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Introduction: The relationship between prostate volume (PV) and erectile function recovery (EFR) after radical prostatectomy (RP) has not been well studied. Objective: We aimed to evaluate PV as a predictor of EFR 24 months after RP. Methods: We included men who underwent RP with surgeon-reported nerve-sparing score (NSS) and 2-year follow up who had documentation of pre-RP PV on MRI and baseline functional erections (pre-RP IIEF-EFD scores ≥ 24). Demographics, ED-related comorbidities, pathological features, PDE5i use, and total testosterone (T) levels were recorded. At 12 months post-RP, patients scored PDE5i use 0-3; 0 never, 1 sometimes, 2 regularly, 3 routinely. NSS on each side (R/L) was scored on a 1-4 scale: 1 complete preservation, 2 near-complete preservation, 3 partial resection, 4 complete resection. Scores of 1 or 2 indicate nerve-sparing and scores of 3 or 4 indicate non-nerve-sparing. We then classified overall NS status as bilateral, unilateral, or non-spared. At 24 months post-RP, EFD score ≥ 24 defined functional erections, ≤ 10 severe ED. Multivariable analysis (MVA) evaluated predictors of EFD score ≥ 24 as well as EFD ≤ 10 after RP; patient age, number of comorbidities, baseline EF, NSS, PDE5i use, and PV were analyzed. Results: 1741 men were included. Median age was 60 (55, 65) years. 36% had ≥ 2 comorbidities. Median PV was 33 (26, 44) mL with 12% having PV ≥ 60 mL. Median pre-RP IIEF-EFD score was 29 (27, 30). Grade group 1, 2, 3, 4 and 5 comprised 12%, 68%, 15%, 2%, and 3% of the cohort, respectively. NSS: bilateral (82%), unilateral (15%), non-spared (3%). Median PDE5i use score within 4 weeks of the 12 month post-RP visit was 1 (0, 1); reported PDE5i use was 44% never, 39% sometimes, 13% regularly, and 4% routinely. At 24 months post-RP, median EFD was 22 (9, 28), and 56% had EFD < 24. Men with post-RP EFD < 24 had greater PV (41 ± 26 mL) vs men with EFD ≥ 24 (36 ± 17 mL, p<0.001). 67% of the men with EFD < 24 had a PV ≥ 60 mL vs 33% of men with EFD ≥ 24 (p=0.02). On MVA, predictors of EFD ≥ 24 included bilateral NS, age and PV. Predictors of EFD ≤ 10 included bilateral NS and age. At 24 months post-RP, neither routine PDE5i use nor a higher comorbidity index were predictive of EF outcome. Conclusions: Among men with functional erections pre-RP, larger PV is associated with a poorer EFR at 24m post-RP independent of degree of nerve-sparing, age, and PDE5i use. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: The association between nerve-sparing (NS) status at the time of radical prostatectomy (RP) and functional outcomes is well described; however, our profession lacks insight as to whether patient factors such as age and baseline erectile function influence surgeon behavior when it comes to nerve-sparing during RP. Objective: We analyzed predictors associated with bilateral nerve damage/resection at the time of RP. Methods: The study included patients who underwent RP with surgeon-reported NS scoring. The NS outcome of the right and left sides were independently scored between 1-4: 1 = completely preserved, 2 = partially preserved, 3 = partially damaged, and 4 = completely resected; scores of 1 or 2 indicate nerve-sparing and scores of 3 or 4 indicate non-nerve-sparing. We classified overall NS status as bilateral, unilateral, or not-spared. Demographics, ED-related comorbidities, pre-RP digital rectal exam (DRE), most recent prostate biopsy (bx) results, and pre-RP IIEF Erectile Function Domain (EFD) were analyzed. Pre-RP prostate MRI was used to define prostate volume (PV). EFD score < 24 defined non-functional erections. We created a multivariable (MV) model to define predictors of poorer NS status. The model included patient age, pre-RP EFD, PV, PSA, DRE, noted possible extracapsular extension (ECE) on pre-RP MRI, number of positive bx cores, and predominant Gleason (G) score on bx. Results: 3805 men met inclusion criteria. Median age was 64 (57, 67) years. Median pre-RP EFD score was 26 (15, 30); 41% had a pre-RP EFD score < 24. Median PV and PSA were 35 (27, 47) mL and 5.7 (4.2, 8.4) ng/dL, respectively. 64% had a normal pre-RP DRE. Median total bx cores 12 (9, 14). Median positive bx cores 4 (2, 7). Distribution of bx pathology: 17% G6, 64% G7, 10% G8, 8% G9, <1% G10. 65% had predominant G3 and 34% G4 pathology. 26% of MRI reports noted some degree of suspicion for ECE. NS status at RP: bilateral (69%), unilateral (20%), non-spared (11%). Median NS score was 3 (2, 4). On MV analysis, abnormal DRE, number of positive bx cores, and predominance of G4 were predictive of non-NS surgery. Most notably, the non-oncological factors – older patient age and a pre-RP EFD < 24 – were also predictive of non-NS surgery (Table). Conclusions: While patient age and baseline erectile function (EF) are not necessarily predictors of a patient's interest in preserving EF, these non-oncologic factors were identified as predictors of non-NS surgery in this analysis. Surgeons should define the individual patient's sexual function goals prior to RP. Disclosure: No. [ABSTRACT FROM AUTHOR]

Background: Erectile dysfunction (ED) is seen in some men who have undergone bilateral nerve-sparing surgery. Corporo-venocclusive dysfunction (CVOD) is the major pathway to permanent ED after radical prostatectomy (RP)., Aim: To identify comorbidity factors that are associated with the presence of CVOD in men who had undergone bilateral nerve-sparing RP., Methods: We included patients who had no ED before RP, underwent bilateral nerve-sparing RP, were unresponsive to pharmacotherapy, and had a penile Duplex Doppler Ultrasound (PDDU) with a diagnosis of CVOD. PDDU was performed with a redosing vasoactive agent protocol. A logistic regression model was created to define predictors of CVOD, defined as end-diastolic velocity (EDV) ≥ 5 cm/s bilaterally., Outcomes: CVOD diagnosis., Results: 135 patients with a median age of 60 (IQR 54, 64) years were included. 45% reported ≥2 comorbidities, 10% diabetes, 28% obstructive sleep apnea (OSA), and 44% were current or former smokers. At PDDU, 34% had less than penetration hardness erections, and 43% received 100 units of vasoactive agent. 44% were diagnosed with CVOD. Increased age at RP (OR 2.12 per 10 years, 95% CI 2.35, 3.73, P = .007) and OSA (OR 2.44, 95% CI 1.07, 5.73, P = .036) were associated with a diagnosis of CVOD., Clinical Implications: Comorbidities, especially OSA, have a role in erection recovery after surgery., Strengths and Limitations: The study used a well-established institutional RP nerve-sparing score, a strict PDDU vasoactive agent redosing protocol, validated cut-offs for CVOD diagnosis, and a validated erectile function questionnaire both pre- and post-operatively. The major limitation is that this is a cohort of men seeking treatment at a sexual medicine clinic for post-operative ED, which limits the generalizability of the results to patients without ED symptoms or who decided not to seek treatment. The dichotomous definition of comorbidities is also a limitation since patients can have differing degrees of comorbidities' severity., Conclusion: Older patients and the presence of OSA were associated with the presence of CVOD., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society for Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Testosterone (T) therapy (TTh) in men with T deficiency who have undergone radical prostatectomy (RP) for prostate cancer remains controversial. We aimed to assess the impact of TTh on biochemical recurrence (BCR) rates after RP in men with low-intermediate organ-confined disease., Materials and Methods: This study included men who underwent an RP at our institution for organ-confined prostate cancer and had grade groups 1 to 3 on RP pathology. A Cox model was created for time to BCR with T use included as a time-dependent covariate, adjusted for age, preoperative PSA, grade group at RP, and the presence of comorbidities. A landmark analysis was used: Patients were included in the analysis if their last PSA in the 18 weeks postoperatively was undetectable and they had not had BCR or been lost to follow-up by that point, and follow-up for BCR began at 18 weeks. BCR was defined as a PSA ≥ 0.1 ng/mL after RP with a second confirmatory rise ≥ 0.1 ng/mL., Results: The study population included 5199 men after RP, with 198 patients receiving T at any point after RP and 5001 not receiving T. The median age was 59 (interquartile range, 55-65) and 61 (interquartile range, 56-66) years, respectively. Men in the T group tended to present with more vascular comorbidities. For those receiving T, clomiphene citrate was prescribed in 49% of men, 32% received transdermal T, and 19% intramuscular T. We found a nonsignificantly decreased risk of BCR associated with the use of T after RP (hazard ratio, 0.84; 95% CI, 0.48-1.46; P = .5), and overall rates of BCR were low, with probability of BCR at 5 years less than 2% in both groups., Conclusions: TTh can be given to select men after RP. We found no evidence that administration of TTh after RP causes BCR.

Objective: To outline our surgical technique and outcomes of a ipsilateral "transoblique" ileal conduit performed during pelvic exenteration with a Vertical Rectus Abdominis Myocutaneous flap. We report hernia rates in a transrectus group as reference., Methods: We identified patients from January 2007 to August 2020. The transoblique conduit is placed on the ipsilateral side as the VRAM, through the internal, external oblique, and transverse abdominis muscles. Stomal hernias were assessed radiologically. Transrectus patients were those undergoing radical cystectomy matched based on surgery date, age, and sex in a 3:1 ratio. We employed a Kaplan-Meier plot to visualize the duration between surgery and hernia. We calculated the hernia rate 2 years after surgery. Additionally, we present the 30-day postoperative complication rate., Results: Fifty underwent transoblique conduits and we matched them to 190 transrectus patients. Sixty-seven percent were men with a median age of 62. Exactly 10/50 patients in the transoblique and 44/190 in the transrectus group developed a hernia, with a median follow-up of 2.2 years (IQR 0.8, 4.0). The 2-year KM-estimated parastomal hernia rate was 14% (95% CI 1.6%, 25%) for the transoblique conduits, 21% (95% CI 15%, 28%) for the transrectus and 24% (95% CI 6.5%, 39%) for colostomies. Among the transoblique patients, 22 (44%) experienced at least 1 postoperative complication., Conclusion: A transoblique ileal conduit is safe in patients undergoing a right VRAM flap during a pelvic exenteration with a low parastomal hernia and complication rates., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Patients who undergo primary retroperitoneal lymph node dissection (pRPLND) for early-stage testicular cancer and have no cancer (pN0) found in the retroperitoneum are believed to have an excellent prognosis. However, some experience relapse, potentially due to limitations of current staging methods. We aim to describe long-term outcomes and relapse patterns among a contemporary cohort of patients found to be pN0 at pRPLND to identify opportunities for improved diagnostic approaches and optimal patient selection., Methods: We reviewed our prospectively maintained database for patients who underwent pRPLND for nonseminomatous germ cell tumors at our tertiary cancer center during the period from January 1, 2000, through September 30, 2023 (n = 628). We excluded 282 patients with node-positive pathology for a final analytic cohort of 346 patients. Our primary outcome was recurrence-free survival (RFS). Secondary outcomes included timing and location of recurrence., Results: Of 346 included patients with pN0 pathology, 23 experienced relapse with a 2-year RFS rate of 93% (95% confidence interval: 90, 96). Most recurrences (70%) occurred in the lungs and within 6 months of pRPLND. Serum tumor markers were positive in 43% of patients at the time of relapse. All patients who relapsed were treated with salvage chemotherapy; 6 patients required additional surgical procedures. There was no testis cancer-related deaths., Conclusions: Two-year RFS for patients with pN0 pRPLND pathology is excellent. All recurrences were outside of the retroperitoneum, suggesting subclinical distant metastases at time of surgery and the benefits of a bilateral template dissection. Improved diagnostics may help better identify patients with disease within or outside of the retroperitoneum prior to pRPLND, helping guide treatment decisions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To review the presentation and long-term oncologic outcomes of patients with regressed ("burnt out") primary testicular germ cell tumors (GCT). Certain testicular GCT can present with complete regression of the primary tumor. It is not well established if this is associated with more aggressive disease or worse oncologic outcomes., Methods: We queried our prospectively maintained testicular cancer clinical database at a tertiary cancer center and identified patients without prior chemotherapy who had regressed primary GCT at radical orchiectomy from 1990 to 2023. All specimens were reviewed by a genitourinary pathologist at diagnosis. Long-term clinical outcomes were reported by Kaplan-Meier method., Results: Fifty-six patients met inclusion criteria; at diagnosis, 17 had no evidence of extra-testicular disease and 39 had advanced (clinical stage [CS] II+) GCT. All CSx (no viable disease or germ cell neoplasia in situ at orchiectomy, and no evidence of advanced disease) and CS0 patients were managed with surveillance and had 5-year recurrence-free survival (RFS) of 88% (95% CI: 39%, 98%). All patients with CS II+ disease underwent primary treatment with surgery (n = 5) or first-line chemotherapy (n = 34). Two- and 5-year RFS for patients with CSII+ disease was 94% (95% CI: 78%, 98%) and 90% (95% CI: 72%, 97%), respectively., Conclusion: Patients with regressed primary testicular GCT often present with advanced disease, possibly due to lack of early clinical signs from the primary tumor. Our analysis shows excellent long-term oncologic outcomes similar to those reported in the literature for patients with viable primary testicular GCT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objective: Lymph node dissection (LND) has been standard in cancer surgery for more than a century, yet evidence from randomized trials showing a benefit is scarce. We conducted a clinically integrated randomized trial comparing limited versus extended pelvic LND (PLND) during radical prostatectomy and previously reported comparable biochemical recurrence (BCR) rates. We report updated BCR rates and compare rates of metastasis between the study arms., Methods: Between October 2011 and March 2017, 1432 patients undergoing radical prostatectomy were enrolled at a single center. Surgeons were cluster randomized to perform limited (external iliac nodes) or extended PLND (external iliac, obturator, and hypogastric nodes) with crossover for 3-mo periods. Cox proportional-hazards regression with robust standard errors clustered by surgeon was used to assess whether the PLND template affected BCR or distant or locoregional metastasis., Key Findings and Limitations: There were 452 BCR events at median follow-up of 4.2 yr for participants who did not develop BCR. The results confirm our previous finding of comparable BCR rates between the arms (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.97-1.13; p = 0.3). However, with 123 metastasis events and median follow-up of 5.4 yr for patients without metastasis, we found a clinically and statistically significant protective effect of extended PLND against metastasis (any metastasis: HR 0.82, 95% CI 0.71-0.93; p = 0.003; distant metastasis: HR 0.75, 95% CI 0.64-0.88; p < 0.001)., Conclusions and Clinical Implications: Patients undergoing radical prostatectomy should receive extended PLND that includes the external iliac, obturator, and hypogastric nodes. Further research should examine biological mechanisms regarding the anatomic location of affected nodes. Trials of LND for other cancers are warranted and should consider our clinically integrated design. This trial is registered on ClinicalTrials.gov as NCT01407263., (Copyright © 2024. Published by Elsevier B.V.)

Background: MicroRNAs (miRNAs) show promise as blood-based tumor markers for germ cell tumors (GCTs), with miRNA-371-3p being the most studied. The marginal benefit of including other candidate miRNAs to aid with the management of testicular GCTs remains unclear., Objective: To assess the performance of our combined miRNA assay (371a-3p and 372-3p) in patients with clinically localized testicular masses., Design Setting and Participants: This was a retrospective review of patients prospectively enrolled in an ongoing protocol collecting serum miR-371a-3p and miR-372-3p levels (together, Memorial Sloan Kettering Cancer Center [MSK] miRNA assay [MMA]) in patients with a suspected or diagnosed testicular GCT., Outcome Measurements and Statistical Analysis: The coprimary outcomes of interest were sensitivity and specificity of miR-371a-3p and 372-3p, individually and together, to detect nonteratomatous GCTs in the orchiectomy specimen. Secondary outcomes included additional assay diagnostic parameters, the relationship of patient and disease factors with variations in miRNA levels, and temporal patterns of miRNA normalization after orchiectomy., Results and Limitations: Sixty-two patients were included, 52 had a viable GCT at orchiectomy, and ten had no cancer or a non-GCT. Forty-six patients with a GCT had positive preorchiectomy MMA (sensitivity 88.5% [95% confidence interval {CI}: 79.8, 97.2]), and one patient had positive preorchiectomy MMA but no GCT (specificity 90.0% [95% CI: 71.4, 100]). The diagnostic performance of miR-371a-3-p and miR-372-3p was similar. The time for miRNA to decrease to undetectable levels varied, with some patients having positive levels up to 3 wk after orchiectomy., Conclusions: The biomarkers miR-371a-3p and miR-372-3p demonstrated high sensitivity and specificity for localized testicular GCTs, but causes of variation in relative miRNA levels and time to normalization for individual patients remain unclear., Patient Summary: We studied the ability of the blood-based biomarkers miR-371a-3p and miR-372-3p to detect testicular cancer (germ cell tumors) in patients with small testicular masses. We found that together and individually these were sensitive and specific for testicular cancer., (© 2024 The Author(s).)