Sildenafil preserves intracorporeal smooth muscle after radical retropubic prostatectomy

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.

Sexual dysfunctions in breast cancer patients: evidence in context

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.

Management of male sexual dysfunction after cancer treatment

BACKGROUND

With an increase in the number of cancer survivors each year, male sexual dysfunction becomes an important topic for discussion between patients and providers who treat cancer. The aim of this article is to review types and mechanisms of sexual dysfunction after cancer therapy and discuss treatment options.

METHODS

Contemporary concepts regarding male sexual dysfunction after cancer treatment are reviewed and translated for clinical utility.

FINDINGS

To optimize recovery of erectile capacity after erectile dysfunction causing cancer treatments, a penile rehabilitation protocol involving phosphodiesterase inhibitors, vacuum erection device, intra corporal injections, or a combination is likely to provide some degree of clinically significant benefit. Treating hypogonadism post cancer treatment depends on the type of cancer that has been treated and patient comorbidities. Anejaculation after cancer treatments is typically not successfully or reliably treated due to the mechanism and severity of sympathetic nerve injury. Semen cryopreservation prior to cancer treatments that may injure nerve fibers essential for the ejaculatory response is highly recommended.

CONCLUSION

Management of post cancer treatment sexual dysfunction requires identification of this problem and referral to a specialist if necessary. There are several management options available that can greatly enhance quality of life in this often overlooked aspect of post cancer treatment care.

Erectile dysfunction post radical cystectomy. The role of early rehabilitation with pharmacotherapy in nerve sparing and non-nerve sparing group: A randomized, clinical trial

OBJECTIVES

No clinical studies testing erectile function (EF) post radical cystectomy (RC) were done. Our objective was to assess the effect of early pharmacologic therapy after RC using intracorporeal injection (ICI), phosphodiesterase inhibitor (PDE5i) and PDE5i+ICI.

MATERIALS AND METHODS

In our randomized, double-blinded study, we prospectively enrolled 160 potent male patients with invasive bladder cancer. Patients were operated by RC using the nerve-sparing (NS) or non-nerve sparing (NNS) technique. They were treated since 1 month postoperatively by different regimens (PDE5i vs. ICI vs. ICI+PDE5i). Patients were evaluated using the international index of erectile function questionnaire and were followed up regularly at 1, 3, 6, and 12 months using the same parameters.

RESULTS

One month after therapy, the mean of EF domain improved in both NS and NNS group. In the NNS group, in patients treated with ICI alone and ICI+PDE5i, the EF domain at 12 months moved to the moderate and to the mild category respectively. In patients treated by the NS approach, the mean value remained in the mild category with or without therapy.

CONCLUSIONS

Early pharmacotherapy since one-month post RC using ICI and a combination of ICI+PDE5i can improve the erectile function of patients operated with a NNS approach.

Phosphodiesterases 5 Inhibitors and Erectile Dysfunction Recovery after Pelvic Surgery: Future Perspectives for New Drugs and New Formulations

BACKGROUND

Phosphodiesterase 5 inhibitors (PDE5I) represent the first-line treatment in the management of post-operative erectile dysfunction (ED) after pelvic oncological surgery. The aim of our study is to evaluate the available evidence on the efficacy of PDE5Is, including new formulations and penile rehabilitation post-pelvic surgery.

EVIDENCE ACQUISITION

A systematic review of the literature was performed until May 2020. The following databases were searched: Scopus, Medline and Web of Science. The MeSH search was conducted by combining the following terms: 'erectile dysfunction', 'radical prostatectomy' 'pelvic' 'bladder' 'phosphodiesterase' inhibitors' 'avanafil' 'sildenafil' 'tadalafil' 'lodenafil' 'mirodenafil' 'udenafil' 'vardenafil' 'sublingual' 'orodispersible' 'penile' 'rehabilitation'.

EVIDENCE SYNTHESIS

Sildenafil, Tadalafil, vardenafil and Avanafil improve EF compared with placebo in men with all levels of ED severity after radical prostatectomy with good tolerability. No specific recommendations can be suggested regarding the superiority of a drug over the other. The optimal dose, continuous vs. on-demand and duration of treatment, is still under investigation. In vitro and preclinical studies suggest the possible role for lodenafil, mirodenafil and oro-dispersible formulations in patients undergoing oncological pelvic surgery. Few studies demonstrated the efficacy of udenafil in improving ED after rectal surgery or radical prostatectomy. Complete recovery of EF after surgery is still an unmet need in the field of penile rehabilitation after pelvic surgery.

CONCLUSION

PDE5Is have a crucial role in the management of post pelvic surgery of ED. New drugs and new formulations have shown excellent results in patients with ED; however, data in patients after surgery is still scarce. Further well designed RCT should clarify the role of these new compounds and oro-dispersible formulations in the management of ED in patients undergoing pelvic surgery.

Sildenafil orodispersible film in the treatment of erectile dysfunction after radical prostatectomy: A single-centre open-label uncontrolled trial

Phosphodiesterase-5 inhibitors are the first-line therapy for erectile dysfunction (ED) after radical prostatectomy (RP). This single-centre open-label uncontrolled study evaluated the efficacy and safety of the new sildenafil orodispersible film (ODF) in ED treatment after RP. Sildenafil 100 mg ODF was administered twice a week for 3 months to patients under 75 years of age, with a Framingham cardiovascular risk score < 20% and a pre-operative International Index of Erectile Function (IIEF)-5 score ≥ 17, who had undergone open RP between 2016 and 2018. Erectile function was assessed pre-operatively, post-operatively and after treatment through the IIEF-5 score, the Sexual Encounter Profile Question (SEP-Q) 2 and SEP-Q3; adverse events (AE) were also investigated after 3 months. A total of 65 patients with a median (25th-75th percentile) post-operative IIEF-5 score of 8 (7-9) were treated. Nine (13.8%) patients reported AE of mild/moderate grade and discontinued treatment. A significant IIEF-5 score median (25th-75th percentile) increase of 10 (0-12) was found after treatment in the other 56 patients (p < .001). Sildenafil 100 mg ODF was effective in ED after RP in terms of improved IIEF-5 score and improved SEP-Q2 and SEP-Q3 in 67.9% of patients. It could represent a valid alternative for those patients with low compliance to tablet intake.

Placebo Responses Among Men With Erectile Dysfunction Enrolled in Phosphodiesterase 5 Inhibitor Trials: A Systematic Review and Meta-analysis

IMPORTANCE

Placebo responses in the treatment of erectile dysfunction (ED) are poorly described in the literature to date.

OBJECTIVE

To quantify the association of placebo with ED outcomes among men enrolled in placebo-controlled, phosphodiesterase 5 inhibitor (PDE5I) trials.

DATA SOURCES

For this systematic review and meta-analysis, a database search was conducted to identify double-blind, placebo-controlled studies using PDE5Is for the treatment of ED published from January 1, 1998, to December 31, 2018, within MEDLINE, Embase, Cochrane Library, and Web of Science. Only articles published in the English language were included.

STUDY SELECTION

Double-blind, placebo-controlled randomized clinical trials of PDE5Is for ED were included. Studies were excluded if they did not provide distribution measures for statistical analysis. Study selection review assessments were conducted by 2 independent investigators. A total of 2215 studies were identified from the database search, and after review, 63 studies that included 12 564 men were analyzed.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. Data were extracted from published reports by 2 independent reviewers. Quality assessment was performed using the Jadad scale. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The main outcome was improvement in the erectile function domain of the International Index of Erectile Function questionnaire in the placebo arm of the included studies. Effect size was reported as bias-corrected standardized mean difference (Hedges g). The hypothesis was formulated before data extraction.

RESULTS

A total of 63 studies that included 12 564 men (mean [SD] age, 55 [7] years; age range, 36-68 years) were included. Erectile function was significantly improved among participants in the placebo arm, with a small to moderate effect size (Hedges g [SE], 0.35 [0.03]; P < .001). Placebo effect size was larger among participants with ED associated with posttraumatic stress disorder (Hedges g [SE], 0.78 [0.32]; P = .02) compared with the overall analysis. No significant difference was found between placebo and PDE5Is for ED after prostate surgery or radiotherapy (Hedges g [SE], 0.30 [0.17]; P = .08).

CONCLUSIONS AND RELEVANCE

In this study, placebo was associated with improvement of ED, especially among men with ED-related posttraumatic stress disorder. No difference was found between placebo and PDE5I among men treated for ED after prostate surgery.

Erectile Dysfunction: A Primer for in Office Management

Introduction: Optimizing erectile dysfunction (ED) remains a clinically significant endeavor as insufficient outcomes from oral, injectable and even surgical approaches to treatment remain less than ideal. In this report, we integrate evolving knowledge and provide an algorithmic approach for the clinician to fine-tune management. Methods: We performed a PubMed and Medline search of Erectile Dysfunction treatment optimization, enhanced patient efficacy for ED, and why men fail ED treatment. All relevant papers for the past two decades were reviewed. Results: Establishing the goals and objectives of the patient and partner while providing detailed instructions for treatment can minimize failures and create an environment that allows treatment optimization. A thorough work-up may identify reversible or contributing causes. We identified several areas where treatment of ED could be optimized. These include; management of associated medical conditions, lifestyle improvements, PDE5 inhibitor prescription strategies, management of hypogonadism and the initiation of intracavernosal injection therapy (ICI). Conclusions: In our view, once a man presents for help to the clinician, use of the simple strategies identified in this review to optimize the tolerability, safety and effectiveness of the selected treatment should result in enhanced patient and partner satisfaction, with improved outcomes.

Transplantation of induced pluripotent stem cell-derived mesenchymal stem cells improved erectile dysfunction induced by cavernous nerve injury

Erectile dysfunction (ED) is an important kind of postoperative complication of pelvic surgery that affects patients' quality of life. Transplantation of mesenchymal stem cells (MSC) has been found to alleviate ED caused by cavernous nerve injury (CNI) in rats. However, little is known about whether induced pluripotent stem cell-derived mesenchymal stem cells (iMSC) have a therapeutic effect on CNI ED. We established an ED model on rats and evaluated the effect of iMSC on it. Methods: Eight-week-old male Sprague-Dawley rats were assigned to four groups and received following operation: sham operation (sham group); bilateral CNI and phosphate-buffered saline (PBS) injections (PBS group); bilateral CNI and adipose-derived mesenchymal stem cells transplantation (adMSC group); or bilateral CNI and iMSC injection (iMSC group). After therapy, the cavernous nerve was stimulated by electricity and the intracavernous pressure (IAP)/mean arterial blood pressure (MAP) was measured. The endothelial and smooth muscle tissue in the penis was assessed histologically with Masson's trichrome stain. Immunofluorescence/immunohistochemical stains were applied for the detection of nNOS, vWF, eNOS, SMA, Desmin, S100β, and caspase-3. Nude rats CNI ED model was established for the evaluation of iMSC longevity and differentiation capacity. The paracrine factors were assessed by real-time PCR. Results: Transplantation of iMSC significantly restored the IAP/MAP in this CNI ED model and showed long-term effects. It could rescue the expression of vWF, eNOS, SMA, and Desmin, which indicated the alleviation of endothelial and smooth muscle tissues of the penis. iMSC therapy also could increase the expression of nNOS in the cavernosum and S100β in the major pelvic ganglia (MPG) which contributed to the erectile function. Moreover, the level of BAX and caspase-3 were reduced and Bcl-2 was increased, which indicated the anti-apoptosis effects of iMSC. The iMSC showed little transdifferentiation and exerted their function by activating the secretome of the host. Conclusion: Transplantation of iMSC significantly improved ED induced by CNI. The iMSC may exert their effects via paracrine factors and may be a promising therapeutic candidate for treating CNI ED in the future.

Penile Rehabilitation: The "Up"-date

Purpose of Review

The purpose of this review is to review the penile rehabilitation literature published since the beginning of 2017. Specific emphasis was placed on determining how the new findings increase our understanding of the mechanisms leading to recovery of erectile function after pelvic surgery and to identify potential focus areas for future studies.

Recent Findings

A meta-analysis of penile rehabilitation after prostatectomy was published in early 2017 reporting that PDE-5 inhibitors, intracavernosal injection (ICI) therapy and vacuum erection devices (VED) improved erectile function; however, the benefit was not observed after a washout period. Preclinical studies have identified potential regenerative therapies after cavernous nerve injury.

Summary

While significant methodological challenges remain, recent literature suggests benefits to starting penile rehabilitation immediately after surgery, but not extending past 1 year post-operatively. The cost-benefit ratio of penile rehabilitation remains unclear; however, decreasing costs of PDE-5 inhibitors as well as improvements in characterizing post-surgical erectile dysfunction may help to personalize penile rehabilitation, improve outcomes and improve the cost-benefit ratio. Better and more consistent trial design is needed to develop the optimal regimen(s) for restoring sexual function in men. Finally, future studies to translate promising preclinical regeneration therapies to humans are also needed.

Sildenafil in postprostatectomy erectile dysfunction (perspective)

Erectile dysfunction (ED) is a common side effect to radical prostatectomies, even with nerve-sparing procedures. To ameliorate the problem so-called "penile rehabilitation" programs have been developed. The most widely used method of this is subscribing sildenafil or other PDE5-inhibitors to patients following surgery. This is based on a theory that these drugs may increase penile oxygenation and provide antiapoptotic factors (primarily NO and cGMP), thus protecting the penile tissue in a period with reduced nerve function following the surgery. Preclinical studies have confirmed the potential of sildenafil in this context and early human trials have suggested that a steady ingestion of sildenafil might protect the structural integrity of the penis. However, subsequent well-designed trials have not been able to confirm the initial findings. This fits well with sildenafil's mechanism of action because it does not actually induce erections or the production of either nitric oxide or cGMP. Rather, the drug enhances effects of an erectile response induced by neurotransmitters from the cavernous nerves. Therefore, sildenafil should no longer be offered as a sole means of penile rehabilitation. Rather, more research is needed, and clinicians need to apply a broader concept of sexual rehabilitation in postprostatectomy ED.

Impact of the baseline study with penile doppler ultrasound in patients with prostate cancer before radical prostatectomy

INTRODUCTION

Given the high prevalence of erectile dysfunction in male population between 40-70 years old and the effect of radical prostatectomy on this domain, it is important to perform a baseline study.

MATERIAL AND METHODS

Prior radical prostatectomy, erectile function has been assessed prospectively in 112 prostate cancer patients using the erectile function (EF) domain of the International Index of Erectile Function (EF-IIEF), Erectile Hardness Score (EHS) and a penile doppler ultrasound (PDUS). Comorbidities and Charlson index were collected. The EORTC QLQ C-30 and PR-25 tests were administered.

RESULTS

According to EF-IIEF questionnaire, 50.9% of patients showed normal EF and EHS grade 3-4 erection was achieved in the 75.9%. PDUS was normal only in 28.6% of patients and 51.8% showed arterial insufficiency. We found a significant association (P<.0001) between categorized EF-IIEF (normal, mild/moderate/severe) and the EHS value. Between PDUS (normal vs. pathologic) and EHS (3-4 vs. 1-2) statistically significant association (P=.005) was found. Just 35.3% of patients with EHS 3-4 showed normal PDUS. Correlation between the PDUS and the EF-IIEF (≥26 vs.<26) was statistically significant (P=.043). Moreover, only 38.6% of patients with EF-IIEF≥26 had a normal PDUS.

CONCLUSIONS

In order to predict EF recovery after surgery, global assessment is required. Solely self-administered tests are not enough. In this baseline study, PDUS can play an important role.

Perplexity of penile rehabilitation following radical prostatectomy

Radical prostatectomy has significantly improved prostate cancer survival rates but continues to have a negative impact on the patient's erectile function (EF). In attempts to improve erectile dysfunction (ED), clinicians have incorporated different treatment modalities to restore EF. Penile rehabilitation consists of understanding the mechanisms that affect post-prostatectomy EF and utilizing pharmacologic agents, devices, and interventions to promote the male sexual function. This article aims to summarize the available scientific research involving penile rehabilitation. Even though the current literature lacks to prove its irrefutable effectiveness, penile rehabilitation has a positive impact at the molecular and cellular levels, and it is widely adopted in clinic practices.

Effect of ginger, Paullinia cupana, muira puama and l- citrulline, singly or in combination, on modulation of the inducible nitric oxide- NO-cGMP pathway in rat penile smooth muscle cells

INTRODUCTION

COMP-4 is a natural compound-based dietary supplement consisting of the combination of ginger, Paullinia cupana, muira puama and l-citrulline, which when given long-term has been shown in the aged rat to a) upregulate iNOS in the penile smooth muscle cells (SMC), b) reverse the corporal SMC apoptosis and fibrosis associated with corporal veno-occlusive dysfunction (CVOD), and c) improve resulting erectile function. To elucidate the mechanism of how COMP-4 and its individual components modulate the iNOS-cGMP pathway, an in vitro study was conducted using a rat corporal primary SMC culture to determine its effect on NOS, soluble guanylate cyclase (sGC), cGMP and the phosphodiesterase 5 enzyme (PDE5).

MATERIALS AND METHODS

Primary SMC cultures using the explant technique were initiated by cutting small pieces of corporal tissue from 8 week old Sprague-Dawley rats. The SMC were grown in Dulbecco media with 20% fetal calf serum. The SMC were then incubated with or without COMP-4 (0.69 mg/ml) or its ingredients alone (ginger: 0.225 mg/ml; muira puama, Paullinia cupana and l-citrulline each at 0.9 mg/ml) for up to 24 h mRNA and protein were extracted and used for the determination of NOS, sGC and PDE5 content. cGMP content was determined by ELISA. L-NIL (4 μM) was used as an inhibitor of iNOS activity.

RESULTS

Compared to the control values, COMP-4 upregulated expression of cGMP by 85%, induced a 42 fold increase in sGC as well as a 15 fold increase in both iNOS protein and mRNA content while it decreased both PDE5 mRNA and protein content each by about 50%. L-NIL completely inhibited the effect of COMP-4 on cGMP production. When compared with each of the individual four components of COMP-4, it appears that COMP-4 itself had the most profound effect in modulating each one the specific steps within the iNOS-cGMP pathway.

CONCLUSIONS

This in vitro study demonstrates that COMP-4 is capable of activating the endogenous cellular iNOS-cGMP pathway within the CSM cells, which is theorized to be responsible for reducing the fibrosis and apoptosis as well as the CVOD observed in the aging rat penis. Further studies will be necessary in order to determine whether supplementation of COMP-4 on a daily basis may be beneficial in halting or reversing this aging related erectile dysfunction in the clinical setting.

Comparison of erectile dysfunction guidelines between the UK (BSSM/NICE) and Europe (EAU)

Erectile dysfunction is a common and often debilitating condition. The National Institute of Clinical Excellence (NICE) and the British Society of Sexual Medicine (BSSM) in the UK and the European Association of the Urology (EAU) have guidelines on the management of ED. This article will look at the similarities of the guidelines commenting where and how they differ.

Does penile rehabilitation have a role in the treatment of erectile dysfunction following radical prostatectomy?

In men undergoing radical treatment for prostate cancer, erectile function is one of the most important health-related quality-of-life outcomes influencing patient choice in treatment. Penile rehabilitation has emerged as a therapeutic measure to prevent erectile dysfunction and expedite return of erectile function after radical prostatectomy. Penile rehabilitation involves a program designed to increase the likelihood of return to baseline-level erectile function, as opposed to treatment, which implies the therapeutic treatment of symptoms, a key component of post–radical prostatectomy management. Several pathological theories form the basis for rehabilitation, and a plethora of treatments are currently in widespread use. However, whilst there is some evidence supporting the concept of penile rehabilitation from animal studies, randomised controlled trials are contradictory in outcomes. Similarly, urological guidelines are conflicted in terms of recommendations. Furthermore, it is clear that in spite of the lack of evidence for the role of penile rehabilitation, many urologists continue to employ some form of rehabilitation in their patients after radical prostatectomy. This is a significant burden to health resources in public-funded health economies, and no effective cost-benefit analysis has been undertaken to support this practice. Thus, further research is warranted to provide both scientific and clinical evidence for this contemporary practice and the development of preventative strategies in treating erectile dysfunction after radical prostatectomy.

A Double-Blind, Randomized Trial on the Efficacy and Safety of Hyperbaric Oxygenation Therapy in the Preservation of Erectile Function after Radical Prostatectomy

PURPOSE

We evaluated the efficacy and safety of hyperbaric oxygenation therapy to preserve erectile function as part of penile rehabilitation after robot assisted bilateral nerve sparing radical prostatectomy for prostate cancer.

MATERIALS AND METHODS

We performed a prospective, randomized, double-blind study from January 2009 to April 2013. Men 40 to 65 years old who underwent robot assisted bilateral nerve sparing radical prostatectomy were randomized 1:1 to the control or the treatment group. Participants were exposed to air as the control or to 100% oxygen as the treatment in hyperbaric conditions. The primary outcome was erectile function at 18 months as measured by IIEF (International Index of Erectile Function). Secondary outcomes were 12-month urinary symptoms, and 18-month sexual, urinary, bowel and hormonal related symptoms as measured by EPIC-26 (Expanded Prostate Index Composite-26). Adverse events and long-term cancer outcomes were monitored. Primary and secondary outcomes in the 2 groups were compared by the independent group t-test, the Wilcoxon rank sum test and the chi-square test of proportion.

RESULTS

A total of 109 potent men were randomized to hyperbaric oxygenation therapy or the control group. A total of 43 men in the air group and 40 in the hyperbaric oxygenation therapy group completed the 18-month followup. No statistically significant differences were observed between the 2 groups on any outcome measure.

CONCLUSIONS

This study revealed no difference in erectile recovery in men treated with hyperbaric oxygenation therapy vs placebo. Larger studies involving more diverse comorbidities and different hyperbaric oxygenation therapy regimens are needed to better evaluate the usefulness of hyperbaric oxygenation therapy for penile rehabilitation after radical prostatectomy.

Sexual Function after Surgery for Prostate or Bladder Cancer

Background

Compromised sexual function is often a side effect for patients following radical surgical procedures for bladder or prostate cancer.

Methods

The authors review the classification and physiology of sexual function and dysfunction. Moreover, they explain the possible pathophysiology directly resulting from surgery, and they discuss several approaches available to address these problems.

Results

Options for male sexual dysfunction, primarily erectile dysfunction resulting from radical prostatectomy or surgery for bladder cancer, range from patient education to penile prosthesis implantation. Female sexual dysfunction caused by surgical intervention for bladder cancer includes problems with libido, arousal, orgasm, and dyspareunia. Treatment options for women can include sex therapy, hormonal therapy, and preventive strategies. However, no consensus has been established on the most effective agents and time points to treat male or female sexual dysfunction following radical cystectomies or prostatectomies. The chronic intermittent treatment of erectile dysfunction following radical prostatectomy has been commonly referred to as penile rehabilitation.

Conclusions

Additional research is needed to obtain further data concerning sexual dysfunction in both men and women following radical pelvic surgeries. Modification of surgical techniques, the use of various treatment modalities for sexual dysfunction, and the development of new agents will help to successfully minimize or prevent damage and restore normal sexual function after local surgical therapy for prostate or bladder cancer in the future.

Erectile function recovery in men treated with phosphodiesterase type 5 inhibitor administration after bilateral nerve-sparing radical prostatectomy: a systematic review of placebo-controlled randomized trials with trial sequential analysis

The impact of phosphodiesterase type 5 inhibitor (PDE5I) treatment modality (on-demand vs. daily), PDE5I half-life and time from surgery to PDE5I prescription on the achievement of drug-assisted erectile function (EF) recovery is uncertain. We systematically reviewed published randomized clinical trials (RCTs). We performed meta-analyses of data on 2317 men treated with PDE5Is after nerve-sparing radical prostatectomy (NSRP). A PubMed and SCOPUS search was performed for trials published from 1 January 1969 to 30 June 2016. PDE5Is are effective in achieving drug-assisted recovery of erectile function (EF). From a statistical standpoint, these studies were subjected to Trial Sequential Analysis to determine whether the pooled data were adequately powered to verify the study outcomes. On-demand treatment with PDE5Is was significantly better than daily treatment in recovering drug-assisted EF. This effect was maintained even when the drugs were stratified according with half-life. Although not based on head-to-head trials, Avanafil used on-demand was the most effective PDE5I in recovering drug-assisted EF. Whereas tadalafil was equally effective when used both on-demand and daily, vardenafil significantly improved drug-assisted EF recovery only when used on-demand. The start of PDE5I treatment six months or more after surgery compared to treatment started earlier did not negatively affect the rate of drug-assisted EF recovery or the possibility to have successful intercourse based on the Sexual Encounter Profile question-3 (SEP-3). Current trials do not support the hypothesis that PDE5I use recovers drug-unassisted EF, although chronic low-dose tadalafil administration may help to preserve erectile tissue integrity. Potential shortcomings in the trials design may partially explain these disappointing results and several questions concerning the recovery of drug-unassisted EF remain unanswered. Thus, there is a need for well-designed new RCTs requiring changes in the timing of PDE5I administration as well as in the dose and the treatment duration.

Aging related erectile dysfunction-potential mechanism to halt or delay its onset

Erectile dysfunction (ED) will visit every man at some time in his life. The age at when that knock on the door is heard is totally dependent on one’s genetics as well as other extrinsic factors. Unlike guests who come for a visit and then leave, once ED shows up it tends to hang around forever. To add insult to injury, the longer ED hangs around, the worse it will get. It is estimated that by the time a man is in his 40’s, he has about a 40% chance of having some form of ED and this prevalence increases about 10% per decade thereafter. This suggests that the aging related process that leads to ED begins early in life. It turns out that the most common cause of ED, regardless of the patient’s age, is due to a problem with the vascular system of the penis. However, this specific aging related vascular problem is not caused by arterial disease but due to a dysfunction and/or loss of the corporal smooth muscle cells (SMC), the main constituent of the corporal sinusoids. As one gets older, these SMC continue to degrade and disappear. When approximately 15% of these cells have been impacted, it results in an inability of the corporal tissue to retain and/or prevent the blood from “leaking” out of the corporal sinusoids into the systemic veins. However, the corporal SMC themselves begin to combat this aging process by expressing the inducible nitric oxide synthase (iNOS) enzyme to make nitric oxide (NO) in an attempt to quench the high intracellular oxidative stress responsible for the SMC apoptosis. When this iNOS pathway is then pharmacologically upregulated, reversal of these aging related changes in the corpora with correction of the venous leakage is observed. Since we believe that aging related ED is pathologically the same disorder as essential hypertension, the development of a therapeutic regimen that can halt, delay or possibly reverse the cellular processes that lead to aging related ED should also be applicable to those patients diagnosed with essential hypertension.

Pharmacodynamics, pharmacokinetics and clinical efficacy of phosphodiesterase-5 inhibitors

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5Is) are the first-line drugs in the management of erectile dysfunction (ED). However, over the past two decades tremendous efforts have been made to identify new clinical uses of PDE5Is beyond their roles in ED. Areas covered: Basic science articles, clinical trials, reviews, and meta-analysis published between 1996 and 2015 were searched using MEDLINE (PubMed interface) to collect the most relevant and impactful studies from our perspectives as practicing urologists. This review mainly focuses on the level one evidence-based clinical efficacy and drug-related toxicity of oral PDE5Is. In addition, drug discovery, pharmacokinetics and pharmacodynamics, potential use in other diseases, and future directions are discussed. Expert opinion: On-demand PED5Is for the treatment of ED has shifted toward chronic administration in a broad spectrum of conditions that are thought to be associated with endovascular health. Several studies have shown that PDE5Is may play a cardioprotective or neuroprotective role. Further studies are under way to verify beneficial effects of PDE5I in non-urological conditions.

[Functional results and treatment of functional dysfunctions after radical prostatectomy]

OBJECTIVE

To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer.

MATERIAL AND METHOD

Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta.

RESULTS

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach.

CONCLUSION

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.

Effect of daily sildenafil on patients with absent nocturnal erections due to pelvic fracture urethral disruption: a single-centre experience

Erectile dysfunction (ED) is a common sequel of pelvic fracture urethral disruption. Those patients with nocturnal erections may respond favourably to sildenafil; however, little is known about the response to sildenafil in patients with absent nocturnal erections. The aim was to evaluate the response to the treatment of sildenafil 50 mg taken once daily in the patients with absent nocturnal erections. From January 2008 to December 2011, a total of 28 patients with absent nocturnal erections were evaluated. We recorded nocturnal penile tumescence and rigidity with an erectometer. If nocturnal erections were absent for three nights, patients were administrated sildenafil 100 mg at bedtime and tested again at the fourth night. Penile duplex ultrasound with intracavernous injection was performed to define the cause of ED. All patients received a daily dose of sildenafil 50 mg for 12 weeks. Response to sildenafil treatment was defined as sustained erections allowing vaginal penetration and intercourse. Twenty-three (78%) patients completed the daily sildenafil treatment, and follow-up was available. The nocturnal erections at the fourth night in 13 patients (46.4%) were improved. About 61.5% (8/13) reported effective response to daily sildenafil. The improvement of nocturnal erections induced by sildenafil taken at bedtime might predict the response to sildenafil taken daily.

Minimally invasive infrapubic inflatable penile prosthesis implant for erectile dysfunction: evaluation of efficacy, satisfaction profile and complications

Erectile dysfunction (ED), the second most common male sexual disorder, has an important impact on man sexuality and quality of life affecting also female partner's sexual life. ED is usually related to cardiovascular disease or is an iatrogenic cause of pelvic surgery. Many non-surgical treatments have been developed with results that are controversial, while surgical treatment has reached high levels of satisfaction. The aim is to evaluate outcomes and complications related to prosthesis implant in patients suffering from ED not responding to conventional medical therapy or reporting side effects with such a therapy. One hundred eighty Caucasian male suffering from ED were selected. The patient population were divided into two groups: 84 patients with diabetes and metabolic syndrome (group A) and 96 patients with dysfunction following laparoscopic radical prostatectomy for prostate cancer (group B). All subjects underwent primary inflatable penile prosthesis implant with an infrapubic minimally invasive approach. During 12 months of follow-up, we reported 3 (1.67%) explants for infection, 1 (0.56%) urethral erosion, 1 (0.56%) prosthesis extrusion while no intraoperative complications were reported. Mean International Index of Erectile Function-5 (IIEF-5) was 8.2 ± 4.0 and after the surgery (12 months later) was 20.6 ± 2.7. The improvement after the implant is significant in both groups without a statistically significant difference between the two groups (P-value 0.65). Mean Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score 1 year after the implant is 72.2 ± 20.7, and there was no statistically significant difference between groups A and B (P-value 0.55). Implantation of an inflatable prosthesis, for treatment of ED, is a safe and efficacious approach; and the patient and partner satisfaction is very high. Surgical technique should be minimally invasive and latest technology equipment should be implanted in order to decrease after surgery common complications (infection and mechanical failure).

Landmarks in erectile function recovery after radical prostatectomy

The description of the nerve-sparing technique of radical prostatectomy by Walsh was one of the major breakthroughs in the surgical treatment of prostate cancer in the 20(th) century. However, despite this advance and consequent technological refinements to nerve-sparing surgery, a large proportion of men still suffer from erectile dysfunction (ED) as a complication of prostatectomy. A plethora of therapeutic approaches have been proposed to optimize erectile function recovery in these patients. Several preclinical and translational studies have shown benefits of therapies including PDE5 inhibitor (PDE5I) treatment, immunomodulation, neurotrophic factor administration, and regenerative techniques, such as stem cell therapy, in animal models. However, most of these approaches have either failed to translate to clinical use or have yet to be studied in human subjects. Penile rehabilitation with PDE5Is is currently the most commonly used clinical strategy, in spite of the absence of solid clinical evidence to support its use.

Penile rehabilitation after radical prostatectomy: does it work?

CONTEXT

Erectile dysfunction (ED) represents one of the most common long-term side effects in patients with clinically localized prostate cancer (PCa) undergoing nerve-sparing radical prostatectomy (RP).

OBJECTIVE

To analyze the role of penile rehabilitation in the recovery of erectile function (EF) after nerve-sparing RP.

EVIDENCE SYNTHESIS

Penile rehabilitation is defined as the use of any intervention or combination with the goal not only to achieve erections sufficient for satisfactory sexual intercourses, but also to return EF to preoperative levels. The concept of rehabilitation is based on the implementation of protocols aimed at improving oxygenation, preserving endothelial structure, and preventing smooth muscle structural alterations. Nowadays, the most commonly adopted approaches for penile rehabilitation after nerve-sparing RP are represented by the administration of phosphodiesterase type-5 inhibitors (PDE5-Is), intracorporeal injection therapy, vacuum erection devices (VED), and the combination of these therapies. Several basic science studies support the rational for the adoption of penile rehabilitation protocols. Particularly, rehabilitation, set as early as possible, seems to be better than leaving the erectile tissues unassisted. On the other hand, results from solid prospective randomized trials finally assessing the long-term beneficial effects of PDE5-Is, intracavernosal injections, or VED on EF recovery after surgery are still lacking.

CONCLUSIONS

Although preclinical evidences support the rationale for penile rehabilitation after nerve-sparing RP, clinical studies reported conflicting results regarding its efficacy on long-term EF recovery. Nowadays, which is the optimal rehabilitation program still represents a matter of debate.

Management of erectile dysfunction post-radical prostatectomy

Radical prostatectomy is a commonly performed procedure for the treatment of localized prostate cancer. One of the long-term complications is erectile dysfunction. There is little consensus on the optimal management; however, it is agreed that treatment must be prompt to prevent fibrosis and increase oxygenation of penile tissue. It is vital that patient expectations are discussed, a realistic time frame of treatment provided, and treatment started as close to the prostatectomy as possible. Current treatment regimens rely on phosphodiesterase 5 inhibitors as a first-line therapy, with vacuum erection devices and intraurethral suppositories of alprostadil as possible treatment combination options. With nonresponders to these therapies, intracavernosal injections are resorted to. As a final measure, patients undergo the highly invasive penile prosthesis implantation. There is no uniform, objective treatment program for erectile dysfunction post-radical prostatectomy. Management plans are based on poorly conducted and often underpowered studies in combination with physician and patient preferences. They involve the aforementioned drugs and treatment methods in different sequences and doses. Prospective treatments include dietary supplements and gene therapy, which have shown promise with there proposed mechanisms of improving erectile function but are yet to be applied successfully in human patients.

Penile rehabilitation after pelvic cancer surgery

Erectile dysfunction is the most common complication after pelvic radical surgery. Rehabilitation programs are increasingly being used in clinical practice but there is no high level of evidence supporting its efficacy. The principle of early penile rehabilitation stems from animal studies showing early histological and molecular changes associated with penile corporal hypoxia after cavernous nerve injury. The concept of early penile rehabilitation was developed in late nineties with a subsequent number of clinical studies supporting early pharmacologic penile rehabilitation. These studies included all available phosphodiesterase type 5 inhibitors, intracavernosal injection and intraurethral use of prostaglandin E1 and to lesser extent vacuum erectile devices. However, these studies are of small number, difficult to interpret, and often with no control group. Furthermore, no studies have proven an in vivo derangement of endothelial or smooth muscle cell metabolism secondary to a prolonged flaccid state. The purpose of the present report is a synthetic overview of the literature in order to analyze the concept and the rationale of rehabilitation program of erectile dysfunction following radical pelvic surgery and the evidence of such programs in clinical practice. Emphasis will be placed on penile rehabilitation programs after radical cystoprostatectomy, radical prostatectomy, and rectal cancer treatment. Future perspectives are also analyzed.

Effects of three-times-per-week versus on-demand tadalafil treatment on erectile function and continence recovery following bilateral nerve sparing radical prostatectomy: results of a prospective, randomized, and single-center study

Erectile dysfunction (ED) and urinary incontinence after bilateral nerve-sparing radical prostatectomy (BNSRP) still remain major causes of morbidity. Phosphodiesterase type 5 inhibitors (PDE5-Is) have a role in the treatment of ED after BNSRP. Several studies in patients with ED and lower urinary tract symptoms demonstrated that PDE5-Is could improve both erectile function and urinary symptoms. The aim of this study was to compare the efficacies of two dosing regimens of 20 mg tadalafil (on-demand and 3 times per week) and to assess the role of tadalafil in recovery of erectile function and continence after BNSRP. We conducted a single-center, prospective, randomized controlled trial of three times per week versus on-demand tadalafil 20 mg and a control group after BNSRP. A total of 129 preoperatively potent and continent patients were included in the study. The patients were evaluated at 6 weeks and 12 months postoperatively for erectile function and continence status. There was no significant difference between all three groups with respect to erectile function at 6 weeks after the surgery. Twelve months after the surgery, the International Index of Erectile Function score was significantly higher in the group using tadalafil 20 mg three times per week. However, there was no significant difference between the treated groups and the control group with respect to the continence status at 12 months after the surgery. There was no correlation between incontinence and ED after the surgery in all groups. Tadalafil 20 mg three times per week is an efficacious and well-tolerated treatment option for ED after BNSRP. Treatment with 20 mg tadalafil either three times per week or on demand cannot improve continence recovery after BNSRP compared with the control group.

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

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

Post-prostatectomy erectile dysfunction: contemporary approaches from a US perspective

Success of cancer surgery often leads to life-changing side effects, and surgical treatment for malignant urologic disease often results in erectile dysfunction (ED). Patients that undergo surgical prostatectomy or cystoprostatectomy will often experience impairment of erections due to disruption of blood and nerve supply. Surgical technique, nerve sparing status, patient age, comorbid conditions, and pretreatment potency status all have an effect on post-surgical ED. Regardless of surgical technique, prostatectomy results in disruption of normal anatomy and nerve supply to the penis, which governs the functional aspects of erection. A variety of different treatment options are available for men who develop ED after prostatectomy, including vacuum erection device, oral phosphodiesterase 5 inhibitors (PDE5I), intracorporal injections, and penile prosthesis. The vacuum erection device creates an artificial erection by forming a vacuum via suction of air to draw blood into the penis. The majority of men using the vacuum erection device daily after prostatectomy, regardless of nerve-sparing status, have erections sufficient for intercourse. Phosphodiesterase 5 inhibitors remain a common treatment option for post-surgical ED and are the mainstay of therapy. They work through cyclic adenosine monophosphate and cyclic guanine monophosphate pathways and are recommended in all forms of ED. Intracorporal injections or intraurethral use of vasoactive substances may be a good second-line therapy in men who do not experience improvement with oral medications. Surgical placement of a penile prosthesis is typically the treatment strategy of choice after other options have failed. Semi-rigid and inflatable devices are available with high satisfaction rates. With careful patient counseling and proper treatment selection, patient satisfaction and improved erectile function can be achieved. We advise that patients use a vacuum erection device daily in the early postoperative period in combination with an oral PDE5I. For patients who do not respond to a vacuum erection device or PDE5I, consideration should be given to intraurethral alprostadil, intracorporal injections, or a penile prosthesis.

Development of UK recommendations on treatment for post-surgical erectile dysfunction

AIM

To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted.

RESULTS

Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies.

CONCLUSION

Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

Is there a rationale for penile rehabilitation following radical prostatectomy?

Erectile function recovery after radical prostatectomy (RP) is an increasingly prominent quality-of-life outcome following surgery. Following RP many men, despite the advent of cavernous nerve-sparing surgical technique, have moderately or significantly impaired erectile function (EF). The term penile rehabilitation (PR) is used to define interventions that maintain the health of erectile tissue in the context of nervous, vascular, and structural tissue injury. The goal of PR is to regain, as closely re-approximate, preoperative erectile function. PR is based on an increasing volume of preclinical and clinical data, but conclusive evidence of efficacy has not been established, and therefore the concept of PR remains controversial. The optimal PR regimen has not been established, but all strategies rely on one or more erectile dysfunction treatments to be administered on a regular basis regardless of actual use for sexual activity. This review highlights recent studies and evidence related to PR.

The effects of trimetazidine and sildenafil on bilateral cavernosal nerve injury induced oxidative damage and cavernosal fibrosis in rats

AIM

The aim of this study was to compare the effects of sildenafil and trimetazidine on bilateral cavernosal nerve injury-induced oxidative damage and fibrotic changes in cavernosal tissue in rat model.

MATERIAL AND METHODS

A total of 32 male Sprague-Dawley rats were randomly divided into 4 groups; each group consist 8 rats (control, BCI, BCI + TMZ, and BCI + sildenafil groups). Tissue superoxide dismutase (SOD), malondialdehyde (MDA), and protein carbonyl (PC) levels were determined biochemically and distribution of cavernosal fibrosis density among groups was performed histopathologically.

RESULTS

Tissue SOD levels in BCI group were significantly lower than the control group (P < 0.05). Tissue MDA and PC levels in BCI group were significantly higher than the control group (P < 0.05). TMZ and sildenafil administration significantly increased tissue SOD levels (P < 0.05) and reduced tissue MDA and PC levels (P < 0.05). Histologically, the degree of cavernosal fibrosis and collagen density was higher in BCI group in comparison to control, TMZ-treated, and sildenafil-treated groups.

CONCLUSION

BCI caused oxidative damage and increased cavernosal fibrosis in rat penis. TMZ and sildenafil treatment decreased oxidative damage and reduced the degree of fibrosis in penile tissue due to BCI.

Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial

OBJECTIVE

To examine the effect of penile vibratory stimulation (PVS) in the preservation and restoration of erectile function and urinary continence in conjunction with nerve-sparing radical prostatectomy (RP).

PATIENTS AND METHODS

The present study was conducted between July 2010 and March 2013 as a randomized prospective trial at two university hospitals. Eligible participants were continent men with an International Index of Erectile Function-5 (IIEF-5) score of at least 18, scheduled to undergo nerve-sparing RP. Patients were randomized to a PVS group or a control group. Patients in the PVS group were instructed in using a PVS device (FERTI CARE(®) vibrator). Stimulation was performed at the frenulum once daily by the patients in their own homes for at least 1 week before surgery. After catheter removal, daily PVS was re-initiated for a period of 6 weeks. Participants were evaluated at 3, 6 and 12 months after surgery with the IIEF-5 questionnaire and questions regarding urinary bother. Patients using up to one pad daily for security reasons only were considered continent. The study was registered at http://clinicaltrials.gov/ (NCT01067261).

RESULTS

Data from 68 patients were available for analyses (30 patients randomized to PVS and 38 patients randomized to the control group). The IIEF-5 score was highest in the PVS group at all time points after surgery with a median score of 18 vs 7.5 in the control group at 12 months (P = 0.09), but the difference only reached borderline significance. At 12 months, 16/30 (53%) patients in the PVS group had reached an IIEF-5 score of at least 18, while this was the case for 12/38 (32%) patients in the control group (P = 0.07). There were no significant differences in the proportions of continent patients between groups at 3, 6 or 12 months. At 12 months 90% of the PVS patients were continent, while 94.7% of the control patients were continent (P = 0.46).

CONCLUSION

The present study did not document a significant effect of PVS. However, the method proved to be acceptable for most patients and there was a trend towards better erectile function with PVS. More studies are needed to explore this possible effect further.

Neglected side effects after radical prostatectomy: a systematic review

INTRODUCTION

A series of previously neglected sexually related side effects to radical prostatectomy (RP) has been identified over the recent years. These include orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasm-associated pain (OAP), penile shortening (PS), and penile deformity.

AIM

The aim of this article is to conduct a systematic review of the literature regarding the above-mentioned side effects.

METHODS

A predefined search strategy was applied in a thorough search of Medline, Web of science, and the online Cochrane library. The PRISMA guidelines for systematic reviews were followed, and protocol as well as search strategies was registered at http://www.crd.york.ac.uk/Prospero/ (RN: CRD42012003165).

MAIN OUTCOME MEASURE

The main outcome measure was incidence rates for the relevant side effects.

RESULTS

A total of 43 articles were included. OAI and UISS are experienced by 20-93% of RP patients at least a few times after surgery. Although these issues are associated to postoperative daytime incontinence, previous transurethral resection of the prostate (TURP) is the only known predicting factor. Alterations of orgasmic function are experienced by approximately 80% after RP. Erectile dysfunction seems to play an important role in waning orgasmic function. OAP is only experienced by a subset of the patients with reported rates varying between 3% and 19%. Sparing of the tips of the seminal vesicles has been shown to double the risk of OAP. PS occurs in 15-68% of RP patients. Nerve sparing and preservation of erectile function may help preserve penile length. With regard to all side effects, studies indicate that they are reduced over time.

CONCLUSIONS

The sexually related side effects summarized in this review are common after RP. Meanwhile, it is difficult to predict which patients are at risk. Daytime incontinence, previous TURP, a lack of nerve sparing, and erectile dysfunction are all associated with the above-mentioned sexually related side effects.

Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT)

BACKGROUND

The potential rehabilitative and protective effect of phosphodiesterase type 5 inhibitors (PDE5-Is) on penile function after nerve-sparing radical prostatectomy (NSRP) remains unclear.

OBJECTIVE

The primary objective was to compare the efficacy of tadalafil 5mg once daily and tadalafil 20mg on demand versus placebo taken over 9 mo in improving unassisted erectile function (EF) following NSRP, as measured by the proportion of patients achieving an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score ≥ 22 after 6-wk drug-free washout (DFW). Secondary measures included IIEF-EF, Sexual Encounter Profile question 3 (SEP-3), and penile length.

DESIGN, SETTING, AND PARTICIPANTS

Randomised, double-blind, double-dummy, placebo-controlled trial in men ≤ 68 yr of age with adenocarcinoma of the prostate (Gleason ≤ 7) and normal preoperative EF who underwent NSRP at 50 centres from nine European countries and Canada.

INTERVENTIONS

1:1:1 randomisation to 9 mo of treatment with tadalafil 5mg once daily, tadalafil 20mg on demand, or placebo followed by a 6-wk DFW and 3-mo open-label tadalafil once daily (all patients).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression, mixed-effects model for repeated measures, and analysis of covariance, adjusting for treatment, age, and country, were applied to IIEF-EF scores ≥ 22, SEP-3, and penile length.

RESULTS AND LIMITATIONS

Four hundred twenty-three patients were randomised to tadalafil once daily (n=139), on demand (n=143), and placebo (n=141). The mean age was 57.9 yr of age (standard deviation: 5.58 yr); 20.9%, 16.9%, and 19.1% of patients in the tadalafil once daily, on demand, and placebo groups, respectively, achieved IIEF EF scores ≥ 22 after DFW; odds ratios for tadalafil once daily and on demand versus placebo were 1.1 (95% confidence interval [CI], 0.6-2.1; p=0.675) and 0.9 (95% CI, 0.5-1.7; p=0.704). At the end of double-blind treatment (EDT), least squares (LS) mean IIEF-EF score improvement significantly exceeded the minimally clinically important difference (MCID: ΔIIEF-EF ≥ 4) in both tadalafil groups; for SEP-3 (MCID ≥ 23%), this was the case for tadalafil once daily only. Treatment effects versus placebo were significant for tadalafil once daily only (IIEF-EF: p=0.016; SEP-3: p=0.019). In all groups, IIEF-EF and SEP-3 decreased during DFW but continued to improve during open-label treatment. At month 9 (EDT), penile length loss was significantly reduced versus placebo in the tadalafil once daily group only (LS mean difference 4.1mm; 95% CI, 0.4-7.8; p=0.032).

CONCLUSIONS

Tadalafil once daily was most effective on drug-assisted EF in men with erectile dysfunction following NSRP, and data suggest a potential role for tadalafil once daily provided early after surgery in contributing to the recovery of EF after prostatectomy and possibly protecting from penile structural changes. Unassisted EF was not improved after cessation of active therapy for 9 mo.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01026818.

Effectiveness of intracavernous delivery of adenovirus encoding Smad7 gene on erectile function in a mouse model of cavernous nerve injury

INTRODUCTION

Men with erectile dysfunction (ED) respond poorly to oral phosphodiesterase-5 inhibitors following radical prostatectomy. Recent studies have reported that up-regulation of transforming growth factor-β1 (TGF-β1) and activation of the Smad signaling pathway play important roles in cavernous fibrosis and in the deterioration of erectile function in a mouse model of cavernous nerve injury (CNI) and in patients with spinal cord injury. The mothers against decapentaplegic homolog 7 (Smad7) is known to inhibit the phosphorylation of Smad2 and Smad3.

AIM

To investigate the effectiveness of adenoviruses encoding Smad7 gene (Ad-Smad7) on erectile function in a mouse model of CNI.

METHODS

Twelve-week-old C57BL/6J mice were used and distributed into 7 groups: sham operation group, untreated CNI group, and CNI groups receiving a single intracavernous injection of adenovirus encoding LacZ (1 × 10(8) virus particles [vp]/20 μL) or adenovirus encoding Smad7 (Ad-Smad7; 1 × 10(7), 1 × 10(8), 2 × 10(8), or 1 × 10(9) vp/20 μL).

MAIN OUTCOME MEASURES

Two weeks after bilateral cavernous nerve crushing and treatment, erectile function was measured by electrical stimulation of the cavernous nerve. The penis was harvested for histologic examinations and Western blot analysis.

RESULTS

The highest erectile response was noted in CNI mice treated with Ad-Smad7 at a dose of 1 × 10(8)  vp, which reached up to 82-85% of sham control values. Local delivery of Ad-Smad7 significantly decreased endothelial cell apoptosis and the production of extracellular matrix proteins, including plasminogen activator inhibitor-1, fibronectin, collagen I, and collagen IV, and induced endothelial nitric oxide synthase phosphorylation in the corpus cavernosum tissue of CNI mice.

CONCLUSION

The adenovirus-mediated gene transfer of Smad7 successfully restored erectile function by enhancing endothelial cell function and through antifibrotic effects. These findings suggest that inhibition of the TGF-β signaling pathway by use of Smad7 may represent a promising therapeutic strategy for ED induced by radical prostatectomy.

Sonic hedgehog protein is decreased and penile morphology is altered in prostatectomy and diabetic patients

Erectile dysfunction (ED) is a debilitating medical condition and current treatments are ineffective in patients with cavernous nerve (CN) injury, due to penile remodeling and apoptosis. A critical regulator of penile smooth muscle and apoptosis is the secreted protein sonic hedgehog (SHH). SHH protein is decreased in rat prostatectomy and diabetic ED models, SHH inhibition in the penis induces apoptosis and ED, and SHH treatment at the time of CN injury suppresses smooth muscle apoptosis and promotes regeneration of erectile function. Thus SHH treatment has significant translational potential as an ED therapy if similar mechanisms underlie ED development in patients. In this study we quantify SHH protein and morphological changes in corpora cavernosal tissue of control, prostatectomy and diabetic patients and hypothesize that decreased SHH protein is an underlying cause of ED development in prostatectomy and diabetic patients. Our results show significantly decreased SHH protein in prostatectomy and diabetic penis. Morphological remodelling of the penis, including significantly increased apoptotic index and decreased smooth muscle/collagen ratio, accompanies declining SHH. SHH signaling is active in human penis and is altered in a parallel manner to previous observations in the rat. These results suggest that SHH has significant potential to be developed as an ED therapy in prostatectomy and diabetic patients. The increased apoptotic index long after initial injury is suggestive of ongoing remodeling that may be clinically manipulatable.

Penile rehabilitation after radical prostatectomy: what the evidence really says

The pathophysiology of erectile dysfunction after radical prostatectomy (RP) is believed to include neuropraxia, which leads to temporarily reduced oxygenation and subsequent structural changes in penile tissue. This results in veno-occlusive dysfunction, therefore, penile rehabilitation programmes focus on tissue oxygenation. Animal studies support the use of phosphodiesterase type 5 inhibitors (PDE5Is) after cavernous nerve damage but results from human studies are contradictory. The largest study to date found no long-term effect of either daily or on-demand PDE5I administration after RP compared with placebo. The effects of prostaglandin and vacuum erection devices are questionable and high-quality studies are lacking. Better documentation for current penile rehabilitation and/or better rehabilitation protocols are needed. One must be careful not to repeat the statement that penile rehabilitation improves erectile function after RP so many times that it becomes a truth even without the proper scientific backing.