Tadalafil rehabilitation therapy preserves penile size after bilateral nerve sparing radical retropubic prostatectomy

Advancing Precision in Penile Length Measurement: Evidence-based Synthesis of Stretched Penile Length INdicator Technique (SPLINT)

Purpose

The purpose of this study was to synthesize evidence and propose a technique for estimation of stretched penile length (SPL) applicable to children.

Materials and Methods

This review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. PubMed, Embase, and Scopus databases were queried on penile length (PL) measurement techniques in humans published from 1990 onward. The devices and the techniques used for PL measurement, state of the penis, the habitus of the participants, proximal and distal landmarks for measurement, handling the foreskin and pubic pad of fat, optimal stretching of the penis, and other factors (including the environment) which should be accounted for in the technique were identified from the study cohort (90895 participants across 145 included studies).

Results

PL has been represented through flaccid (33.79%), stretched (81.3%), and erect (12.41%) PLs as well as the greatest corporeal length (1.4%). Following devices have been used to measure the PL in the study cohort: rulers [54.68%], calipers [9.7%], measuring tapes [14.5%], coloured measuring strips [2.06%], spatulas/tongue depressors [11.03%], FitKit, syringe [1.4%], cotton swab (and ruler), titan cylinders, slide gauge and ultrasonography [1.37%]. The factors relevant to SPL measurement have been incorporated into the proposed SPL INdicator Technique (SPLINT) which is essentially a holistic extension of the "Conventional PL Measurement" technique.

Conclusions

There is a wide range of heterogeneity in the technique for estimation of PL across the study cohort; the underlying factors have been identified along with the respective variables, and the SPLINT for SPL has been described.

Dimethyl fumarate ameliorates erectile dysfunction in bilateral cavernous nerve injury rats by inhibiting oxidative stress and NLRP3 inflammasome-mediated pyroptosis of nerve via activation of Nrf2/HO-1 signaling pathway

OBJECTIVE

To investigate the therapeutic potential of dimethyl fumarate (DMF) in improving erectile function of bilateral cavernous nerve injury (BCNI) rats, along with elucidating its underlying mechanisms.

METHODS

A BCNI rat model was established by clamping bilateral cavernous nerve (CN). DMF was given by gavage at low (20 mg/kg/day) and high (40 mg/kg/day) dosages for a duration of 4 weeks. Erectile function was assessed by electrical stimulation of CN. Penis and CN tissues were collected for subsequent analysis. Additionally, PC-12 cell line was used to verify the mechanism of DMF in vitro. Nfe2l2 or Ho-1 gene knockdown PC-12 cell lines were constructed by lentiviral transfection, respectively. A damaged cell model was induced using H2O2. And then molecular biological methods were employed to analyze cellular molecules and proteins.

RESULTS

DMF administration for 4 weeks led to improvements in erectile function, reduced fibrosis of penis corpus cavernosum in BCNI rats. The morphology of CN was improved and the number of nerve fibers increased. Furthermore, the levels of nNOS, NO, and cGMP were increased, while Ca2+ was decreased in penis corpus cavernosum. Notably, the levels of ROS, 3-NT and NLRP3 inflammasomes production were reduced, alongside increased expression of Nrf2 and HO-1 proteins in the dorsal penile nerve (DPN) and CN. In vitro, DMF increased cell viability, reduced ROS level, promoted SOD, diminished 3-NT, MDA and DNA damage markers, and inhibited the activation of NLRP3 inflammasomes in H2O2 induced PC-12 cells. Nfe2l2 knockdown and Ho-1 knockdown significantly attenuated the protective effect of DMF, respectively. Furthermore, inhibition of ROS production by N-acetylcysteine led to a reduction in NLRP3 inflammasome activation in H2O2 induced PC-12 cells.

CONCLUSIONS

DMF improved erectile function of BCNI rats by protecting nerves through inhibiting oxidative stress and the activation of NLRP3 inflammasome-mediated pyroptosis via activation of Nrf2/HO-1 pathway.

Impact of Pelvic Anatomical Changes Caused by Radical Prostatectomy

Simple Summary

After radical prostatectomy, the pelvic anatomy is altered such that the postoperative structure differs from the preoperative one, resulting in a variety of complications. In this review, the complications and mechanisms of pelvic anatomical changes associated with radical prostatectomy, as well as countermeasures, are outlined. An analysis of the anatomical mechanisms that cause complications after radical prostatectomy using imaging and other modalities is in progress. In addition, many surgical techniques that ensure the prevention of postoperative complications have been reported, and their usefulness has been evaluated. The preservation of as much periprostatic tissue and periprostatic structures as possible may lead to favorable postoperative functions, as long as the cancer condition permits.

Abstract

During radical prostatectomy, the prostate is removed along with the seminal vesicles, and the urinary tract is reconstructed by dropping the bladder onto the pelvic floor and suturing the bladder and urethra together. This process causes damage to the pelvic floor and postoperative complications due to the anatomical changes in the pelvic floor caused by the vesicourethral anastomosis. Urinary incontinence and erectile dysfunction are major complications that impair patients’ quality of life after radical prostatectomy. In addition, the shortening of the penis and the increased prevalence of inguinal hernia have been reported. Since these postoperative complications subsequently affect patients’ quality of life, their reduction is a matter of great interest, and procedural innovations such as nerve-sparing techniques, Retzius space preservation, and inguinal hernia prophylaxis have been developed. It is clear that nerve sparing is useful for preserving the erectile function, and nerve sparing, urethral length preservation, and Retzius sparing are useful for urinary continence. The evaluation of pre- and postoperative imaging to observe changes in pelvic anatomy is also beginning to clarify why these techniques are useful. Changes in pelvic anatomy after radical prostatectomy are inevitable and, therefore, postoperative complications cannot be completely eliminated; however, preserving as much of the tissue and structure around the prostate as possible, to the extent that prostate cancer control is not compromised, may help reduce the prevalence of postoperative complications.

New Possibilities in Heart Failure: The Effects of Tadalafil on Diastolic Function in Patients Undergoing Robot-Assisted Radical Prostatectomy

Inhibitors of phosphodiesterase type 5 (PDE5i) are the first-line treatment for erectile dysfunction and are also used to treat pulmonary hypertension. PDE5i impedes the breakdown of nitric oxide (NO)-driven cyclic guanosine monophosphate (cGMP) in smooth muscle cells of the vascular bed, acting as a potent vasodilator. In heart failure, cGMP signaling is altered. The modulation of cGMP has therefore emerged as a potential therapeutic option for heart failure. In this prospective observational study, we aim to investigate whether tadalafil, a long-acting PDE5i used for erectile dysfunction, could also improve diastolic function assessed by cardiac ultrasound. A total of 23 patients were enrolled, undergoing nerve-sparing robot-assisted radical prostatectomy for prostate cancer and treated with 20 mg tadalafil on alternate days to recover erectile function. All patients underwent tadalafil treatment for at least 6 months. Participants underwent a clinical and cardiac ultrasound with color Doppler assessment at baseline, after 3 months, and after 6 months. At 6 months, no significant difference was found apart from lower E/e’ ratio (7.4 ± 2.7 vs. 6.3 ± 1.3; p < 0.03), peak velocity of TR jet (2.4 ± 0.2 vs. 2.1 ± 0.2; p < 0.001), and PAPs (27.3 ± 3.6 vs. 22.9 ± 5.7; p < 0.005). Our prospective study shows that 6 months of erectile dysfunction therapy for secondary to radical prostatectomy is associated with a favorable effect on diastolic function, improving the E/e’ ratio and peak velocity of the TR jet.

Penile rehabilitation with low-intensity extracorporeal shock wave therapy in patients after prostate cancer surgery. Early physiological changes and postoperative follow-up outcomes

INTRODUCTION

To investigate the efficacy, safety and postoperative outcomes of using tadalafil and low-intensity extracorporeal shock wave therapy (Li-ESWT) on penile rehabilitation and preventing urinary incontinence after radical prostatectomy.

METHODS

In total, we included 66 patients who used only tadalafil (n = 32) in group 1 and used tadalafil and treated by Li-ESWT (n = 34) in group 2. We noted International Index of Erectile Function (IIEF) 5, daily incontinence pad measurements at preoperative, postoperative 3rd, 6th and 12th months respectively. We also evaluated penis blood flow and neovascularisation by penile doppler ultrasonography at postoperative 3rd and 12th months for all patients. Statistical analyses were performed with SPSS version 18. A P-value < .05 was considered significant.

RESULTS

Preoperative demographic characteristics were similar in the two groups. There was a statistically significant improvement in IIEF-5, which started at the 6th month and continued increasingly at the 12th month in group 2 compared with group 1. Also, there was a significant decrease in incontinence rate in group 2 compared with group 1 in the sixth month.

CONCLUSIONS

Combined use of tadalafil and Li-ESWT is highly effective and safe for the treatment of erectile dysfunction and for the prevention of urinary incontinence after prostate cancer surgery.

Canadian Urological Association guideline: Erectile dysfunction

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Focusing on sexual rehabilitation besides penile rehabilitation following radical prostatectomy is important

Erectile dysfunction is commonly reported after radical prostatectomy. Besides the loss of erections, sexual life after prostatectomy is impacted by urinary incontinence, orgasmic dysfunction, and psychological stress. In this review, we describe classical medical therapies used for erectile function rehabilitation such as PDE5 inhibitors and injection therapy. A vast amount of data support the idea of focusing on restoration of sexual function on top of erectile function after prostatectomy. The important strategies described to rehabilitate sexual function include pelvic floor muscle therapy, couple therapy, appropriate preoperative counseling, and focusing on non-penetrative alternatives. A multidisciplinary approach and including the partner is important. Erectile function alone is not sufficient for satisfactory sexual experience and may not be used as a proxy for sexual quality of life. Adding full-spectrum sexual rehabilitation to a standard penile rehabilitation regimen has the highest chances of obtaining satisfactory sexual outcomes in men and their partners after radical prostatectomy.

Phosphodiesterase type-5 inhibitors for erectile dysfunction following nerve-sparing radical prostatectomy: A network meta-analysis

BACKGROUND

To verify which phosphodiesterase type 5 inhibitors (PDE5is) strategy is better for erectile dysfunction (ED) following nerve-sparing radical prostatectomy (NSRP).

METHODS

This systematic literature search was conducted in MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials database to identify eligible studies from the startup of these databases to 1 November, 2019. The ED recovery rate was the main outcome. Traditional pair-wise meta-analysis and multivariate random-effects network meta-analysis (NMA) were performed to explore direct and indirect comparisons, respectively. The surface under the cumulative ranking (SUCRA) probabilities was used to evaluate the efficacy of treatments.

RESULTS

A total of 14 randomized controlled trials with four kinds of PDE5is were included. Further pooled evidence suggested that PDE5is followed by NSRP had a benefit for penile rehabilitation compared to placebo using traditional pair-wise meta-analyses. Our NMA showed that Avanafil 200 mg on demand might be most likely to be the best treatment option according to the first rank of SUCRA both in NMA (SUCRA 83.5) and sensitivity analysis (SUCRA 90.2).

CONCLUSION

Avanafil 200 mg on demand has the highest probability of being the best intervention among PDE5is in treating ED following NSRP. However, more randomized controlled trials are needed to validate this in consideration of the published data regarding Avanafil is relatively small scale.

Generating comprehensive comparative evidence on various interventions for penile rehabilitation in patients with erectile dysfunction after radical prostatectomy: a systematic review and network meta-analysis

Background

We aim to present a comprehensive comparison of various treatments in the management of penile recovery after radical prostatectomy (RP) and provide recommendations for future research.

Methods

Literature search of electronic databases including PubMed, the Cochrane Library, Embase, PsycInfo, and Web of Science, and manual retrieval were conducted from inception through March 2020. “Erectile dysfunction” and “prostatectomy” were used as the Mesh terms. The patients, intervention, comparison, outcome, and study design (PICOS) approach were used to define study eligibility. Two authors independently selected studies, evaluated the methodological quality, and extracted data using Cochrane Collaboration’s tools. The data analysis was completed by STATA version 14.2.

Results

A total of 24 studies with 3,500 patients were incorporated in the final analysis after screening 6,131 records. Our findings indicated that vacuum constriction devices (VCD) ranked 1st which meant that patients in VCD group had the best effect regarding mean IIEF scores within 3 months after RP, and no significant difference was observed between VCD and VCD with 20 mg/day tadalafil (V20DT) (MD: 5.44; 95% CI: −0.81 to 11.69). VCD and 50 mg/day sildenafil (VC50DS) showed superiority over 50 mg/day sildenafil (50DS) (MD: 3.75; 95% CI: 2.74–4.76) and intraurethral alprostadil 125–250 µg (MD: 3.05; 95% CI: 0.38 to 5.72), respectively. Moreover, V20DT showed significant superiority over the other interventions for ≥6 months mean International Index Erectile of Function (IIEF) scores after RP. Monotherapy appeared to have similar efficacy in terms of mean IIEF scores and proportion of patients return to baseline, and the effect of phosphodiesterase type 5 inhibitors (PDE5is) did not seem to be affected by the patterns of administration (regular or on demand).

Conclusions

The combination therapy showed certain advantages over monotherapy, and we recommended the combination of VCD and PDE5is to be considered in the clinical management of penile rehabilitation after RP.

Current management strategy of treating patients with erectile dysfunction after radical prostatectomy: a systematic review and meta-analysis

The aim of this study is to present a summary of current evidence concerning the various treatments in the management of penile rehabilitation after radical prostatectomy (RP) and provide recommendations for future research. Randomized controlled trials (RCTs) were identified from electronic databases including PubMed, the Cochrane Library, Embase, and Web of Science from inception through March 2020 with no limitation to language. Comparable data from each study were combined in a meta-analysis where possible, otherwise data were synthesized narratively. The data analysis was completed by Review Manager version 5.3. A total of 39 RCTs were included in this study. At present, phosphodiesterase type 5 inhibitors (PDE5is) remain the first-line treatment for patients with erectile dysfunction (ED) after RP. Compared with the placebo group, patients in regular PDE5is group (mean difference (MD): 0.76; 95% confidence interval (CI): 1.69-4.44; p < 0.0001) and on demand group (MD: 3.92; 95% CI: 2.95-4.88; p < 0.00001) had a significantly higher mean Erectile Function domain of the International Index of Erectile Function (IIEF-EF) scores within 3 months after RP. As for the proportion of IIEF-EF ≥ 22, patients in regular PDE5is group and on demand PDE5is group had significantly higher proportion than those in placebo group 6 months after RP, and the odds ratios were 1.87 (95% CI: 1.32-2.66; p = 0.0005) and 2.17 (95% CI: 1.20-3.93; p = 0.01), respectively. No significant difference was observed between regular PDE5is group and on demand group regardless of mean IIEF-EF score or the proportion of IIEF-EF ≥ 22. Intracorporeal injection therapy seemed to have similar efficacy to PDE5is. The International Index of Erectile Function-5 items (IIEF-5) scores were significantly higher in vacuum constriction devices group than control group at 6-9 months after RP (MD: 6.70, 95% CI: 2.30-11.10, p = 0.003) with great between-study heterogeneity (p = 0.06, I² = 72%). The other therapeutics including low-intensity extracorporeal shockwave therapy, statin therapy, psychotherapy interventions, and pelvic floor muscle training plus electrical stimulation showed certain improvement on erectile function. We found that the combination therapy showed certain advantages over monotherapy. Currently, PDE5is-based combination therapy remains the mainstream treatment for ED after RP. Intracorporeal injection therapy and vacuum therapy could be served as alternative treatments if PDE5is are ineffective and contraindicated.

Adding a vacuum erection device to regular use of Tadalafil improves penile rehabilitation after posterior urethroplasty

This study aimed to evaluate whether adding a vacuum erection device (VED) to regular use of Tadalafil could achieve better penile rehabilitation following posterior urethroplasty for pelvic fracture-related urethral injury (PFUI). Altogether, 78 PFUI patients with erectile dysfunction (ED) after primary posterior urethroplasty were enrolled and divided into two treatment groups: VED combined with Tadalafil (Group 1, n = 36) and Tadalafil only (Group 2, n = 42). Changes in penile length, testosterone level, International Index of Erectile Function-5 (IIEF-5) questionnaire, Quality of Erection Questionnaire (QEQ), and nocturnal penile tumescence (NPT) testing were used to assess erectile function before and after 6 months of ED treatment. Results showed that the addition of VED to regular use of Tadalafil preserved more penile length statistically (0.4 ± 0.9 vs −0.8 ± 0.7 cm, P < 0.01). IIEF-5 score and QEQ score in Group 1 were higher than Group 2 (both P < 0.05). After treatment, 21/36 (58.3%) Group 1 patients and 19/42 (45.2%) Group 2 patients could complete vaginal penetration. Group 1 patients also had markedly improved testosterone levels (P = 0.01). Unexpectedly, there was no significant difference in NPT testing between two therapies. For PFUI patients with ED after posterior urethroplasty, the addition of VED to regular use of Tadalafil could significantly improve their conditions – improving erection and increasing penile length – thus increasing patient satisfaction and confidence in penile rehabilitation.

Functional recovery after radical prostatectomy for prostate cancer

With the enthusiasm regarding robotic application in radical prostatectomy in accordance with the widespread use of serum prostate-specific antigen as a screening test, the number of surgeries performed for complete removal of the gland is increasing continuously. However, owing to the adjacent anatomical location of the prostate to the nerve and urethral sphincter complex, functional recovery, namely improvement from post-prostatectomy incontinence (PPI) and post-prostatectomy erectile dysfunction, still remains a main problem for patients who are reluctant to undergo surgery and tend to choose alternative ways instead. Since the late 1980s, the introduction of radical prostatectomy by open surgical modalities, the depth of the anatomical understanding of the structure surrounding the prostate is getting tremendous, which leads to the development of new surgical modalities and techniques that are consequently aimed at reducing the incidences of PPI and erectile dysfunction. Briefly, recent data from robotic radical prostatectomy, particularly on PPI, are quite acceptable, but by contrast, the reported potency regain rate still remains <20%, which indicates the need for advanced surgical modification to overcome it. In this review, the authors summarized the recent findings on the anatomy and surgical techniques reported up to now.

Penile rehabilitation for postprostatectomy erectile dysfunction

BACKGROUND

Despite efforts to preserve the neurovascular bundles with nerve-sparing surgery, erectile dysfunction remains common following radical prostatectomy. Postoperative penile rehabilitation seeks to restore erectile function but results have been conflicting.

OBJECTIVES

To evaluate the effects of penile rehabilitation strategies in restoring erectile function following radical prostatectomy for prostate cancer.

SEARCH METHODS

We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase), the Cochrane Library, Web of Science, clinical trial registries (ClinicalTrials.gov, International Clinical Trials Registry Platform) and a grey literature repository (Grey Literature Report) from their inception through to 3 January 2018. We also searched the reference lists of other relevant publications and abstract proceedings. We applied no language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised trials with a parallel or cross-over design.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently screened the literature, extracted data, assessed risk of bias and rated quality of evidence according to GRADE on a per-outcome basis. Primary outcomes were self-reported potency, erectile function measured by validated questionnaires (with potency defined as an International Index of Erectile Function (IIEF-EF) score of 19 or greater and or an IIEF-5 of score of 17 or greater) and serious adverse events. For all quality of life assessments on a continuous scale, higher values indicated better quality of life.

MAIN RESULTS

We included eight randomised controlled trials with 1699 participants across three comparisons. This abstract focuses on the primary outcomes of this review only.Scheduled phosphodiesterase type 5 inhibitors (PDE5I) versus placebo or no treatmentScheduled PDE5I may have little or no effect on short-term (up to 12 months) self-reported potency (risk ratio (RR) 1.13, 95% confidence interval (CI) 0.91 to1.41; very low quality evidence), which corresponds to 47 more men with self-reported potency per 1000 (95% CI 33 fewer to 149 more) and short-term erectile function as assessed by a validated instrument (RR 1.11, 95% CI 0.80 to 1.55; very low quality evidence), which corresponds to 28 more men per 1000 (95% CI 50 fewer to 138 more), but we are very uncertain of both of these findings. Scheduled PDE5I may result in fewer serious adverse events compared to placebo (RR 0.32, 95% CI 0.11 to 0.94; low quality evidence), though this does not appear biologically plausible and may represent a chance finding. We are also very uncertain of this finding. We found no long-term (longer than 12 months) data for any of the three primary outcomes.Scheduled PDE5I versus on-demand PDE5I Daily PDE5I appears to result in little to no difference in both short-term and long-term (greater than 12 months) self-reported potency (short term: RR 0.97, 95% CI 0.62 to 1.53; long term: RR 1.00, 95% CI 0.60 to 1.67; both very low quality evidence); this corresponds to nine fewer men with self-reported short-term potency per 1000 (95% CI 119 fewer to 166 more) and zero fewer men with self-reported long-term potency per 1000 (95% CI 153 fewer to 257 more). We are very uncertain of these findings. Daily PDE5I appears to result in little to no difference in short-term and long-term erectile function (short term: RR 1.00, 95% CI 0.65 to 1.55; long term; RR 0.74, 95% CI 0.48 to 1.14; both very-low quality evidence), which corresponds to zero men with short-term erectile dysfunction per 1000 (95% CI 80 fewer to 125 more) and 119 fewer men with long-term erectile dysfunction per 1000 (95% CI 239 fewer to 64 more). We are very uncertain of these findings. Scheduled PDE5I may result in little or no effects on short-term adverse events (RR 0.69 95% CI 0.12 to 4.04; very low quality evidence), which corresponds to seven fewer men with short-term serious adverse events (95% CI 18 fewer to 64 more), but we are very uncertain of these findings. We found no long-term data for serious adverse events.Scheduled PDE5I versus scheduled intraurethral prostaglandin E1At short-term follow-up, daily PDE5I may result in little or no effect on self-reported potency (RR 1.10, 95% CI 0.79, to 1.52; very low quality evidence), which corresponds to 46 more men per 1000 (95% CI 97 fewer to 241 more). Daily PDE5I may result in a small improvement of erectile function (RR 1.64, 95% CI 0.84 to 3.20; very low quality evidence), which corresponds to 92 more men per 1000 (95% CI 23 fewer to 318 more) but we are very uncertain of both these findings. We found no long-term (longer than 12 months) data for any of the three primary outcomes.We found no evidence for any other comparisons and were unable to perform any of the preplanned subgroup analyses based on nerve-sparing approach, age or baseline erectile function.

AUTHORS' CONCLUSIONS

Based on mostly very-low and some low-quality evidence, penile rehabilitation strategies consisting of scheduled PDE5I use following radical prostatectomy may not promote self-reported potency and erectile function any more than on demand use.

Penile Rehabilitation Therapy Following Radical Prostatectomy: A Meta-Analysis

BACKGROUND

Penile rehabilitation, defined as the use of any drug or device at or after radical prostatectomy to maximize erectile function recovery, is commonly used for post-prostatectomy erectile dysfunction; however, conflicting results based on each study make it difficult to give a recommendation for clinical practice.

AIM

To clarify the effect of oral phosphodiesterase type 5 inhibitors (PDE5is), vacuum erection devices, intracorporeal injection therapy, and the combination of these treatments on penile rehabilitation.

METHODS

A comprehensive publication search was done through the PubMed and Embase databases up to February 8, 2017. The reference lists of the retrieved studies also were investigated. Data were analyzed using STATA 12.0. A fixed- or random-effects model was used to calculate the overall combined odds ratio (OR) or standard mean differences (SMDs). Publication bias was assessed using the Begg and Egger tests.

OUTCOMES

Change in sexual function before and after treatment.

RESULTS

After screening, 11 randomized controlled trials and 5 case-control studies were included. The overall meta-analysis showed that penile rehabilitation with PDE5is, vacuum erection devices, and intracorporeal injection significantly increased the number of patients with erectile function improvement (OR = 2.800, 95% CI = 1.932-4.059, P = .000) and International Index of Erectile Function (IIEF) score (SMD = 5.896, 95% CI = 4.032-7.760, P = .000). In subgroup analysis based on study design, randomized controlled trials and case-control studies showed that penile rehabilitation increased the number of patients with erectile function improvement (randomized controlled trials: OR = 2.154, 95% CI = 1.600-2.895, P = .000; case-control studies: OR = 2.800, 95% CI = 1.932-4.059, P = .000). Subgroup analysis for PDE5i treatment also only demonstrated an increased patient response rate (OR = 2.161, 95% CI = 1.675-2.788, P = .000) and IIEF scores (SMD = 0.922, 95% CI = 0.545-1.300, P = .000). However, after PDE5i washout, there was no improvement of spontaneous erectile function (OR = 1.027, 95% CI = 0.713-1.478, P = .610).

CLINICAL TRANSLATION

This study provides information about the efficacy of penile rehabilitation that can help clinicians decide treatment strategies.

STRENGTHS AND LIMITATIONS

This meta-analysis has higher statistical power than each study. Preoperative patient characteristics, various treatment methods, and different follow-up times might bring bias to pooled effects.

CONCLUSION

Our meta-analysis confirmed that administration of PDE5is, vacuum erection devices, and intracorporeal injection after radical prostatectomy can increase erection function during treatments. However, current evidence does not support that penile rehabilitation with PDE5is can improve recovery of spontaneous erectile function. Further studies with adequate follow-up and larger samples should be conducted to generate a comprehensive conclusion. Liu C, Lopez DS, Chen M, Wang R. Penile Rehabilitation Therapy Following Radical Prostatectomy: A Meta-Analysis. J Sex Med 2017;14:1496-1503.

Comparisons of regular and on-demand regimen of PED5-Is in the treatment of ED after nerve-sparing radical prostatectomy for Prostate Cancer

Phosphodiesterase type-5 inhibitors (PDE5-Is) have been recommended as first line therapy for erectile dysfunction for patients received nerve-sparing radical prostatectomy for prostate cancer. We examed the efficiency of PDE5-Is and considered the optimal application. Systematic search of PubMed, Embase and the Cochrane Library was performed to identify all the studies. We identified 103 studies including 3175 patients, of which 14 were recruited for systematic review. Compared with placebo, PDE5-Is significantly ameliorated the International Index of Erectile Function-Erectile Function domain score (IIEF) scores (MD 4.89, 95% CI 4.25-5.53, p < 0.001). By network meta-analysis, sildenafil seems to be the most efficiency with a slightly higher rate of treatment-emergent adverse events (TEATs), whereas tadalafil had the lowest TEATs. In terms of IIEF scores, regular regimen was remarkably better than on-demand (MD 3.28, 95% CI 1.67-4.89, p < 0.001). Regular use was not associated with higher proportion of patients suffering TEATs compared with on-demand (RR 1.02, 95% CI 0.90-1.16, p = 0.72). Compared with placebo, PDE5-Is manifested significantly improved treatment outcomes. Overall, regular regimen demonstrated statistically pronounced better potency than on-demand. Coupled with the comparable rate of side effects, these findings support the regular delivery procedure to be a cost-effective option for patients.

[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.

Let’s rethinking about the safety of phosphodiesterase type 5 inhibitor in the patients with erectile dysfunction after radical prostatectomy

As the radical prostatectomy (RP) for the patient diagnosed as localized prostate cancer has been increasing, erectile dysfunction (ED) associated with RP is increased and ED after RP is a significant risk factor to reduce the quality of life for the patient after RP. Therefore, the treatment concept called penile rehabilitation was introduced and phosphodiesterase type 5 inhibitor (PDE5I) is used widely for the prostate cancer patient after RP. Generally PDE5I is considered as safe and effective drug for the prostate cancer patient after RP. Recently, a report against the general opinion that PDE5I use is safe in the patient with prostate cancer was reported and the analysis of 5-yr biochemical recurrence-free survival after RP between the PDE5I users and non-PDE5I users after bilateral nerve sparing RP showed decreased 5-yr biochemical recurrence-free survival in the PDE5I users. In addition, a longitudinal cohort study reported that sildenafil, a kind of PDE5I, use might be associated with the development of melanoma and this result suggested the possibility of adverse effect of PDE5I on some kinds of cancers as well as prostate cancer. Moreover, the studies to evaluate the influence of nitric oxide (NO) and guanosine monophosphate (cGMP) signaling pathway associated with PDE5 showed both cancer reduction and cancer development. Therefore, the role of NO and cGMP signaling pathway in cancer was reviewed based on the previous studies and suggested the necessity of further clinical studies concerning about the safety of PDE5I in prostate cancer.

Have rates of erectile dysfunction improved within the past 17 years after radical prostatectomy? A systematic analysis of the control arms of prospective randomized trials on penile rehabilitation

Based on case series, potency rates after radical prostatectomy (RPE) differ substantially and - furthermore - it remains unclear whether they have improved in more recent surgical series. The purpose of this study was to investigate whether potency rates after RPE have improved over the years. A systematic analysis of the control arms of all randomized controlled trials (RCT; n = 11) on penile rehabilitation after RPE was carried out. In total, 2009 patients were included in these RCTs, 685 thereof in the respective control arms, who were either observed or received placebo. Assessment of erectile function in these studies was carried out by the Sexual Encounter Profile (SEP) or the International Index of Erectile Function (IIEF). Eight trials used SEP3 as study endpoint. The rate of positive response to SEP3 (=erectile function sufficient for successful intercourse) in the control arms was 20% in 1997 (year of publication), 10% in 2003, 19% in 2004, 25% in 2008, 21% in 2010, 67% in 2011, 10% in 2013, and 22% in 2014. Eight RCTs assessed the IIEF-EF, yet results were not reported uniformly. In the control arms the IIEF-EF was 9.2 (year of publication 2003), 13.3 (2004), 8.8 (2008), 25% ≥22.0 (2008), 17.4 (2010), 58% ≥26.0 (2011), 9.3 (2013), and 11.6 (2014). Limitations of this analysis are a positive selection bias regarding patient recruitment, surgical approach, and the non-uniform inclusion and outcome criteria. This systematic analysis of the control arms of all RCTs on penile rehabilitation after nerve-sparing RPE shows (i) that the rate of undisturbed erectile function is in the range 20-25% in most studies and (ii) that these rates have not substantially improved or changed over the past 17 years.

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.

Effect of Tadalafil Once Daily on Penile Length Loss and Morning Erections in Patients After Bilateral Nerve-sparing Radical Prostatectomy: Results From a Randomized Controlled Trial

OBJECTIVE

To report penile integrity measures, including stretched penile length (SPL), from a randomized, double-blind, double-dummy, placebo-controlled trial evaluating treatment with tadalafil initiated after nerve-sparing radical prostatectomy (nsRP).

METHODS

Patients aged ≤ 68 years were randomized after nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg once daily (OaD), 20-mg tadalafil on-demand ("pro-re-nata"; PRN), or placebo, followed by 6-week drug-free washout and 3-month open-label OaD treatment. Secondary outcome measures included the change in SPL from pre-nsRP to the end of DBT (analysis of covariance adjusting for treatment, country, baseline, age, and nerve-sparing score), responses to Sexual Encounter Profile (SEP) questions 1-3 (mixed models for repeated measures adjusting for treatment, country, visit, visit-treatment-interaction, age), and Standardized Morning Erection Question (Cochran-Mantel-Haenszel test adjusted for age and country).

RESULTS

Four hundred twenty-three patients were randomized to tadalafil OaD (N = 139), tadalafil PRN (N = 143), and placebo (N = 141). Greater retainment of SPL was observed with tadalafil OaD vs placebo at the end of DBT (least-square mean [95% confidence interval] difference OaD vs placebo, 4.1 mm [0.4 to 7.8 mm]; P = .032). No significant effects on SPL were found for tadalafil PRN vs placebo, or for the nerve-sparing score. Penile tumescence (SEP1) and ability for vaginal insertion (SEP2) significantly improved vs placebo at the end of double-blind and open-label treatment for patients randomized to tadalafil OaD only. The ability for successful sexual intercourse (SEP3) significantly improved with tadalafil OaD vs placebo only during DBT. The distribution of Standardized Morning Erection Question responses was different at the end of DBT (P = .045); 34.2% of patients on tadalafil OaD, 50.0% on tadalafil PRN, and 56.5% on placebo reported absence of morning erections.

CONCLUSION

These data suggest the early initiation of tadalafil OaD protects from penile length loss and may contribute to protection from structural cavernosal changes after nsRP.

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.

Effects of tadalafil once daily or on demand versus placebo on time to recovery of erectile function in patients after bilateral nerve-sparing radical prostatectomy

Purpose

We report time to erectile function (EF)-recovery data from a multicenter, randomized, double-blind, double-dummy, placebo-controlled trial evaluating tadalafil started after bilateral nerve-sparing radical prostatectomy (nsRP).

Methods

Patients ≤68 years were randomized post-nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg once daily (OaD), 20 mg tadalafil on demand (“pro-re-nata”; PRN), or placebo, followed by 6-week drug-free washout (DFW) and 3-month open-label OaD treatment. Secondary outcome measures included Kaplan–Meier estimates of time to EF-recovery (IIEF-EF ≥ 22) during DBT (Cox proportional hazard model adjusting for treatment, age, and country).

Results

A total of 423 patients were randomized to tadalafil OaD (N = 139), PRN (N = 143), and placebo (N = 141); 114/122/155 completed DBT. The proportion of patients achieving IIEF-EF ≥22 at some point during DBT with OaD, PRN, and placebo was 29.5, 23.9, and 18.4 %, respectively. DBT was too short to achieve EF-recovery (IIEF-EF ≥ 22) in >50 % of patients; median time to EF-recovery was non-estimable. Time for 25 % of patients to achieve EF-recovery (95 % CI) was 5.8 (4.9, 9.2) months for OaD versus 9.0 (5.5, 9.2) and 9.3 (9.0, 9.9) months for PRN and placebo, respectively. Showing a significant overall treatment effect (p = 0.038), the probability for EF-recovery was significantly higher for OaD versus placebo [hazard ratio (HR); 95 % CI 1.9; 1.2, 3.1; p = 0.011], but not for PRN versus placebo (p = 0.140). Of 57 OaD patients (41.0 %) with ED improved (by ≥1 IIEF-EF severity grade) at the end of DBT, 16 (28.1 % of 57) maintained this improvement through DFW and 27 (47.4 %) declined but maintained improvement from baseline after DFW.

Conclusions

Data suggest that the use of tadalafil OaD can significantly shorten the time to EF-recovery post-nsRP compared with placebo.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-014-1377-3) contains supplementary material, which is available to authorized users.

American Cancer Society prostate cancer survivorship care guidelines

Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow-up care to address the myriad of long-term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow-up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow-up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long-term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility-specific and population databases.

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.

Systematic review and meta-analysis of the use of phosphodiesterase type 5 inhibitors for treatment of erectile dysfunction following bilateral nerve-sparing radical prostatectomy

Prostate cancer is relatively common cancer occurring in males. Radical prostatectomy (RP) is the most effective treatment for a localized tumor but erectile dysfunction (ED) is common complication, even when bilateral nerve-sparing RP (BNSRP) is performed. Clinical trials have shown varied effectiveness of phosphodiesterase type-5 inhibitors (PDE5-Is) for treatment of post-BNSRP ED, but there remains controversy over the application of this treatment and no formal systematic review and meta-analysis for the use of PDE5-Is for this condition has been conducted. This review was to systematically assess the efficacy and safety of oral PDE5-Is for post-BNSRP ED. A database search was conducted to identify randomized controlled trials (RCTs). The comparative efficacy of treatments was analyzed by fixed or random effect modeling. Erectile function was measured using the International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP) question-2, 3 and the Global Assessment Question (GAQ). The rate and incidence of adverse events (AEs) were determined. The quality of included studies was appraised using the Cochrane Collaboration bias appraisal tool. Eight RCTs were included in the analyses. PDE5-Is were effective for treating post-BNSRP ED compared to placebo when erectile function was determined using the IIEF score [mean difference (MD) 5.63, 95% confidence interval (CI) (4.26-6.99)], SEP-2 [relative risk (RR) 1.63, 95% CI (1.18-2.25) ], SEP-3 [RR 2.00, 95% CI (1.27-3.15) ] and GAQ [RR 3.35, 95% CI (2.68-4.67) ]. The subgroup analysis could find a trend that longer treatment duration, higher dosage, on-demand dosing, sildenafil and mild ED are associated with more responsiveness to PDE5-Is. PDE5-Is were overall well tolerated with headache being the most commonly reported AE. Our data provides compelling evidence for the use of PDE5-Is as a primary treatment for post-BNSRP ED. However, further studies are required to optomize usage parameters (such as dosage and duration of treatment).

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.

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.

The natural history of penile length after radical prostatectomy: a long-term prospective study

OBJECTIVE

To describe the penile length after radical prostatectomy (RP) in a long-term follow-up.

MATERIALS AND METHODS

We evaluated prospectively the penile length of 105 patients with localized prostate cancer treated by open RP. Participants using therapy for penile rehabilitation were excluded from statistical analysis. Measurements of the stretched penis were taken preoperatively and at 3, 6, 12, 24, 36, 48, and 60 months postoperatively. The International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaire was used to evaluate erectile function. The penile anthropometric measure used was the stretched length of the flaccid penis, from the pubopenile skin angle to the end of the glans, after the prepubic fat was depressed under maximum manual traction.

RESULTS

The mean stretched penile length 3 months after RP decreased an average of 1 cm from baseline (P <.001). This mean difference persisted until 24 months. At 36 months, the penile length differed 0.6 cm. At 48 months (-0.3 cm) and 60 months (+0.4 cm), the mean differences in penile length before and after RP were not significant (P = .080 and P = .065, respectively). Erectile function was a predictor for early return of penile length.

CONCLUSION

Nearly 1 cm of penile shortening after RP may be expected up to 12 months. However, a trend toward recovery of penile length occurs after 24 months of follow-up and is completely re-established after 48 months. The preserved erectile function after RP is a predictor for penile length recovery.