A Guide to Erectile Preservation After Radical Prostatectomy
A Guide to Erectile Preservation After Radical Prostatectomy
Radical prostatectomy (RP) is a commonly performed procedure for the management of prostate cancer. While documented oncologic outcome for early stage disease is excellent, functional impairments such as incontinence and erectile dysfunction (ED) are common after the procedure. Recent evidence has implicated cavernous nerve damage and subsequent corporal oxygen deprivation, as well as corporal inflammation, in the pathogenesis of post-RP ED. Targeted therapies such as oral phosphodiesterase-5 inhibitors, mechanical vacuum erection devices, local alprostadil delivery and testosterone replacement (for hypogonal patients) have demonstrated some efficacy in the management of post-RP ED. This review aggregates much of the recent data in support of these therapies and critically reviews them. The article then presents tools to assess patients and partner sexual function to aid in identifying and monitoring post-RP ED. Finally, the article describes a protocol in use at Baylor College of Medicine as a guide toward the development of a protocol for erectile preservation (EP). The purpose of this work is to educate clinicians on emerging concepts in EP and provide an implementable protocol for use in practice.
Prostate cancer, the most common non-dermatological malignancy in men in the United States with an annual incidence of approximately 220 000, is responsible for almost 30% of cancer diagnoses and 9% of cancer-related mortality in US men. Definitive therapeutic strategies include radical prostatectomy (RP) and radiation therapy. The number of RPs performed per annum is estimated at 110 000 in the United States alone. Recent advances in screening and early detection of prostate cancer have yielded excellent oncologic outcomes for low-risk patients and shifted the focus of surgeons to enhance functional outcomes for patients undergoing RP. Such functional outcomes include recovery of urinary continence and erectile function.
While several factors influence post-RP erectile function recovery, pre-operative erectile function and nerve sparing (NS) status are critical predictors. Tal and coworkers identified the aggregate recovery rate of erectile function after surgery at approximately 60%. Even within this fraction of patients, a large variability in the quality of erections likely exists because of the subjective nature of assigning a binary response to the presence of satisfactory function.
In general, erectile dysfunction (ED) and reduced sexual satisfaction have a negative impact on quality of life. Various studies assessing the efficacy of interventions to treat ED include quality of life measures as secondary outcomes. Importantly, studies have consistently indicated that erectile function correlates with favorable quality of life outcomes in patients. Perhaps an even higher impact observation is that the quality of erectile function correlates with emotional well being.
Interestingly, data regarding management of patients after RP remain fragmented and inconsistent. A study of French urologist's suggests that only a minority actually provide formal post-RP therapy directed at sexual function outcomes. The questionnaire-based study found that only 38% of urologists prescribed a systematic program for patients despite the fact that the overwhelming fraction of urologists assesses pre-RP sexual function. The most commonly used therapy was injection based, perhaps suggesting that other effective modalities for post-RP therapy would shift this dynamic. Physicians familiar with sexual medicine as a discipline are more likely to implement post-RP therapy targeted at preservation of erectile function, supporting the role for increased awareness of this concept.
Given the impact of RP on erectile function, it is prudent for physicians to implement strategies related to minimizing and reversing post-RP ED. This requires both a thorough understanding of the pathogenesis of post-RP ED and the role of various therapies to mechanistically impact the process. Clinically, physicians require treatment strategies and assessment tools to capture response and satisfaction. This review article attempts to synthesize the literature on the various modalities of post-RP therapy targeted for recovery of erectile function. We discuss the clinical strategies designed to overcome the non-surgical factors believed to precipitate the development of post-RP ED. Additionally, we present some commonly used validated instruments that are useful to define baseline erectile function and follow response to therapy.
Abstract and Introduction
Abstract
Radical prostatectomy (RP) is a commonly performed procedure for the management of prostate cancer. While documented oncologic outcome for early stage disease is excellent, functional impairments such as incontinence and erectile dysfunction (ED) are common after the procedure. Recent evidence has implicated cavernous nerve damage and subsequent corporal oxygen deprivation, as well as corporal inflammation, in the pathogenesis of post-RP ED. Targeted therapies such as oral phosphodiesterase-5 inhibitors, mechanical vacuum erection devices, local alprostadil delivery and testosterone replacement (for hypogonal patients) have demonstrated some efficacy in the management of post-RP ED. This review aggregates much of the recent data in support of these therapies and critically reviews them. The article then presents tools to assess patients and partner sexual function to aid in identifying and monitoring post-RP ED. Finally, the article describes a protocol in use at Baylor College of Medicine as a guide toward the development of a protocol for erectile preservation (EP). The purpose of this work is to educate clinicians on emerging concepts in EP and provide an implementable protocol for use in practice.
Introduction
Prostate cancer, the most common non-dermatological malignancy in men in the United States with an annual incidence of approximately 220 000, is responsible for almost 30% of cancer diagnoses and 9% of cancer-related mortality in US men. Definitive therapeutic strategies include radical prostatectomy (RP) and radiation therapy. The number of RPs performed per annum is estimated at 110 000 in the United States alone. Recent advances in screening and early detection of prostate cancer have yielded excellent oncologic outcomes for low-risk patients and shifted the focus of surgeons to enhance functional outcomes for patients undergoing RP. Such functional outcomes include recovery of urinary continence and erectile function.
While several factors influence post-RP erectile function recovery, pre-operative erectile function and nerve sparing (NS) status are critical predictors. Tal and coworkers identified the aggregate recovery rate of erectile function after surgery at approximately 60%. Even within this fraction of patients, a large variability in the quality of erections likely exists because of the subjective nature of assigning a binary response to the presence of satisfactory function.
In general, erectile dysfunction (ED) and reduced sexual satisfaction have a negative impact on quality of life. Various studies assessing the efficacy of interventions to treat ED include quality of life measures as secondary outcomes. Importantly, studies have consistently indicated that erectile function correlates with favorable quality of life outcomes in patients. Perhaps an even higher impact observation is that the quality of erectile function correlates with emotional well being.
Interestingly, data regarding management of patients after RP remain fragmented and inconsistent. A study of French urologist's suggests that only a minority actually provide formal post-RP therapy directed at sexual function outcomes. The questionnaire-based study found that only 38% of urologists prescribed a systematic program for patients despite the fact that the overwhelming fraction of urologists assesses pre-RP sexual function. The most commonly used therapy was injection based, perhaps suggesting that other effective modalities for post-RP therapy would shift this dynamic. Physicians familiar with sexual medicine as a discipline are more likely to implement post-RP therapy targeted at preservation of erectile function, supporting the role for increased awareness of this concept.
Given the impact of RP on erectile function, it is prudent for physicians to implement strategies related to minimizing and reversing post-RP ED. This requires both a thorough understanding of the pathogenesis of post-RP ED and the role of various therapies to mechanistically impact the process. Clinically, physicians require treatment strategies and assessment tools to capture response and satisfaction. This review article attempts to synthesize the literature on the various modalities of post-RP therapy targeted for recovery of erectile function. We discuss the clinical strategies designed to overcome the non-surgical factors believed to precipitate the development of post-RP ED. Additionally, we present some commonly used validated instruments that are useful to define baseline erectile function and follow response to therapy.
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