Vacuum erection devices to treat erectile dysfunction and early penile rehabilitation following radical prostatectomy

The Early Use of Vacuum Therapy for Penile Rehabilitation After Radical Prostatectomy: Systematic Review and Meta-Analysis

Vacuum therapy has been widely used for penile rehabilitation after radical prostatectomy (RP), but its efficacy and safety are unclear. The study was to evaluate the efficacy and safety of the early use of vacuum therapy for post-RP men. Randomized clinical trials were selected according to predefined inclusion and exclusion criteria. RevMan 5.3 software was used for meta-analyses. In total, six randomized controlled trials were included with a total of 273 post-RP patients. The meta-analysis revealed that the early use of vacuum therapy could significantly improve the five-item International Index of Erectile Function and penile shrinkage in post-RP patients. Few adverse events were reported across the included studies. This review suggests that the early use of vacuum therapy appears to have excellent therapeutic effect on post-RP patients and no serious side effects were identified. Due to overall limited quality of the included studies, the therapeutic benefit of vacuum therapy in penile rehabilitation needs be substantiated to a limited degree in the future. Better methodological, large controlled trials are expected to verify the therapeutic effect of vacuum therapy in penile rehabilitation.

The science of vacuum erectile device in penile rehabilitation after radical prostatectomy

INTRODUCTION

Radical prostatectomy (RP) is a standard surgical treatment for clinically localized prostate cancer. Erectile dysfunction (ED) and penile shrinkage are common complications. Vacuum Erectile Device (VED) therapy uses negative pressure to distend the corporal sinusoids and to increase blood inflow into the penis. It is the second most commonly used method for penile rehabilitation after RP. However, the underlying mechanisms are still unclear. This paper is designed to review the scientific evidences of VED therapy after RP and discuss the possible mechanisms.

METHODS

We reviewed published papers of post-prostatectomy penile rehabilitation using VED. We analyzed the scientific evidences of VED therapy and discussed the possible underlying mechanisms.

RESULTS

There are existing clinical evidences for VED therapy to improve ED and preserve penile size. Emerging basic scientific evidence is available and further study is still needed to understand the mechanisms at the molecular level.

CONCLUSIONS

Current clinical evidences support the safety, tolerability, effectiveness and benefits of early VED therapy after RP. The available basic scientific evidences demonstrate that VED therapy for penile rehabilitation is achieved by increasing arterial inflow, anti-apoptotic, anti-fibrotic and anti-hypoxia mechanisms.

Penile rehabilitation: the evolutionary concept in the management of erectile dysfunction

A compromise in erectile function is commonly experienced after radical prostatectomy and has been attributed to injury to vascular, neurogenic, and smooth muscle. The concept of rehabilitation after organ injury is not a novel concept and is one that has been applied to all aspects of medicine. Penile rehabilitation has been classically defined as the use of a device or pharmacologic agent to aid erectile function recovery after radical prostatectomy. Here we redefine penile rehabilitation as the use of any device, medication, or intervention to promote male sexual function as a primer before and after any insult to the penile erectile physiologic axis. We also review the epidemiology, rational and current literature on penile rehabilitation after prostatectomy.

The resurgence of the vacuum erection device (VED) for treatment of erectile dysfunction

INTRODUCTION

Vacuum erection devices (VEDs) have been approved in the United States since 1982 and offer a viable alternative to oral phosphodiesterase type 5 inhibitors (PDE5i), injections and transurethral suppositories. Studies have demonstrated efficacy in erectile dysfunction (ED) associated with a variety of conditions. More recently, this modality has been evaluated in initial phosphodiesterase inhibitor nonresponders as well as for post-prostatectomy penile rehabilitation.

AIM

This article provides a detailed overview of the history of VEDs, a review of the literature, and a concise description of their new applications in modern urological practice.

METHODS

A retrospective review of publications relevant to the field of VEDs.

MAIN OUTCOME MEASURES

Review of the historical milestones, evolution, and modern utilization of VEDs in modern urological protocols.

RESULTS

Studies have demonstrated efficacy in ED associated with a variety of conditions. Early penile rehabilitation after surgery for prostate cancer with the VED appears to improve erectile function and penile length. Adverse events are transient and not serious.

CONCLUSIONS

The VED has continued to show efficacy for treatment of ED due to various etiologies and should be considered an attractive second-line therapy. In select cases such post-prostatectomy penile rehabilitation, as well as in men who cannot use a PDE5i, the vacuum device should be considered first-line treatment.

Long-term potency after early use of a vacuum erection device following radical prostatectomy

OBJECTIVE

To evaluate the long-term potency after radical prostatectomy (RP) with the early use of a vacuum erection device (VED), and reasons for sexual inactivity and long-term attrition and maintenance of sexual activity, as RP is one of the most common treatments for prostate cancer but erectile dysfunction (ED) is a common side-effect.

PATIENTS AND METHODS

We identified 141 sexually active patients who underwent RP at Cleveland Clinic Foundation. Patients were offered various non-oral treatment options to prevent ED and were also motivated for early penile rehabilitation. At 5 years 62% remained sexually active, of whom 71% had natural erections sufficient for intercourse without assistance, 8.5% were still using sildenafil, 10% were using combined therapy (sildenafil plus VED). At 5 years 38% (43/113) men were sexually inactive. The reasons included loss of interest in 17 (40%), cardiovascular/neurological diseases in 18 (42%), hormonal therapy in three (7%), loss of partner in three (7%) and two had other surgery. The natural rate of erections for sufficient vaginal penetration without an erection aid were preserved and maintained in the early-prophylaxis group, and almost 60% of them had used a VED as early prophylaxis.

CONCLUSION

Despite current phosphodiesterase-5 inhibitor treatments for ED, VED is becoming recognized again as having a primary role in early penile rehabilitation in many patients, specifically those treated for prostate cancer.

Implants, mechanical devices, and vascular surgery for erectile dysfunction

INTRODUCTION

The field of erectile dysfunction (ED) is evolving and there is a need for state-of-the-art information in the area of treatment. Aim. To develop an evidence-based, state-of-the-art consensus report on the treatment of erectile dysfunction by implants, mechanical devices, and vascular surgery.

METHODS

To provide state-of-the-art knowledge concerning treatment of erectile dysfunction by implant, mechanical device, and vascular surgery, representing the opinions of 7 experts from 5 countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

The inflatable penile prosthesis (IPP) is indicated for the treatment of organic erectile dysfunction after failure or rejection of other treatment options. Comparisons between the IPP and other forms of ED therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis. Organic ED responds well to vacuum erection device (VED) therapy, especially among men with a suboptimal response to intracavernosal pharmacotherapy. After radical prostatectomy, VED therapy combined with phosphodiesterase type 5 therapy improved sexual satisfaction in patients dissatisfied with VED alone. Penile revascularization surgery seems most successful in young men with absence of venous leakage and isolated stenosis of the internal pudendal artery following perineal or pelvic trauma. Currently, surgery to limit venous leakage is not recommended.

CONCLUSIONS

It is important for the future of the field that patients be made aware of all treatment options for erectile dysfunction in order to make an informed decision. The treating physician should be aware of the patient's medical and sexual history in helping to guide the decision. More research is needed in the area of revascularization surgery, in particular, venous outflow surgery.

Erectile aid use by men treated for localized prostate cancer

PURPOSE

We evaluated associations between demographic and clinical characteristics, quality of life outcome measures and erectile aids in men treated for localized prostate cancer.

MATERIALS AND METHODS

Patients had clinically localized prostate cancer, were not using erectile aids at baseline and chose treatment with radical prostatectomy (275), external beam radiotherapy (70) or brachytherapy (80). Patient characteristics and health related quality of life outcomes were prospectively assessed at baseline and at regular intervals up to 48 months after treatment. Outcomes were assessed with SF-36, the American Urological Association symptom index and UCLA-PCI. We categorized use of a phosphodiesterase type 5 inhibitor, urethral alprostadil suppositories, penile injection therapy or a vacuum erection device after treatment as erectile aid use. We created a multivariate model examining baseline demographic, clinical and health related quality of life covariates associated with erectile aid use.

RESULTS

Of the 425 patients 237 (56%) used an erectile aid at some point during the posttreatment period. In our multivariate model patients treated with external beam radiation were less likely to use an aid (OR 0.34, 95% CI 0.16-0.69) and men with significant sexual bother (OR 2.68, 95% CI 1.37-5.23), or with 1 or more comorbidities (OR 1.80, 95% CI 1.08-2.93) were more likely to use an aid. Patient demographic characteristics were not associated with erectile aids.

CONCLUSIONS

After treatment for localized prostate cancer more than half of men use erectile aids, especially when they are significantly bothered by dysfunction. This is most pronounced after radical prostatectomy and in men with significant comorbidity.