113 Expedited algorithm for IPP following Radical Prostatectomy
Authors: Suarez-Sarmiento A , Perito P , Fakhoury M , Levitt B 
Published: April 2022

ABSTRACT

Introduction
Erectile dysfunction (ED) following radical prostatectomy (RP) is a postoperative result that negatively impacts patient quality of life. The recovery of potency following radical prostatectomy varies depending on a multitude of factors including but not limited to surgical technique, surgeon experience and patient comorbidities. There are several factors that contribute to this decline in erectile function as a result of oncologic control after RP which may be classified as vasculogenic, neurogenic, and psychological. Current guidelines recommend patients wait up to 24 months before IPP surgery. However, no definitive algorithm or guideline has been established for the expedited management of ED in the postoperative setting following radical prostatectomy.

Objective
We are proposing an expedited algorithm for patients who fail PDE-5 inhibitors at the three-month follow-up following RP.

Methods
Patients who underwent inflatable penile prosthesis (IPP) surgery for the treatment of ED over a 36-month period following RP were identified from our IRB approved database. All patients completed an IIEF-5 questionnaire and had a penile doppler ultrasound (PDUS) performed preoperatively. Validated scoring for erectile function was performed with the International Index of Erectile Function (IIEF-5), and the Sexual Health Inventory for Men (SHIM) was defined. The relationships, according to Doppler diagnosis, IIEF-5 score, SHIM scale, and erection score were evaluated as well as surgical outcomes and patient comorbidities. Logistic regression and Wilcoxon rank sum tests were performed.

Results
1,158 patients were evaluated in this series, of whom 121 met inclusion criteria. PDUS determined that 88 (72.8%) suffered from veno-occlusive disease, while 19 (15.7%) had arterial insufficiency. 101 (83.4%) had a RALP vs 20 (16.6%) who received an open RP. The mean time between RP and IPP was 20 months, with the mean ages of RP and IPP being 58 and 64 years respectively. Ages of patients ranged from 40 to 82 years old. Increased time between RP and subsequent IPP was correlated with lower SHIM scores. Additionally, each month that passed caused a decrease of 1.8% in SHIM scores (p&lt; 0.05), as well as a greater likelihood of developing worsening vasculogenic ED (p= 0.042). Increased patient age during RP and subsequent IPP was also correlated with lower SHIM scores (p= 0.049), while RALP was found to be a predictor of higher patient satisfaction (p= 0.02).

Conclusions
As a result of the overwhelming diminishing SHIM scores over the 20 month postoperative course following RP as well as the significant prevalence of veno-ccclusive disease in this common patient population, we are strongly recommending a baseline PDUS at the 3 month followup. Furthermore, if veno-occlusive disease is identified upon the 3 month baseline PDUS, we encourage frank discussion of IPP placement with the patient. Equally important is it to consider discussing the degree of veno-occlusive disease and resultant ED will worsen as the postoperative period lengthens. Those patients found to have veno-occlusive etiology should have early surgical intervention mitigating further severity of the subsequent veno-occlusive disease.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific