Current therapeutic strategies for erectile function recovery after radical prostatectomy – literature review and meta-analysis

Abstract

Radical prostatectomy is the most commonly performed treatment option for localised prostate cancer. In the last decades the surgical technique has been improved and modified in order to satisfy both oncological safety and postoperative functional results. Urinary incontinence and erectile dysfunction (ED) are the main postoperative functional impairments in patients that undergo radical prostatectomy (RP). [1] According to the EAU Guidelines erectile dysfunction is defined as “the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance”. To this moment it is estimated that 25-75% of the patients who underwent RP develop ED with major implications in postoperative quality of life. [2] Various risk factors can be related to post-prostatectomy ED, among which the most important are the patient’s age, comorbidities, preoperative erectile function, but also surgical approach (robot-assisted, laparoscopic, open) and nerve-sparing technique (inter/intrafascial). [2, 3] Among physiopathological modifications that concur to ED, the nerve damage (neuropraxia) appears to be the main domino piece that triggers other alterations like structural changes of the smooth muscle, arterial damage and veno-oclusive dysfunction which lead to cavernosal oxygenation impairments. [4–6] The clinical results of physiopathological alterations are shortening of penile size, impairment of orgasm and ejaculation achievement which have tremendous impact on psychological and mental health. [5] Various treatment options include oral medication with phosphodiesterase 5 inhibitors (PDE5i), intracavernosal injections or intraurethral applications of prostaglandin E1 (PGE1), vacuum or vibratory treatments. Though there are many options for ED treatment, to this date there is no definitive protocol for penile rehabilitation (PR) after prostatectomy. [5, 7] In this regard we have made a literature review and meta-analysis of the most important randomised trials published in the last 5 years in order to find the best strategies of penile rehabilitation after radical prostatectomy. MATERIALS AND METHODS We have systematically reviewed and collected data from randomised trials published in the last 5 years involving patients diagnosed with prostate cancer who experienced ED after radical prostatectomy. In order to find the necessary trials we have searched PubMed and ScienceDirect databases and used several key words like: erectile dysfunction, penile rehabilitation, phosphodiesterase 5 inhibitors, erectile functional recovery, prostate cancer, prostatectomy and nerve sparing – in various combinations. The first aspect for our meta-analysis inclusion criteria was to identify randomized (prospective or retrospective) placebo-controlled trials involving patients with localised prostate cancer that benefited of nerve sparing radical prostatectomy and developed postoperative ED. The key aspect of our research was the penile rehabilitation strategy which included the therapeutic means used for erectile 1 Dimitrie Gerota Emergency Hospital, Bucharest, Romania 2 Dr. Carol Davila University Central Emergency Military Hospital, Bucharest, Romania 3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 10 function recovery and the treatment duration. Other aspects followed by us regarded the means of ED assessment, the surgical means and invasiveness and the rate of treatment success reported to ED severity. In this regard we have conducted our research for each year between January 2014 and December 2018 and reviewed a total of 631 articles published on this theme collected from both search engines. For a time-efficient assessment we have read the title and abstract of each article and included only those articles that matched our criteria. We have excluded the reviews and meta-analyses and also the trials of ED that was not related to prostate cancer surgery. That left us 194 publications from which to select