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How do Sexual Medicine specialists Handle Patient Counseling and Penile Rehabilitation in patients undergoing Robotic Assisted Radical Prostatectomy (RALP): Trends in Pre op and Post Operative Management
Dylan Heckscher, MD1, Katherine Rotker, MD1, Stanton Honig, MD2.
1Yale-New Haven Hospital, New Haven, CT, USA, 2Yale School of Medicine, New Haven, CT, USA.

Background: Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel has been published in Journal of Sexual Medicine in late 2022. However, evaluation and treatment in this subset of patients appears to be variable and not evidence driven. The objective of our study was to poll sexual medicine specialists regarding their current evaluation and treatment of sexual dysfunction before and after RALP. Methods: 22 sexual medicine specialists took a questionnaire at the time of the SMSNA/ISSM meeting in the fall of 2022. Queries were made regarding the demographics of the specialists, their pre operative evaluation, guidance and treatments, and the nature of their referral base. Information was also collected regarding pre operative questions about multiple sexual parameters such as ejaculation, penile curvature, erectile function, climacturia and any initiation of pre op therapies. Post operative questionnaire data included timing of initial evaluation, therapeutic recommendations and likelihood and timing of post operative recovery of function.

Pre- and Post-operative RALP Outpatient Sexual Medicine Practices
Yes, routinelySometimesNo
Counsel about risk of ejaculatory pain7 (31.8%)5 (22.7%)10 (45.5%)
Counsel about risk of climacturia11 (47.8%)4 (17.4%)8 (34.8%)
Counsel about risk of penile length loss16 (69.6%)1 (4.3%)6 (26.1%)
Counsel about risk of significant erectile dysfunction17 (73.9%)5 (21.7%)1 (4.3%)
Counsel about risk of penile curvature7 (30.4%)12 (52.2%)4 (17.4%0
Counsel about likely need for ED medication22 (95.7%)01 (4.3%)
Start PDE5is12 (54.5%)6 (27.3%)4 (18.2%)
Recommend vacuum erection device7 (30.4%)1 (4.3%)15 (65.2%)
Recommend pelvic floor rehabilitation3 (13%)1 (4.3%)19 (82.6%)
Review risk factors for postoperative outcomes19 (86.4%)3 (13.6%)
Recommend vacuum erection device13 (56.5%)3 (13%)7 (30.4%)
Encourage PDE5i use19 (82.6%)1 (4.3%)3 (13%)
Recommend penile injection therapy for rehabilitation19 (82.6%)04 (17.4%)

23 responses were collected. 100% of respondents were SMSNA members, 8 (34.8%) were ISSM members. 22 (95.7%) had a subspecialty practice in sexual medicine. 100% were located in North America.
A majority of respondents (19/23, 82.6%) had between 2-10 prostate surgeons in their practice. 9 (39.1%) reported that those surgeons routinely sent patients for preoperative optimization; 4 (17.4%) reported that none did so.7 (31.8%) regularly counseled patients preoperatively about the risk of ejaculatory pain, 11 (47.8%) about the risk of climacturia, 16 (69.6%) about the risk of penile length loss, 17 (73.9%) about the risk of significant erectile dysfunction, and 7 (30.4%) about the risk of penile curvature. 22 (95.7%) cautioned patients that they would most likely need medication to assist with erectile function postoperatively. For preoperative optimization, 12 (54.5%) respondents regularly recommend preoperative PDE5is, 7 (30.4%) regularly recommend a vacuum erection device, and 3 (13%) recommend pelvic floor rehabilitation. Postoperatively, 13 (56.5%) recommend a vacuum device postoperatively, another 3 (13%) sometimes do so, and 19 (82.6%) encouraged patients to start PDE5is immediately postoperatively. 19 (82.6%) continued PDE5is after 3 months without spontaneous erections.17 (73.9%) recommended Tadalafil 5mg daily, others used Sildenafil at varying doses.
15 (65.2%) of respondents believed that penile rehabilitation made a difference in outcomes at 2 years. Another 5 (21.7%) were unsure, but had enough data to continue with their protocol. Conclusions: Despite new guidelines for evaluation and treatment of patients undergoing RALP, there appears to be diverse counseling, recommendations and treatment both preoperatively and postoperatively. Evidence based and expert opinion guidelines may alter pre operative counseling and treatment in the future.

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