Penile Rehabilitation Strategy after Nerve Sparing Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Trials

Abstract

Purpose: Despite the advances in nerve sparing and minimally invasive radical prostatectomy, erectile dysfunction remains an important adverse event after radical prostatectomy. Penile rehabilitation strategies have been developed to expedite and improve erectile function recovery. However, the differential efficacy and the best penile rehabilitation strategy are unclear as yet. We conducted a systematic review and network meta-analysis to investigate and compare the efficacy of different penile rehabilitation strategies.

Materials and methods: A systematic search was performed in May 2020 using PubMed® and Web of Science™ databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) extension statement for network meta-analysis. Studies that compared the erectile function recovery rate and adverse events between penile rehabilitation treatment groups (eg medications, devices and actions) and control group were included. We used the Bayesian approach in the network meta-analysis.

Results: A total of 22 studies (2,711 patients) met our eligibility criteria. Out of 16 different penile rehabilitation strategies and schedules vs placebo, only pelvic floor muscle training (OR 5.21, 95% CrI 1.24-29.8) and 100 mg sildenafil regular doses, ie once daily or nightly (OR 4.00, 95% CrI 1.40-13.4) were associated with a significantly higher likelihood of erectile function recovery. The certainty of results for 100 mg sildenafil regular dose was moderate, while pelvic floor muscle training had low certainty. The sensitivity analysis confirmed that the regular high dose of phosphodiesterase-5 inhibitors regardless of type vs placebo (OR 2.09, 95% CrI 1.06-4.17) was associated with a significantly higher likelihood of erectile function recovery with a moderate certainty. The on-demand doses of phosphodiesterase-5 inhibitors were not proven to be more beneficial than placebo. Secondary outcomes such as adverse events were not analyzed due to incomplete data in the literature. However, no serious adverse events were reported in any of the studies.

Conclusions: Sildenafil 100 mg regular dose is the best penile rehabilitation strategy to improve erectile function recovery rates after radical prostatectomy. Although pelvic floor muscle training has been shown to be effective in increasing the erectile function recovery rate, well designed randomized controlled trials with larger sample sizes are needed to confirm the presented early results. The on-demand dose of phosphodiesterase-5 inhibitors should not be considered as a penile rehabilitation strategy.

Keywords: erectile dysfunction; penis; prostatectomy; prostatic neoplasms; urogenital surgical procedures.