Management strategies for SUI
First-line treatment for men with SUI is conservative, involving behavioral therapy and pelvic floor muscle training/pelvic physiotherapy. Patients should be counseled about behavioral interventions, focusing mainly on treating patient comorbidities, such as diabetes (DM), obstructive sleep apnea, obesity, and chronic obstructive pulmonary disease. Ideally, this should be done with a comprehensive team, including the primary care doctor, endocrinologist, nutritionist, and other specialists. We recommend pelvic floor muscle exercises (PFME) or pelvic floor muscle training (PFMT) to all patients three to four weeks before surgery to allow for neuromuscular adaptation. The efficacy of both techniques remains a topic of debate during the preoperative phase; nevertheless, their potential advantages surpass any possible risks.
Male sling procedures are classified as either fixed or adjustable. Fixed slings are recommended for patients with mild to moderate SUI, while severe cases of incontinence should be treated with AUS. The recovery rates for male slings vary widely in the literature. The heterogeneous outcomes are influenced not only by the diverse definitions of cure and varying follow-up procedures but also by including patients with severe SUI in many studies. Pain was identified as the predominant complication, and the second most common post-operative issue is temporary urinary retention, which is typically self-resolved
Adjustable slings offer the flexibility to adjust tension or compress the urethra by tightening the sling arms. Regarding their effectiveness, meta-analyses show cure rates varying between 17% and 92%. Chronic pain was noted in 1.5% of cases, with infection being the most frequent complication, often necessitating the removal of the device. Nevertheless, it is crucial to emphasize that the functional outcomes are similar to those observed with fixed slings.
Adjustable balloons are filled via a percutaneous puncture in an outpatient setting, which results in mechanical compression of the urethra. The AUA Guidelines recommend this device for men with mild SUI post-RALP. Success rates vary from 62% to 68%, while the explantation rate is 12.3%. The most frequent complications are erosion (3.2% to 10.9%) and dislocation (4% to 6.2%).
Artificial Urinary Sphincter (AUS) is the gold standard for the treatment of SUI in men. It should be offered to patients with moderate or severe SUI if they have the necessary physical and cognitive dexterity to manipulate the device. The AUS provides a consistent and standardized implantation method and has proven effective even in cases involving pelvic RT. The most common complications include the risk of infection, urethral erosion, and mechanical failures.
Management strategies for ED
No definitive recommendations can be made regarding the superiority of any particular PDE5 inhibitor over others. The optimal dosage, whether continuous or on-demand, and the duration of treatment are still under investigation. However, PDE5i remains the first-line option in treating post-RALP ED and penile rehabilitation programs.
Intracavernosal injections (ICI) therapy is a vital treatment for post-RALP ED, inducing erection by relaxing the corpora cavernosa smooth muscle. ICI has advantages like reproducible erection responses without irreversible procedures or devices, but studies report a significant dropout rate primarily due to pain and efficacy issues. ICI, as part of a penile rehabilitation protocol, has shown increased spontaneous erections and improved EF post-RALP. ICI potential side effects include priapism, corporal fibrosis, hypotension, tachycardia, and penile pain. Patients should be informed about these side effects and seek immediate medical assistance in the setting of priapism.
Early Vacuum erection devices (VED) use post-nerve sparing RALP showed 80% success in achieving sexual intercourse and 17% spontaneous erections after nine months. This results from preserving smooth muscle and endothelial integrity through anti-hypoxia, anti-apoptosis, and antifibrotic mechanisms. Combining VED with PDE5i enhanced EF recovery, while VED alone showed no improvement. Daily VED use may also preserve penile length after RALP. Side effects include mild discomfort and rare complications of leg spasms and urethral bleeding.
In the setting of severe preoperative ED or for ED refractory to other rehabilitation measures, penile prosthesis is the most effective treatment. Satisfaction rates post-implantation is notably high, with improvements in EF, libido, mood, and anxiety levels. Significant complications include mechanical failure and infection. Device improvements have reduced failure rates, and proper surgical techniques and antibiotic prophylaxis minimize the infection rate. Manual dexterity is essential for effective IPP use, making malleable devices an option for those who lack the dexterity needed to operate inflatable devices.
Novel therapies for post-RALP ED have emerged in the literature. Low-intensity extracorporeal shockwave therapy (Li-ESWT) has shown efficacy in vasculogenic ED and is now gaining interest in the post-RALP population. Currently, data is limited, and the protocols lack standardization and involve a limited number of participants, often with short follow-up durations. Further assessment is necessary to establish optimal protocols and incorporate longer follow-up periods to genuinely assess the clinical significance and durability of Li-ESWT in post-RALP ED treatment.
Penile Rehabilitation Programs
Recovery of EF post-RALP can take up to 2 years, with only a limited number of patients fully recovering. PR can aid and accelerate this process by enhancing oxygenation and preventing nerve injury-induced structural changes in penile tissue. Starting rehabilitation within six months of RALP may enhance overall EF recovery, and recent studies advocate initiating PDE5i as soon as POD1.
At Indiana University, our approach involves evaluating patients before surgery or within the first eight weeks after the procedure. During this appointment, we conduct a detailed assessment of sexual and reproductive health, perform a physical examination, and provide education on potential post-surgical effects, treatment strategies, and our rehabilitation protocol. We strongly encourage patients to involve their partners in the initial or subsequent visit to facilitate shared decision-making and goal setting. A key component of our regimen includes initiating a low-dose PDE5 inhibitor two weeks before surgery, which patients continue daily for up to one year post-RALP or two years following radiation therapy. Around the third postoperative week, patients are advised to take a high-dose PDE5I once a week in conjunction with sexual activity. At their follow-up visit, scheduled between six to eight weeks postoperatively, we assess medication adherence, side effects, and various post-surgical concerns such as erectile function, orgasmic issues, and urinary incontinence. If maximum-dose PDE5Is fail to produce a penetrative erection, we introduce ICI as an alternative. Patients maintain a regimen of daily low-dose PDE5Is alongside a weekly high-dose PDE5I or ICI therapy for a year post-surgery. Follow-up visits occur every three months until one year post-surgery or two years RT.
Conclusion
A substantial number of patients still experience SUI after RALP. Preoperative counseling and early initiation of PFPT should be considered for all patients. Male slings are effective treatment options for mild to moderate post-RALP SUI. AUS is the gold standard for treating moderate to severe SUI in men with preserved dexterity to operate the device. Regarding ED, notable obstacles to EF recovery post-RALP include patient characteristics, compliance, and cost. Currently, there is no standardized protocol for PR. Further research should focus on studies that evaluate the optimal approach and management to overcome barriers and maximize patient compliance.
Written by:
- Thairo A. Pereira, MD, Sexual Medicine Fellow, Department of Urology, MD Anderson Cancer Center, University of Texas, Houston, TX
- Helen L Bernie, DO, MPH, Department of Urology, Indiana University, Carmel, Indianapolis, IN