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Bock M, Burns RT, Pereira TA, Bernie HL. A contemporary review of the treatments and challenges associated with penile rehabilitation after radical prostatectomy including a proposed optimal approach. Int J Impot Res 2024; 36:480-485. [PMID: 37853240 DOI: 10.1038/s41443-023-00782-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/01/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023]
Abstract
Prostate cancer is one of the most prevalent malignancies affecting men worldwide. Despite advancements in understanding prostate anatomy and minimally invasive approaches to surgical treatment, surgery can have significant adverse effects on sexual function. Penile rehabilitation strategies have emerged as a promising approach to mitigate the impact of prostate cancer treatments on erectile function and improve quality of life. Several methods have been employed for penile rehabilitation, including pharmacotherapy, vacuum erection devices, intracavernous injections, and emerging novel techniques. Yet, there is no consensus on the exact programs or timing of initiation that should be utilized for optimal recovery after surgery. This review discusses various rehabilitation protocols and long-term outcomes and explores the cost-effectiveness of different interventions. Additionally, this review discusses the importance of a multidisciplinary approach to penile rehabilitation which includes patient education, counseling, and the selection of an appropriate rehabilitation strategy tailored to each individual's needs and preferences. Continued research and collaboration among healthcare professionals are essential to refine rehabilitation approaches and ensure optimal outcomes for patients with prostate cancer.
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Affiliation(s)
- Megan Bock
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Ramzy T Burns
- Department of Urology, Indiana University, Indianapolis, IN, USA.
| | - Thairo A Pereira
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Helen L Bernie
- Department of Urology, Indiana University, Indianapolis, IN, USA
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2
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Hinojosa-Gonzalez DE, Talamas Mendoza A, Torres-Martinez M, Diaz-Garza K, Hernandez BS, Muñoz Hibert MI, Ramirez-Mulhern I, Morales Palomino KL, Gonzalez-Oyervides R. Indirect assessment of low-intensity shockwave therapy's energy density and pulse frequency for erectile dysfunction: a systematic review, bayesian network meta-analysis and meta-regression. Int J Impot Res 2024:10.1038/s41443-024-00910-w. [PMID: 38778153 DOI: 10.1038/s41443-024-00910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/24/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024]
Abstract
Shockwaves are thought to activate regenerative and angiogenic pathways, providing a possible therapeutic benefit for patients with erectile dysfunction. This study aimed to analyze the effectiveness of low-intensity extracorporeal shockwave therapy energy density and pulse frequency. In May 2022, a systematic search of online databases was performed to identify randomized clinical trials related to low-intensity extracorporeal shockwave therapy in erectile dysfunction. Eligible articles compared low-intensity extracorporeal shockwave therapy to controls or sham procedures. A Bayesian framework with 200,000 Markov chains was performed. We included a total of 1272 patients from 18 studies. The energy flux density measured in joules included 0.09 mJ/mm2 (mean difference 3.2 IIEF [95% CrI 2.8, 3.6]), 0.15 mJ/mm2 (mean difference 4.9 IIEF [95% CrI 2.8, 7.2]) and 0.20 mJ/mm2 (mean difference 1.2 IIEF [95% CrI 0.11, 2.3]). Of these, 0.15 mJ/mm2 had the greatest ranking (SUCRA = 0.983) compared with placebo. When analyzed by pulse frequency, significant increases were found in 500 pulses/session (mean difference 2.5 IIEF [CrI 1.9, 3.2]), 1500 pulses/session (mean difference 4.6 IIEF [95% CrI 3.9, 5.4]) and > 3000 pulses/session (mean difference 3.1 IIEF [95% CrI 2.1, 4.2]). Of these, 1500 pulses/session had the highest SUCRA, at 0.996. Our network meta-analysis suggests that low-intensity extracorporeal shockwave therapy is an effective intervention for erectile dysfunction, as measured by increases in the IIEF-EF. Sessions featuring 1500 pulses and an energy flux density of 0.15 mJ/mm2 appear to be the most effective.
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Affiliation(s)
- David E Hinojosa-Gonzalez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico.
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Alejandro Talamas Mendoza
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
| | - Mauricio Torres-Martinez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
| | - Karla Diaz-Garza
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
| | - Beatriz S Hernandez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
| | - Monica Isabel Muñoz Hibert
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
| | - Isabela Ramirez-Mulhern
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
| | | | - Roberto Gonzalez-Oyervides
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Ave Morones Prieto 3000, Monterrey, NL, 64000, Mexico
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Stinson J, Bennett N. Reviving intimacy: Penile rehabilitation strategies for men after prostate cancer treatment. Prostate Int 2023; 11:195-203. [PMID: 38196554 PMCID: PMC10772180 DOI: 10.1016/j.prnil.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/05/2023] [Indexed: 01/11/2024] Open
Abstract
There have been considerable advances in the field of penile rehabilitation for upwards of 90% of men adversely affected by either short-term or long-term erectile dysfunction after definitive prostate cancer treatment. Despite the evolving landscape of treatment modalities for penile rehabilitation, there is a lack of consensus in the urologic community on the best therapies due to the level of evidence and efficacies of the current and emerging offerings. This review of current and next-generation interventions provides a practical approach to the myriad of data to make a better-informed decision based on the pathophysiology and highest-quality evidence available.
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Affiliation(s)
- James Stinson
- Division of Urology, Cook County Health and Hospitals System, Chicago IL, USA
| | - Nelson Bennett
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago IL, USA
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Vieiralves RR, Schuh MF, Favorito LA. Low-intensity extracorporeal shockwave therapy in the treatment of erectile dysfunction - a narrative review. Int Braz J Urol 2023; 49:428-440. [PMID: 36794846 PMCID: PMC10482445 DOI: 10.1590/s1677-5538.ibju.2023.9904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/02/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES To provide an overview of low-intensity extracorporeal shockwave therapy (LIEST) for erectile dysfunction (ED), pointing out which concepts are already consolidated and which paths we still need to advance. MATERIALS AND METHODS We performed a narrative review of the literature on the role of shockwave therapies in erectile dysfunction, selecting publications in PUBMED, including only relevant clinical trials, systematic reviews and meta-analyses. RESULTS We found 11 studies (7 clinical trials, 3 systematic review and 1 meta-analysis) that evaluated the use of LIEST for the treatment of erectile dysfunction. One clinical trial evaluated the applicability in Peyronie's Disease and one other clinical trial evaluated the applicability after radical prostatectomy. CONCLUSIONS The literature presents little scientific evidence but suggests good results with the use of LIEST for ED. Despite a real optimism since it is a treatment modality capable of acting on the pathophysiology of ED, we must remain cautious, until a larger volume of higher quality studies allows us to establish which patient profile, type of energy and application protocol will achieve clinically satisfactory results.
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Affiliation(s)
- Rodrigo R. Vieiralves
- Universidade do Estado do Rio de Janeiro - UERJUnidade de Pesquisa UrogenitalRio de JaneiroRJBrasilUnidade de Pesquisa Urogenital - Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil
| | - Mathias Ferreira Schuh
- Universidade do Estado do Rio de Janeiro - UERJUnidade de Pesquisa UrogenitalRio de JaneiroRJBrasilUnidade de Pesquisa Urogenital - Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil
| | - Luciano Alves Favorito
- Universidade do Estado do Rio de Janeiro - UERJUnidade de Pesquisa UrogenitalRio de JaneiroRJBrasilUnidade de Pesquisa Urogenital - Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil
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Vizza R, Capomolla EM, Tosetto L, Corrado G, Bruno V, Chiofalo B, Di Lisa FS, Filomeno L, Pizzuti L, Krasniqi E, Sanguineti G, Villa A, Giannini A, Kayal R, Stranges V, Tomao S, Botti C, Tomao F, Barba M, Vizza E, Ciliberto G, Vici P. Sexual dysfunctions in breast cancer patients: evidence in context. Sex Med Rev 2023:7128131. [PMID: 37076125 DOI: 10.1093/sxmrev/qead006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION In breast cancer patients, endocrine therapy may exert a negative impact on sexual functioning in both genders, with potentially relevant consequences concerning quality of life and treatment adherence. The availability of effective interventions to maintain and/or restore sexual health in breast cancer patients is a key issue to a research agenda. OBJECTIVES To summarize and critically discuss the most updated and qualitatively relevant literature on the therapeutic approach to sexual impairment in breast cancer patients, with a focus on patients treated with endocrine therapy. METHODS We searched PubMed from its inception to February 2022 for observational and intervention trials including participants with sexual dysfunctions. We were particularly interested in studies of breast cancer patients with sexual dysfunctions while undergoing endocrine therapy. We developed a search strategy with the aim of maximizing the number of articles considered for screening and potential inclusion. RESULTS Forty-five studies were selected: 3 observational and 42 intervention studies. Thirty-five studies were exclusively focused on female breast cancer populations. We could not identify studies exclusively focused on or also including male breast cancer patients. Overall, in female patients, the available armamentarium encompasses vaginal lubricants, moisturizers, estrogens, dehydroepiandrosterone, CO2 laser, ospemifene, and counseling. None of these interventions has been demonstrated to completely solve sexual dysfunctions when singularly considered. More favorable outcomes have come from the combination of different therapies. CONCLUSION In female breast cancer, future research is oriented toward the gain of evidence on combined therapies and long-term data on safety issues on the most promising interventions. The lack of evidence on sexual disturbances in male breast cancer patients remains a major concern.
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Affiliation(s)
| | | | - Livia Tosetto
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Giacomo Corrado
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bruno
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Francesca Sofia Di Lisa
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Lorena Filomeno
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Laura Pizzuti
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Eriseld Krasniqi
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Alice Villa
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome 00161, Italy
| | - Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome 00189, Italy
| | - Ramy Kayal
- Department of Radiology and Diagnostic Imaging, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | | | - Silverio Tomao
- Department of Radiological, Oncological and Anatomo-pathological Sciences, "Sapienza" University of Rome, Rome 00161, Italy
| | - Claudio Botti
- Department of Surgery, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Federica Tomao
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome 00161, Italy
| | - Maddalena Barba
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Gennaro Ciliberto
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Patrizia Vici
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
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Kohada Y, Babasaki T, Goto K, Inoue S, Kurimura Y, Tasaka R, Takemoto K, Miyamoto S, Kobatake K, Kitano H, Ikeda K, Hieda K, Hayashi T, Hinata N. Long-term efficacy of penile rehabilitation with low-intensity extracorporeal shock wave therapy for sexual and erectile function recovery following robotic-assisted radical prostatectomy: a single-cohort pilot study. Sex Med 2023; 11:qfad023. [PMID: 37228769 PMCID: PMC10204648 DOI: 10.1093/sexmed/qfad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/20/2023] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
Background The long-term efficacy of low-intensity extracorporeal shock wave therapy (LIESWT) for penile rehabilitation after robot-assisted radical prostatectomy (RARP) has not yet been reported. Aim To assess the long-term efficacy of LIESWT for penile rehabilitation after RARP by evaluating the postoperative recovery of sexual and erectile functions following RARP. Methods Patients who underwent RARP at our institution were categorized into 2 groups: those who received LIESWT and those who underwent penile rehabilitation with a phosphodiesterase type 5 inhibitor (PDE5i). The control group included patients who did not undergo penile rehabilitation. Potency and scores on the Expanded Prostate Cancer Index Composite for sexual function and 5-item International Index of Erectile Function (IIEF-5) were evaluated preoperatively and over 60 months after RARP. Outcomes The LIESWT group had significantly higher postoperative sexual function and total IIEF-5 scores and potency than the control group over the long term, and its results were not inferior to those of the PDE5i group. Results The LIESWT, PDE5i, and control groups comprised 16, 13, and 139 patients, respectively. As compared with the control group, the LIESWT group had significantly higher sexual function scores at 6, 12, and 60 months after surgery (P < .05) and total IIEF-5 scores at 24 and 60 months (P < .05). The LIESWT group also had a significantly higher potency rate than the control group at 60 months (P < .05). For all time points after surgery, there were no significant differences between the LIESWT and PDE5i groups in terms of sexual function and total IIEF-5 scores and potency. Clinical Implications LIESWT may be a new option for penile rehabilitation in patients with erectile dysfunction after RARP. Strengths and Limitations This pilot study was performed at a single center and involved relatively few patients, which may have led to selection bias. Furthermore, the selection of this study for penile rehabilitation was not made randomly but by the patient's choice. Despite these limitations, our results provide evidence in support of LIESWT for penile rehabilitation after RARP because this is the first study to assess the long-term efficacy of LIESWT. Conclusion LIESWT can improve sexual and erectile functions in patients with erectile dysfunction after RARP, and its efficacy can be maintained over a long period after surgery.
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Affiliation(s)
- Yuki Kohada
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Takashi Babasaki
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Keisuke Goto
- Corresponding author: Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan.
| | - Shogo Inoue
- Shobara Redcross Hospital, Hiroshima 723-0013, Japan
| | | | - Ryo Tasaka
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenshiro Takemoto
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shunsuke Miyamoto
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kohei Kobatake
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Kitano
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenichiro Ikeda
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Keisuke Hieda
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Tetsutaro Hayashi
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuyuki Hinata
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Bocchino AC, Pezzoli M, Martínez-Salamanca JI, Russo GI, Lo Giudice A, Cocci A. Low-intensity extracorporeal shock wave therapy for erectile dysfunction: Myths and realities. Investig Clin Urol 2023; 64:118-125. [PMID: 36882170 PMCID: PMC9995960 DOI: 10.4111/icu.20220327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/16/2022] [Accepted: 01/04/2023] [Indexed: 02/16/2023] Open
Abstract
To review the evidence of clinical efficacy of low-intensity extracorporeal shock wave therapy (Li-ESWT) for the treatment of erectile dysfunction (ED). A search on PubMed using Medical Subject Headings terms [((low intensity extracorporeal shockwave therapy) OR (Li-ESWT)) AND (erectile dysfunction)] was conducted in August 2022, to obtain studies on the use of Li-ESWT for the treatment of ED. Its success rate in terms of International Index of Erectile Function-5 (IIEF-5) score and Erection Hardness Score (EHS) improvement was recorded and analysed. A total of 139 articles were reviewed. Overall, 52 studies were included in the final review. 17 studies were on vasculogenic ED, 5 on post pelvic surgery ED, 4 specifically on ED in diabetic patients, 24 on non-specified origin ED and 2 on mixed pathophysiological origin ED. The mean age of patients was 55.87±7.91 (standard deviation) years and the duration of ED was 4.36±2.08 years. The mean IIEF-5 score went from 12.04±2.67 at baseline to 16.12±5.72, 16.30±3.26 and 16.85±1.63 respectively at 3, 6 and 12 months. The mean EHS went from 2.00±0.46 at baseline to 2.58±0.60, 2.75±0.46 and 2.87±0.16 respectively at 3, 6 and 12 months. Li-ESWT may be a safe and efficacy option for the treatment and cure of ED. Further studies are needed to assess which patients are more suitable for this procedure and which Li-ESWT protocol can lead to the best outcomes.
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Affiliation(s)
| | - Marta Pezzoli
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
| | | | | | | | - Andrea Cocci
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy.
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Penile Rehabilitation after Prostate Cancer Treatment: Which Is the Right Program? URO 2023. [DOI: 10.3390/uro3010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
The management of sexual complications after treatment of localized prostate cancer, such as erectile dysfunction, changes in the length of the penis, pain during sexual intercourse, and lack of orgasm, is still an unsolved problem with an important impact on patients’ quality of life. In this review, we summarize the current scientific literature about the rehabilitation of erectile dysfunction after prostate cancer treatment. The therapy for penile rehabilitation includes different types of treatments: the combination of phosphodiesterase type 5 inhibitors (PDE5-I) and the vacuum erectile device (VED) are considered first-line treatment options. When therapy begins, the duration of treatment, the dosage and the drug used all play very important roles in the treatment outcome. Intracavernous injection (ICI) therapy represents the second-line option for patients ineligible for PDE5-I therapy. Technological development has led to the emergence of devices for the stimulation of the penis without the use of drugs, such as penile vibratory stimulation (PVS) for stimulation of ejaculation in spinal cord injury and low-intensity extracorporeal shockwave therapy (LIESWT). The rapid diffusion of the latter, thanks to its easy use, attains good results without side effects. The panorama of penile rehabilitation after PC treatments is vast and many studies are needed, especially on new technologies, to find the best therapeutic regimen possible, personalized to the patient’s characteristics and the type of treatment for PC.
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Sighinolfi MC, Eissa A, Bellorofonte C, Mofferdin A, Eldeeb M, Assumma S, Panio E, Calcagnile T, Stroppa D, Bozzini G, Gaia G, Terzoni S, Sangalli M, Micali S, Rocco B. Low-intensity Extracorporeal Shockwave Therapy for the Management of Postprostatectomy Erectile Dysfunction: A Systematic Review of the Literature. EUR UROL SUPPL 2022; 43:45-53. [PMID: 35928730 PMCID: PMC9344341 DOI: 10.1016/j.euros.2022.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/22/2022] Open
Abstract
Context Erectile dysfunction (ED) following radical prostatectomy is a concern for patients and their partners. Low-intensity extracorporeal shockwave therapy (LI-ESWT) can potentially enhance tissue repair and regeneration. The aim of the current study was to systematically review the literature to assess the role of LI-ESWT in the management of patients with postprostatectomy ED. Evidence acquisition Two authors independently performed a systematic search of the PubMed and Web of Science databases to identify all relevant articles. Non-English reports, case reports, reviews, letters, and editorials were excluded. Risk of bias was assessed according to the GRADE guidelines. Evidence synthesis Nine articles met the inclusion criteria and were included in the qualitative analysis. All the studies included were published between 2015 and 2022 and the majority of them compared phosphodiesterase type 5 inhibitors (PDE5Is) alone versus a combination of LI-ESWT and PDE5Is. Only three studies were randomized controlled trials (RCTs). In general, there is no standardized protocol for LI-ESWT for postprostatectomy ED. In comparisons of LI-ESWT + PDE5Is versus PDE5Is alone, some authors found a statistically significant improvement in erectile function with LI-ESWT + PDE5Is. The starting time for LI-ESWT differed among the studies, ranging from 3 d to 6 mo after surgery. The main limitations of the review are the scarcity of studies, small sample sizes, high risk of bias, and high heterogeneity among studies. Conclusions There is currently limited evidence on the use of LI-ESWT either alone or in combination with PDE5Is in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow-up show that LI-ESWT could potentially play a role in the management of postprostatectomy ED in the future. Further RCTs with larger sample sizes are needed. Patient summary Despite limited reports in the literature, low-intensity shockwave therapy after removal of the prostate is a promising noninvasive treatment for dealing with erectile dysfunction after surgery.
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Affiliation(s)
| | - Ahmed Eissa
- Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Corresponding author. Department of Urology, Tanta University Hospitals, Al-Giesh Street, El-Gharbia 31527, Tanta, Egypt. Tel. +2 11 10304666.
| | | | | | - Mosaab Eldeeb
- Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Simone Assumma
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
- Urology Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Enrico Panio
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
- Urology Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Tommaso Calcagnile
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
- Urology Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Daniele Stroppa
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | | | - Giorgia Gaia
- Gynecology Department, ASST Santi Paolo e Carlo, Milan, Italy
| | - Stefano Terzoni
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Mattia Sangalli
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Salvatore Micali
- Urology Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Bernardo Rocco
- Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
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Asker H, Yilmaz-Oral D, Oztekin CV, Gur S. An update on the current status and future prospects of erectile dysfunction following radical prostatectomy. Prostate 2022; 82:1135-1161. [PMID: 35579053 DOI: 10.1002/pros.24366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/30/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Radical prostatectomy (RP) and radiation treatment are standard options for localized prostate cancer. Even though nerve-sparing techniques have been increasingly utilized in RP, erectile dysfunction (ED) due to neuropraxia remains a frequent complication. Erectile function recovery rates after RP remain unsatisfactory, and many men still suffer despite the availability of various therapies. OBJECTIVE This systematic review aims to summarize the current treatments for post-RP-ED, assess the underlying pathological mechanisms, and emphasize promising therapeutic strategies based on the evidence from basic research. METHOD Evaluation and review of articles on the relevant topic published between 2010 and 2021, which are indexed and listed in the PubMed database. RESULTS Phosphodiesterase type 5 inhibitors, intracavernosal and intraurethral injections, vacuum erection devices, pelvic muscle training, and surgical procedures are utilized for penile rehabilitation. Clinical trials evaluating the efficacy of erectogenic drugs in this setting are conflicting and far from being conclusive. The use of androgen deprivation therapy in certain scenarios after RP further exacerbates the already problematic situation and emphasizes the need for effective treatment strategies. CONCLUSION This article is a detailed overview focusing on the pathophysiology and mechanism of the nerve injury developed during RP and a compilation of various strategies to induce cavernous nerve regeneration to improve erectile function (EF). These strategies include stem cell therapy, gene therapy, growth factors, low-intensity extracorporeal shockwave therapy, immunophilins, and various pharmacological approaches that have induced improvements in EF in experimental models of cavernous nerve injury. Many of the mentioned strategies can improve EF following RP if transformed into clinically applicable safe, and effective techniques with reproducible outcomes.
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Affiliation(s)
- Heba Asker
- Department of Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
- Department of Medical Pharmacology, Faculty of Medicine, Lokman Hekim University, Ankara, Turkey
- Graduate School of Health Sciences, Ankara University, Ankara, Turkey
| | - Didem Yilmaz-Oral
- Department of Pharmacology, Faculty of Pharmacy, Cukurova University, Adana, Turkey
| | - Cetin Volkan Oztekin
- Department of Urology, Faculty of Medicine, University of Kyrenia, Girne, Turkey
| | - Serap Gur
- Department of Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
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11
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Rho BY, Kim SH, Ryu JK, Kang DH, Kim JW, Chung DY. Efficacy of Low-Intensity Extracorporeal Shock Wave Treatment in Erectile Dysfunction following Radical Prostatectomy: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11102775. [PMID: 35628901 PMCID: PMC9145026 DOI: 10.3390/jcm11102775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/25/2022] [Accepted: 05/12/2022] [Indexed: 11/23/2022] Open
Abstract
Erectile dysfunction (ED) is a well-known complication of radical prostatectomy (RP). Oral 5-phosphodiesterase inhibitors are currently the most widely used penile rehabilitation treatment for ED following RP, but they are less effective than for those with general ED. Low-intensity extracorporeal shock wave treatment (LI-ESWT), causing a biological change that induces neovascularization, has recently been used as a treatment for ED. Therefore, we conducted a systematic review and meta-analysis to investigate the efficiency of LI-ESWT in ED following RP. PubMed, Embase, and the Cochrane Library were searched up until December 2021. The endpoint was the change in IIEF scores after LI-ESWT. Five papers (460 patients) were included in the final analysis. In IIEF scores performed 3–4 months after LI-ESWT, the group receiving LI-ESWT showed statistically significantly better results than the control (WMD = −2.04; 95% CI, −3.72 to −0.35; p = 0.02). However, there were a total of two studies that measured the results after 9–12 months. There was no statistical difference between the two groups (WMD = −5.37; 95% CI, −12.42 to 1.69; p = 0.14). The results of this analysis indicate that LI-ESWT showed a statistically significant effect on early recovery in penile rehabilitation of ED following RP. However, the level of evidence was low. Therefore, careful interpretation of the results is required.
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12
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Yao H, Wang X, Liu H, Sun F, Tang G, Bao X, Wu J, Zhou Z, Ma J. Systematic Review and Meta-Analysis of 16 Randomized Controlled Trials of Clinical Outcomes of Low-Intensity Extracorporeal Shock Wave Therapy in Treating Erectile Dysfunction. Am J Mens Health 2022; 16:15579883221087532. [PMID: 35319291 PMCID: PMC8949743 DOI: 10.1177/15579883221087532] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We conducted a meta-analysis to evaluate the efficacy of low-intensity extracorporeal shock wave therapy (LI-ESWT) in the treatment of erectile dysfunction (ED). From July 2011 to June 2021, we finally selected 16 randomized controlled trials (RCTs) including 1,064 participants to evaluate the efficacy of LI-ESWT in the treatment of ED from PubMed, EMBASE, and Cochrane databases. The data are analyzed by Review Manager Version 5.4. Fifteen articles mentioned International Index of Erectile Function (IIEF), in the follow-up of 1 month (mean difference [MD] = 3.18, 95% confidence interval [CI] = [1.38, 4.98], p = .0005), 3 months (MD = 3.01, 95% CI = [2.04, 3.98], p < .00001), and 6 months (MD = 3.20, 95% CI = [2.49, 3.92], p < .00001). After treatment, the improvement of IIEF in the LI-ESWT group was better than that in the control group. Besides, eight of the 16 trials provided data on the proportion of patients with baseline Erectile Hardness Score (EHS) ≤ 2 improved to EHS ≥ 3. The LI-ESWT group was also significantly better than the placebo group (odds ratio [OR] = 5.07, 95% CI = [1.78, 14.44], p = .002). The positive response rate of Questions 2 and 3 of the Sexual Encounter Profile (SEP) was not statistically significant (SEP2: OR = 1.27, 95% CI = [0.70, 2.30], p = .43; SEP3: OR = 4.24, 95% CI = [0.67, 26.83], p = .13). The results of this meta-analysis suggest that treatment plans with an energy density of 0.09 mJ/mm2 and pulses number of 1,500 to 2,000 are more beneficial to IIEF in ED patients. In addition, IIEF improvement was more pronounced in patients with moderate ED after extracorporeal shockwave therapy.
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Affiliation(s)
- Huibao Yao
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xiaofeng Wang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Hongquan Liu
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Fengze Sun
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Gonglin Tang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xingjun Bao
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jitao Wu
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Zhongbao Zhou
- Department of Urology, Beijing TianTan Hospital, Capital Medical University, Fengtai District, Beijing, China
| | - Jian Ma
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
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13
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Grushina TI, Orlov II. [Shock wave therapy in oncology: in vitro, in vivo, rehabilitation]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2022; 99:58-65. [PMID: 35700377 DOI: 10.17116/kurort20229903158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED Extracorporeal shock wave therapy (ESWT) is a relatively new branch of physiotherapy. PURPOSE OF THE STUDY Conduct an analytical review of the available literature data on the use of ESWT in oncology. MATERIAL AND METHODS A review was conducted, including data from electronic databases: Scopus, Web of Science, MedLine, World Health Organization, The Cochrane Central Register of Controlled Trials, ScienceDirect, US National Library of Medicine National Institutes of Health, PubMed, Google Scholar, elibrary, CyberLeninka, disserCat. RESULTS AND CONCLUSION The study of ESWT in oncology is carried out in two directions: 1) impact on the tumor with the aim of its disintegration, inhibition of growth, enhancement of the action of radiation and/or chemotherapy; 2) rehabilitation of cancer patients. Shock waves in vitro and in vivo significantly reduce the viability and activate apoptosis of cell lines of osteosarcoma, cancer of the stomach, colon, rectum, bladder, breast, urothelial cancer of the upper urinary tract, adenocarcinoma of the cervix, Burkitt's lymphoma, sarcoma, anaplastic thyroid cancer glands, glioblastoma multiforme. Shock waves also sensitize tumor cells for adjuvant chemotherapy and increase its antitumor activity. The lack of a stimulating effect on a number of malignant tumors in this physical factor makes it possible to conduct ESWT studies in the rehabilitation of cancer patients. The data obtained by a number of authors indicate the clinical efficacy of ESWT in the rehabilitation of patients with erectile dysfunction after radical prostatectomy, with postmastectomy lymphedema of the upper limb, with myofascial pain syndrome after cervical lymph node dissection due to malignant neoplasms of the head and neck, with peripheral polyneuropathy induced by cytostatics. However, in order to develop indications and contraindications for the appointment of ESWT in the rehabilitation of cancer patients, it is not enough just to evaluate its clinical effectiveness; currently absent scientific studies with long-term follow-up of patients who received this method of physiotherapy are needed.
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Affiliation(s)
- T I Grushina
- Moscow Scientific and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine of the Department of Health of the City of Moscow, Moscow, Russia
| | - I I Orlov
- Moscow Scientific and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine of the Department of Health of the City of Moscow, Moscow, Russia
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Mykoniatis I, Pyrgidis N, Zilotis F, Kapoteli P, Fournaraki A, Kalyvianakis D, Hatzichristou D. The Effect of Combination Treatment with Low-Intensity Shockwave Therapy and Tadalafil on Mild and Mild-To-Moderate Erectile Dysfunction: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial. J Sex Med 2022; 19:106-115. [PMID: 34866029 DOI: 10.1016/j.jsxm.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Combination of different first-line treatments for erectile dysfunction (ED) has emerged as a promising therapeutic approach. AIM To conduct the first double-blind, randomized, placebo-controlled clinical trial to evaluate the efficacy and safety of combination therapy with low-intensity shockwave therapy (LiST) and tadalafil vs LiST and placebo in patients with mild or mild-to-moderate vasculogenic ED. METHODS Fifty sexually active patients fulfilling the eligibility criteria were randomly assigned to 6 sessions of LiST twice weekly for 3 weeks and tadalafil (n = 25) or placebo (n = 25) once daily for 4 weeks. Patients were evaluated at 1, 3, and 6 months after completion of the treatment protocol. OUTCOMES The primary outcome was the mean change from baseline in the International Index of Erectile Function-Erectile Function (IIEF-EF) domain between the 2 groups at 3 months after treatment. Erectile function was also assessed at 1 and 6 months. The number of patients attaining a minimal clinically important difference (MCID) in the IIEF-EF, as well as the safety of combination therapy were evaluated. RESULTS Adjusting for the baseline values, IIEF-EF improved by 0.8 points more (95% confidence interval [CI] = -0.2 to 1.9, P = .12) at 1 month, 1 point more (95% CI = 0.1-1.9, P = .02) at 3 months and 1.7 points more (95% CI = 0.8-2.7, P < .001) at 6 months in patients treated with combination therapy compared to monotherapy. The number of patients attaining a MCID in the IIEF-EF between the 2 groups improved significantly only at the 3-month evaluation. No adverse events were reported during the whole study period. CLINICAL IMPLICATIONS Combination of LiST twice weekly for 3 weeks and tadalafil 5 mg once daily for 4 weeks may further ameliorate mild or mild-to-moderate vasculogenic ED compared to LiST monotherapy. STRENGTHS & LIMITATIONS We conducted the first randomized trial exploring the role of LiST and tadalafil in the management of ED. Conversely, our study lacks external validity due to its single-center design. CONCLUSION The addition of daily low-dose tadalafil during application of LiST may further improve erectile function compared to application of LiST as a standalone treatment in patients with mild or mild-to-moderate vasculogenic ED. Still, further high-quality studies are warranted to corroborate our findings.
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Affiliation(s)
- Ioannis Mykoniatis
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Nikolaos Pyrgidis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Filimon Zilotis
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Paraskeui Kapoteli
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Agrippina Fournaraki
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Kalyvianakis
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Dimitrios Hatzichristou
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
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15
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Chung E. A review of regenerative therapies as penile rehabilitation in men following primary prostate cancer treatment: Evidence for erectile restoration and cavernous nerve regeneration. Asian J Urol 2021; 9:287-293. [PMID: 36035357 PMCID: PMC9399549 DOI: 10.1016/j.ajur.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/23/2021] [Accepted: 09/30/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
- Eric Chung
- AndroUrology Centre, Brisbane, QLD, Australia
- University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Macquarie University Hospital, Sydney, NSW, Australia
- AndroUrology Centre, Brisbane, QLD, Australia.
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16
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Pyrgidis N, Mykoniatis I, Haidich AB, Tirta M, Talimtzi P, Kalyvianakis D, Ouranidis A, Hatzichristou D. The Effect of Phosphodiesterase-type 5 Inhibitors on Erectile Function: An Overview of Systematic Reviews. Front Pharmacol 2021; 12:735708. [PMID: 34557099 PMCID: PMC8452927 DOI: 10.3389/fphar.2021.735708] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Multiple systematic reviews explore the effect of phosphodiesterase type 5 (PDE5) inhibitors on erectile dysfunction (ED), with each study addressing specific outcomes. However, physicians and policymakers require a holistic approach of this topic. Objective: To summarize the current evidence regarding the efficacy and safety of PDE5 inhibitors for the management of ED through an overview of systematic reviews. Methods: Studies were identified by searching PubMed, Web of Science, Cochrane Library and Scopus databases, as well as sources of grey literature until June 12, 2021 (PROSPERO: CRD42020216754). We considered systematic reviews, meta-analyses or network meta-analyses of randomized trials that provided outcomes about the efficacy and safety of any approved PDE5 inhibitor (avanafil, sildenafil, tadalafil and vardenafil). We constructed forest plots for meta-analytic effects regarding the change in erectile function, adverse events and dropouts after administration of PDE5 inhibitors in the general population and in specific patient groups. Results: We included 23 studies with 154,796 participants and a total of 258 meta-analytic effects. Sildenafil 25 mg [Weighted Mean Difference (WMD): 13.08, 95% Confidence Interval (CI): 10.1-16.06] seemed to be statistically superior to all interventions in improving erectile function compared to placebo, but studies with low-dose sildenafil are lacking. Moreover, comparing among different PDE5 inhibitors, sildenafil 50 mg or sildenafil 100 mg were considered the most effective compounds in the general population. The latter derived, however, predominantly from indirect comparisons among different PDE5 inhibitors. Still, sildenafil 100 mg was associated with more treatment-related adverse events and dropouts. Interestingly, low-dose daily tadalafil may be more effective than high-dose on-demand tadalafil (WMD: 1.24, 95% CI: 0.03-2.44). Furthermore, testosterone and PDE5 inhibitors in patients with ED and hypogonadism seem to further improve symptoms, while the addition of a-blockers in patients with urinary symptoms treated with PDE5 inhibitors does not provide additional benefits (WMD: −0.8, 95% CI: −1.65-0.06). Conclusion: Although the efficacy and safety of PDE5 inhibitors, compared to placebo, is well-documented, the existing evidence comparing different PDE5 inhibitors is low. Therefore, high-quality, head-to-head, trials comparing different PDE5 inhibitors are necessary to determine their ideal dosage and formulation based on their safety and efficacy profile. Systematic Review Registration: PROSPERO, identifier [CRD42020216754].
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Affiliation(s)
- Nikolaos Pyrgidis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Mykoniatis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Tirta
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Persefoni Talimtzi
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Kalyvianakis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Ouranidis
- Department of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Department of Chemical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Hatzichristou
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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17
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Chung E. Regenerative technology to restore and preserve erectile function in men following prostate cancer treatment: evidence for penile rehabilitation in the context of prostate cancer survivorship. Ther Adv Urol 2021; 13:17562872211026421. [PMID: 34434257 PMCID: PMC8381411 DOI: 10.1177/17562872211026421] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/01/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction Erectile dysfunction (ED) following prostate cancer treatment is not uncommon and penile rehabilitation is considered the standard of care in prostate cancer survivorship (PCS), where both patient and his partner desire to maintain and/or recover pre-treatment erectile function (EF). There is a clinical interest in the role of regenerative therapy to restore EF, since existing ED treatments do not always achieve adequate results. Aim To review regenerative therapies for the treatment of ED in the context of PCS. Materials and Methods A review of the existing PubMed literature on low-intensity extracorporeal shockwave therapy (LIESWT), stem cell therapy (SCT), platelet-rich plasma (PRP), gene therapy, and nerve graft/neurorrhaphy in the treatment of ED and penile rehabilitation, was undertaken. Results IESWT promotes neovascularization and neuroprotection in men with ED. While several systematic reviews and meta-analyses showed positive benefits, there is limited published clinical data in men following radical prostatectomy. Cellular-based technology such as SCT and PRP promotes cellular proliferation and the secretion of various growth factors to repair damaged tissues, especially in preclinical studies. However, longer-term clinical outcomes and concerns regarding bioethical and regulatory frameworks need to be addressed. Data on gene therapy in post-prostatectomy ED men are lacking; further clinical studies are required to investigate the optimal use of growth factors and the safest vector delivery system. Conceptually interpositional cavernous nerve grafting and penile re-innervation technique using a somatic-to-autonomic neurorrhaphy are attractive, but issues relating to surgical technique and potential for neural 'regeneration' are questionable. Conclusion In contrast to the existing treatment regime, regenerative ED technology aspires to promote endothelial revascularization and neuro-regeneration. Nevertheless, there remain considerable issues related to these regenerative technologies and techniques, with limited data on longer-term efficacy and safety records. Further research is necessary to define the role of these alternative therapies in the treatment of ED in the context of penile rehabilitation and PCS.
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Affiliation(s)
- Eric Chung
- AndroUrology Centre, Suite 3, 530 Boundary St., Brisbane, QLD 4000, Australia
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18
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Sandoval-Salinas C, Saffon JP, Corredor HA, Fonseca L, Manrique L, Solis G. Are Radial Pressure Waves Effective in Treating Erectile Dysfunction? A Systematic Review of Preclinical and Clinical Studies. Sex Med 2021; 9:100393. [PMID: 34274822 PMCID: PMC8360928 DOI: 10.1016/j.esxm.2021.100393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 12/09/2022] Open
Abstract
Introduction Radial waves are used to treat erectile dysfunction; however, they are different than focal waves, and their mechanism of action or effect on improving this condition is not known. Aim To evaluate the effect of radial waves at the cellular level and their effectiveness at the clinical level for the treatment of erectile dysfunction. Methods Systematic literature review. Electronic database searches and manual searches were performed to identify (i) clinical trials or cohort studies evaluating the effectiveness of radial waves in men with erectile dysfunction and (ii) preclinical trials in animal models or cell cultures in which the production of nitric oxide or endothelial growth factor was evaluated. Study quality was assessed, and data were extracted from each study. A narrative synthesis of the results was performed given the high heterogeneity between the selected studies. Main outcomes measures Nitric oxide production, endothelial growth factor expression, and changes in the Erection Hardness Score (EHS) and the International Index of Erectile Function (IIEF) Questionnaire score. Results Four studies in animal models and 1 randomized clinical trial in men with erectile dysfunction and kidney transplantation were identified that met the selection criteria. Preclinical studies in animals suggest that radial waves increase cellular apoptosis in penile tissue, while vascular endothelial growth factor expression increases in brain tissue. In men with erectile dysfunction, no differences were found between radial wave therapy and placebo therapy in the mean IIEF score (15.6 ± 6.1 vs 16.6 ± 5.4 at 1 month after treatment), EHS (2.5 ± 0.85 vs 2.4 ± 0.7 at 1 month after treatment), or penile Doppler parameters. Conclusions No quality evidence was found to support the use of radial waves in humans for the treatment of erectile dysfunction. In animal models and at the cellular level, the results are contradictory. More research is needed. Sandoval-Salinas C, Saffon JP, Corredor HA, et al. Are Radial Pressure Waves Effective in Treating Erectile Dysfunction? A Systematic Review of Preclinical and Clinical Studies. Sex Med 2021;9:100393.
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Affiliation(s)
| | - José P Saffon
- Elexial Research Center, Bogotá, Colombia; Boston Medical Group, Bogotá, Colombia
| | - Hector A Corredor
- Elexial Research Center, Bogotá, Colombia; Boston Medical Group, Bogotá, Colombia
| | | | - Laura Manrique
- Elexial Research Center, Bogotá, Colombia; Boston Medical Group, Bogotá, Colombia
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19
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Towe M, Peta A, Saltzman RG, Balaji N, Chu K, Ramasamy R. The use of combination regenerative therapies for erectile dysfunction: rationale and current status. Int J Impot Res 2021; 34:735-738. [PMID: 34253869 DOI: 10.1038/s41443-021-00456-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 11/09/2022]
Abstract
Erectile Dysfunction (ED) is defined as the inability to achieve and maintain an erection sufficient for sexual intercourse. Available treatments for ED provide only symptomatic relief, which is for the most part temporary. Regenerative therapies such as Low Intensity Shockwave, Platelet-Rich Plasma, and Stem Cell therapy can potentially provide a "cure" for ED by reversing the underlying pathology of ED rather than just treating the symptoms. Low Intensity Shockwave therapy is the most evidence based at this point and is thought to act by improving penile blood flow, repairing previous nerve damage, and activating stem cells. Stem Cell therapy takes advantage of the self-replicative potential of stem cells to create new corporal tissue, but also to recruit host cells and angiogenic factors to stimulate endogenous repair. Platelet-Rich Plasma therapy uses concentrated growth factors that already exist within the bloodstream to repair damaged nerves and increase penile blood flow. The use of combination restorative therapy may provide an additive or synergistic benefit greater than any one therapy alone because of its overlapping mechanisms of action on the penis but is a topic that remains to be studied.
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Affiliation(s)
- Maxwell Towe
- Department of Urology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Akhil Peta
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Russell G Saltzman
- Interdisciplinary Stem Cell Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Navin Balaji
- Department of Urology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Kevin Chu
- Department of Urology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Ranjith Ramasamy
- Department of Urology, University of Miami, Miller School of Medicine, Miami, FL, USA.
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20
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Canguven O, Khalafalla K, Al Ansari A. Low-intensity extracorporeal shockwave therapy for erectile dysfunction. Arab J Urol 2021; 19:340-345. [PMID: 34552784 PMCID: PMC8451630 DOI: 10.1080/2090598x.2021.1948158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/05/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives: To review the current evidence of clinical effectiveness of low-intensity extracorporeal shockwave therapy (LI-ESWT) treatment for erectile dysfunction (ED). METHODS A selective database search using Medical Subject Headings (MeSH) terms 'low intensity extracorporeal shock wave therapy' and 'erectile dysfunction' was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA) guidelines to review the effectiveness of LI-ESWT for ED. We performed a systematic search of publications using the PubMed and Web of Science databases (January 2010-December 2020) for prospective randomised clinical trials (RCTs). The success rate of LI-ESWT associated with ED were recorded and analysed. RESULTS A total of 106 articles were reviewed after searching for the keywords. Overall, 11 RCTs were included in this systematic review. A total of 920 male patients were treated in 11 RCTs. The patients' ages ranged from 18 to 80 years and they had ≥3 months of ED symptoms. Vasculogenic and neurogenic causes were addressed in 81% and 19% of patients, respectively. Of the 920 patients, 348 patients had a statistically significant improvement in their erectile function after LI-ESWT; however, 572 did not have a statistically significant improvement. CONCLUSIONS The present review found that LI-ESWT has a role in ED treatment in laboratory studies, but its role in human clinical trials is still controversial. Further good quality studies need to be conducted to properly assess its true potential in ED treatment.
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21
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Chung E, Cartmill R. Evaluation of Long-Term Clinical Outcomes and Patient Satisfaction Rate Following Low Intensity Shock Wave Therapy in Men With Erectile Dysfunction: A Minimum 5-Year Follow-Up on a Prospective Open-Label Single-Arm Clinical Study. Sex Med 2021; 9:100384. [PMID: 34126432 PMCID: PMC8360926 DOI: 10.1016/j.esxm.2021.100384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Low intensity extracorporeal shock wave therapy (LIESWT) improves erectile function (EF) in men with vascular erectile dysfunction (ED) but longer-term outcomes remain unknown. Aim To evaluate the clinical outcomes of LIESWT at a minimum 5-year follow-up. Methods This is an open-label single-arm prospective study involved men with vascular ED who received LIESWT. Main Outcome Measure Changes in patient demographics, IIEF-5 and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, as well as overall satisfaction score (on a 5-point scale) were reviewed at 12, 24, 48, and 60 months after completion of LIESWT. A chi-square contingency analysis was used to examine the relationship between erectile function score and treatment satisfaction, with statistical significance set at 5%. Results The mean follow-up period was 69.9 (63–82; median 76) months. The mean IIEF-5 scores for pretreatment and after treatment at 12, 24, 48, and 60 months were 14.8, 17.6, 16.8, 16.5, and 16.5 while the percentages of patients who reported an improvement in IIEF-5 score by 5 points were 60%, 45%, 40%, and 40%; and EDITS scores >50% were recorded in 70%, 55%, 50%, and 48% of patients at 12, 24, 48, and 60 months post-LIESWT. Ten patients required medical therapy and 2 patients opted for penile prosthesis implantation. The overall satisfaction rate appeared sustained subsequent follow-up (score 4 out of 5; 68% vs 50% vs 40% vs 40% at 12, 24, 48, and 60 months). There were minor time-limited, but no significant adverse event reported. Conclusion This long-term study showed the observed clinical improvement in EF continues to deteriorate but appears to plateau at 40% clinical efficacy at 48–60 months after completion of LIESWT. The absence of penile pain and deformity at 5-year follow-up supports the long-term safety data of LIESWT in men with ED. Chung E, Cartmill R. Evaluation of Long-Term Clinical Outcomes and Patient Satisfaction Rate Following Low Intensity Shock Wave Therapy in Men With Erectile Dysfunction: A Minimum 5-Year Follow-Up on a Prospective Open-Label Single-Arm Clinical Study. Sex Med 2021;9:100384.
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Affiliation(s)
- Eric Chung
- The University of Queensland, Department of Urology, Princess Alexandra Hospital, Brisbane, QLD, Australia; AndroUrology Centre, Brisbane, QLD, Australia; AndroUrology Centre, Sydney, NSW, Australia.
| | - Ross Cartmill
- The University of Queensland, Department of Urology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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de Oliveira PS, Ziegelmann MJ. Low-intensity shock wave therapy for the treatment of vasculogenic erectile dysfunction: a narrative review of technical considerations and treatment outcomes. Transl Androl Urol 2021; 10:2617-2628. [PMID: 34295748 PMCID: PMC8261418 DOI: 10.21037/tau-20-1286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/27/2022] Open
Abstract
Erectile dysfunction (ED) impacts a significant portion of the aging male population. Standard treatments such as oral medications, intracavernosal injections, intraurethral suppositories, vacuum erection aids, and penile prosthesis placement have stood the test of time. Recently, there has been a growing interest in the concept of regenerative medicine with the goal of restoring or renewing functional tissue. Low intensity shock wave therapy (LiSWT) is one example of a regenerative therapy. A strong body of basic science data suggests that shockwaves, when applied to local tissue, will encourage blood vessel and nerve regeneration. Clinical evidence supports the use of LiSWT to treat conditions ranging from ischemic heart disease, musculoskeletal injuries, and even chronic non-healing wounds. LiSWT is also being used to treat male sexual dysfunction conditions such as Peyronie's Disease and ED. The first studied application of LiSWT for ED was published in 2010. Since then multiple randomized, sham-controlled trials have sought to evaluate outcomes for this novel therapy in men with vasculogenic ED. Additionally, several meta-analyses are available with pooled data suggesting that LiSWT results in a significantly greater improvement in erectile function relative to sham-control. Despite these promising findings, the current body of literature is marred by significant heterogeneity relating to treatment protocols, patient populations, and follow-up duration. Further work is necessary to determine optimal device technologies, patient characteristics, and treatment duration prior to considering LiSWT as standard of care for men with ED.
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Affiliation(s)
- Pedro Simoes de Oliveira
- Department of Urology, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Lisbon, Portugal.,Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Ochoa A, Guillot-Tantay C, Misrai V, Rouprêt M. [Low-intensity extracorporeal shock wave therapy for erectile dysfunction: A systematic review]. Prog Urol 2021; 31:506-518. [PMID: 33941461 DOI: 10.1016/j.purol.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/13/2020] [Accepted: 11/10/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Our purpose was to assess the efficacy of low intensity extracorporeal shock waves (SW) for the treatment of organic erectile dysfunction (ED). METHODS A systematic review of the literature published between 2000 and 2020 was conducted using the PRISMA methodology. We used Medline data with the following key words (MesH): "extracorporeal shock wave therapy"; "erectile dysfunction"; "sexuality". RESULTS Nineteen articles were selected: thirteen randomised controlled trial and six meta-analyses. Most of them studied vascular etiology. Low intensity SW is beneficial ED is evaluated by the IIEF, EHS scores and penile hemodynamic. CONCLUSION SW may have a theoretical impact on the vascular etiology of organic DE. Their use in this context is supported by the European Society of urology and the European Society of sexual medecine. However, there are discrepancies in current data to establish a protocol to follow in daily practice.
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Affiliation(s)
- A Ochoa
- Sorbonne université, GRC 5 onco-urologie prédictive, Assistance publique-Hôpitaux de Paris, hôpital La Pitié Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Guillot-Tantay
- Sorbonne université, GRC 5 onco-urologie prédictive, Assistance publique-Hôpitaux de Paris, hôpital La Pitié Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - V Misrai
- Service d'urologie, Clinique Pasteur, Toulouse, France
| | - M Rouprêt
- Sorbonne université, GRC 5 onco-urologie prédictive, Assistance publique-Hôpitaux de Paris, hôpital La Pitié Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
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24
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Male sexual dysfunction and rehabilitation strategies in the settings of salvage prostate cancer treatment. Int J Impot Res 2021; 33:457-463. [PMID: 33854206 DOI: 10.1038/s41443-021-00437-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/08/2022]
Abstract
Male sexual dysfunction, a common sequela following primary prostate cancer (PC) treatment, is likely to be more significant following salvage PC therapy. In general, these impairments in sexual domains can be divided into three groups, namely (1) sexual desire, sexuality and masculinity; (2) erectile function (EF); and (3) ejaculation and orgasm. However, there is considerable overlap between these sexual domains and male sexual response cycle, and various factors such as cancer status, mental well-being, medical conditions and social circumstances can adversely impact on the male sexual function. While several preventive and treatment strategies for the preservation and recovery of sexual function are available, there is limited consensus guidelines exist regarding the optimal rehabilitation or treatment protocol for men with sexual dysfunction following salvage therapy. While penile rehabilitation may be effective to restore erectile function and the ability to have coital sex, there is lack of effective treatments in other domains of male sexual function, thereby underscoring the importance of psychological and sexual counselling in sexual rehabilitation. Indeed, a comprehensive multidisciplinary approach is necessary to better understand and optimally assist and manage the men and their respective partners for better sexual health and activity.
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Nicolai M, Urkmez A, Sarikaya S, Fode M, Falcone M, Albersen M, Gul M, Hatzichristodoulou G, Capogrosso P, Russo GI. Penile Rehabilitation and Treatment Options for Erectile Dysfunction Following Radical Prostatectomy and Radiotherapy: A Systematic Review. Front Surg 2021; 8:636974. [PMID: 33738297 PMCID: PMC7961076 DOI: 10.3389/fsurg.2021.636974] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/13/2021] [Indexed: 11/13/2022] Open
Abstract
After radical prostatectomy (RP) or radiotherapy (RT) for prostate cancer, erectile dysfunction (ED) is the main complication next to urinary incontinence, affecting quality of life. The pathophysiology of ED after these treatments is believed to include neuropraxia causing reduced oxygenation and structural changes of the tissue in the corpora cavernosa. Next to the option of sparing the nerves during RP, research has been focusing on methods for penile rehabilitation after RP and RT, since it occurs often, even after nerve-sparing techniques were used. In animal studies, the use of phosphodiesterase type 5 inhibitors (PDE5i) after cavernous nerve damage is supported, but results in human studies are contradictory. Non-medical treatment options such as vacuum device therapy, hyperbaric oxygen therapy, yoga, aerobic, or pelvic floor training may be helpful, but evidence is scarce. Clear guidelines for penile rehabilitation are not yet available. However, care and support for ED after RP and RT is highly demanded by a large group of patients, so measures have to be taken even though the evidence is not strong yet. In this systematic review, an overview of the literature for penile rehabilitation and treatment options for ED after RP and RT is provided, using only randomized controlled trials (RCT).
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Affiliation(s)
- Melianthe Nicolai
- Urology Department, The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands.,Urology Department, Diakonessenhospital, Utrecht, Netherlands
| | - Ahmet Urkmez
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | - Mikkel Fode
- Urology Department, University of Copenhagen, Copenhagen, Denmark
| | - Marco Falcone
- Urology Department, Molinette Hospital, Turin, Italy
| | - Maarten Albersen
- Urology Department, University Hospitals Leuven, Leuven, Belgium
| | - Murat Gul
- School of Medicine, Selcuk University, Konya, Turkey
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Mykoniatis I, Pyrgidis N, Sokolakis I, Ouranidis A, Sountoulides P, Haidich AB, van Renterghem K, Hatzichristodoulou G, Hatzichristou D. Assessment of Combination Therapies vs Monotherapy for Erectile Dysfunction: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2036337. [PMID: 33599772 PMCID: PMC7893498 DOI: 10.1001/jamanetworkopen.2020.36337] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Combining 2 first-line treatments for erectile dysfunction (ED) or initiating other modalities in addition to a first-line therapy may produce beneficial outcomes. OBJECTIVE To assess whether different ED combination therapies were associated with improved outcomes compared with first-line ED monotherapy in various subgroups of patients with ED. DATA SOURCES Studies were identified through a systematic search in MEDLINE, Cochrane Library, and Scopus from inception of these databases to October 10, 2020. STUDY SELECTION Randomized clinical trials or prospective interventional studies of the outcomes of combination therapy vs recommended monotherapy in men with ED were identified. Only comparative human studies, which evaluated the change from baseline of self-reported erectile function using validated questionnaires, that were published in any language were included. DATA EXTRACTION AND SYNTHESIS Data extraction and synthesis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES A meta-analysis was conducted that included randomized clinical trials that compared outcomes of combination therapy with phosphodiesterase type 5 (PDE5) inhibitors plus another agent vs PDE5 inhibitor monotherapy. Separate analyses were performed for the mean International Index of Erectile Function (IIEF) score change from baseline and the number of adverse events (AEs) by different treatment modalities and subgroups of patients. RESULTS A total of 44 studies included 3853 men with a mean (SD) age of 55.8 (11.9) years. Combination therapy compared with monotherapy was associated with a mean IIEF score improvement of 1.76 points (95% CI, 1.27-2.24; I2 = 77%; 95% PI, -0.56 to 4.08). Adding daily tadalafil, low-intensity shockwave therapy, vacuum erectile device, folic acid, metformin hydrochloride, or angiotensin-converting enzyme inhibitors was associated with a significant IIEF score improvement, but each measure was based on only 1 study. Specifically, the weighted mean difference (WMD) in IIEF score was 1.70 (95% CI, 0.79-2.61) for the addition of daily tadalafil, 3.50 (95% CI, 0.22-6.78) for the addition of low-intensity shockwave therapy, 8.40 (95% CI, 4.90-11.90) for the addition of a vacuum erectile device, 3.46 (95% CI, 2.16-4.76) for the addition of folic acid, 4.90 (95% CI, 2.82-6.98) for the addition of metformin hydrochloride and 2.07 (95% CI, 1.37-2.77) for the addition of angiotensin-converting enzyme inhibitors. The addition of α-blockers to PDE5 inhibitors was not associated with improvement in IIEF score (WMD, 0.80; 95% CI, -0.06 to 1.65; I2 = 72%). Compared with monotherapy, combination therapy was associated with improved IIEF score in patients with hypogonadism (WMD, 1.61; 95% CI, 0.99-2.23; I2 = 0%), monotherapy-resistant ED (WMD, 4.38; 95% CI, 2.37-6.40; I2 = 52%), or prostatectomy-induced ED (WMD, 5.47; 95% CI, 3.11-7.83; I2 = 53%). The treatment-related AEs did not differ between combination therapy and monotherapy (odds ratio, 1.10; 95% CI, 0.66-1.85; I2 = 78%). Despite multiple subgroup and sensitivity analyses, the levels of heterogeneity remained high. CONCLUSIONS AND RELEVANCE This study found that combination therapy of PDE5 inhibitors and antioxidants was associated with improved ED without increasing the AEs. Treatment with PDE5 inhibitors and daily tadalafil, shockwaves, or a vacuum device was associated with additional improvement, but this result was based on limited data. These findings suggest that combination therapy is safe, associated with improved outcomes, and should be considered as a first-line therapy for refractory, complex, or difficult-to-treat cases of ED.
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Affiliation(s)
- Ioannis Mykoniatis
- Department of Urology, Faculty of Medicine, Aristotle University of Thessaloniki School of Health Sciences, Thessaloniki, Greece
| | - Nikolaos Pyrgidis
- Department of Urology, Faculty of Medicine, Aristotle University of Thessaloniki School of Health Sciences, Thessaloniki, Greece
- Department of Urology, Martha-Maria Hospital Nuremberg, Nuremberg, Germany
| | - Ioannis Sokolakis
- Department of Urology, Martha-Maria Hospital Nuremberg, Nuremberg, Germany
| | - Andreas Ouranidis
- Department of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Chemical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Petros Sountoulides
- Department of Urology, Faculty of Medicine, Aristotle University of Thessaloniki School of Health Sciences, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Aristotle University of Thessaloniki Medical School, University Campus, Thessaloniki, Greece
| | - Koenraad van Renterghem
- Department of Urology, Jessa Hospital, Hasselt University, Hasselt, Belgium
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | - Dimitrios Hatzichristou
- Department of Urology, Faculty of Medicine, Aristotle University of Thessaloniki School of Health Sciences, Thessaloniki, Greece
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Drury R, Natale C, Hellstrom WJG. Reviewing the evidence for shockwave- and cell-based regenerative therapies in the treatment of erectile dysfunction. Ther Adv Urol 2021; 13:17562872211002059. [PMID: 33796149 PMCID: PMC7968013 DOI: 10.1177/17562872211002059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
Erectile dysfunction (ED) is both a common and complex disease process. Existing ED treatments do not always achieve adequate results. There is clinical interest in employing regenerative therapies, including low-intensity extracorporeal shockwave therapy (Li-ESWT), platelet rich plasma (PRP), and stem cell therapy (SCT), in the treatment of ED as adjunct or alternative treatments. Here, we present evidence for emerging shockwave- and cell-based regenerative therapies for the treatment of ED following a thorough review of the existing PubMed literature pertaining to Li-ESWT, PRP, and SCT in relation to the treatment of ED. Li-ESWT causes microtrauma in tissue that hypothetically upregulates angiogenesis and recruits stem cells. Several large-scale systematic reviews and meta-analyses have reported that Li-ESWT improved ED in humans. Additionally, evidence has commenced to show that Li-ESWT may be effective against two recognized and complex etiologies of ED: diabetic and neurogenic. PRP delivers an autologous sample rich in growth factors to damaged tissue. Animal model studies have demonstrated improved erectile function recovery as well as preservation of cavernous nerve axons. Studies with PRP in humans are limited. SCT utilizes the regenerative potential of stem cells for healing of damaged tissue. In the treatment of ED, SCT has been used in the setting of diabetic and post-prostatectomy ED. Results of human studies are varied, although SCT treatments did result in increased erectile rigidity with some patients recovering the ability to achieve penetration. While these regenerative therapies show potential to augment the current treatment regimen for ED, there is a paucity of evidence to support the safety and efficacy of these treatments. Further research is necessary to define the role of these alternative therapies in the treatment of ED.
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Affiliation(s)
- Robert Drury
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Caleb Natale
- Tulane University School of Medicine, New Orleans, LA, USA
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Feng D, Tang C, Liu S, Yang Y, Han P, Wei W. Current management strategy of treating patients with erectile dysfunction after radical prostatectomy: a systematic review and meta-analysis. Int J Impot Res 2020; 34:18-36. [PMID: 33099581 DOI: 10.1038/s41443-020-00364-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/27/2020] [Accepted: 10/08/2020] [Indexed: 02/05/2023]
Abstract
The aim of this study is to present a summary of current evidence concerning the various treatments in the management of penile rehabilitation after radical prostatectomy (RP) and provide recommendations for future research. Randomized controlled trials (RCTs) were identified from electronic databases including PubMed, the Cochrane Library, Embase, and Web of Science from inception through March 2020 with no limitation to language. Comparable data from each study were combined in a meta-analysis where possible, otherwise data were synthesized narratively. The data analysis was completed by Review Manager version 5.3. A total of 39 RCTs were included in this study. At present, phosphodiesterase type 5 inhibitors (PDE5is) remain the first-line treatment for patients with erectile dysfunction (ED) after RP. Compared with the placebo group, patients in regular PDE5is group (mean difference (MD): 0.76; 95% confidence interval (CI): 1.69-4.44; p < 0.0001) and on demand group (MD: 3.92; 95% CI: 2.95-4.88; p < 0.00001) had a significantly higher mean Erectile Function domain of the International Index of Erectile Function (IIEF-EF) scores within 3 months after RP. As for the proportion of IIEF-EF ≥ 22, patients in regular PDE5is group and on demand PDE5is group had significantly higher proportion than those in placebo group 6 months after RP, and the odds ratios were 1.87 (95% CI: 1.32-2.66; p = 0.0005) and 2.17 (95% CI: 1.20-3.93; p = 0.01), respectively. No significant difference was observed between regular PDE5is group and on demand group regardless of mean IIEF-EF score or the proportion of IIEF-EF ≥ 22. Intracorporeal injection therapy seemed to have similar efficacy to PDE5is. The International Index of Erectile Function-5 items (IIEF-5) scores were significantly higher in vacuum constriction devices group than control group at 6-9 months after RP (MD: 6.70, 95% CI: 2.30-11.10, p = 0.003) with great between-study heterogeneity (p = 0.06, I2 = 72%). The other therapeutics including low-intensity extracorporeal shockwave therapy, statin therapy, psychotherapy interventions, and pelvic floor muscle training plus electrical stimulation showed certain improvement on erectile function. We found that the combination therapy showed certain advantages over monotherapy. Currently, PDE5is-based combination therapy remains the mainstream treatment for ED after RP. Intracorporeal injection therapy and vacuum therapy could be served as alternative treatments if PDE5is are ineffective and contraindicated.
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Affiliation(s)
- Dechao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Cai Tang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Shengzhuo Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yubo Yang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ping Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wuran Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Wu SS, Ericson KJ, Shoskes DA. Retrospective comparison of focused shockwave therapy and radial wave therapy for men with erectile dysfunction. Transl Androl Urol 2020; 9:2122-2128. [PMID: 33209675 PMCID: PMC7658170 DOI: 10.21037/tau-20-911] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Low-intensity shockwave therapy (SWT) is an emerging treatment for erectile dysfunction (ED). Devices used for SWT include focused shockwave therapy (fSWT) or radial wave therapy (rWT), which differ in how the waves are generated, their tissue penetration, and the shape of their pressure waves. Most studies of SWT for ED to date have utilized fSWT. Although widely used, the efficacy of rWT for ED is unknown. Our objective is to compare the efficacy of rWT and fSWT for ED at our institution. Methods A retrospective chart review was performed to identify all men with ED treated by fSWT or rWT. Men with history suggesting non-vasculogenic ED were excluded. All men received 6 consecutive weekly treatments. The fSWT group received 3,000 shocks per treatment at 0.09 mJ/mm2. The rWT group received 10,000 shocks per treatment at 90 mJ and 15 Hz. Pre-treatment and 6-week post-treatment Sexual Health Inventory in Men (SHIM) scores were measured. Treatment response was categorized on a scale of 1–3 (1 if no improvement, 2 if erections sufficient for intercourse with phosphodiesterase 5 inhibitors (PDE5i), or 3 if sufficient erections without PDE5i). Primary endpoint was self-reported improvement score of 2 or greater. Results A total of 48 men were included: 24 treated by fSWT and 24 by rWT. There were no significant differences in age, duration of ED, pre-treatment PDE5i use, or pre-treatment SHIM scores between the groups. Following treatment with rWT, the mean SHIM score improved from 9.3 to 16.1 (P<0.001). The mean SHIM following fSWT improved from 9.3 to 15.5 (P<0.001). The mean improvement in SHIM score did not differ between rWT (6.8) and fSWT (6.2) (P=0.42). 54% of men treated by fSWT experienced a significant clinical improvement (≥ grade 2 response) compared to 75% in the rWT group (P=0.42). There were no reported side effects with either device. Conclusions In our patient population, both fSWT and rWT were moderately effective treatments for arteriogenic ED with no observable difference in efficacy between the two modalities.
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Affiliation(s)
- Shannon S Wu
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Kyle J Ericson
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, USA
| | - Daniel A Shoskes
- Department of Urology, Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH, USA
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Low-intensity extracorporeal shockwave therapy among urologist practitioners: how the opinion of urologists changed between 2016 and 2019. Int J Impot Res 2020; 33:839-843. [PMID: 32826969 DOI: 10.1038/s41443-020-00347-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 11/08/2022]
Abstract
Over the past few years, an increase use of low-intensity shockwave therapy (LISWT) for the treatment of erectile dysfunction (ED) has been observed. However, many controversies in the scientific literature about its efficacy still exist. We aimed to investigate changes in the pattern of usage and attitudes toward LISWT for ED among experts over the last years. A dedicated online survey was sent to delegates at the Congress for the EAU Section of Andrological Urology (ESAU) in Prague from 31st October to 1st November 2019. The survey captured demographic data, professional background, and the experience and personal knowledge about LISWT. The results were compared with a previous survey conducted in 2016 and investigating the same topics in order to assess changes in the knowledge and opinion on LISWT over time. Overall, 172 and 192 questionnaires were available from 2019 and 2016, respectively. Participants in the 2019 survey were 80 (45.7%) urologists, 52 (29.7%) uro-andrologists, and 34 (19.4%) residents in urology, from 30 different countries. Compared to the past, we observed an increase of respondents who were familiar with LISWT (75 vs. 95%; p < 0.0001) and who performed LISWT in their routine practice (38% in 2019 vs. 14% in 2016; p < 0.0001). Conversely, no changes in terms of overall perception of treatment efficacy were registered over time (68% in 2019 vs. 72% in 2016 considered LISWT as an effective treatment, respectively (p = 0.5)). An increased proportion of physicians had suggested a wider application of LISWT, and some even advocated its use in nonvasculogenic ED (33% in 2019 vs. 5.9% in 2016; p < 0.0001). The awareness and clinical application of LISWT for ED have increased over time, despite the lack of robust evidence in terms of effectiveness. Further research on the benefit of LISWT is needed to guide physicians in the therapeutic management of ED patients.
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Vinay J, Moreno D, Rajmil O, Ruiz-Castañe E, Sanchez-Curbelo J. Penile low intensity shock wave treatment for PDE5I refractory erectile dysfunction: a randomized double-blind sham-controlled clinical trial. World J Urol 2020; 39:2217-2222. [PMID: 32696128 DOI: 10.1007/s00345-020-03373-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/16/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Over the last decade, penile low-intensity extracorporeal shockwave therapy (LI-ESWT) has emerged as a promising alternative for the treatment of erectile dysfunction (ED). The aim of this trial is to assess the effect of electromagnetic LI-ESWT on the erectile function of vascular phosphodiesterase type 5 inhibitor (PDE5I) refractory ED patients. METHODS Randomized, double-blind, sham-controlled study. 76 patients with vascular PDE5I-refractory ED completed the study. 40 men were treated with LI-ESWT (1 session/week for 4 weeks, 5000 shocks/session, 0.09 mJ/mm2 energy density) and 36 were treated with a sham probe. Baseline and post-treatment (1, 3 and 6 months) evaluations were performed using validated erectile function questionnaires (IIEF-EF, EHS, SEP2, SEP3 and GAQ1). The groups were compared using Mann-Whitney-Wilcoxon and chi-squared tests, with results considered statistically significant at p < 0.05. RESULTS At the 3-month follow-up, median change in IIEF-EF score for active and sham groups was 3.5 (IQR 0-10) and - 0.5 (IQR - 11 to 1), respectively (p < 0.05). Six months after treatment, 52.5% of patients (21/40) in the active group and 27.8% of patients (10/36) in the sham group presented an EHS > 2 (p < 0.05). At the same evaluation, 40.0% (16/40) and 13.9% (5/36) of patients had positive answers to GAQ-1, in the treated and sham groups, respectively (p < 0.05). No adverse events were observed during the study. CONCLUSION This study showed that penile electromagnetic shockwave therapy may improve erectile function, to a modest extent, on certain patients that do not respond to PDE5I; making it an alternative for vascular ED patients that reject more invasive therapies.
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Affiliation(s)
- Jose Vinay
- Andrology Department, Fundació Puigvert/Universidad Autònoma de Barcelona, Carrer de Cartagena, 340-350, 08025, Barcelona, Spain.
- Urology Department, University of Chile Clinical Hospital, Santiago, Chile.
- Andrology Unit, Shady Grove Fertility, Santiago, Chile.
| | - Daniel Moreno
- Andrology Department, Fundació Puigvert/Universidad Autònoma de Barcelona, Carrer de Cartagena, 340-350, 08025, Barcelona, Spain
| | - Osvaldo Rajmil
- Andrology Department, Fundació Puigvert/Universidad Autònoma de Barcelona, Carrer de Cartagena, 340-350, 08025, Barcelona, Spain
| | - Eduard Ruiz-Castañe
- Andrology Department, Fundació Puigvert/Universidad Autònoma de Barcelona, Carrer de Cartagena, 340-350, 08025, Barcelona, Spain
| | - Josvany Sanchez-Curbelo
- Andrology Department, Fundació Puigvert/Universidad Autònoma de Barcelona, Carrer de Cartagena, 340-350, 08025, Barcelona, Spain
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Albersen M. Latest addition to a long LIST of negative penile rehabilitation trials does not come as a shock. Nat Rev Urol 2020; 17:199-200. [PMID: 32127693 DOI: 10.1038/s41585-020-0299-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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