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Introduction: Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus. Materials and Methods: A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naive adult patients after uncomplicated procedures. Results: Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement. Conclusion: Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making before prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.

Introduction: This is a report on urinary function results from a randomized trial of nightly versus on-demand sildenafil after nerve-sparing radical prostatectomy (RP), a secondary objective. We analyzed the effects of these sildenafil administration schemes on urinary health-related quality of life after RP., Methods: In total, 100 potent men were equally randomized to nightly and on-demand sildenafil 50 mg after minimally-invasive RP for 1 year. Health-related quality of life questionnaires were administered at various postoperative intervals. Urinary function was assessed using appropriate expanded prostate cancer index composite (EPIC) subscales. Analyses of covariance and linear mixed-effects modeling were used to compare the effects of treatment over time on urinary recovery, controlling for age, nerve-sparing score, and time from surgery., Results: The nightly (n = 50) and on-demand (n = 50) sildenafil groups were well-matched at baseline. Nightly sildenafil patients had worse EPIC urinary bother and urinary irritative/obstructive subscale scores at 3 and 6 months after RP, even after controlling for multiple variables. On mixed-model analyses, the differences between groups for these EPIC subscales (4.9 and 2.5, respectively) were greater than documented thresholds for clinical significance. Increasing nerve-sparing score was associated with improvements in EPIC urinary summary, bother, incontinence, and function scores; time from surgery was associated with improvements in all EPIC urinary health-related quality of life subscales., Conclusions: In this specific population and drug dose, we found that on-demand short-acting phosphodiesterase-5 inhibitor (PDE5i) dosing may be more effective after RP to maximize early urinary health-related quality of life. In preoperatively potent men, nightly sildenafil 50 mg impaired urinary health-related quality of life more than on-demand use in the early months after nerve-sparing RP, independent of effects on urinary continence.

Introduction: Despite the widespread use of minimally invasive radical prostatectomy (MIRP), there remain concerns regarding its safety in patients with a history of prior abdominopelvic or inguinal surgery., Methods: A prospective database of 1165 MIRP procedures performed by a single surgeon at a high-volume tertiary care center from 2001 to 2013 was analyzed. After an initial period of transperitoneal MIRP (TP), an extraperitoneal (EP) approach was used preferentially beginning in 2005 (for both laparoscopic and robotic cases), and robotics were used preferentially beginning in 2010. Overall perioperative complications, major complications (Clavien-Dindo III or IV), and abdominal complications (e.g., ileus, bowel/organ injury, or vascular injury) were compared for patients with and without a prior surgical history. Uni- and multivariate logistic regression were used to control the impact of robotics, approach, operative time, estimated blood loss, case number, prostate weight, and primary Gleason on complications., Results: Three hundred patients undergoing MIRP had prior abdominopelvic or inguinal surgery (25.8%). Of these, 102 (34%) underwent TP and 198 (66%) EP MIRP. Robotics was used in 286 cases (24.6%) and pure laparoscopy in 879 (75.4%). Complications occurred in 111 patients (9.5%) from the total cohort, with major complications in 32 (2.75%) and abdominal complications in 19 (1.63%). Prior surgery was not associated with overall, major, or abdominal complications. Of the controlling factors, only increasing operative time was associated with postoperative abdominal complications (most of which were ileus) on multivariate analysis., Conclusions: In this large single-surgeon series where both EP and TP approaches to MIRP are utilized, prior abdominopelvic or inguinal surgery was not associated with an increased risk of perioperative complications.

Objectives: To determine how high-resolution transrectal ultrasound (HiTRUS) compares with conventional TRUS (LoTRUS) for the visualization of prostate cancer., Methods and Materials: Twenty-five men with known prostate cancer scheduled for radical prostatectomy were preoperatively imaged with both LoTRUS (5MHz) and HiTRUS (21MHz). Dynamic cine loops and still images for each modality were saved and subjected to blinded review by a radiologist looking for hypoechoic foci ≥ 5 mm in each sextant of the prostate. Following prostatectomy, areas of prostate cancer ≥ 5 mm on pathologic review were anatomically correlated to LoTRUS and HiTRUS findings. The accuracy of LoTRUS and HiTRUS to visualize prostate cancer in each sextant of the prostate and to identify high-grade and locally advanced disease was assessed. The McNemar test was used to compare sensitivity and specificity and paired dichotomous outcomes between imaging modalities., Results: Among 69 sextants with pathologically identified cancerous foci at radical prostatecomy, HiTRUS visualized 45 and missed 24, whereas LoTRUS visualized 26 and missed 43. Compared with LoTRUS, HiTRUS demonstrated improved sensitivity (65.2% vs. 37.7%) and specificity (71.6% vs. 65.4%). HiTRUS's agreement with pathologic findings was twice as high as LoTRUS (P = 0.006). HiTRUS provided a nonsignificant increase in visualization of high-grade lesions (84% vs. 60%, P = 0.11)., Conclusions: HiTRUS appears promising for prostate cancer imaging. Our initial experience suggests superiority to LoTRUS for the visualization of cancerous foci, and supports proceeding with a clinical trial in the biopsy setting., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To assess the effect of nerve sparing (NS) quality on self-reported patient urinary outcomes after radical prostatectomy., Methods: A total of 102 preoperatively potent men underwent laparoscopic or robotic radical prostatectomy; NS was prospectively graded at surgery using a 0-4 scale/neurovascular bundle. Urinary functional outcomes were measured by validated Expanded Prostate Cancer Index Composite questionnaire at baseline and follow-up time points (1, 3, 6, 9, and 12 months) in 99 men who underwent various degrees of NS. Mixed linear regression was used to analyze the effect of NS quality and other clinical factors on urinary outcomes., Results: Patients with at least 1 neurovascular bundle spared completely, along with its supportive tissues (NS grade 4/4), noted significantly improved Expanded Prostate Cancer Index Composite urinary functional and continence outcomes as early as 1 month postoperatively and up to 12 months. Significantly less urinary bother was also noted in these men by 9-12 months postoperatively. Multivariate analysis revealed that bilateral or unilateral excellent NS (at least 1 bundle graded 4/4), increasing time from surgery, young patient age, and lower body mass index positively and significantly affected urinary functional outcomes, including pad use. Men who received excellent unilateral NS recovered urinary function about as well as men who had both neurovascular bundles spared in similar fashion., Conclusion: The quality of NS significantly influences patient-defined urinary functional convalescence. Completely sparing at least 1 neurovascular bundle along with its supportive tissues has a dramatic effect on the recovery of urinary continence and quality of life in preoperatively potent men., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To clarify the role of phosphodiesterase type 5 (PDE5) inhibitors in post-prostatectomy penile rehabilitation (PPPR). To compare nightly and on-demand use of PDE5 inhibitors after nerve-sparing minimally invasive radical prostatectomy (RP)., Patients and Methods: We conducted a single-institution, double-blind, randomized controlled trial of nightly vs on-demand 50-mg sildenafil citrate after nerve-sparing minimally invasive RP. A total of 100 preoperatively potent men, aged <65 years, with scores on the Erectile Function domain of the International Index of Erectile Function (IIEF-EF) ≥26, underwent nerve-sparing surgery. The patients were randomized to either nightly sildenafil and on-demand placebo (nightly sildenafil group), or on-demand sildenafil and nightly placebo (on-demand sildenafil group; maximum on-demand dose six tablets/month) for 12 months. Patients then underwent a 1-month washout period. Validated measures of erectile function (IIEF-EF score and the Expanded Prostate Cancer Index Composite [EPIC]) were compared between treatment groups over the entire 13-month time course, using multivariable mixed linear regression models., Results: The treatment groups were well matched preoperatively (mean age 54.3 vs 54.6 years, baseline IIEF-EF score 29.4 vs 29.3, for the nightly vs the on-demand sildenafil groups, respectively). No significant differences were found in erectile function between treatments (nightly vs on-demand sildenafil) at any single timepoint after RP, after adjusting for potential confounding factors. When evaluated over all timepoints simultaneously, no significant effects of treatment group (nightly vs on-demand sildenafil) were found on recovery of potency, as assessed by absolute IIEF-EF scores (P = 0.765), on percentage of men returning to an IIEF-EF score >21 (P = 0.830), or on IIEF-EF score recovery to a percentage of baseline value (P = 0.778). When evaluated over all timepoints simultaneously, no significant effects of treatment group were found on secondary endpoints such as assessment of potency (including EPIC item 59 response 'erections firm enough for intercourse'), attempted intercourse frequency or confidence., Conclusions: Erectile recovery up to 1 year after RP does not differ between previously potent men who use sildenafil nightly compared to on-demand. This trial does not support chronic nightly sildenafil as being any better than on-demand sildenafil for use in penile rehabilitation after nerve-sparing minimally invasive RP., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To evaluate the operative and pathologic outcomes of laparoscopic radical prostatectomy and robot-assisted radical prostatectomy in men with progressive changes in body mass index (BMI) category., Materials and Methods: A single-surgeon series of 1023 laparoscopic radical prostatectomy and robot-assisted radical prostatectomy (mostly extraperitoneal) patients was considered. Of these patients, 987 were evaluable. Results were stratified by the World Health Organization BMI category. Multivariate linear and logistic regression analysis was used to model the operating time, length of stay, positive surgical margins, and noncurable cancer., Results: Of the 987 patients, 563 (57%) were overweight and 193 (19.6%) were obese. Of the 193 obese patients, 152 (15.4%) had a BMI of 30 to <35 kg/m(2) (class I obesity), 28 (2.8%) a BMI of 35 to <40 kg/m(2) (class II), and 13 (1.3%) a BMI of ≥40 kg/m(2) (class III). No differences were found in the estimated blood loss, complications, PSM, pathologic stage, or biochemical recurrence across the BMI categories (6-month median follow-up). However, pelvic lymph node dissection was more commonly omitted and the nerve-sparing score was inferior in the obese men. On multivariate analysis, a higher BMI was a significant predictor of a longer operating time., Conclusion: Obese men can safely undergo laparoscopic radical prostatectomy or robot-assisted radical prostatectomy, although the ability to perform excellent nerve sparing appears to decrease with increasing obesity. Nevertheless, obese men can expect perioperative and early oncologic outcomes comparable to those of normal weight men without an increased risk of perioperative complications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) has prognostic and possible therapeutic benefits. We assessed whether an extraperitoneal minimally invasive RP (MiRP) allows for standard-template PLND comparable to transperitoneal MiRP+PLND., Patients and Methods: A retrospective clinicopathologic study of 914 consecutive patients who underwent MiRP (laparoscopic or Da Vinci robot-assisted laparoscopic) with bilateral PLND by one surgeon (CPP) from 2001 to 2010 was performed. Low-risk patients generally received a limited dissection (external iliac nodes) when PLND was performed. Those with intermediate- and high-risk disease generally received a standard PLND (external iliac and obturator nodes). Patients were stratified into groups based on operative approach (extraperitoneal vs transperitoneal) for most analyses., Results: Overall, 192 patients had transperitoneal MiRP+PLND, and 377 had extraperitoneal MiRP+PLND. The extraperitoneal group had higher body mass index (P=0.03), a higher percentage of low-risk (P=0.003), and a lower percentage of intermediate-risk disease (P=0.006). Lymph node yield (LNY) was higher with extraperitoneal PLND overall (6.5 vs 5.3, P=0.003). When stratified by risk category, LNY was greater in the extraperitoneal group for patients with low-risk disease only (6.6 vs 4.9, P=0.008). There was no difference in nodal yield in intermediate/high-risk patients receiving standard PLND by either the transperitoneal or extraperitoneal approach (6.0 vs 5.5, P=0.36 and 8.0 vs 5.8, P=0.14, respectively). Lymph node involvement was rare overall. Estimated blood loss and complication rates were comparable between operative approaches., Conclusion: The extraperitoneal MiRP approach does not compromise the oncologic efficacy or safety of routine PLND.

Objectives: To investigate the association of prostate weight with recovery of sexual function after minimally invasive radical prostatectomy., Methods: Between April 2001 and September 2007, two surgeons performed 856 consecutive laparoscopic radical prostatectomies for clinically localized prostate cancer. Patients were stratified into three groups by prostate weight: <35 g, 35-70 g, and >70 g. Sexual and urinary outcomes were assessed prospectively using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Patients who underwent nerve sparing (unilateral or bilateral) with complete preoperative EPIC data, a minimum preoperative Sexual Health Inventory for Men score ≥21, and a minimum of 3 months of complete postoperative EPIC data were included in the analysis., Results: Of the cohort of 856 men, 324 (38%) had complete, evaluable data and met the inclusion criteria for this study. Preoperatively, there were no significant differences by prostate weight in the EPIC sexual function or bother subscale scores or the proportion of patients participating in sexual intercourse. Postoperatively, we observed statistically similar returns to baseline EPIC sexual function and bother subscale scores and participation in sexual intercourse across all gland weight groups at all time points. EPIC sexual domain scores and the proportions of patients participating in sexual intercourse continued to increase up to 24 months postoperatively, but no group returned to preoperative function at any sampling point., Conclusions: Prostate size is not associated with postoperative recovery of sexual function in men undergoing minimally invasive radical prostatectomy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

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., (Copyright 2010 Elsevier Inc. All rights reserved.)

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.

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.

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.

Purpose: We performed a prospective analysis of pathological and oncological outcomes following laparoscopic radical prostatectomy at a medical center in the United States., Materials and Methods: A total of 528 men underwent laparoscopic radical prostatectomy between April 2001 and August 2005. We excluded 4 open surgical conversions (0.8%) and 16 men (3.0%) without followup. The remaining 508 men had a mean preoperative prostate specific antigen of 6.0 ng/ml (range 0.3 to 27) and Gleason score of 6.3 (range 6 to 10). Stage was cT1b in 1 case (0.2%), cT1c in 350 (68.9%), cT2a in 135 (26.6%), cT2b in 21 (4.1%) and cT2c in 1 (0.2%). Of the patients 89% underwent cavernous nerve preservation. Biochemical recurrence was defined and timed at the first prostate specific antigen of 0.2 ng/ml or greater if at repeat testing it remained 0.2 ng/ml or greater., Results: Mean followup was 13.2 months (median 12, range 2 to 52). Pathological stage was pT0N0/Nx in 2 men (0.4%), pT2N0/Nx in 414 (81.5%), pT3aN0/Nx in 72 (14.2%), pT3bN0/Nx in 17 (3.3%) and pT2-3N1 in 3 (0.6%). Positive margin rates increased with higher stage (8.2% in pT2 and 39.3% in pT3 cases, p <0.0001). Three-year actuarial biochemical recurrence-free survival was 98.2% for pT2N0/Nx and 78.7% for pT3N0/Nx/N1 disease (p <0.0001), and it was 94.5% overall. Multivariate analysis controlling for age, preoperative prostate specific antigen, postoperative Gleason score and stage, and margin status showed that only Gleason score (greater than vs less than 7) and stage (pT3 or any N1 vs pT2) predicted biochemical progression., Conclusions: Laparoscopic radical prostatectomy can provide excellent cancer control outcomes for clinically localized prostate cancer with high actuarial biochemical recurrence-free survival rates at 3 years.