Efficacy of a preprostatectomy multi-modal penile rehabilitation regimen on recovery of postoperative erectile function

A contemporary review of the treatments and challenges associated with penile rehabilitation after radical prostatectomy including a proposed optimal approach

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.

Vacuum erection device for erectile function rehabilitation after radical prostatectomy: which is the correct schedule? Results from a systematic, scoping review

Vacuum erection device (VED), for its capacity to improve the peak flow and elasticity of cavernous arteries, is a well-known tool to improve recovery of erectile function (EF) after radical prostatectomy. Aim of this study is to compare the different therapeutic schemes proposed in literature to find the most effective timing for VED treatment and to evaluate its efficacy alone or associated with phosphodiesterase 5 inhibitors (PDE5i). We performed a systematic review of Literature in October 2022 using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials to retrieve all articles dealing with EF rehabilitation after radical prostatectomy (excluding non-English papers, reviews, or meeting abstracts). Patients were divided among those receiving VED alone or combined with other treatments. Study outcomes were compared dividing them between those with follow-up shorter or longer than 12 months. Sixteen papers were included according to selection criteria. Among them, seven were randomized-controlled trials, five were prospective observational studies and four were retrospective. VED alone was evaluated in eight articles, while the remaining papers evaluated the combination of VED with PDE5i. Regarding VED therapeutic protocol, 7/16 studies used it daily. Rehabilitation protocol lasted less than 1 year in 4 studies, up to 12 months in 6 studies and more than 1 year in 6 studies. All the studies show improvement in International Index of Erectile Function Questionnaire (IIEF-5), conservation of penile length and satisfactory intercourses when compared to controls. VED results appear to increase when patients were addressed to VED-dedicated programs to enhance their compliance with the device.

Understanding human aging and the fundamental cell signaling link in age-related diseases: the middle-aging hypovascularity hypoxia hypothesis

Aging-related hypoxia, oxidative stress, and inflammation pathophysiology are closely associated with human age-related carcinogenesis and chronic diseases. However, the connection between hypoxia and hormonal cell signaling pathways is unclear, but such human age-related comorbid diseases do coincide with the middle-aging period of declining sex hormonal signaling. This scoping review evaluates the relevant interdisciplinary evidence to assess the systems biology of function, regulation, and homeostasis in order to discern and decipher the etiology of the connection between hypoxia and hormonal signaling in human age-related comorbid diseases. The hypothesis charts the accumulating evidence to support the development of a hypoxic milieu and oxidative stress-inflammation pathophysiology in middle-aged individuals, as well as the induction of amyloidosis, autophagy, and epithelial-to-mesenchymal transition in aging-related degeneration. Taken together, this new approach and strategy can provide the clarity of concepts and patterns to determine the causes of declining vascularity hemodynamics (blood flow) and physiological oxygenation perfusion (oxygen bioavailability) in relation to oxygen homeostasis and vascularity that cause hypoxia (hypovascularity hypoxia). The middle-aging hypovascularity hypoxia hypothesis could provide the mechanistic interface connecting the endocrine, nitric oxide, and oxygen homeostasis signaling that is closely linked to the progressive conditions of degenerative hypertrophy, atrophy, fibrosis, and neoplasm. An in-depth understanding of these intrinsic biological processes of the developing middle-aged hypoxia could provide potential new strategies for time-dependent therapies in maintaining healthspan for healthy lifestyle aging, medical cost savings, and health system sustainability.

A review of experimental techniques for erectile function researches and development of medical technology using animal erectile dysfunction models in sexual and reproductive medicine

Background

Erectile dysfunction (ED) is one of the causes of male infertility and is a disease that requires treatment. The first-line drugs for ED are phosphodiesterase 5 (PDE-5) inhibitors, and further treatment options are currently limited. Medical technologies, such as genetic control and regenerative medicine, are developing rapidly. Research on erectile function is progressing rapidly, coupled with technological innovations in other areas.

Methods

A PubMed search using the keywords "animal (rat, mouse, rabbit, dog, and monkey)" and "erectile" was conducted, and all relevant peer-reviewed English results were evaluated.

Main findings

The methods for evaluating erectile function include intracavernous pressure (ICP) measurements, isometric tension studies, and dynamic infusion cavernosometry. Papers also reported various disease model animals for the study of diabetes mellitus, cavernous nerve injury, and drug-induced ED.

Conclusion

Basic research on ED treatment has progressed rapidly over the past 20 years. In particular, research on the mechanism of ED has been accelerated by the publication of a study on the evaluation of erectile function using ICP measurements in rats. In addition, molecular biological experimental methods such as polymerase chain reaction (PCR) and western blotting have become relatively easy to perform due to technological progress, thus advancing research development.

A new strategy for stem cells therapy for erectile dysfunction: Adipose-derived stem cells transfect Neuregulin-1 gene through superparamagnetic iron oxide nanoparticles

PURPOSE

Our previous studies showed that nanotechnology improves derived adipose-derived stem cells (ADSCs) therapy for erectile dysfunction (ED). In this study, the Neuregulin-1(NRG1) gene was transfected into ADSCs with superparamagnetic iron oxide nanoparticles (SPION) further to improve the therapeutic effect of ADSCs on ED.

MATERIALS AND METHODS

ADSCs were isolated from epididymal adipose tissue of Sprague-Dawley rats. The optimal concentration of PEI-SPION (SPION modified with polyethyleneimine) was selected to construct the gene complex. After electrostatic binding of PEI-SPION and DNA, a PEI layer was wrapped to make the PEI-SPION-NRG1-PEI gene transfection complex. Different groups were set up for transfection tests. Lipo2000 transfection reagent was used as the control. PEI-SPION-NRG1-PEI in the experimental group was transfected under an external magnetic field.

RESULTS

When the concentration of PEI-SPION was 10 µg/mL, it had little cytotoxicity, and cell activity was not significantly affected. PEI-SPION-NRG1-PEI forms positively charged nanocomposites with a particle size of 72.6±14.9 nm when N/P ≥8. The PEI-SPION-NRG1-PEI gene complex can significantly improve the transfection efficiency of ADSCs, reaching 26.74%±4.62%, under the action of the external magnetic field. PCR and Western blot showed that the expression level of the NRG1 gene increased significantly, which proved that the transfection was effective.

CONCLUSIONS

PEI-SPION can be used as a vector for NRG1 gene transfection into ADSCs. PEI-SPION-NRG1-PEI packaging has the highest transfection efficiency under the external magnetic field than the other groups. These findings may provide a new strategy for ADSCs therapy for ED.

Nutraceuticals and Phytotherapy in Men's Health: Antioxidants, Pro-oxidants, and a Novel Opportunity for Lifestyle Changes

Patients using nutraceuticals represent a diverse patient population with a keen potential interest and/or adherence to healthy lifestyle changes. BPH nutraceuticals, including saw palmetto were as safe, but not more effective than placebo in the STEP and CAMUS clinical trials, but another high-quality saw palmetto product could be tested in a phase 3 trial. Several other BPH supplements need more recent robust clinical data, environmental oversight, or safety data. ED supplements, including Panax ginseng, and the notable nitric oxide (NO) enhancing amino acids arginine and citrulline have positive preliminary short-term efficacy data with and without PDE-5 inhibitors, but herbal quality control (QC) or safety signals with some of these agents in specific patient populations need to be resolved. "Less is more" should be the current mantra in the prostate cancer milieu, and potentially in some men with male infertility based on the FAZST trial because it is plausible some antioxidants are exhibiting prooxidant activity in some settings. Some prescription anthelmintic medications are being studied, others are being purchased over-the-counter (OTC), but their preliminary safety and efficacy against cancer have been concerning and questionable. In fairness, ongoing additional objective clinical trial data should become available soon, especially with mebendazole. DHEA or DHEA enhancing products have multiple concerns including HDL reductions, and their questionable use in men with BPH or prostate cancer based on the limited data. Some of these concerns should also be addressed in long-term robust clinical trials of prescription testosterone agents. Regardless, more attention should be directed toward heart-healthy lifestyle changes for most urologic men's health conditions, whether they are used in a preventive or synergistic setting with other acceptable clinical treatment options.

Efficacy of Tadalafil in Penile Rehabilitation Started Before Nerve-Sparing Robot-Assisted Radical Prostatectomy: A Double-Blind Pilot Study

Background

Despite the widespread practice of nerve-sparing robot-assisted radical prostatectomy (nsRARP) for the treatment of localized prostate cancer (PCa), erectile dysfunction remains a significant sequela of radical prostatectomy.

Aim

This study aimed to compare the efficacy of tadalafil 5 mg once daily for erectile function recovery in patients who underwent nsRARP according to the timing of rehabilitation initiation.

Methods

In this double-blind, prospective pilot study, a total of 41 patients who underwent nsRARP were randomly assigned into 2 groups according to the timing of rehabilitation initiation. In the preRARP group (n = 20), tadalafil was started 2 weeks before nsRARP, and in the postRARP group (n = 21), it was started 4 weeks after nsRARP. Erectile function recovery after nsRARP was defined as an International Index of Erectile Function (IIEF-5) score of ≥17.

Outcomes

The measures of EF recovery were the changes in IIEF-5 score.

Results

The rate of erectile function recovery at 12-month follow-up was 80.0% and 71.4% in the preRARP and postRARP groups, respectively. The mean differences between baseline and postoperative IIEF-5 scores at 1-, 3-, 6-, and 12-month follow-up were −11.7 ± 3.2, −7.4 ± 3.2, −5.6 ± 1.5, and −4.1 ± 1.1 in the preRARP group and −14.7 ± 4.7, −12.0 ± 5.0, −9.7 ± 3.9, and −6.0 ± 3.1 in the postRARP group, respectively (1-month, P = .259; 3-months, P = .077; 6-months, P = .014; 12-months, P = .007).

Clinical implications

Preoperative tadalafil 5 mg once a day could be used effectively and safely as a strategy for penile rehabilitation after nsRARP.

Strengths and Limitations

This study is the first prospective trial of penile rehabilitation with tadalafil 5 mg once a day prior to nsRARP. This is a pilot study with the limitations of a small sample; further and large-scale studies with multiple cohorts, such as an untreated control group and an early immediate rehabilitation group for EF recovery, are needed.

Conclusion

This study suggests that preoperative penile rehabilitation using tadalafil may lead to better erectile function recovery than postoperative penile rehabilitation using tadalafil.

Noh T, Shim JS, Kang SG, et al. Efficacy of Tadalafil in Penile Rehabilitation Started Before Nerve-Sparing Robot-Assisted Radical Prostatectomy: A Double-Blind Pilot Study. Sex Med 2022;10:100508.

Patient Education for Radical Prostatectomy: Development of a Program Tailored to the Needs of Prostate Cancer Patients

In all, 30% to 90% of prostate cancer patients undergoing radical prostatectomy (RP) recover their erectile capacity. No effective post RP erectile rehabilitation program exists to date. The aim of this exploratory qualitative study is to explore the needs of these patients and to develop a patient education program (PEP) which meets these needs. Interviews were carried out by a socio-anthropologist with prostate cancer patients treated by RP within the 6 previous months. The needs and expectations identified led to the choice of a logical model of change for the construction of the PEP. Nineteen patients were included in the study; 17 of them were living with a partner. Two categories of patients appeared during the interviews: informed patients resigned to lose their sexuality and patients misinformed about the consequences of the surgery. The tailored program was built on the Health Belief Model and provides six individual sessions, including one with the partner, to meet the needs identified. This study designed the first program to target comprehensively the overall sexuality of the patient and his partner, and not only erection issues. To demonstrate the effectiveness of this program, a controlled, multicentric clinical trial is currently ongoing.

Factors associated with various strategies for maintaining sexual activity after prostate cancer treatment

Many men experience sexual difficulties after receiving prostate cancer treatment. We investigated sexual and relationship factors associated with management strategies to maintain sexual activity in prostate cancer patients. 210 prostate cancer patients (66.7 ± 7.4 years old) completed our survey online. Higher sexual function distress (Incidence rate ratio, IRR = 0.99, p = 0.005) and less frequent relationship strain (IRR = 1.01, p = 0.002) were associated with trying a higher number of sexual management strategies. Higher sexual function distress was associated with the use of oral medication (Odds Ratio, OR = 0.98, p = 0.026), vacuum erection device (OR = 0.98, p = 0.005), and vibrators (OR = 0.97, p = 0.005). Perceived importance of sexual interaction with a partner was associated with using oral medication (OR = 1.95, p = 0.027). Participant's higher ideal frequency of sexual interaction with a partner was a predictor for the use of vibrators (OR = 1.03, p = 0.024). Less frequent relationship strain was associated with the use of vacuum erection device (OR = 1.03, p = 0.002), and vibrators (OR = 1.02, p = 0.012). Lastly, patients' communication with their partner about sexual intimacy was also associated with use of vacuum erection device (OR = 3.24, p = 0.050, CI 1.0-10.5). Few participants (13-27%) were interested in trying penile implant, penile support device, external penile prosthesis, penile sleeve and anal devices. From our qualitative analyses, the main barriers to retaining sexual activity were erectile dysfunction and psychological issues. Three themes participants found useful to maintain sexual activity: preparatory behaviours for initiating or maintaining erections, adapting their sexual activity to fit with what was now possible, and the importance of the relationship or intimacy with their sexual partner. Psychological and relationship factors contribute to patients' motivation to remain sexually active after treatment.

Is it Worth Starting Sexual Rehabilitation Before Radical Prostatectomy? Results From a Systematic Review of the Literature

Background and Purpose: Sexual dysfunction (SD) is a frequent side effect associated with radical prostatectomy (RP) for prostate cancer (PCa). Some studies have showed the benefit associated with preoperative sexual rehabilitation (prehabilitation) and Enhanced Recovery After Surgery (ERAS) for RP, but no clear clinical recommendations are available yet. Our aim was to conduct a systematic review on sexual prehabilitation prior to RP for patients with a localized PCa and analyze the impact on postoperative sexual health compared with the standard post-operative care. Methods: We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations. Results: Four randomized control trials and one retrospective comparative study were included in the analyses. Three of the five studies showed an improved EF recovery post-RP in the prehabilitation group compared to the standard of care represented by: higher International Index of Erectile Function 5 score (IIEF5) or IIEF score (p < 0.0001) and a higher percentage of patients reporting return of EF based on the Sexual Encounter Profile (SEP) (56 vs. 24%, p = 0.007). Self-confidence, therapeutic alliance, and adherence to treatment were stronger for patients with preoperative consultations (p < 0.05) and EF recovery was better in cases of a higher number of follow-up visits (OR 4-5 visits vs. 1:12.19, p = 0.002). Discussion: Despite heterogenous methods and high risks of bias in this systematic review, starting sexual rehabilitation prior to surgery seems to ensure better EF recovery. This prehabilitation should include information of both the patient and his or her partner, with a closer follow up and the use of a multimodal treatment approach that still remains to be defined and validated (oral medication, vacuum devices, pelvic floor muscle training, etc.).

Sexual aspects of shared decision making and prehabilitation in men diagnosed with prostate cancer

This article addresses sexual aspects of two related HCP-roles in the period between a diagnosis of prostate cancer (PC) and the start of treatment. First, the 'lovemap-perspective' is used to fine-tune the process of shared decision making. Then sexual prehabilitation is explored in detail, in the belief that better sexual function before starting treatment is more likely to lead to better post-treatment outcomes. Recommendations will be shared on further development of sexual prehabilitation approaches.

Alternative Treatment for Erectile Dysfunction: a Growing Arsenal in Men's Health

PURPOSE OF REVIEW

To highlight and review encouraging preliminary studies behind several alternative products and interventions for erectile dysfunction (ED).

RECENT FINDINGS

Alternative treatments for ED are becoming more prevalent with increased consumer interest. "Natural" products are sold online, and numerous clinics offer various off-label and investigational interventions. These alternative treatments have demonstrated varying degrees of efficacy in randomized trials and meta-analyses, but none of these interventions has robust enough evidence to be considered first-line therapy. These treatments may find a role in combination with guideline treatments or may be used in novel penile rehabilitation research protocols. With growing interest in alternative treatment for men's health, an awareness of the literature is imperative for patient counsel. Alternative treatments, like L-arginine, have a growing body of evidence for efficacy in combination with PDE5i, and low-intensity shock wave therapy and stem cell therapy continue to demonstrate encouraging outcomes in ED trials.

Management of erectile dysfunction following robot-assisted radical prostatectomy: a systematic review

INTRODUCTION

We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines were followed. Population consisted of patients with erectile disfunction after RARP (P), conservative and surgical intervention were considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of erectile function after conservative treatments and sexual function after surgical treatments (O).

EVIDENCE SYNTHESIS

Eleven studies were included. Seven studies focused on the use of phosphodiesterase-5 inhibitors (PDE5i) alone (five studies) or associated with other treatments (two studies). All the studies confirmed the efficacy of PDE5i, while the most promising association is with vacuum pump erectile devices. Two studies investigated topical treatments, namely low intensity extracorporeal shock wave therapy and alprostadil. Low intensity extracorporeal shock wave therapy may be a promising option in patients in whom nerve-sparing surgery was performed. The use of alprostadil could be an effective alternative to intracorporeal injection in those who underwent non-nerve-sparing surgery. One study focused and confirmed the efficacy of penile implants. Furthermore, one study reported the efficacy of a multi-modal treatment with preoperative medication, showing the benefits of a multimodal approach.

CONCLUSIONS

Penile rehabilitation with PDE5i is effective after nerve sparing RARP. The association of PDE5i with vacuum devices could led to a faster recovery. A multimodal approach with preoperative specific care seems to be effective to fasten erectile function recovery.