The nasal speculum is immediately directed cephalad and advanced.
The nasal speculum paddles are spread to dilate the space posterior to transversalis fascia but anterior to the peritoneum.

23. Surgical Technique Enhancements
ATF Reservoir Insertion
In patients with a history of significant pelvic surgery, after the tip of the nasal speculum is passed to the external ring, it is forcibly advanced cephalad without perforating the transversalis fascia.
The superior wall of the inguinal canal is thus perforated and the paddles of the nasal speculum are spread, allowing introduction of a 12 Hagar dilator to further develop the space.

24. Surgical Technique Enhancements
ATF Reservoir Insertion
In patients with a history of significant pelvic surgery, after the tip of the nasal speculum is passed to the external ring, it is forcibly advanced cephalad without perforating the transversalis fascia.
The superior wall of the inguinal canal is thus perforated and the paddles of the nasal speculum are spread, allowing introduction of a 12 Hagar dilator to further develop the space.

25. Surgical Technique Enhancements
The reservoir is deployed in both ATF and PTF techniques by fashioning the device into a “cup” shape.
This maneuver facilitates deployment of the reservoir into the newly created PTF or ATF spaces by folding it over a small pediatric Yankauer suction tip.

26. Surgical Technique Enhancements
High Submuscular Reservoir Placement
In 2013, Morey popularized the “high submuscular” approach using a Foerster lung clamp from a penoscrotal approach.
This clamp is 14 inches long and allows even more cephalad displacement of the reservoir into the abdominal wall.
Recently, a new clamp has been invented with
This clamp is specifically designed for “ectopic” placements (ie, ATF and high submuscular reservoir placement).

27. n:2,239 patients, Posterior -TF reservoir
n:2,687 IPP
n:2,239 patients, Posterior -TF reservoir
n:447 Anterior-TF( previous surgery group)
Anterior placement of reservoir in patients with previous pelvic surgery is a safe procedure
Severe organ and vascular structure injury may be prevented by this way
Stember DS, Garber BB, and Perito PE.. J Sex Med 2014;11:605–612.

28. n:572 rezervoir at Retzius space
n:749 IPP AMS700
n:572 rezervoir at Retzius space
n:177 rezervoir at the anterior of transvers fascia
High submuscular placcement
Similar complication rates
Similar patient satisfaction rates
BMI and reservoir volume (mean 38 cc) do not effect the results
Karpman E, J Urol

29. Reservoir complication
Bladder injury %
Herniation %
Revision for palpable reservoir %
Autoinflation %
Infection %
Stember 2014
ATF
447
1.34
0.45
PTF
2239
0.09
0.94
Karpman 2015
177
1.1
572
0.03

30. Conclusion
Management of sexual dysfunction in Pca survivors can be difficult, but various effective management options exist.
The early intervention of rehabilitative strategies may prevent loss of penile length and increased EF score.
PPI should be suggested for the non-responders to medical therapy.
Alternative reservoir placement is recommended for patients with the risk factor that their pelvic anatomy has been altered by previous surgery