الفهرس 
Material and methodsOnly 14 pages are availabe for public view
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Abstract
bladder cancer necessitating radical cystoprostatectomy. Nerve sparing technique was used in 33 cases, bilateral nerve sparing in 23 cases and unilateral in 10 cases. In eight cases the neurovascular bundles were sacrificed bilaterally. The sexual function of those patients was assessed before and after surgery subjectively using questions number 3, 4 and question number 7 of the International Index of Erectile Function (IIEF), total score of 1 to 4 equal poor erectile function, score 5 to 10 equal moderate erectile function, and score 11 to 15 equal good erectile function with objective evaluation by assessing the penile hemodynamic profile using intracavernous injection testing. In addition, single potential analysis of the cavernous electrical activity to assess the integrity of the cavernous nerves and corpus cavemostun smooth muscles as well. Patients fall into one of three groups according to age at operation, group
I (below 50 years old), group H (50 to 60 years old), and group III (above
60 years old).
Six months postoperatively, subjective good erectile function was found in 30% while moderate and poor erectile function was found in 70%. Twelve months postoperatively, good erectile function in 45% and moderate and poor in 55% of patients. According to age groups, below 50 years old the erectile function was good in 100% of cases (five cases). In the age group 50 to 60 years old (16 cases) the erectile function. Was good in 31%, moderate and poor in 69%. Above the age of 60 years old (12 cases) the erectile function moderate and poor in 100% of cases.
(le(tAri
This study was conducted in Urology Department, Benha Faculty 5 2
of Medicine since July 1999 till June 2002 on 41 cases with invasive remarn
/AI
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SUMMARY AND CONCLUSION
After non-nerve sparing surgery the erectile function was found to be moderate and poor in 100% of cases.
Hemodynamic evaluation of the patients preoperatively showed that the peak systolic velocity tend to be decreased with age and this was statistically significant also two cases of increased end diastolic velocity were observed. Postoperatively hemodynamic evaluation revealed affection of all parameters in all patients and this was mostly in patients with moderate and poor erectile function. The cause of postoperative hemodynamic affection may be secondary to cavernous ischemia due to hypoxia from loss of erection in the early postoperative course. Another explanation is denervation or partial injury of the cavernous nerves that lead to defective blood flow with altered nitric oxide mediated responses. Hence, the development of penile fibrotic lesions that were noticed after mean postoperative time about 14 months, a new complication recently reported due to denervation.
The use of single potential analysis of cavernous electrical activity (SPACE) enabled us to detect integrity of the cavernous nerves pre- and postoperatively hence success of sparing nerves either unilaterally or bilaterally. Also SPACE gave an idea about the changes that might occur in the cavernous smooth muscles postoperatively, these changes may give an explanation of the etiology of erectile dysfunction postoperatively.
Causes of postoperative erectile dysfunction after nerve-sparing technique in this study include: veno — occlusive dysfunction (30%), arterial insufficiency (15%), cavernous nerve injury (12%) and psychogenic (24%). We addressed these causes as early as at least 6 months postoperatively for discovering this complication early to find appropriate solutions for those patients, the part that was beyond the
scope of our study.
214
SUMMARY AND CONCLUSION
After non-nerve sparing cystoprostatectomy, veno-occlusive dysfunction was found in 25% and arterial insufficiency in 25% of cases denoting that there are other causes for erectile dysfunction after non-nerve sparing cystoprostatectomy in addition to the neurogenic cause. Furthermore, it was shown that erectile inactivity does not affect the possible return of drug-induced sexual potency.
The nerve sparing technique is not a guarantee that the erectile function will be preserved. Age at operation, preoperative erectile function score and tumor stage were found to be the statistically significant predictors of good postoperative erectile function. The previously mentioned factors could affect the outcome as regarding the return of sexual function, also it was noticed that patients with preoperative affection of the cavernous nerves got little benefit from the
technique.
Factors affecting the postoperative erectile function are:
•Age at operation.
•The preoperative sexual activity.
•Tumor stage.
•The integrity of the cavernous nerves and the corpus cavernosum smooth muscles.
•Hypoxia of the cavernous erectile tissue due to delayed return of erections.
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RECOMMENDATIONS
Nerve sparing technique must be offered for all patients with invasive bladder cancer and organ confined disease as it is followed by decreased incidence of genitourinary complications due to iatrogenic
injury during this major pelvic surgery.
When the integrity of the cavernous nerves is questioned
preoperatively and nerve-sparing technique will be applied, corpus cavernosum electromyography might be needed as it gives an idea about the integrity of the cavernous nerves and smooth muscles of the corpora
cavemosa.
We encourage early postoperative administration of prostaglandin
E1 as early as the first postoperative month according to Montorsi et at, (1995) as this may guard against the fibrotic changes in the corpus cavernosum smooth muscles.