Abstract and Introduction
Abstract
We retrospectively analyzed the effects on the erectile function (EF) of no treatment (NT), and an oral therapy (OT; on-demand therapy (OD) or a regimented rehabilitation (RR) program with phosphodiesterase type 5 inhibitors (PDE5-Is)), in a cohort of 196 consecutive patients following nerve-sparing radical retropubic prostatectomy (NSRRP). Patients undergoing bilateral NSRRP (BP; n=147) and unilateral NSRRP (UP; n=49), chose between OT (PDE5-Is OD or RR program) and NT. Patients who chose OD therapy received PDE5-Is (100 mg sildenafil, 20 mg tadalafil and vardenafil), whereas patients who chose the RR program received 100 mg sildenafil or 20 mg vardenafil three times a week, or 20 mg tadalafil twice a week at bedtime. The t-test for unpaired data and Fisher test were used for univariate analyses, logistic regression multivariate analysis was used to test the accuracy of available variables to predict EF recovery after radical prostatectomy. Potency rates were significantly correlated with the surgical technique and with OT when compared to NT (P<0.02), respectively 68.7% for BP (61% with no therapy and 71% with PDE5-Is) and 44% for UP (29% with no therapy and 51% with PDE5-Is), while no statistically significative differences were found between OD and rehabilitation protocols (72% with rehabilitation and 70% with OD therapy in BP, 52% with rehabilitation and 50% with OD therapy in UP; P=NS). Early OT with PDE5-Is (OD or RR program) was superior to NT in recovery of EF in NSRRP. Furthermore, an RR program with PDE5-Is did not appear to be superior to OD therapy.
Introduction
As prostate cancer is being detected at a younger age and earlier stage, an increasing number of relatively young men are facing the prospect of living with erectile dysfunction (ED) following radical retropubic prostatectomy (RRP).[1,2] The incidence of ED after nerve-sparing RRP (NSP) depends on the age of the patient, erectile function prior to surgery, pre-existing medical conditions, the surgical technique and the surgeon's experience.[3–6] However, it appears that a number of pathophysiological mechanisms are also implicated in ED following RRP, and nerve-sparing techniques alone have been shown to be insufficient for preserving erectile function.[7] The concept of penile rehabilitation in addressing ED after RRP was first explored by Montorsi et al.,[8] who used intracavernosal injections of the prostaglandin E1, alprostadil, soon after surgery to accelerate the return of spontaneous erections, followed by the use of oral phosphodiesterase type 5 inhibitors (PDE5-Is) by Schwartz et al.[9] Since these initial steps, further research has explored the concept of penile rehabilitation, focusing on the use of pharmacotherapy to minimize the damage involving the cavernosal tissue via preservation of adequate oxygenation, and protection of the endothelia and smooth muscle after injury to the cavernous nerves. Studies in animals[10–12] and initial studies in humans[8,13,14] provide support for penile rehabilitation.[4,7,15] Interest has also been growing in the use of regimented rehabilitative programs rather than on-demand therapy.[1] However, the conclusions drawn from some of these studies have been criticized, mechanisms remain unclear, and evidence supporting penile rehabilitation and a rationale for the use of rehabilitation protocols are not available from large, multicentre placebo-controlled trials.[7] These factors make the issue of penile rehabilitation a major controversy in sexual medicine at the current time.[7,15] Despite this ongoing controversy, supportive evidence from animal studies continues to emerge,[16] and there is evidence that penile rehabilitation is widely used in everyday clinical practice.[17] Giuliano et al.[18] explored practice patterns of French urologists and found that >88% used some form of early therapy after RRP, such as regular intracavernous injection (ICI) for rehabilitation (39%), ICI on demand for intercourse (30%), PDE5-Is on demand (16%) or regular PDE5-Is for rehabilitation (8%), alternating ICI and PDE5-Is (7%) and vacuum devices (<1%).
Aim of our study was to retrospectively analyze the effects on potency of no treatment, on-demand therapy and the regimented rehabilitation program after NSP in a single referral center.
Int J Impot Res. 2015;27(1):1-5. © 2015 Nature Publishing Group
