Penile rehabilitation after radical prostatectomy: does it work?

Abstract

Context: Erectile dysfunction (ED) represents one of the most common long-term side effects in patients with clinically localized prostate cancer (PCa) undergoing nerve-sparing radical prostatectomy (RP).

Objective: To analyze the role of penile rehabilitation in the recovery of erectile function (EF) after nerve-sparing RP.

Evidence synthesis: Penile rehabilitation is defined as the use of any intervention or combination with the goal not only to achieve erections sufficient for satisfactory sexual intercourses, but also to return EF to preoperative levels. The concept of rehabilitation is based on the implementation of protocols aimed at improving oxygenation, preserving endothelial structure, and preventing smooth muscle structural alterations. Nowadays, the most commonly adopted approaches for penile rehabilitation after nerve-sparing RP are represented by the administration of phosphodiesterase type-5 inhibitors (PDE5-Is), intracorporeal injection therapy, vacuum erection devices (VED), and the combination of these therapies. Several basic science studies support the rational for the adoption of penile rehabilitation protocols. Particularly, rehabilitation, set as early as possible, seems to be better than leaving the erectile tissues unassisted. On the other hand, results from solid prospective randomized trials finally assessing the long-term beneficial effects of PDE5-Is, intracavernosal injections, or VED on EF recovery after surgery are still lacking.

Conclusions: Although preclinical evidences support the rationale for penile rehabilitation after nerve-sparing RP, clinical studies reported conflicting results regarding its efficacy on long-term EF recovery. Nowadays, which is the optimal rehabilitation program still represents a matter of debate.

Keywords: Prostate cancer (PCa); penile rehabilitation; phosphodiesterase type-5 inhibitors (PDE5-Is); radical prostatectomy (RP); sexual function.

Figure 1

Flow diagram for the identification of the studies included in the literature review.

Figure 2

Number of studies assessing the efficacy of PDE5-Is stratified according to the type of drug administered. PDE5-Is, phosphodiesterase type-5 inhibitors.

Figure 3

SEP question 3 patient success rates for the overall double-blind treatment and single-blind washout study periods. SEP, Sexual Encounter Profile. Reproduced with permission from Elsevier (50).

Figure 4

LS mean change in IIEF-EF score over time (error bars present the 95% confidence interval). IIEF-EF, International Index of Erectile Function-Erectile Function domain; LS, least squares; MCID, minimal clinically important difference; MMRM, mixed-effect model for repeated measures; OaD, once a day; PLC, placebo; PRN, on demand; TAD, tadalafil. Reproduced with permission from Elsevier (48).