The Efficacy and Safety of Tadalafil 5 mg Once Daily in the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: 1-Year Follow-up

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Role of application of tadalafil 5 mg once-daily (≥6 months) in men with erectile dysfunction from six randomized controlled trials

This meta-analysis was performed to assess the efficacy and safety of taking tadalafil 5 mg once-daily for at least 6 months in the treatment of erectile dysfunction (ED). Based on databases: MEDLINE, EMBASE and Cochrane Controlled Trials Register, this analysis was performed to collect randomized controlled trials (RCTs) of tadalafil 5mg once-daily in treating ED over 6 months. Reviewers also investigated the references of each literature. The meta-analysis covered a total of 1,596 patients in six RCTs. The tadalafil group performed a better effect in terms of the international index of erectile function-erectile function (IIEF) domain (P=0.005) for the treatment of ED compared with the placebo group. Safety assessments including discontinuations due to adverse events (AEs) (P=0.31) and treatment-emergent AEs (P=0.06) indicated that the tadalafil group had a better tolerate. The analysis elucidates that the dose of 5 mg per day of tadalafil showed a good effect after the treatment of at least 6 months relative to the control group with fewer side effects.

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.

Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up

BACKGROUND

Although nerve-sparing robot-assisted radical prostatectomy (NS-RALP) is performed, a large number of patients still experience erectile dysfunction (ED) after surgery.

AIM

To evaluate the efficacy and safety of tadalafil 5 mg once daily (OaD) in ED treatment over 2 years and investigate the cause of vascular ED after NS-RARP.

METHODS

We retrospectively evaluated 95 men who underwent NS-RARP and had a penile rehabilitation treatment with tadalafil 5 mg OaD. They were classified into 3 groups: tadalafil 5 mg OaD for 2 years (group I), tadalafil 5 mg OaD for 1 year (group II), and no tadalafil (group III). All patients in group I underwent penile color duplex ultrasound to evaluate the cause of vascular ED.

OUTCOMES

Patients were surveyed using the abridged 5-item International Index of Erectile Function (IIEF-5).

RESULTS

Statistically significant improvements were observed in group I for all IIEF-5 domain scores (P = .000). There was no statistically significant difference in recovery of erectile function (EF) the 2-year follow-up between groups I and II. Sub-analysis based on NS status showed no difference in recovery of EF. However, group I showed better trends in EF improvement. Those with venogenic ED had poor responses compared with those with arteriogenic ED or unremarkable findings with tadalafil 5-mg OaD treatment (14.2% vs 55.0% vs 53.3%). The overall side effects included hot flushing in 9.5%, headache in 7.1%, and dizziness in 2.3% of patients.

CLINICAL IMPLICATIONS

Long-term usage of tadalafil 5 mg OaD after RARP can be an effective option for penile rehabilitation.

STRENGTHS AND LIMITATIONS

The present study is a retrospective study with a relatively small sample.

CONCLUSIONS

Although the responses of patients with venogenic ED were limited compared with those with arteriogenic ED, tadalafil 5-mg OaD treatment was well tolerated and significantly improved EF up to 2 years after NS-RARP. Kim S, Sung GT. Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up. Sex Med 2018;6:108-114.

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.

Efficacy and safety of short- and long-term, regular and on-demand regimens of phosphodiesterase type 5 inhibitors in treating erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis

Background

We performed a meta-analysis to evaluate the efficacy and safety of short-term (≤6 months) and long-term (>6 months), regular (OaD) and on-demand (PRN) regimens of phosphodiesterase type 5 inhibitors (PDE5-Is) in treating erectile dysfunction (ED) after nerve-sparing radical prostatectomy (NSRP).

Methods

We conducted a literature search in August 2016. Sources included PubMed, EMBASE, and MEDLINE databases. The main outcome was International Index of Erectile Function-Erectile Function (IIEF-EF) domain score, and the secondary outcome was treatment-emergent adverse events (TEAEs).

Results

Eight articles involving 13 randomized controlled trials (RCTs) were used in this analysis: they suggested that PDE5-Is can improve the IIEF-EF distinctly in comparison with placebo in short and long term (mean difference [MD]: 2.26, 95% confidence interval [CI]: 1.45–3.08, P<0.00001, and MD: 4.5, 95% CI: 3.6–5.4, P<0.00001), and long-term use of PDE5-Is (>6 months) can improve the IIEF-EF distinctly in comparison with short-term use of PDE5-Is (≤6 months) (MD: 3.9, 95% CI: 3.01–4.8, P<0.00001). OaD of PDE5-Is significantly improved the IIEF-EF compared to placebo in short and long term (MD: 4.08, 95% CI: 3.2–4.97, P<0.00001, and MD: 4.74, 95% CI: 3.79–5.69, P<0.00001). No significant differences were found in IIEF-EF changes between PRN and placebo (≤6 months) (MD: 2.64, 95% CI: −0.87 to 6.14, P=0.14), and between PRN and OaD group (>6 months) (MD: −0.58, 95% CI: −9.86 to 8.74, P=0.91). There were more TEAEs in PDE5-Is group in comparison with placebo (odds ratio [OR]: 1.55, 95% CI: 1.26–1.91, P<0.0001), and TEAEs in OaD group were not significantly different from those seen in PRN group (OR: 1.05, 95% CI: 0.78–1.4, P=0.77).

Conclusion

Our meta-analysis suggests that PDE5-Is are efficient and safe for treatment of ED after NSRP, and we should choose the regular regimen for short term and regular or on-demand regimen for long term. Further high-quality RCTs are needed to validate this result.

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.

Erectile function post robotic radical prostatectomy: technical tips to improve outcomes?

Robotic surgery is becoming more and more commonplace. At the same time, so are complications, especially related to erectile function. The population being diagnosed with cancer is younger, with more aggressive cancers and higher expectations for good erectile function postoperatively. We conduct a retrospective analysis of literature over 20 years for Embase and Medline. Search terms used include (Robotic) AND (prostatectomy) AND (erectile function). There are a variety of multifactorial causes, resulting in worsening ED post-robotic radical prostatectomy; however, there are a number of treatments that can support this. There is much we can do to help prevent patients getting postoperative erectile dysfunction post-radical surgery. However, part of this is management of realistic patient expectations.

Tadalafil therapy for erectile dysfunction following prostatectomy

Erectile dysfunction is a major complication affecting the quality of life of patients and partners after radical prostatectomy. Evolving evidence suggests that early penile rehabilitation may provide better erectile function after surgery. Phosphodiesterase type 5 (PDE-5) inhibitors are routinely considered a first-line treatment option in most algorithms for penile rehabilitation owing to their efficacy, ease of use, wide availability and minimal morbidity. Tadalafil is a long-acting, potent PDE-5 inhibitor for erectile dysfunction, with demonstrated effect in animal studies at preserving penile smooth muscle content and prevention of fibrosis of cavernosal tissue. This article evaluates the existing literature on tadalafil and critically analyzes its impact on erectile function following radical prostatectomy.

Efficacy and safety of phosphodiesterase type 5 (PDE5) inhibitors in treating erectile dysfunction after bilateral nerve-sparing radical prostatectomy

We carried out a systematic review and meta-analysis to assess the efficacy and safety of phosphodiesterase type 5 (PDE5) inhibitors for treating erectile dysfunction (ED) after bilateral nerve-sparing radical prostatectomy (BNSRP). A literature review was performed to identify all published randomised double-blind, placebo-controlled trials of PDE5 inhibitors for the treatment of ED after BNSRP. The search included the following databases: MEDLINE, EMBASE and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated. Six publications involving a total of 1678 patients were used in the analysis, including six RCTs that compared PDE5 inhibitors (tadalafil, sildenafil, avanafil and vardenafil) with placebo. Co-primary efficacy end points: International Index of Erectile Function-Erectile Function (IIEF-EF) domain score [the standardised mean difference (SMD) = 4.04, 95% confidence interval (CI) = 2.87-5.22, P < 0.00001]; successful vaginal penetration (SEP2) [the odds ratio (OR) = 14.87, 95%CI = 4.57-48.37, P < 0.00001]; and successful intercourse (SEP3) (OR = 47, 95%CI = 3-13.98, P < 0.00001) indicated that PDE5 inhibitors was more effective than the placebo. Specific adverse events with PDE5 inhibitors included headache (12.08%), dyspepsia (6.76%) and flushing (6.52%), which were significantly less likely to occur with placebo. This meta-analysis indicates that PDE5 inhibitors to be an effective and well-tolerated treatment for ED after BNSRP.

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.