Penile rehabilitation following treatment for prostate cancer: an analysis of the current state of the art

Abstract

Despite recent advances in surgical technique using laparoscopic and robotic approaches for the management of early organconfined prostate cancer, most contemporary reports demonstrate significant rates of erectile dysfunction comparable to standard open approaches. Controversy remains related to many of the preand postoperative management strategies, including agents to enhance nerve recovery, erectogenic drugs, antioxidants, vasoactive injectables, vacuum erection devices and nerve grafting procedures. Additionally, the optimal timing of these interventions and their duration, dose, frequency and outcome thresholds remain ill-defined. In our paper, we provide a comprehensive literature review involving both the basic and clinical data surrounding rehabilitative approaches. RésuméMalgré des avancées récentes dans les techniques chirurgicales utilisant la laparoscopie et la robotique pour la prise en charge du cancer de la prostate au stade précoce, la majorité des rapports récents font état de taux significatifs de dysfonction érectile se comparant aux taux associés aux approches ouvertes standard. Bon nombre des stratégies de traitement préopératoires et postopératoires, comme les agents favorisant la récupération nerveuse, les médicaments érec-togènes, les antioxydants, les agents vasoactifs injectables, les pompes péniennes et les greffes de nerfs, font toujours l'objet de controverses. Par ailleurs, le moment optimal pour effectuer ces interventions, la durée de ces dernières, la dose, la fréquence et le seuil d'évaluation des résultats demeurent encore bien mal défi-nis. Cet article de synthèse présente une revue approfondie de la littérature comprenant les données de recherche fondamentale et les données cliniques concernant les approches de réadaptation.going surgery and are thus expressing concern about preservation of erectile function after the procedure, a fact that is true for older men as well. Since Walsh and Donker 4 published their landmark article describing the etiology and prevention of impotence following retropubic RP in 1982, the nerve-sparing technique they described is widely employed and believed to improve postoperative erectile function. 5 Furthermore, there continue to be modifications to the nervesparing technique in an attempt to minimize nerve compromise and improve postoperative potency, as reported by Chuang and coauthors 6 and Masterson and colleagues. 7 However, optimal sexual functioning often requires 18 to 42 months to return, even among men in whom bilateral nerve sparing was performed, with reported recovery rates varying from 16% to 86%. 8,9 Sexual dysfunction has been reported to be an independent determinant of a poorer general health-related quality of life at 2 years after primary treatment for prostate cancer. 10 Recent advances in the understanding of the pathophysiology of postprostatectomy erectile dysfunction (PED) have stimulated great attention directed toward the concept of penile rehabilitation, in which prophylactic measures are instituted to prom...

A national study of adverse effects and global quality of life among candidates for curative treatment for prostate cancer

“…Response shift reflects the gradual acceptance of treatment-related AEs and change of expectations as to global QoL. Based on our results we speculate that response shift related to low global QoL develops less easily with regard to irritative-obstructive urinary symptoms and poor sexual [37], early and more frequent post-treatment management of ED is challenging, also after RAD. About half of 'ever-users' report that they had not used EDmed within the 4 weeks before the survey which may indicate that today's EDmed is not effective for many of these patients.…”

“…Both explanations are probably relevant. With today's knowledge of the importance of early activation of nervous pathways responsible for erectile function , early and more frequent post‐treatment management of ED is challenging, also after RAD. About half of ‘ever‐users’ report that they had not used EDmed within the 4 weeks before the survey which may indicate that today's EDmed is not effective for many of these patients.…”

A randomised, double‐blind, placebo‐controlled trial of nightly sildenafil citrate to preserve erectile function after radiation treatment for prostate cancer

“…13,26,[43][44][45][46] Conflicting results have appeared recently from a large, multicentre RCT that compared placebo, 'on demand' vardenfil and nightly vardenfil. 48 More recent nonrandomised studies have examined the efficacy of combining two therapies (e.g. 47 Past studies have concentrated on examining the efficacy of single interventions including; PDE5-Is, intracavernosal self-injection, intraurethral prostaglandin and vacuum constrictive devices (VCDs) -all with varying degrees of success.…”

Optimizing sexual function outcomes after radical prostatectomy

“…Al Shaiji and colleagues 4 have reported a well-balanced contemporary review of "penile rehabilitation" concepts and contemporary strategies to optimize recovery of sexual function. However, it is clear there remains a significant gap between pathophysiology and treatment.…”

“…Clinically, the data are incomplete but compelling with ample basic science evidence for beneficial effects of phosphodiesterase type 5 (PDE5) inhibitors and intracavernous injections in this population. Al Shaiji and colleagues 4 have correctly emphasized the need to identify patient goals and provide an overview of the ever-evolving literature and its limitations. If considering penile rehabilitation, early initiation is likely best, given the time-dependent penile changes that occur after surgery.…”