EAU 2019: Has Penile Rehabilitation Following Prostatectomy Proven Useful?

Barcelona, Spain (UroToday.com) In this session, Dr. Gandaglia reviewed the data supporting penile rehabilitation therapy in post prostatectomy patients. The rates of erectile dysfunction in the literature range from 15-70%. Variations in recovery rates depend on the definition employed, baseline patient characteristics, follow up duration, and surgical approach. Penile rehabilitation is defined as the use of any intervention with the goal of restoring erectile function to pretreatment levels. The effects of rehabilitation are dependent on improving oxygenation to the corpora cavernosum, preserving endothelial structure and function and preventing smooth muscle fibrosis. PDE5 inhibitors represent the most commonly employed rehabilitation strategy.

Multiple studies have reported pre-clinical evidence for PDE5 inhibition: reduction of penile hypoxia, smooth muscle apoptosis and fibrosis, prevention of veno-occlusive dysfunction, preserving endothelial function, and promotion of neuroprotection and nerve regeneration. Following this, the first clinical evidence supporting PDE5 inhibition was published in 2008, where 76 men randomized to nightly sildenafil (50 or 100mg) or placebo for 36 weeks starting 1 month following surgery and a washout period, had improved recovery of spontaneous erections.

However, the REACTT trial was a randomized controlled trial, comparing patients treated with tadalafil to placebo. No differences were seen in the open label phase between placebo and tadalafil. However, tadalafil resulted in a shorted time to regaining erectile function and had a protective effect on penile length. Furthermore, a meta-analysis of 11 randomized trials and 5 case control studies published in 2017 demonstrated that penile rehabilitation with PDE5 inhibition, vacuum erection devices and intracorporal injection significantly increased the number of patients with erectile function improvement. Two studies in 2013 and 2014 compared daily versus on demand PDE5 inhibitor utilization which appeared to have mixed results. More recent data suggest that patients treated with early PDE5 inhibition also seem to have improved results.

Dr. Gandaglia reviewed their program at San Raffaele:
  • Preoperative and postoperative pelvic floor muscle exercises taught by a dedicated psychotherapist
  • Starting 3 months post-surgery, intracavernosal injections of a vasoactive mixture twice weekly for 6 months and on-demand PDE5 prior to sexual stimulation on days injections are not used
In summary, Dr. Gandaglia believes that rehabilitation using ICI and PDE5 inhibitors in a protocol should improve the recovery of erectile function post prostatectomy with proper patient selection and optimal timing use to help improve its efficacy.

Presenter: Giorgio Gandaglia, MD, Department of Urology, Urological Research Institute, Vita e Salute San Raffaele University, Milan, Italy

Written by: David B. Cahn, DO, MBS @dbcahn Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.

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