Erectile dysfunction following nerve-sparing radical retropubic prostatectomy and its treatment with sildenafil

BACKGROUND: We retrospectively evaluated the erectile function after nerve-sparing radical retropubic prostatectomy (RRP) and the efficacy of sildenafil for erectile dysfunction (ED) following RRP according to the preoperative erectile function. METHODS: We evaluated 48 Japanese patients who underwent nerve-sparing RRP at the Sapporo Medical University School of Medicine, Sapporo, Japan, between January 1996 and December 2001. Erectile function following nerve-sparing RRP was assessed by a simple mailed questionnaire that was constructed for the study. RESULTS: Of the 48 patients, 36 had normal erectile function preoperatively, but for 12, function was not sufficient to penetrate. The overall estimated recovery rates of any degree of erection were 50.6% at 36 months and 94.3% at 60 months. However, that of erection sufficient to penetrate was only 17.7% at 36 months and was only seen in bilateral nerve-sparing patients. Sildenafil was effective in 9 of 13 ED patients (69.2%) in both nerve-sparing groups. When patients were divided according to preoperative erectile function, no difference was found in the efficacy rate between patients with normal function and those with ED. CONCLUSIONS: Even bilateral nerve-sparing RRP can not always guarantee a sufficient erection. However, sildenafil is effective for ED following nerve-sparing RRP regardless of the nerve-sparing procedure or preoperative erectile function. Thus, preoperative function alone, although depending on its severity, may not necessarily be a reason for exclusion from receiving nerve-sparing RRP if patients want to have the operation.     

Erectile dysfunction after radical prostatectomy: the impact of nerve-sparing status and surgical approach

The core question of the study was whether the nerve-sparing status and surgical approach affected the patients' sexual life in the first year after surgery. In addition, determinants of erectile function (EF) and the extent of sexual activity were investigated. We conducted a multicentric, longitudinal study in seven German hospitals before, 3, 6 and 12 months after radical prostatectomy (RP). A total of 329 patients were asked to self-assess the symptoms associated with erectile dysfunction (ED). These symptoms were assessed using the International Index of Erectile Function and EORTC QLQ-PR25 questionnaires. A multiple regression model was used to test the influence of clinical, socio-demographic and quality-of-life-associated variables on the patients' EF 1 year after RP. Before surgery, 39% of patients had a severe ED (complete impotence). At 3, 6 and 12 months after surgery, it was 80, 79 and 71%, respectively. Although the surgical approach had no significant effect on EF, patients who had undergone nerve-sparing surgery had significantly lower ED rates. Nevertheless, 1 year after RP, 66% of these patients had severe ED. Age, nerve-sparing status and the burden of urinary symptoms had the greatest impact on the patients' EF. Regardless of nerve-sparing status and surgical approach, postsurgical improvement of EF does not mean a full convalescence of presurgical EF. Instead, it may rather reduce the degree of postsurgical ED in time. Consequently, urologists should disclose to the patient that ED is a likely side effect of RP.     

Use of combined intracorporal injection and a phosphodiesterase-5 inhibitor therapy for men with a suboptimal response to sildenafil and/or vardenafil monotherapy after radical retropubic prostatectomy

OBJECTIVE: To report experience with combined therapy using intracorporal injection (ICI) of alprostadil and oral phosphodiesterase 5 (PDE-5) inhibitors for the minimally invasive treatment of erectile dysfunction (ED) after radical prostatectomy (RP), as PDE-5 inhibitors are effective but a few patients may have a suboptimal response. PATIENTS AND METHODS: In a retrospective study, 34 men (aged 46-66 years) had a nerve-sparing retropubic RP and subsequent ED. Patients were titrated on sildenafil citrate or vardenafil to maximum doses. All had a suboptimal response after a maximum of eight doses of oral therapy and were then treated with ICI therapy using 15 or 20 microg alprostadil. Erectile function was assessed with the Sexual Health Inventory for Men (SHIM). RESULTS: Of the 32 patients who continued combined therapy, 22 (68%) had an improvement in erectile function after ICI therapy, as assessed by the SHIM score. On follow-up, 36% of these patients used ICI therapy only intermittently, instead of regularly, as they felt that this was adequate enough for good results. CONCLUSIONS: PDE-5 oral pharmacotherapy is the most commonly used effective therapy for ED but may not be as effective in patients who have radical surgery; the addition of testosterone patches may have side-effects or be considered a risk in patients with a history of prostate cancer. The use of ICI therapy as an adjunct or maintenance therapy to their oral medication may be another alternative in these patients.     

Nerve injury-related erectile dysfunction following nerve-sparing radical prostatectomy: A novel experimental dissection model

Objectives:   To establish a new experimental rat model in order to define the mechanisms of erectile dysfunction (ED) and to evaluate the changes of neuronal nitric oxide synthase (nNOS) in the pelvic ganglia following nerve-sparing radical prostatectomy.
Methods:   Sprague-Dawley rats were randomized to sham operation, bilateral cavernous nerve dissection (BCND) and bilateral cavernous nerve resection (BCNR) groups. In the BCND group, the cavernous nerves were only dissected bilaterally from the major pelvic ganglion (MPG) to the apex of the prostate without crushing or cutting. At 1, 2, 4 and 8 weeks after surgery, we examined intracavernous pressure along with arterial pressure (ICP/AP), retrograde dye tracing using Fluorogold (FG) and expression of nNOS in the MPG.
Results:   Intracavernous pressure and arterial pressure in the BCND group was significantly decreased at 2 and 4 weeks after surgery compared with the sham group, and improved at 8 weeks. The number of FG-positive cells in the MPG also recovered at 8 weeks. ICP/AP and FG-positive cells in the BCNR group were greatly decreased until 8 weeks. The percentage of nNOS-positive cells per total cells was not different between the sham and BCND groups during the experimental period, whereas that in the BCNR group gradually decreased with time.
Conclusions:   We established a novel rat model, in which cavernous nerve dissection alone caused nerve injury-related ED. We believe that this cavernous nerve dissection model might help clarify the mechanism of nerve injury-related ED and the recovery from ED after nerve-sparing radical prostatectomy.     

Technical advances in radical retropubic prostatectomy techniques for avoiding complications. Part II: vesico-urethral anastomosis and nerve-sparing prostatectomy

We previously reviewed different technical modifications and improvements in apical dissection in radical retropubic prostatectomy which have a considerable effect in optimizing the results. This second paper focuses on the vesico-urethral anastomosis and aspects of nerve-sparing prostatectomy.     

Comparative evaluation of treatments for erectile dysfunction in patients with prostate cancer after radical retropubic prostatectomy.

OBJECTIVE: To assess the effectiveness of a progressive local treatment protocol for erectile dysfunction (ED) in patients after undergoing radical retropubic prostatectomy (RRP) for prostate cancer. PATIENTS AND METHODS: The study included 85 patients (mean age 59.5 years, range 50--75) with ED after RRP. Treatment was offered in four progressive phases, with patients passing to the next phase only if they failed the previous one: in phase I patients used a vacuum erection device; in phase II, sildenafil; in phase III, intracorporal injection; and in phase IV, intracorporal injection plus the vacuum erection device. The patients were followed for 1 year. RESULTS: Of the 85 patients, 78 (92%) responded to the vacuum erection device (with an erection sufficient for vaginal penetration), but only 11 (14%) agreed to continue with it at home. Of the remaining 74 patients, 69 with no contraindications were given sildenafil and 14 (20%) had a positive response. Sixty patients were then treated with intracorporal injection and 51 (85%) had a positive response; four of the nine failures in phase III responded to intracorporal injection plus vacuum therapy. Five patients failed all four protocols. After 1 year of follow-up, 76 of the 80 patients were successfully continuing treatment at home; seven (9%) used the vacuum erection device, 11 (14%) sildenafil, 54 (71%) intracorporal injection and four (5%) intracorporal injection plus the vacuum erection device. CONCLUSION: Overall, this progressive treatment method gave a positive response in 80 of the 85 patients (94%). After 1 year of follow-up, 76 of the 80 patients (95%) continued to respond well. Of all the methods used, intracorporal injection was the most effective for ED after RRP.     

Erectile dysfunction： on the efficacy of a phosphodiester~ inhibitor with concurrent sex therapy

Erectile dysfunction (ED) is a condition that affectsperhaps 25 to 30 million men in the U, S.A. constitutingone of the most significant concerns of sex therapists fromvarious disciplines. Depending on age, 10 to 52 percentof all men can be expected to experience at least tempo-rary ED during their lifetime.     

Erectile dysfunction and sexual health after radical prostatectomy: impact of sexual motivation

The life expectancy of patients with localized prostate cancer at treatment initiation has increased, and post-treatment quality of life has become a key issue. The aim of this study is to assess the impact of Radical prostatectomy (RP) on patients' sexual health and satisfaction according to sexual motivation using a self-administered questionnaire completed by two groups of RP patients, with high or lower levels of sexual motivation. A total of 63 consecutive patients were included (mean age, 63.9 years), of whom 74.6% were being treated for erectile dysfunction (ED). After RP, patients reported lower sexual desire (52.4%), reduced intercourse frequency (79.4%), anorgasmia (39.7%), less satisfying orgasm (38.1%), climacturia (25.4%), greater distress (68.3%) and/or lower partner satisfaction (56.5%). Among the most sexually motivated patients, 76.0% reported loss of masculine identity, 52% loss of self-esteem and 36.0% anxiety about performance. These rates were lower among less motivated patients (52.6, 28.9, and 18.4%, respectively). Mean overall satisfaction score was 4.8 ± 2.9. The score was significantly lowered in motivated than less motivated patients (3.4 vs 5.8) (P = 0.001). In conclusion, RP adversely affected erectile and orgasmic functions but also sexual desire, self-esteem and masculinity. The more motivated patients experienced greater distress and were less satisfied.     

Efficacy of phosphodiesterase type 5 inhibitors in patients with erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis

BackgroundNerve-sparing radical prostatectomy (NSRP) had to be performed because approximately 94% of patients are diagnosed with localized prostate cancer (PCa). Although NSRP is generally done to improve functional outcomes, erectile dysfunction (ED) is one of the most prevailing complications after radical prostatectomy (RP). Phosphodiesterase type 5 inhibitors (PDE5-Is) are the most well-known treatment agent for postoperative ED. This study aimed to assess the efficacy of PDE5-Is in patients with ED after NSRP.MethodsIn this systematic literature review, randomized controlled trials on the efficacy and safety of PDE5-Is in patients who underwent NSRP were searched in MEDLINE, EMBASE, and the Cochrane Controlled Trials Register using the OVID platform. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Review Methods. The quality of the evidence of the outcome data was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.ResultsA total of 14 trials involving 2,822 patients were included. Significant improvements in the International Index of Erectile Function—Erectile Function (IIEF) domain score [mean difference (MD) =4.93; 95% confidence interval (CI): 4.14–5.71; P<0.00001] and erectile function recovery events [odds ratio (OR) =2.06; 95% CI: 1.45–2.94; P<0.0001] were observed after PDE5-I treatment. A higher positive response to Sexual Encounter Profile (SEP) question 2 (OR =2.27; 95% CI: 1.80–2.86; P<0.00001) and question 3 (OR =2.78; 95% CI: 1.97–3.91; P<0.00001) was also found after PDE5-I treatment. However, the incidence of treatment-emergent adverse events (TEAEs) was higher after PDE5-I treatment than after placebo treatment (OR =2.91; 95% CI: 1.84–4.61). Furthermore, the incidence of headache (OR =3.38; 95% CI: 2.40–4.75) and flushing (OR =9.44; 95% CI: 4.30–20.70) was also significantly higher after PDE5-I treatment (P<0.00001). In terms of the quality of the evidence of the outcome data, inconsistency problems were detected in all outcomes and imprecision problems in most outcomes.DiscussionPDE5-I treatment was more effective to placebo treatment in patients with ED after NSRP. No clinically serious complications were found in spite of the incidence of TEAEs being higher after PDE5-I treatment.     

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

Four weeks after bilateral nerve-sparing radical retropubic prostatectomy, men with normal erectile function before surgery were randomized to double-blind sildenafil (50 or 100 mg) or placebo nightly for 36 weeks, followed by an 8-week drug-free period before assessment of erectile function. Enrollment was prematurely ceased and only 76 men completed because, assuming a placebo response rate similar to the published literature (for example, 34% in meta-analysis), the 25% response at blinded interim review suggested a lack of treatment effect. On the contrary, spontaneous erectile function (a combined score of >or=8 for questions 3 and 4 of the International Index of Erectile Function and a positive response to 'Were erections good enough for satisfactory sexual activity?') occurred in only 4% of the placebo group (n=1 of 25) versus 27% (n=14 of 51, P=0.0156, Fisher's exact test) of the sildenafil group. Nightly sildenafil administration for 36 weeks after surgery markedly increased the return of normal spontaneous erections.     

Long-term efficacy and compliance of MUSE for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis

Baseline and follow-up data of 54 patients from a single surgical series (1998-2001), who used medicated urethral system for erection (MUSE) for the erectile dysfunction (ED) associated with radical prostatectomy (RP), were obtained. Patients were surveyed using the abridged five-item version of the International Index of Erectile Function (IIEF) questionnaire, commonly referred to as the Sexual Health Inventory of Men (SHIM), to determine presence and severity of ED and efficacy of ED treatment modalities. The mean patient age was 63.7+/-5.6 y and the mean follow-up period was 2.3+/-1.2 y. All patients experienced ED for at least 6 months after their surgery before starting MUSE therapy. Overall, 55% of the patients achieved and maintained erections sufficient for sexual intercourse while on MUSE and 48% continued long-term therapy with a mean use of 2.32+/-1.2 y. The mean presurgery SHIM score in these patients was 19.2+/-1.3, which decreased to 5.2+/-0.5 after surgery and increased to 16.3+/-1.3 after MUSE treatment. A total of 28 patients (52%) discontinued treatment after a mean use of 8+/-1.4 months. The reasons for discontinuation were insufficient erections (n = 16, mean SHIM score of 10.5+/-4.4), switch to other ED therapies (n = 4), natural return of erections (n = 4) and urethral pain and burning (n = 4). Excluding the patients (n = 8) who preferred other therapies and return of natural erections, the compliance to MUSE was 63%. There were no significant differences in the IIEF-5 responses between the patients who had a nerve-sparing technique (n=34) and those who did not (n = 20) or among patients who used different doses (250, 500 or 1000 microg) of MUSE. The results of the current trial indicate that MUSE is a successful treatment option in RP patients with established ED. It appears that a post-treatment SHIM score of > or = 16 defines a successful outcome with MUSE therapy.     

Current and future strategies for preventing and managing erectile dysfunction following radical prostatectomy

INTRODUCTION AND OBJECTIVES: As radical prostatectomy remains a commonly used procedure in the treatment of clinically localized prostate cancer, we critically analyzed current and future strategies for preventing and managing postoperative erectile dysfunction. METHODS: Systematic literature review using Medline and CancerLit from January 1997 to June 2003. Abstracts published in the journals European Urology, The Journal of Urology and the International Journal of Impotence Research as official proceedings of internationally known scientific societies held in the same time period were also assessed. RESULTS: Patient selection and surgical technique are the major determinants of postoperative erectile function. Apoptosis of corporeal smooth muscle cells plays a role in the development of cavernous veno-occlusive dysfunction following radical prostatectomy. Pharmacological prophylaxis and treatment of postoperative erectile dysfunction is effective and safe. The concepts of cavernous nerve reconstruction and neuroprotection have been associated to promising results. CONCLUSIONS: In the hands of experienced surgeons, properly selected patients undergoing a nerve sparing radical prostatectomy should achieve unassisted or medically assisted erections postoperatively.     

Case report: a novel and easy technique to remove stitched urethral foley catheter after radical retropubic prostatectomy

The inability to remove a urethral catheter because of inadvertent stitching or entrapped sutures after radical retropubic prostatectomy is rarely reported in the literature. Various methods are recommended to solve this problem. Here, we discuss a method developed by using a pediatric optical urethrotome to remove endoscopically a Foley urethral catheter that was encircled by a vesicouretheral anastomotic suture.     

Early recovery of urinary continence after laparoscopic versus retropubic radical prostatectomy: evaluation of preoperative erectile function and nerve-sparing procedure as predictors

The aim of this study was to evaluate preoperative erectile function and attempted nerve-sparing procedure as predictors for early recovery of urinary continence after retropubic and laparoscopic radical prostatectomy. Patients were divided into two groups according to surgical approach (retropubic or laparoscopic) and learning curve for laparoscopic approach: group 1—retropubic approach (37 patients operated on from April 2000 to June 2006), group 2—laparoscopic approach (109 patients operated on from April 2003 to June 2006). We assessed state of urinary continence at 1, 3, 6, and 12 months after removal of the urinary catheter. Overall rates of urinary continence were 18%, 49%, 68%, and 80% at 1, 3, 6, and 12 months, respectively. Between groups 1 and 2, no statistically significant differences in recovery of urinary continence were evident, being 27% versus 15% at 1 month, 54% versus 47% at 3 months, 77% versus 65% at 6 months, and 91% versus 77% at 12 months in groups 1 and 2, respectively. An attempted nerve-sparing procedure (one or both neurovascular bundles) was statistically associated with urinary continence at 3 month, and International Index of Erectile Function-5 (IIEF-5) score (≥14) was identified as a significant factor predicting urinary continence at 6 months after laparoscopic radical prostatectomy. Younger age tended to result in early recovery of urinary continence after retropubic radical prostatectomy.