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Background: Prediction of side-specific extraprostatic extension (EPE) is crucial in selecting patients for nerve-sparing radical prostatectomy (RP). Multiple nomograms, which include magnetic resonance imaging (MRI) information, are available predict side-specific EPE. It is crucial that the accuracy of these nomograms is assessed with external validation to ensure they can be used in clinical practice to support medical decision-making., Methods: Data of prostate cancer (PCa) patients that underwent robot-assisted RP (RARP) from 2017 to 2021 at four European tertiary referral centers were collected retrospectively. Four previously developed nomograms for the prediction of side-specific EPE were identified and externally validated. Discrimination (area under the curve [AUC]), calibration and net benefit of four nomograms were assessed. To assess the strongest predictor among the MRI features included in all nomograms, we evaluated their association with side-specific EPE using multivariate regression analysis and Akaike Information Criterion (AIC)., Results: This study involved 773 patients with a total of 1546 prostate lobes. EPE was found in 338 (22%) lobes. The AUCs of the models predicting EPE ranged from 72.2% (95% CI 69.1-72.3%) (Wibmer) to 75.5% (95% CI 72.5-78.5%) (Nyarangi-Dix). The nomogram with the highest AUC varied across the cohorts. The Soeterik, Nyarangi-Dix, and Martini nomograms demonstrated fair to good calibration for clinically most relevant thresholds between 5 and 30%. In contrast, the Wibmer nomogram showed substantial overestimation of EPE risk for thresholds above 25%. The Nyarangi-Dix nomogram demonstrated a higher net benefit for risk thresholds between 20 and 30% when compared to the other three nomograms. Of all MRI features, the European Society of Urogenital Radiology score and tumor capsule contact length showed the highest AUCs and lowest AIC., Conclusion: The Nyarangi-Dix, Martini and Soeterik nomograms resulted in accurate EPE prediction and are therefore suitable to support medical decision-making., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: Accurate prediction of extraprostatic extension (EPE) is pivotal for surgical planning. Herein, we aimed to provide an updated model for predicting EPE among patients diagnosed with MRI-targeted biopsy., Materials and Methods: We analyzed a multi-institutional dataset of men with clinically localized prostate cancer diagnosed by MRI-targeted biopsy and subsequently underwent prostatectomy. To develop a side-specific predictive model, we considered the prostatic lobes separately. A multivariable logistic regression analysis was fitted to predict side-specific EPE. The decision curve analysis was used to evaluate the net clinical benefit. Finally, a regression tree was employed to identify three risk categories to assist urologists in selecting candidates for nerve-sparing, incremental nerve sparing and non-nerve-sparing surgery., Results: Overall, data from 3169 hemi-prostates were considered, after the exclusion of prostatic lobes with no biopsy-documented tumor. EPE was present on final pathology in 1,094 (34%) cases. Among these, MRI was able to predict EPE correctly in 568 (52%) cases. A model including PSA, maximum diameter of the index lesion, presence of EPE on MRI, highest ISUP grade in the ipsilateral hemi-prostate, and percentage of positive cores in the ipsilateral hemi-prostate achieved an AUC of 81% after internal validation. Overall, 566, 577, and 2,026 observations fell in the low-, intermediate- and high-risk groups for EPE, as identified by the regression tree. The EPE rate across the groups was: 5.1%, 14.9%, and 48% for the low-, intermediate- and high-risk group, respectively., Conclusion: In this study we present an update of the first side-specific MRI-based nomogram for the prediction of extraprostatic extension together with updated risk categories to help clinicians in deciding on the best approach to nerve-preservation., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: While the addition of androgen receptor signaling inhibitors (ARSIs) to androgen deprivation therapy (ADT) results in better of overall survival in patients with metastatic hormone-sensitive prostate cancer (mHSPC), information regarding health related quality of life (HR-QoL) is sparse. We aimed at summarizing current evidence on the impact of ARSIs on HR-QoL., Methods: We performed a systematic review of the published literature on PubMed/EMBASE, Web of Science, SCOPUS, and the Cochrane libraries between January 2011 and April 2022. We included only phase III randomized controlled trials (RCT), which were selected according to the PRISMA guidelines. We aimed at evaluating differences in HR-QoL, assessed by validated patient reported outcomes instruments. We analyzed global scores and sub-domains such as sexual functioning, urinary symptoms, bowel symptoms, pain/fatigue, emotional and social/family wellbeing. We reported data descriptively., Results: Six RCTs were included: two used enzalutamide with ADT as intervention arms (ARCHES, ENZAMET); one used apalutamide with ADT (TITAN); two abiraterone acetate and prednisone (AAP) with ADT (STAMPEDE, LATITUDE); and one darolutamide with ADT (ARASENS). Enzalutamide or AAP with ADT increase overall HR-QoL in comparison with ADT alone, ADT with first generation nonsteroideal anti-androgens or ADT with docetaxel, whereas apalutamide and darolutamide with ADT maintain HR-QoL similarly to ADT alone or ADT with docetaxel, respectively. Time to first deterioration of pain was longer with combination therapy with enzalutamide, AAP or darolutamide, but not with apalutamide. No worsening of emotional wellbeing was reported from the addition of ARSIs to ADT than ADT alone., Conclusions: The addition of ARSIs to ADT in mHSPC tends to increase overall HR-QoL and prolong time to first deterioration of pain/fatigue compared with ADT alone, ADT with first generation nonsteroideal anti-androgens, and ADT with docetaxel. ARSIs show a complex interaction with remaining HR-QoL domains. We advocate a standardization of HR-QoL measurement and reporting to allow further comparisons., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Positron Emission Tomography-Computed Tomography using Prostate-Specific Membrane Antigen (PSMA PET/CT) is notable for its superior sensitivity and specificity in detecting recurrent PCa and is under investigation for its potential in pre-treatment staging. Despite its established efficacy in nodal and metastasis staging in trial setting, its role in primary staging awaits fuller validation due to limited evidence on oncologic outcomes. This systematic review and meta-analysis aims to appraise the diagnostic accuracy of PSMA PET/CT compared to CI for comprehensive PCa staging., Methods: Medline, Scopus and Web of science databases were searched till March 2023. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. Primary outcomes were specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) of PSMA PET/CT for local, nodal and metastatic staging in PCa patients. Due to the unavailability of data, a meta-analysis was feasible only for detection of seminal vesicles invasion (SVI) and LNI., Results: A total of 49 studies, comprising 3876 patients, were included. Of these, 6 investigated accuracy of PSMA PET/CT in detection of SVI. Pooled sensitivity, specificity, PPV and NPV were 42.29% (95%CI: 29.85-55.78%), 87.59% (95%CI: 77.10%-93.67%), 93.39% (95%CI: 74.95%-98.52%) and 86.60% (95%CI: 58.83%-96.69%), respectively. Heterogeneity analysis revealed significant variability for PPV and NPV. 18 studies investigated PSMA PET/CT accuracy in detection of LNI. Aggregate sensitivity, specificity, PPV and NPV were 43.63% (95%CI: 34.19-53.56%), 85.55% (95%CI: 75.95%-91.74%), 67.47% (95%CI: 52.42%-79.6%) and 83.61% (95%CI: 79.19%-87.24%). No significant heterogeneity was found between studies., Conclusions: The present systematic review and meta-analysis highlights PSMA PET-CT effectiveness in detecting SVI and its good accuracy in LNI compared to CI. Nonetheless, it also reveals a lack of high-quality research on its performance in clinical T staging, extraprostatic extension and distant metastasis evaluation, emphasizing the need for further rigorous studies., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Limited evidence exists about preserving neurovascular bundles during radical prostatectomy (RP) for high-risk prostate cancer (HRPCa) patients. Hence, we validated an existing algorithm predicting contralateral extraprostatic extension (cEPE) risk in unilateral high-risk cases. This algorithm aims to assist in determining the suitability of unilateral nerve-sparing RP. Among 264 patients, 48 (18%) had cEPE. The risk of cECE varied: 8%, 17.2%, and 30.8% for the low, intermediate, and high-risk groups, respectively. Despite a higher risk of cECE among individuals classified as low-risk in the development group compared to the validation group, our algorithm's superiority over always/never nerve-sparing RP was reaffirmed by decision curve analysis. Therefore, we conclude that bilateral excision may not always be justified in men with unilateral HRPCa. Instead, decisions can be based on our suggested nomogram., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Changes applied to the Prostate cancer (PCa) histopathology grading, where patients with cribriform patterns (CP) may be categorized as grade group 2 and could hypothetically be surveilled. However, CP has been associated with worse oncological outcomes. The aim of our study is to systematically review and meta-analyze the available evidence on CP in PCa patients., Methods: This analysis was registered on PROSPERO (CRD42022298473). We performed a systematic literature search of PubMed, EMBASE and Scopus using Medical Subject Headings (MeSH) indexes, keyword searches, and publication types until December 2021. The search terms included: "prostate", "prostate cancer" and "cribriform". We also searched reference lists of relevant articles. Eligible studies included published journal articles that provided quantitative data on the association between cribriform patterns at radical prostatectomy and the presence of extra-prostatic extension (EPE), seminal vesicle invasion (SVI), positive surgical margins (PSM), biochemical recurrence (BCR) or cancer specific mortality (CSM)., Results: Overall, 31 studies were included for the quantitative analysis. All articles have been published during a span of 11 years (2011-2022) with a mean month of follow-up of 62.87 months. The mean quality of these studies, assessed with the Newcastle Ottawa Scale was 6.27. We demonstrated that CP was associated with greater risk of EPE (odds ratio [OR] 1.96; P < 0.0001), SVI (OR: 2.89; p < 0.01), and PSM (OR: 1.88; p < 0.0007). Our analyses showed that CP was associated with greater risk of BCR (hazard ratio [HR]: 2.14; p < 0.01) and of CSM (HR: 3.30, p < 0.01)., Conclusion: The presence of CP is associated with adverse pathology at radical prostatectomy and worse biochemical recurrence and cancer specific mortality. These results highlight the importance of a better pathologic report of CP to advise clinician for a strict follow-up in PCa patients., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Combination systemic therapies have become the standard for metastatic hormone-sensitive prostate cancer (mHSPC). However, the effect of age on oncologic outcomes remains unknown. Our aim was to perform a systematic review, meta-analysis, and network meta-analysis (NMA) on the effect of chronological age on overall survival (OS) in patients treated with combination therapies for mHSPC., Methods: We searched the PubMed ® , Web of Science TM , and Scopus ® databases to identify randomized controlled trials (RCTs) that analyzed the efficacy of combination systemic therapies using ADT plus docetaxel and/or androgen receptor signaling inhibitor (ARSI) in patients with mHSPC. We included studies, which provided separate hazard ratios (HRs) for younger vs. older patients. The selected age cut-off was 70 years (±5 years). Our outcome of interest was OS., Results: We included nine RCTs with a total of 9183 patients. Younger and older men constituted 51% and 49% of included patients, respectively. Docetaxel plus ADT significantly improved OS among both older (HR 0.79, 95% CI 0.63-0.99, p = 0.04) and younger patients (HR 0.79, 95% CI 0.69-0.90, p < 0.001) with no differences according to age. ARSI plus ADT improved OS in older (HR 0.72, 95% CI 0.64-0.80, p < 0.001) and younger (HR 0.58, 95% CI 0.51-0.66, p < 0.001) patients; younger patients did benefit more (p = 0.02). On NMA treatment ranking, triplet therapy showed the highest probability of OS benefit irrespective of age group; in older patients, the benefit of triplet therapy compared to doublet was less expressed., Conclusions: Patients with mHSPC benefit from combination systemic therapies irrespective of age; the effect is, however, more evident in younger patients. Chronological age alone seems not to be a selection criteria for the administration of combination systemic therapies., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Recently, the use of targeted biopsy has been subject to critics, as it has been speculated that targeted biopsy might lead to overdiagnosis of clinically significant prostate cancer (PCa). In this study, we tried to evaluate whether targeted sampling in patients with organ-confined disease and ISUP 2 disease was associated with downgrading of the prostatectomy specimen, hence, leading to an unnecessary treatment, in terms of radical surgery. We relied on a prospectively-maintained multi-institutional database and identified 1293 patients with ISUP 2 disease on targeted biopsy only. Median (IQR) patients' age at diagnosis was 65 (60, 70) years. Median PSA was 6.8 (5.0, 9.6) ng/ml. Overall, only 33 (2.6%) patients presented downgrading on their RP specimens. Patients who experienced downgrading were biopsied more frequently trans-rectally, had a lower total tumor length in mm and lower percentage of maximum core involvement and lower rates of cancer on systematic biopsy (all p ≤ 0.03). The strongest factors associated with reduced risk of downgrading were total tumor length, in mm, (OR: 0.71, 95% CI: 0.62,0.82, p < 0.001) and transperineal biopsy route (OR: 0.38, 95% CI: 0.14,1.00, p = 0.05)., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: To assess the diagnostic added value of sampling secondary lesions at prostate mpMRI (SL) in addition to index lesion (IL) in detecting significant prostate cancer (csPCa) when also systematic biopsy (SBx) is performed., Methods: We relied on a cohort of 312 men with two suspicious lesions at prostate mpMRI who underwent subsequent targeted biopsy of each lesion (TBx) and concomitant SBx at two tertiary-referral centers between 2013 and 2019. The study outcome was the added value of targeting SL (i.e., the one with a lower PI-RADS score and/or the smaller size compared to IL) in the detection of csPCa. To this aim, we compared different biopsy strategies (SBx + overall TBx vs SBx + IL-targeted biopsy vs SBx + SL-targeted biopsy) and assessed whether SL features could be correlated with detection of csPCa at overall TBx in a multivariable logistic regression model (MVA)., Results: Overall, 44% of men had csPCa at TBx of all lesions while 39% and 23% of men had csPCa found in IL and SL, respectively. The rate of csPCa found at SBx, IL-TBx, and SL-TBx only was 5%, 6%, and 2%, respectively. The detection rate of csPCa for SBx + IL-TBx was 47%. The addition of SL-TBx increased csPCa detection by only 2% (p = 0.12). At MVA, neither PI-RADS of SL nor the number of cores targeting SL was associated with an increased detection of csPCa (all p > 0.3). Conversely, age (OR: 1.07), PSA (OR: 1.07), prostate volume (OR: 0.98), and PI-RADS of the IL (OR: 2.36) were independently associated with csPCa detection at TBx (all p < 0.01)., Conclusions: There is no significant benefit in terms of csPCa detection when an adequate SBx is performed in combination with IL-TBx in patients with multiple mpMRI lesions. In these men target biopsy of secondary lesions can be safely omitted., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To investigate the oncologic safety of neurovascular bundles (NVB) preservation at radical prostatectomy (RP) in patients with high-risk and/or locally advanced prostate cancer (PCa)., Material and Methods: Within a two-institutional high-volume center database we identified patients who harbored high-risk PCa at RP (2000-2017). Only patients with D'Amico high-risk PCa were included. Kaplan-Meier and multivariable Cox regression models tested the effect of NVB preservation on biochemical recurrence (BCR), metastasis and overall survival (OS). Subgroup analyses focused on patients with clinical stage T3 and/or biopsy ISUP grade 5 and pathologic stage T3., Results: Of 4351 patients with D'Amico high-risk, 35.7% vs. 38.0% vs. 26.3% underwent bilateral vs. unilateral vs. no NVB preservation, respectively. At 120 months after RP BCR-free, metastasis-free survival and OS rates were 62.2% vs. 44.3% vs. 27.1% (p < 0.001), 83.7% vs. 66.7% vs. 60.3% (p < 0.001), and 91.8% vs. 87.5% vs. 72.3% (p < 0.001) for bilateral vs. unilateral vs. no NVB preservation, respectively. In multivariable Cox regression models, bilateral and unilateral compared to no NVB preservation did not increase the risk for BCR, metastasis or death in the entire cohort and in subgroups with clinical stage T3 and/or biopsy ISUP grade 5, as well as pathologic stage T3., Conclusions: NVB preservation was not associated with worse oncological outcome in patients with high-risk and/or locally advanced PCa and may be offered to well-selected patients who are at risk of harboring nonorgan-confined PCa.

Background: To investigate the effect of frailty on short-term postoperative outcomes in patients with prostate cancer treated with radical prostatectomy (RP)., Methods: Within the National Inpatient Sample database, we identified 91,618 RP patients treated between 2008 and 2015. The Johns Hopkins Adjusted Clinical Groups frailty-defining indicator was applied, and we examined the rates of frailty over time, as well as its effect on overall complications, major complications, nonhome-based discharge, length of stay (LOS), and total hospital charges (THCs). Time trends and multivariable logistic, Poisson and linear regression models were applied., Results: Overall, 12,185 (13.3%) patients were frail. Rates of frail patients increased over time (from 10.3 to 18.2%; p < 0.001). Frail patients had higher rates of overall complications (16.6 vs. 8.6%), major complications (4.9 vs. 2.6%), nonhome-based discharge (5.9 vs. 5%), longer LOS (2 vs. 1), and higher THCs ($37,186 vs. $35,241) (all p < 0.001). Moreover, frailty was an independent predictor of overall complications (OR: 1.95), major complications (OR: 1.76), nonhome-based discharge (OR: 1.20), longer LOS (RR: 1.19), and higher THCs (RR: $3160) (all p < 0.001). Of frail patients, 10,418 (85.5%) neither exhibited body mass index ≥ 30 nor Charlson comorbidity index ≥ 2., Conclusions: On average, every seventh RP patient is frail and that proportion is on the rise. Frail individuals are at higher risk of adverse short-term postoperative outcomes, that cannot be predicted by other risk factors, such as obesity or comorbidities.

Background: Use of inpatient palliative care (IPC) in advanced cancer patients represents a well-established guideline recommendation. A recent analysis demonstrated that genitourinary (GU) cancer patients benefited of IPC at the second lowest rate within the four examined primaries, namely lung, breast, colorectal, and GU. Based on this observation, we examined temporal trends and predictors of IPC use in metastatic prostate cancer patients receiving critical care therapies (CCT)., Materials and Methods: We identified mPCa patients receiving CCT within the Nationwide Inpatient Sample database (2004-2015). IPC use rates were evaluated using univariable estimated annual percentage changes analyses. Multivariable logistic regression (MLR) models were used after adjustment for clustering at hospital level., Results: Of 4168 mPCa patients receiving CCT, 449 (11.3%) received IPC. IPC use increased from 1.2 to 22.3% (EAPC: +19.6%, p < 0.001). After stratification according to regions, race, and teaching status, the highest increase of IPC use was recorded in the South (from 0 to 25.4 %, EAPC: +27.6%), in Caucasians (from 1.5 to 24.4 %, EAPC: +19.8%; p < 0.001) and in teaching hospitals (from 0.9 to 26.2 %, EAPC: +19.6%; p < 0.001). In MLR models, teaching status (Odds ratio [OR]: 1.74, p < 0.001) and contemporary year interval (OR: 4.63, p < 0.001) were associated with higher IPC rates. Conversely, African American race (OR: 0.66, p < 0.001) and primary diagnosis of GU disorders (OR: 0.49, p < 0.001) and gastrointestinal (GI) disorders at admission (OR: 0.61, p = 0.02) were associated with lower IPC rates., Conclusions: IPC use rate in mPCa patients receiving CCT sharply increased between 2004 and 2015. The highest increase of IPC use across time was recorded in the South, in Caucasian race, and in teaching hospitals. African-American race and nonteaching status were identified as independent predictors of lower IPC use and represent targets for efforts aimed at improving IPC delivery in mPCa patients receiving CCT.

Background: To ascertain 3-year urinary continence (UC) and sexual function (SF) recovery following robot-assisted radical prostatectomy (RARP) for clinically high-risk prostate cancer (PCa)., Methods: Retrospective analyses of a prospectively maintained database for 769 patients with D'Amico high-risk PCa undergoing RARP at two tertiary care centers in the United States and Europe between 2001 and 2014. The association between time since RARP and recovery of UC (defined as 0 pad/one safety liner per day) and SF (defined as sexual health inventory for men (SHIM) score ⩾17) was tested in separate preoperative and post-operative Cox-proportional hazards regression models. Sensitivity analyses were conducted using continence 0 pad per day and erection sufficient for intercourse as end points for UC and SF recovery, respectively., Results: Mean age of the cohort was 62.3 years, and 62.1% harbored ⩾PT3a disease. Nerve sparing (unilateral or bilateral) RARP was performed in 87.7% of patients. Kaplan-Meier estimates of UC recovery at 12, 24 and 36 months after surgery was 85.2%, 89.1% and 91.2%, respectively, while 33.8, 52.3 and 69.0% of preoperatively potent men (preoperative SHIM ⩾17; n=548; 71.3%) recovered SF. Similar results were noted in sensitivity analyses. Patient age and year of surgery were associated with UC and SF recovery; additionally, preoperative SHIM score, degree of nerve sparing, pT3b-T4 disease and surgical margins were associated with SF recovery over the period of observation., Conclusions: Patients with D'Amico high-risk PCa treated with RARP may continue to recover UC and SF beyond 12 months of surgery and show promising outcomes at 3-year follow-up. Appropriate patient selection and counseling may aid in setting realistic expectations for functional recovery post RARP.

Background: Erectile dysfunction (ED) represents one of the most common long-term side effects in prostate cancer (PCa) patients treated with bilateral nerve-sparing radical prostatectomy (BNSRP). The aim of our study was to assess the influence of non-surgically related causes of ED in patients treated with BNSRP., Methods: Overall, 716 patients treated with BNSRP were retrospectively identified. All patients had complete data on erectile function (EF) assessed by the Index of Erectile Function-EF domain (IIEF-EF) and depressive status assessed by the Center for Epidemiologic Studies-Depression (CES-D) questionnaire. EF recovery was defined as an IIEF-EF of ⩾22. Kaplan-Meier analyses assessed the impact of preoperative IIEF-EF, depression and adjuvant radiotherapy (aRT) on the time to EF recovery. Multivariable Cox regression models were used to test the impact of aRT on EF recovery after accounting for depression and baseline IIEF-EF., Results: Median follow-up was 48 months. Patients with a preoperative IIEF-EF of ⩾22 had substantially higher EF recovery rates compared with those with a lower IIEF-EF (P<0.001). Patients with a CES-D of <16 had significantly higher EF recovery rates compared to those with depression (60.8 vs 49.2%; P=0.03). Patients receiving postoperative aRT had lower rates of EF compared with their counterparts left untreated after surgery (40.7 vs 59.8%; P<0.001). These results were confirmed in multivariable analyses, where preoperative IIEF-EF (P<0.001), depression (P=0.04) and aRT (P=0.03) were confirmed as significant predictors of EF recovery., Conclusions: Preoperative functional status and depression should be considered when counseling PCa patients regarding the long-term side effects of BNSRP. Moreover, the administration of aRT has a detrimental effect on the probability of recovering EF after BNSRP. This should be taken into account when balancing the potential benefits and side effects of multimodal therapies in PCa patients.

Background: The therapeutic effect of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) due to prostate cancer (PCa) is still under debate. We aimed at assessing the impact of more extensive PLND on cancer-specific mortality (CSM) in patients treated with surgery for locally advanced PCa., Methods: We examined data of 1586 pT3-T4 PCa patients treated with RP and extended PLND between 1987 and 2012 at a tertiary referral care center. Univariable and multivariable Cox regression analyses tested the relationship between the number of nodes removed and CSM rate, after adjusting for potential confounders. Survival estimates were based on the multivariable models., Results: The average number of nodes removed was 19 (median: 17; interquartile range: 11-23). Mean and median follow-up were 80 and 72 months, respectively. At multivariable analyses, Gleason score 8-10 (hazard ratio (HR): 2.5) and a higher number of positive nodes (HR: 1.06) were independently associated with higher CSM rate (all P<0.05). Conversely, higher number of removed LNs (HR: 0.94) and adjuvant radiotherapy (HR: 0.54) were independent predictors of lower CSM rates (all P⩽0.03)., Conclusions: In pT3-T4 PCa patients, removal of a higher number of LNs during RP was associated with higher cancer-specific survival rates. This supports the role of more extensive PLNDs in this patient group. Further prospective studies are needed to validate our findings.

It is well known that the administration of phosphodiesterase type-5 inhibitors (PDE5-Is) may improve erectile function (EF) recovery after bilateral nerve-sparing radical prostatectomy (BNSRP). The aim of our study was to identify predictors of the use of a high number of PDE5-Is (one or more per week) after surgery among 184 patients taking proerectile medications on demand. At a mean follow-up of 22.7 months, 116 patients (63%) recovered EF. Overall, EF recovery rates at 1- and 2- year follow-up were 47.3% and 65.4%, respectively. Overall, 43 (23.4%) patients used one or more PDE5-Is per week. Preoperative EF was the only predictor of the use of one or more PDE5-Is per week after BNSRP. This held true even after adjusting our analyses for age at surgery, body mass index and EF at 1 month after surgery. Particularly, patients fully potent before surgery had roughly 2.1-fold higher probability of using one or more pills per week compared with their counterparts with some degree of preoperative erectile dysfunction (ED; odds ratio: 2.16; 95% confidence interval: 1.03-4.37). In conclusion, preoperative EF represents the only determinant of the use of a higher number of PDE5-Is after surgery. Patients with better preoperative EF might represent individuals more motivated to achieve satisfactory sexual function after surgery. These observations should provide physicians with better preoperative patient counseling and management of postoperative ED.