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MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION
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MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION

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Mi presentación en las jornadas "MINIMALLY INVASIVE PROSTATE SURGERY" en Oporto del 24 y 25 de enero del 2014 - "Gestión de las complicaciones después de la prostatectomía radical laparoscópica (PRL): …

Mi presentación en las jornadas "MINIMALLY INVASIVE PROSTATE SURGERY" en Oporto del 24 y 25 de enero del 2014 - "Gestión de las complicaciones después de la prostatectomía radical laparoscópica (PRL): Cómo mejorar la incontinencia temprana y gestionar la disfunción eréctil".

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  • 1. MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION Eduard García Cruz Urología y Salud del Hombre Servicio de Urología Hospital Clínic de Barcelona ecruz@clinic.ub.es @drgarciacruz www.reisho.com Conflict of interest: I received funding for investigation from BAYER, Lilly, Pfizer, Auxilium and Janssen, and I have fomred part of comittees for Bayer, Lilly, Gebro, Almirall, Janssen, Italpharmaco abd Menarini. I am speaker for Lilly, Pierre Fabre and Bayer. CEO at DocFitSolution.
  • 2. STEP 1. BEFORE STEP 2. DURING STEP 3. AFTER
  • 3. DO WE GIVE REALISTIC AND COMPREHENSIVE INFO TO OUR PATIENTS? DO WE PREOP STRESS THE IMPORTANCE OF EARLY FUNCTIONAL REHAB? DO WE HAVE RELIABLE PREDICTING TOOLS? DO WE USE VALIDATED QUESTIONAIRES?
  • 4. STEP 1. BEFORE Neurovascular preservation indication. Use Validated Questionaires. Assess Risk. Realistic information about options and timing. STEP 2. DURING STEP 3. AFTER
  • 5. STEP 1. BEFORE Use Validated Questionaires Assess Risk. Neurovascular preservation indication. Realistic information about options and timing. STEP 2. DURING STEP 3. AFTER
  • 6. AGE, URETHRAL LENGTH, ROBOT (NS), NERVE SPARING (NS) AGE, ROBOT, TESTOSTERONE, D´AMICO RISK GROUPS (NS)
  • 7. STEP 1. BEFORE Use Validated Questionaires Assess Risk. Neurovascular preservation indication. Realistic information about options and timing. STEP 2. DURING Best possible surgery. STEP 3. AFTER
  • 8. STEP 1. BEFORE Use Validated Questionaires Assess Risk. Neurovascular preservation indication. Realistic information about options and timing. STEP 2. DURING Best possible surgery. STEP 3. AFTER
  • 9. of Erecti l e Functi on, and al so answ ered ‘yes’ to the questi on, ‘Over the past 4 w eeks, have your erecti ons been good enough for sati sfactory sexual acti vi ty?’ Secondary measures w ere changes from basel i ne i n the si x-i tem Erecti l e Functi on domai n of the Internati onal Index of Erecti l e Functi on and, for the pl ethysmography subgroup, the durati on of penile tumescence and rigidity. The Erectile Functi on domai n has a score range of 1–30, w i th ED graded as severe (1–10), moderate (11–16), mi l d to moderate (17–21), mi l d (22–25) and none (26–30).12 Statistics On the basi s of anal yses of Q3 and Q4 of the Internati onal Index of Erecti l e Functi on i n previ ous studi es, a conservati ve standard devi ati on of 2.00 w as assumed. If the mean si l denafi l versus pl acebo di fference for at l east one of the si l denafi l groups w as 1.5 poi nts for both vari abl es, then a sampl e si ze of 44 pati ents per treatment group w oul d provi de 90% pow er to detect a si gni fi cant di fference betw een vari abl es si ngl y and 80% pow er to detect si gni fi cant di fferences for both vari abl es joi ntl y, based on tw o-si ded anal ysi s of vari ance tests conducted at the 0.05 si gni fi cance l evel w i th Dunnett’s adjustment. Assuming that 80% of randomized patients would contribute to the i ntent-to-treat anal yses, a sampl e si ze of 55 pati ents per treatment group w as requi red. How ever, enrol l ment ceased after 125 because an i nteri m bl i nded revi ew of data from the 35 compl eted pati ents show ed a response rate of onl y 25% (9 of 35), w hi ch w as not w hat w as pl anni ng possi bl e future studi es. A l l stati sti cal anal yses w ere performed usi ng Stati sti cal A nal ysi s System softw are versi on 6.12 for effi cacy anal yses and versi on 8.2 for demographi c and safety anal yses. Pri mary and secondary effi cacy vari abl es w ere anal yzed i n pati ents w ho compl eted the 36-w eek doubl e-bl i nd treatment peri od and the 8-w eek drug-free eval uati on peri od. In the ori gi nal stati sti cal anal ysi s pl an, the pri mary effi cacy measure (percentage of responders) w as to be anal yzed usi ng the pai r-w i se Cochran– M antel –Haenszel (CM H) test. How ever, because the M antel –Fl ei ss cri teri on w as not sati sfi ed, the CM H test w as determi ned to be i nappropri ate for anal ysi s purposes. Therefore, Fi sher’s exact test (tw o-tai l ed) w as used as an al ternati ve (and appropri ate for the exi sti ng number of pati ents) approach, w i th the Bonferroni adjustment to account for mul ti pl e compari sons w i th pl acebo. Secondary effi cacy measures w ere anal yzed usi ng the nonparametri c Wi l coxon rank-sum test. Safety w as assessed i n pati ents w ho took at l east one dose of study medi cati on. Resul ts Of 238 pati ents screened, 125 w ere randomi zed to treatment and 123 recei ved at l east one dose of study drug. In total , 94% (117 of 125) of the randomi zed pati ents w ere enrol l ed at fi ve North A meri can si tes. Pati ents w ere l argel y si mi l ar among treatment groups w i th respect to demographi cs (Tabl e 1). A cross the groups, a si mi l ar number of pati ents Tabl e 1 Demographi cs of the pati ents w ho took study medi cati on and of the anal yzed popul ati on Took study medication (n ¼ 123)/anal yzed (n ¼76) Placebo Number of pati ents (n) M ean age, year (s.d.) (range) Race (% ) Whi te Bl ack Other M ean w ei ght, kg (s.d.) (range) Sildenafil (50 mg) Sildenafil (100 mg) 42/25a 57 (7)/56 (6) (42–70)/(42–67) 40/23a 55 (6)/55 (6) (42–67)/(42–63) 41/28 55 (6)/55 (6) (38–68)/(38–65) 88/92 12/8 0/0 80/83 17/13 3/4 90/89 7/11 3/0 88 (12)/88 (14) (68–123)/(68–123) 89 (11)/90 (12) (68–110)/(71–110) 84 (15)/85 (14) (66–113)/(66–113) a One addi ti onal pati ent w as randomi zed to thi s group, but di sconti nued before recei vi ng study drug. International Journal of Impotence Research
  • 10. Figure 2: The flow of patients throughout the study Mikkel Fode, MD 1, Michael Borre, MD, PhD, DSc (Med) 2, Dana A. Ohl, MD 3, Jonas Lichtbach 4 , Jens Sønksen, MD, PhD, DSc (Med) 1 1. Department of Urology, Herlev University Hospital, Herlev, Denmark The device was set to an amplitude of 2 mm and a vibration frequency of 100 Hz. Patients through a reusable but disposable black plastic disc as seen on the right end of the picture. Figure 1: The FERTI CARE® vibrator. The vibratory stimulation of the device is delivered Accepted Article 2. Department of Urology, Aarhus University Hospital, Aarhus, Denmark 3. Department of Urology, University of Michigan, Ann Arbor, USA Running title: PVS after Radical Prostatectomy Authors: seconds of stimulation every day). seconds of stimulation followed by a 10 second pause repeated 10 times (for a total of 100 were instructed in stimulating the frenulum once daily with a sequence consisting of 10 pted Article Title: Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve sparing radical prostatectomy: A randomized, controlled trial1 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. This article is protected by copyright. All rights reserved. 22 ted Article Title page
  • 11. Article ccepted Articl Table 2: Erectile function outcomes in the two groups after RP. Results reported as median (range) and proportions respectively. IIEF-5 at 3 IIEF-5 at 6 IIEF-5 at 12 IIEF-5 ≥ 18 IIEF-5 ≥ 18 IIEF-5 ≥ 18 at months months months at 3 months at 6 months 12 months PVS 5 (0-25) 10.5 (0-25) 18 (0-25) 5/30 (17%) 13/30 (43%) 16/30 (53%) Control 5 (0-25) 5 (0-25) 7.5 (0-25) 4/38 (11%) 9/38 (24%) 12/38 (32%) p-value 0.25 0.08 0.09 0.46 0.09 0.07 Table 3: Continence rates and pad use (median and range) after surgery Continence at 3 Continence at 6 Continence at Pad use at 3 Pad use at 6 Pad use at 12 months months 12 months months months months PVS 65.5% 83.3% 90% 1 (0 - 6) 0 (0 - 3) 0 (0 - 2) Control 62.9% 91.9% 94.7% 1 (0 - 4) 1/3 (0 - 6)* 0 (0 - 3) p-value 0.83 0.28 0.46 0.09 0.14 0.56 *One patient reported to use 1/3 of a pad daily. As there was no pre-specified decision on how to deal with such reporting, it was taken at face-value when analysing the results.
  • 12. ICI, IUA and VED TIMING OF THE REHAB
  • 13. STEP 1. BEFORE Use Validated Questionaires Assess Risk. Neurovascular preservation indication. Realistic information about options and timing. STEP 2. DURING Best possible surgery. STEP 3. AFTER Early onset? Multimodal? Optimal strategy unknown. PFMT and lifestyle changes
  • 14. AFTER CATHETER REMOVAL Tadalafil 5/24 MUSE* 3/week 3 MONTHS STOP REHAB AND ASSESS BACK TO BASELINE FUNCTIONAL ERECTIONS Observation Tadalafil 5/24 12 MONTHS NON-FUNCTIONAL ERECTIONS Tad 5/24 + MUSE 3/week STOP REHAB AND ASSESS BACK TO BASELINE FUNCTIONAL ERECTIONS Observation Patient preference NON-FUNCTIONAL ERECTIONS PDEI-5* vs MUSE* NON-FUNCTIONAL ERECTIONS PENILE PROSTHESIS * Minimum dose to get functional erections
  • 15. AFTER CATHETER REMOVAL PFMT 3 MONTHS ASSESS DRY 1 PAD Observation PFMT 12 MONTHS >1 PAD PFMT + DULOXETINE STOP REHAB AND ASSESS NOT DRY RSP + DULOXETINE* 1 PAD RSP + DULOXETINE 2 PADS SLING >2 PADS SPHINCTER
  • 16. MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MANAGE ERECTILE DYSFUNCTION Eduard García Cruz Urología y Salud del Hombre Servicio de Urología Hospital Clínic de Barcelona ecruz@clinic.ub.es @drgarciacruz www.reisho.com Conflict of interest: he recibido fondos para investigación de BAYER, Lilly, Pfizer, Auxilium y Janssen, he formado parte de comités asesores para Bayer, Lilly, Gebro, Almirall, Janssen, Italpharmaco y Menarini. Soy ponente para Lilly, Pierre Fabre y Bayer. CEO en DocFitSolution.

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