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PDE-5 inhibitors after prostatectomy

Clinical bottom line

Nerve-sparing surgery results in improved return of sexual function, but over a period of time. Use of PDE-5 inhibitors initially can help.


Background

The last two decades have seen much greater concentration on prostate cancer. The advent of screening using prostate specific antigen has increased detection rates among younger men. The advent of fitter cohorts of older men, and changes in attitudes, have all meant that there has been increased interest in the maintenance in erectile function after operation.

References

Burnett AL. Erectile dysfunction following radical prostatectomy. JAMA. 2005 293:2648-2653.


Montorsi F, Briganti A, Salonia A, Rigatti P, Burnett AL. Current and future strategies for preventing and managing erectile dysfunction following radical prostatectomy. Eur Urol. 2004 45:123-133.


Reviews

There two recent reviews chart how surgical techniques have changed, with increasing interest in maintaining the integrity of the cavernous nerves, and the so-called nerve-sparing technique. This discovery offered the possibility of preserving erectile function which would have been all but totally eliminated without this modification. Experienced surgeons at major academic centres have recovery rates of satisfactory intercourse of 60-85% in their patients.

Recovery of sexual function is not immediate, however, and it can take up to two years for full recovery even after nerve sparing surgery. Where there is delay, oral PDE-5 inhibitors are usually the first line therapy, with reported efficacy in 10-80% of men after nerve sparing surgery, but probably below 15% after non-nerve sparing surgery. Second line therapies include intraurethral medications, intracavernosal injections and vacuum constriction devices, which should restore erectile function to most men. A systematic review [Montorsi et al] examines the literature on recovery of erectile function after radical prostatectomy, including the prophylactic use of PDE-5 inhibitors to aid recovery of erectile function.

Table 1 charts some of the more recent observational studies, and there have been several randomised trials for tadalafil and vardenafil in men following nerve sparing surgery. They all confirm efficacy of PDE-5 inhibitors after nerve sparing surgery.

Table 1: Studies of sildenafil in men after prostatectomy

Reference Condition Number of men Outcome Country
Penson DF.
J Urol 2005 173:1701-1705.
Sample of 1,288 men after radical prostatectomy for cancer. 554 used sildenafil at some time At 24 months erections firm enough for intercourse in 22%, and 28% by 60 months. Stable between 2 and 5 years USA
Rubio Briones J et al.
Actas Urol Esp 2004;28:567-574.
Survey of 111 men after radical prostatectomy taking sildenafil 90 Half the men had complete or patial response. Response to sildenafil better after the first year Spain
Raina R et al.
Urology 2003;62:110-115.
Study after radical prostatectomy at 1 and 4 years after surgery on sildenafil 50-100 mg 91 71% of those orioginally responding were still responding at 3 years. USA
Feng MI et al.
J Urol 2000;164:1935-1938.
Patients after radical prostatectomy taking sildenafil 53 15/21 with bilateral nerve sparing had response, but only 1/17 with non-nerve sparing procedure USA
Blander DS et al.
Int J Impot Res 2000;12:165-168.
Comparison of effects of sildenafil aftter surgery and without surgery 107 Higher success rates without surgery USA
Zagaja GP et al.
Urology 2000;56:631-634.
Men after radical prostatectomy needing sildenafil 170 In young men in whom both neurovascular bundles were preserved response rate was 80%. No adequate response in older patients where bundles were removed USA
Zippe CD et al.
Urology 2000;55:241-245.
Men after radical prostatectomy needing sildenafil 91 Good response in 72% with bilateral nerve sparing, less with unilateral, and poor without nervse sparing surgery USA
Hong EK et al
Int J Impot Res 1999;11 Supp 1:S15-22.
Men after radical prostatectomy needing sildenafil 198 Initial treatment satisfaction rose from 26% at 6 months to 60% at 2 years USA
Lowentritt BH et al.
J Urol 1999 162:1614-1617.
Men after radical prostatectomy needing sildenafil 84 Degree of nerve sparing had a significant impact on efficacy of sildenafil USA