Beyond the Abstract - Erectile preservation following radical prostatectomy, by Arthur L. Burnett, MD, MBA and Robert Segal, MD, FRCS(C)

BERKELEY, CA (UroToday.com) - Penile rehabilitation is defined as medical treatment at the time of or after radical prostatectomy (RP) to improve the restoration of natural penile mechanics to enhance spontaneous erectile function (EF).

This represents a highly controversial concept in the field of sexual medicine: is penile rehabilitation truly effective? What is the optimal treatment regimen? Should it be employed in all patients following RP?

The answers to these questions are not yet truly known. As demonstrated in the review, all currently available erectile dysfunction (ED) treatment options (phosphodiesterase inhibitors, intraurethral alprostadil suppositories, vacuum erection devices and intracorporal injection therapy) have been tried, with varying degrees of success, in an effort to accelerate the return of spontaneous EF following RP. There has never been a head-to-head, randomized controlled clinical trial, however, comparing the different therapies for the purpose of addressing what is the optimal regimen of rehabilitative therapy in terms of agent, dose, frequency and duration of therapy. Furthermore, would any of these different protocols result in improved EF compared to patients who use these therapies as erectile aids not in a rehabilitative manner, but in an effort to treat ED following RP? While it is intuitive that, assuming penile rehabilitation actually is effective, patients would prefer to have spontaneous erections rather than having to rely on a medication to achieve sufficient erectile rigidity for penetrative intercourse, there is no strong evidence supporting the efficacy of the studied penile rehabilitative protocols at ensuring that no “on-demand” erectile aid is needed. In the studies cited in the review, the mean International Index of Erectile Function (IIEF) scores were in the range of at least moderate ED after the stated follow-up period, and the majority of patients required use of erectile aids in an “on-demand” fashion to achieve successful intercourse. As such, if penile rehabilitation results in improved spontaneous EF but without the use of “on-demand” erectile aids, successful intercourse will not be achieved, then patients will inevitably not be satisfied with rehabilitation protocols and will abandon them. Further studies are necessary to address these issues.

Surely, beyond the adverse effects of the specific therapies, it can be assumed that utilization of these methods will not result in worsened EF, nor should they impede the natural recovery of erections following RP. As such, should the patient express interest, he should be encouraged to utilize these treatments, both for penile rehabilitation and ED therapy. However, patients should be clearly counselled that the evidence supporting the use of these therapies specifically for penile rehabilitation is not definitive. The decision to pursue penile rehabilitation should be a joint one between physician and patient after the potential (not proven) benefits are weighed against the drawbacks, including lack of success of the therapy, medication adverse effects, and cost. Finally, which patients should be offered penile rehabilitation? Again, while this has not been specifically addressed, patients with pre-operative ED or strong risk factors for developing post-operative ED (such as age > 70 years, higher PSA level, and non-nerve-sparing surgery)[1,2] likely would not benefit from any attempts at penile rehabilitation. Therefore, a minimum prerequisite of normal preoperative EF should be established for patients in order to consider penile rehabilitation. As well, the concept of patient motivation needs to be considered. As demonstrated in the study performed by Montorsi and colleagues,[3] at least one penile rehabilitation regimen was not shown to be better than an on-demand erectile aid use in men who are motivated to recover EF and who regularly attempt sexual intercourse multiple times weekly. Based on this data, perhaps a penile rehabilitation protocol consisting of a daily medication dosage would be better suited to patients who, while motivated, will not have regular access to a sexual partner.

The future of penile rehabilitation post-RP will depend on rigorous clinical trials to definitively prove the superior utility of one regimen. This may be difficult to attain, however, and it is possible that regimens will have to be tailored to patients based on their marital status, socio-economic status, medical comorbidities, prostate cancer disease parameters, as well as other yet to be defined characteristics. Furthermore, a successful penile rehabilitation regimen will likely not depend on a single medication, but will require full dedication on the part of the patient to consider lifestyle modifications as well as other therapies, including the peri-operative and post-operative administration of a cocktail of medications shown at the molecular level to be of benefit in preserving or recovering EF, and corroborated in human clinical studies.

References:

  1. Briganti A, Gallina A, Suardi, et al. Predicting erectile function recovery after bilateral nerve sparing radical prostatectomy: a proposal of a novel preoperative risk stratification. J Sex Med 2010; 7: 2521-31.
  2. Alemozaffar M, Regan MM, Cooperberg MR, et al. Prediction of erectile function following treatment for prostate cancer. JAMA 2011; 306(11): 1205-14.
  3. Montorsi F, Brock G, Lee J, et al. (2008) Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. Eur Urol 54: 924-931.

Written by:
Arthur L. Burnett, MD, MBA and Robert Segal, MD, FRCS(C) as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

The James Buchanan Brady Urological Institute
The Johns Hopkins Medical Institutions
Baltimore, Maryland

 

 

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