Management of erectile dysfunction following radical prostatectomy

Abstract

Radical prostatectomy is the standard treatment for organ/specimen-confined prostate cancer, yet erectile dysfunction in selected series is still reported as high as 90% after this procedure. Thus, most men need adjuvant treatments to be sexually active following radical prostatectomy. These include vacuum constriction devices, intracorporeal injections of vasoactive drugs, and transurethral dilators, all of which have reported response rates of 50% to 70%. Unfortunately, long-term compliance is suboptimal, with a discontinuation rate of nearly 50% at one year. These non-oral options should be offered on an individual basis to patients who have failed oral therapy since efficacy and compliance vary. Also, these options should be considered in the early postoperative period to enhance sexual activity and penile oxygenation, which may prevent corporeal fibrosis. Early penile rehabilitation with intracavernosal injections or vacuum constriction devices should be encouraged to increase chances for recovery of rigid erections. In patients with some preservation of nerve tissue, oral sildenafil may be effective in promoting an earlier return of erectile function. The potential impact of sildenafil and other new oral therapies should encourage urologists to continue to perform and perfect the nerve-sparing approach.

Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function

“…7,8,10 In our early penile rehabilitation program, the VCD was the preferred erectile aid. The advantage of VCD is that the erections produced are independent of endogenous vasoactive substance such as nitric oxide (NO) production, which is impaired by nerve damage.…”

“…With this approach, the integrity of the cavernous tissues may be maintained, which can potentially prevent cavernous tissue fibrosis from precluding the return of spontaneous erections or decreasing the response to erectile aids. [7][8][9] Vacuum constriction devices (VCD) have been successfully used in a variety of patients with organic ED. 10 Its use included those patients treated for prostate carcinoma with either RP or radiation therapy.…”

“…10 Its use included those patients treated for prostate carcinoma with either RP or radiation therapy. 7,8,10,11 Colombo et al 12 found that their patients who practiced early application of VCD without the constrictive band to produce 'stretching' for the smooth muscle fibers showed significant improvement of spontaneous erectile ability.…”

Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy

“…1 ED after prostatectomy is generally treated symptomatically, as needed when intercourse is anticipated. 5,6 However, early regular use of intracavernosal alprostadil injections, in an uncontrolled study, has been shown to improve the recovery rate of spontaneous erections after nerve-sparing radical retropubic prostatectomy. 7 Despite this benefit, pain, complications and inconvenience detract from the willingness of patients to use intracavernosal injections regularly.…”

The role of vacuum erection devices in penile rehabilitation after radical prostatectomy

“…10,11 Provoking an artificial erection during this time is thought to minimize cavernous tissue fibrosis, leading to potentially improved erection quality or decreased need for supplemental agents. These early observations have led to the development of post-RP penile rehabilitation protocols that employ various combinations of oral [12][13][14] and intercavernosal agents, 15 as well as the vacuum erection device (VED). 16,17 Given recent advances in surgical technique, it is logical that careful examination should be dedicated to the establishment and validation of a post-RP protocol that improves EF outcomes.…”