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Erectile dysfunction post prostate surgery,ednos french,eden park men's clothing stores,natural remedies for dry eyes syndrome - How to DIY

Erectile dysfunction (ED) after radical prostatectomy (RP) has a significant negative impact on a patient's health-related quality of life.
To elucidate the pathophysiologic mechanisms of post-RP ED, to assess the need for rehabilitation following surgery, and to analyze the basic scientific evidence and clinical applications of PDE5-Is for the prevention and treatment of ED. A systematic review of the literature using Medline, Cancerlit, and the Cochrane Library was conducted for the period between January 1997 and June 2008 using the keywords erectile dysfunction, radical prostatectomy, and phosphodiesterase inhibitors. PDE5-Is are an efficacious and safe treatment for post-RP ED in properly selected patients. Phosphodiesterase type 5 inhibitors (PDE5-Is) are an efficacious and safe treatment for postprostatectomy erectile dysfunction in properly selected patients.
Keywords: Radical prostatectomy, Erectile dysfunction, Penile rehabilitation, Phosphodiesterase type 5 inhibitors. Radical prostatectomy (RP) is a commonly used treatment for localized prostate cancer in patients with a life expectancy of at least 10 yr [1].
The advent of phosphodiesterase type 5 inhibitors (PDE5-Is) revolutionized ED treatment with an average success rate of 60–70% in the general ED population [8].
This review aims to elucidate the current knowledge on the pathophysiologic mechanisms of post-RP ED, to assess the need for penile rehabilitation following surgery, and to analyze the basic science rationale of PDE5-I as well their clinical applications for the prevention and treatment of post-RP ED. Neuropraxia results in loss of daily and nocturnal erections associated with persistent cavernous hypoxia. There is evidence that cavernosal nerve injury induces proapoptotic factors (ie, loss of smooth muscle) and profibrotic factors (ie, an increase in collagen) within the corpora cavernosa [19]. In a small study, which included 19 post-RP patients, a significant decrease in the elastic fibers and smooth-muscle fibers and a significant increase in the collagen content were reported in the late (12 mo) postoperative period compared with both the early (2 mo) postoperative period and the preoperative period [26].
In addition to the fundamental role of cavernous nerve preservation during RP, there is evidence that arterial insufficiency contributes to the pathophysiology of ED.
The successful recovery of erections following RP has been revolutionized by the nerve-sparing technique described by Walsh [38].
In addition to the use of the improved BNSRP technique, age and preoperative erectile function are important in predicting postoperative erectile function [5], [39], [48], [49], and [50]. The etiology of ED after RP is multifactorial and includes neurogenic and vasculogenic factors. The aim of a penile rehabilitation program is to preserve the functional smooth-muscle content of the corpus cavernosum during the neuropraxia period. PDE5-Is increase cGMP levels which, in turn, exert an antifibrotic action on the cavernous tissue.
Basic scientific data on the role of phosphodiesterase type 5 inhibitors (PDE5-Is) in the cavernous nerve injury animal model (rats). The earlier application of pharmacologic regimens aimed at preventing cavernosal hypoxia after RP.
The efficacy of nightly doses of sildenafil in post-BNSRP patients was investigated in a prospective, two-center, randomized, double-blind, parallel-group, placebo-controlled study with 76 patients [60]. Mean duration of tip rigidity >55% as a percentage of the baseline (preoperative) value, in responders (R) versus nonresponders (NR) and for sildenafil treatment (sildenafil 100mg or sildenafil 50mg) versus placebo. Gallo et al [70] assessed time-dependent vardenafil response in 40 men treated with vardenafil on demand following RP (22 patients underwent BNSRP and 18 patients underwent unilateral nerve-sparing radical prostatectomy [UNSRP]).
Montorsi et al [71], in a prospective randomized, double-blind, double-dummy, multinational, multicenter, parallel-group study, assessed the efficacy of on-demand versus nightly dosages of vardenafil versus placebo in 628 patients after BNSRP with normal preoperative erectile function. While the concept of penile rehabilitation using a PDE5-I is appealing, several questions remain unanswered: when to start, which dosage regimen to use, what is the optimum treatment period, what are the selection criteria, and which drug is best. Response rates to sildenafil after NSRP range from 10% to 76% (the higher rates reported after BNSRP), while the response rates after non–nerve-sparing RP (NNSRP) ranged from 0% to 15% [72], [73], [74], [75], [76], [77], [78], [79], [80], [81], [82], [83], [84], [85], and [86] (Table 3). Clinical data on sildenafil treatment for post–radical prostatectomy erectile dysfyunction. Another randomized, multi-institution, 12-wk study compared the effects of sildenafil 100mg on-demand in combination with acetyl-L-carnitine 2g per day and propionyl-L-carnitine 2g per day to sildenafil 100mg on demand and to placebo in 96 patients seeking treatment for their ED after surgery [89]. The efficacy and safety of vardenafil was assessed in a 12-wk, multicenter, prospective, randomized, double-blind, placebo-controlled, fixed-dose, parallel group study including 34 centers in the United States, 24 centers in Canada, and a total of 440 men [90]. Efficacy of vardenafil 10mg and vardenafil 20mg after bilateral nerve-sparing radical prostatectomy (BNSRP) and unilateral nerve-sparing radical prostatectomy (UNSRP) compared to placebo.
The efficacy and safety of tadalafil was assessed in a multicenter, prospective, randomized, double blind, placebo-controlled study conducted in 38 sites in the United States, Canada, and Europe, and they included 303 men [93]. Efficacy of tadalafil 20mg after bilateral nerve-sparing radical prostatectomy (BNSRP) compared to placebo. PDE5-Is may be combined with intraurethral alprostadil to salvage oral therapy failures [94] and [95]. Data from limited clinical studies show that PDE5-Is are efficacious in the treatment of post-RP ED.
Critical revision of the manuscript for important intellectual content: Montorsi, Hatzichristou, Mulhall, Burnett, McCullough. Our focus is to obtain expert knowledge in the incidence and prevalence of bladder cancer in specific patient populations and implement screening tests to evaluate the predictive value of these tests. Review of efficacy and long-term compliance of multiple treatments (intracavernous injections, vacuum constriction devices, MUSE- transurethral insertion of alprostatdil and sildenafil citrate) used to treat erectile dysfunction following radical surgeries. Our Center is among the first to conduct novel study to address sexual dysfunction in subset of patients (both male and female) undergoing radical cystectomy. Our ongoing studies are focused on cutting edge issues in the management of erectile dysfunction. We are interested in investigating the potential use of vascular endothelial growth factor gene therapy to stimulate cavernous nerve regeneration after nerve sparing and non-nerve sparing radical prostatectomy and enhance the return of natural erections sufficient for sexual intercourse. To continue our ongoing research on assessment of sexual dysfunction in male and females patients who have undergone radical cystectomy. To assess erectile function after I-125 seed radiation therapy for prostate cancer (T1-2) and the role of sildenafil citrate. Our research interests in bladder cancer are comprehensive, from screening and early detection to monitoring the treatment response of bladder cancer to BCG, to nerve sparing radical cystectomy, and to continent diversion for invasive and metastatic disease.
Our basic science research includes studies on the immunologic response to BCG and whether this response can be augmented with various interferons. We are studying the ability of targeted multicolor fluorescence in situ hybridization (FISH) to identify malignant cells in cytological equivocal cases where morphology alone does not allow definitive diagnosis. We are conducting an open comparative within patient controlled phase 3 multicenter Study of Hexvix fluorescence cystoscopy and standard cystoscopy in the detection of carcinoma in situ in patients with bladder cancer.
Our focus is to expand on this solid foundation and to obtain expert knowledge in the incidence and prevalence of bladder cancer in specific populations and implement screening tests, evaluate the predictive values of these tests, and determine the diagnostic algorithm for early detection of bladder cancer. The research laboratory is interested in the treatment of localized prostate cancer with radical prostatectomy and the associated complications of incontinence and erectile dysfunction (ED). Our clinical research includes the treatment of localized prostate cancer with radical prostatectomy, the associated complications of incontinence and ED, and quality of life issues in urological practice.
Erectile dysfunction is an important morbidity factor after the treatment of localized prostate cancer. Radical cystectomy is the treatment of choice for locally advanced but invasive cancer of the bladder. Early use of vacuum constriction device (VCD) following radical prostatectomy (RP) facilitates early sexual activity and potentially earlier return of erectile function.
Role of sildenafil citrate in the management of erectile dysfunction following I-125 seed insertion for localized prostate cancer. Role of sildenafil citrate in management of sexual dysfunction following radical cystectomy. CONSIDERAZIONI ANATOMICHE Preservazione dei nervi cavernosi contenuti nei neurovascular bundles (NVBs) I NVBs decorrono sul margine posterolaterale della capsula prostatica bilateralmente tra i due foglietti della porzione laterale della fascia pelvica costituiti dalla fascia dellelevatore e dalla fascia prostatica. Representative potency rates after radical retropubic prostatectomy StudyPotency Rates (%) Jonler 199411 Ritchie 198912 Brendler 200018 Pedersen 199319 Leandri 199256 Catalona 199968% bil. Il Cavermap e costituito da una complessa strumentazione che presenta la duplice funzione di nerve stimulator e ditumescence monitoring. Efficacy of first-generation Cavermap to verify location of cavernous nerves during radical prostatectomy: a multi-istitutional evaluation by experienced surgeons Walsh PC, Marschke P, Catalona WJ, Lepor H, Martin S, Myers RP, Steiner MS 50 Pz. Intraoperative nerve stimulation predicts postoperative potency Chang SS, Peterson M, Smith JA Jr 63 Pz. Does epidural anaesthesia affect intraoperative nerve stimulation during radical prostatectomy? At 5 years after implantation, 59% prostate cancer patients had preserved erectile function.
Three-fifths of men receiving permanent seed brachytherapy (BT) for localized prostate cancer (PCa) have preserved erectile function (EF) 5 years after seed implantation, according to researchers. The 5-year actuarial EF preservation rate was significantly higher in patients with a Gleason score below 7 than in those with a Gleason score of 7 (73% vs. On multivariate analysis, Gleason score was the strongest predictor of EF preservation, with a score below 7 associated with a 3.7 increased likelihood of EF preservation compared with a Gleason score of 7.
Second, the follow-up in the current study was longer than in most previous studies of EF after PCa treatment, and the rates of long-term preservation of EF contrast with the widely-held belief that EF after BT rapidly and materially gets worse after 1 or 2 years, he said. Studies conducted by John Hopkins Hospital and other institutes have drawn links between vitamin D deficiency and erectile dysfunction. Prostate and bowel cancer generally necessitate surgical procedures to get rid of the cancerous tissue. If you have any questions regarding the use of Vacurect as part of a penile rehabilitation program after prostate surgery, please post them here. Phosphodiesterase type 5 inhibitors (PDE5-Is) have recently been utilized not only as a treatment of ED in this population but also as a preventive strategy in penile rehabilitation programs. Efficacy and safety of PDE5-Is in the randomized, placebo-controlled trials are evaluated in this review, and the limitations of the remaining studies are also discussed. Cavernosal nerve injury induces pro-apoptotic factors (ie, loss of smooth muscle) and pro-fibrotic factors (ie, an increase in collagen) within the corpora cavernosa.
The experimental results on the protective role of daily dosages of PDE5-Is, while robust, have not been replicated in humans.
Robust experimental data support the protective role of daily PDE5-Is; however, similar data have not yet been replicated in humans, and the role of PDE5-Is in penile rehabilitation programs remains controversial.
The number of RPs has been increasing annually, and currently many patients are treated at younger ages [2]. Nevertheless, these rates are significantly lower and vary considerably in post-RP ED patients [7].
A systematic review of the literature using Medline, Cancerlit, and the Cochrane Library was conducted for the period between January 1997 and June 2008. Based on this theory, smooth-muscle fibrosis and atrophy observed in cavernosal tissue may be due to the ablation by neural trauma of certain key growth factors produced by the cavernosal nerves and to the production of cytokines and reactive oxygen species by the damaged nerve axons [20] and [21]. Mulhall et al [28] reported that the incidence of arterial insufficiency was 59% after RP, not related to postoperative time.


Four studies reported various shortening rates [33], [34], [35], and [36], while one study reported no significant change in penile length [37]. It is well established that BNSRP is associated with higher rates of postoperative potency in the range of 50–90% [3], [5], and [39].
Even with meticulous nerve-sparing technique, the commonly associated neuropraxia may take as long as 4 yr to resolve [4] and [7]. In four studies, sildenafil has been shown to (1) improve or normalize the ratio of smooth-muscle to collagen, (2) increase smooth-muscle replication, (3) reduce the apoptotic index, (4) preserve endothelial integrity (preserving platelet endothelial cell adhesion molecule-1 [CD31] and eNOS expression), (5) increase GPX levels (an antioxidant enzyme), and (6) decrease nitrotyrosine (NT) levels (an oxidative stress marker) [21], [24], [64], and [65]. Montorsi et al [27] showed in a prospective, randomized trial in a small group of patients that early postoperative administration of alprostadil injections significantly increased the recovery rate of spontaneous erections after BNSRP. Sildenafil 50mg, sildenafil 100mg, or placebo was administered every night for a total of 36 wk, followed by an 8-wk washout. Because only one man in the placebo group was a responder, values for the placebo responder group should be interpreted with caution. All patients were treated with vardenafil 20mg on demand for 6 mo, using the drug at least three times per week (before sexual intercourse). The study was done at 87 centers across Europe, Canada, South Africa, and the United States.
Prospective, randomized, placebo-controlled studies are mandatory to definitively assess efficacy of penile rehabilitation programs with PDE5-Is.
There is considerable heterogeneity between these studies, and there are no data currently available from multicenter, randomized, placebo-controlled trials designed specifically to address efficacy of sildenafil in post-RP ED [87]. The x-axis shows the weighted mean difference and 95% CI for (a) International Index of Erectile Function (IIEF) erectile function (EF) domain and (b) Sexual Encounter Profile question 3 (SEP3). All patients had undergone a BNSRP and had been treated with tadalafil 20mg or placebo, and they were between 12 mo and 48 mo postoperative at the time of the study. The x-axis shows the weighted mean difference and 95% CI for International Index of Erectile Function (IIEF) erectile function (EF) domains, odds ratio, and 95% CI for Sexual Encounter Profile question 2 (SEP2) and question 3 (SEP3). Major criticism for both of these studies includes the small number of patients included and the nonrandomized, placebo-controlled design. While experimental evidence suggests that PDE5-Is can prevent smooth-muscle apoptosis and fibrosis related to ED after RP in the animal model, these findings have not yet been replicated in humans.
Our recent study is focused on early treatment program following radical prostatectomy, a strategy used to help promote early nerve recovery and regeneration following radical surgery. We reported sexual function data in a contemporary radical cystectomy series by using the SHIM (IIEF-5) for males and a modified IFSF for females. Our laboratory has been at the forefront of clinical research in the area of urinary tumor markers and their role in screening or early detection of bladder cancer.
This database identifies patients who have been screened for bladder cancer, have been treated with intravesical chemotherapy, and have undergone radical surgery with continent diversion. In future, we would like to examine the relationship between levels of reactive oxygen species and the progression of superficial bladder cancer after intravesical therapy.
Hexvix contains hexyl-5-aminolevulinate which are precursors of photoactive porphyrins preferentially taken up by bladder cancer cells, which can be utilized for identification and treatment guidance of malignant and pre-malignant lesions.
Our interests in this field have been on surgical margin status and the effect of nerve-sparing surgery on incontinence and erectile function. Our research also involves a review of efficacy and long-term compliance of multiple treatments (intracavernous injections, vacuum constriction devices, MUSE- transurethral insertion of alprostatdil and sildenafil citrate) used to treat ED following radical surgeries. In the past, the majority of the patients were elderly, where post-radiation potency was not a major factor in their decision to undergo radiation. Outcome data following radical cystectomy with or without orthotopic diversion has focused primarily on cure, urethral recurrence, and continence. I NVBs sono distanti dalla capsula prostatica circa 1,5mm a livello della base della prostata e circa 3 mm a livello dellapice, pertanto la loro dissezione deve essere meticolosa.
Millar, MBChB, of Monash University in Melbourne, Australia, conducted a prospective, longitudinal single-center study of 366 patients who underwent BT. The 5-year actuarial rate of EF preservation was 59%, the investigators reported online ahead of print in Radiotherapy and Oncology. A BED below 150 Gy was associated with a 60% increased likelihood of EF preservation compared with a BED of 150 Gy or higher.
Other than getting vitamin D directly from the sun, you can also get some from food supplements such as fortified milk, ricotta cheese, salmon, eggs, mushrooms, etc. But what you don’t know is that over 75% of men who underwent bowel surgery as bowel cancer treatment suffered ED post-surgery. With current human data, the role of a PDE5-I alone as a rehabilitation strategy is unclear and deserves further investigation. Erectile dysfunction (ED) is the most common complication in these patients, having a significant negative impact on patients’ health-related quality of life and well-being [3]. New insights into the pathophysiology of post-RP ED have led to the development of penile rehabilitation strategies. An electronic search was conducted that included all English-language studies using the keywords erectile dysfunction, radical prostatectomy, and phosphodiesterase inhibitors. Even in BNSRP, some trauma to the nerves, known as neuropraxia, is inevitable due to their anatomical proximity to the prostate.
The cavernosal tissue counteracts this process through the endogenous induction of the inducible isoform of nitric oxide synthase (iNOS) and its second messenger, cyclic guanosine monophosphate (cGMP). The incidence of venous leakage increases in proportion to the time interval after surgery, supporting these pathophysiologic mechanisms as the cause of the leakage and providing the rationale for early penile rehabilitation before penile fibrosis occurs. Arterial insufficiency is attributed to damage of the lateral and apical accessory pudendal arteries (APAs) during surgery. Several technical tips and modifications have been described to further improve outcome, such as the intraoperative magnification, the intrafascial technique, and the preservation of the nerve fibers on the ventral parts of the prostate [30], [40], [41], [42], [43], and [44]. During this period, cavernosal fibrosis, penile shortening, and venous leakage may become evident. Emerging data from animal studies suggest that rehabilitation is possible [19], [20], [21], [54], and [55]. Mulhall et al [56] showed in a nonrandomized study in a group of BNSRP patients who had not responded to sildenafil that a pharmacologic penile rehabilitation protocol that included sildenafil and intracavernosal injections of alprostadil resulted in higher rates of spontaneous functional erections and sildenafil response 18 mo after surgery. Dropout rates were 31%, 35%, and 33% in the placebo, nightly vardenafil, and on-demand vardenafil groups, respectively. The mean age of the patients was 60 yr, 61 yr, and 60 yr in the placebo, vardenafil 10mg, and vardenafil 20mg groups, respectively.
Rationale for cavernous nerve restorative therapy to preserve erectile function after radical prostatectomy. The laboratory is interested in comparing the efficacy and durability of various types of continent reservoirs.
We are involved in studies to assess the results of sildenafil citrate in salvaging erectile function in postprostatectomy patients.
We are involved in studies to assess the results of sildenafil citrate in management of ED following radical prostatectomy.
In future we are interested in investigating the potential use of vascular endothelial growth factor gene therapy to stimulate cavernous nerve regeneration after nerve sparing and non-nerve sparing radical prostatectomy and enhance the return of natural erections sufficient for sexual intercourse.
A larger percentage of younger patients are choosing radiation therapy in recent years and therefore, the issue of post-radiation potency is becoming a major concern. We were among the first to conduct this novel study to address sexual dysfunction in subset of patient's (male & female) undergoing radical cystectomy. Oncology 2000 Lesplorazione rettale sottostadia le neoplasie organoconfinate Partin: J Urol 1993 601 Pz.
All patients completed the International Index of Erectile Function 5-item questionnaire before treatment and at regular follow-up post-treatment. The rate also was significantly higher among patients younger than 60 years than older patients (69% vs. First, overall, the results are consistent with a large amount of previous work suggesting good rates of EF preservation with BT for PCa, said Dr. Similarly, erectile dysfunction is a “known potential complication” of prostate cancer surgery.
Experimental data support the concept of cavernosal damage and suggest a protective role for daily dosage of a PDE5-I; however, similar data have not yet been replicated in humans. These new strategies are promising, but they are still controversial due to the lack of strong evidence [9].
This vicious cycle leads to ED because of veno-occlusion of the corpus cavernosum and to permanent ED (Fig. In a landmark study, Montorsi et al [27] showed that penile rehabilitation with intracavernous alprostadil is associated with venous leakage in 17% of the treated patients compared with 53% of patients in the control group.
The prevalence of damaged APAs ranges from 4% to 75%, being higher in laparoscopic RP and after cadaveric dissection or use of arteriography [29] and [30]. Major concerns include the age of the patients, the preoperative erectile function assessed by the International Index for Erectile Function (IIEF), the preservation or neurovascular bundles (bilateral or unilateral), and the time of the postoperative measurement.
Laparoscopic and robotic-assisted approaches appear to be associated with results that are at least equivalent [7], [45], [46], and [47]. These pathophysiologic changes are not reversible, and response to pharmacotherapy will be suboptimal or absent. Several clinical trials support the use of intracavernosal injections, PDE5-Is, intraurethral alprostadil, vacuum constriction devices (VCD), combination treatments, and neuromodulatory therapy in penile rehabilitation programs [9], [27], [55], [56], [57], [58], [59], and [60]. Long-term use of a PDE5-I may amplify the depressed NO signaling pathway that inhibits hypoxia-associated fibrosis.
Finally, vardenafil has been shown, in one study, to increase iNOS and to proliferate cellular nuclear antigen expression (smooth-muscle cell replication), with normalization of the ratio of smooth muscle to collagen and without effecting the apoptotic index. Schwartz et al [68] assessed the effect of sildenafil on the intracorporeal smooth-muscle content of patients after RP.
The authors reported statistically significant improvement of the IIEF-5 score compared with the baseline, but no further improvement was noticed at 9 mo and at 12 mo.
Erectile function and sexual intercourse completion rates improved significantly in both treatment arms compared to placebo during the initial double-blind period.
Improvement was also reported in the sexual intercourse satisfaction, orgasm, and general sexual well-being domains of the IIEF; however, no specific statistical data were provided beyond a statement that improvement was significant. Nonresponders to sildenafil and patients who discontinued sildenafil due to adverse events were excluded from this study. The right part of the graph (right to the vertical line) supports the use of vardenafil in terms of efficacy while the left part supports the use of placebo (no efficacy). The right part of the graph (right to the vertical line) supports the use of tadalafil in terms of efficacy, while the left part supports the use of placebo (no efficacy). However, only one study was prospective, crossover, and placebo-controlled [97], while the number of patients treated was also low.
More prospective, randomized, placebo-controlled studies are needed to firmly establish efficacy of PDE5-Is in rehabilitation programs.


Penile rehabilitation following radical prostatectomy: role of early intervention and chronic therapy. We were among the first to investigate the effects of this new oral medication in patients following radical prostatectomy and to study the impact of the presence or absence of the neurovascular bundles.
Using a SHIM (IIEF-5) validated questionnaire for males and a modified IFSF for females, we are assessing sexual function data in a contemporary radical cystectomy series.
Of the 366 patients, 277 (76%) reported normal erectile function and 89 (24%) reported mild erectile dysfunction prior to treatment.
The reason behind this is that the surgery involves working around the nerves that supply blood to the penis, and more often than not, the nerves get damaged during the delicate operation. Penile rehabilitation programs are common in clinical practice, but there is no definitive evidence to support their use or the best treatment strategy.
The immunophilin ligand FK506 has been reported to exert a neuroprotective effect, preserving penile erections in rats as early as 1 d following a partial nerve-crush injury [22].
Furthermore, Mulhall et al [28] reported that postoperative venous leakage increased from 14% at 4 mo to 35% between 9 mo and 12 mo. Rogers et al [31] reported that preservation of APAs may be associated with better recovery of sexual function (93% vs 70%) and shorter interval to recovery (6 mo vs 12 mo).
Patients recovering early potency may be protected from fibrosis which leads to penile shortening. These techniques have been described to improve potency rates, but this has yet to be proven with a methodologically sound, head-to-head comparative study. The major criticisms of these studies include retrospective design, absence of control group, nonrandomized nature, small patient number, and short term of follow-up [55]. All of the previously mentioned animal studies were based on cavernosal nerve resection or crush (without removal of the rat prostate).
Twenty-one previously potent volunteers received sildenafil 50mg or sildenafil 100mg, respectively, every other night for 6 mo beginning on the day of catheter removal. Normalization of spontaneous erectile function occurred in only 4% of the placebo group (n=1 of 25) versus 27% (n=14 of 51, p=0.0156) of the sildenafil group.
However, this study provides limited information because it lacked a control group and because the definition of on-demand treatment and the number of vardenafil treatments were not reported. The patient's penile vascular status assessed by duplex penile Doppler ultrasonography within 6 mo after RP is correlated with the response to sildenafil. The rationale of this combination is poorly supported by the possibly antifibrotic activity of carnitines. Combination treatment may be a treatment alternative in a carefully selected subgroup of patients, but larger, properly designed trials are necessary to assess efficacy and safety.
Much like breast reconstruction after mastectomy for breast cancer, the treatment of ED after RP has a tremendously positive impact on quality of life for the patient and his partner.
Treatment of erectile dysfunction following therapy for clinically localized prostate cancer: patient reported use and outcomes from the Surveillance, Epidemiology, and End Results Prostate Cancer Outcomes Study. We have recently assessed long-term follow-up compliance with sildenafil citrate therapy following radical prostatectomy. We are stratifying the sexual response as per orthotopic diversion to assess the efficacy of sildenafil citrate (in male) for salvaging ED following radical cystectomy.
Even if “nerve-sparing” techniques are used by a skilled surgeon, chances are high that the trauma of the operation itself may cause short-term ED. PDE5-Is are efficacious and safe in young patients with normal preoperative erectile function who have undergone bilateral nerve-sparing radical prostatectomy. Müller et al [18] studied the effect of hyperbaric oxygen therapy (HBOT) in rats with cavernous nerve injury.
McCullough et al [32], in a penile duplex Doppler study with 174 patients after nerve-sparing radical prostatectomy (NSRP), found a low incidence of arterial insufficiency (19%), questioning the clinical importance of APAs.
It must be emphasized that the definition of potency in post–RP studies is unique for the ED literature because almost all studies include the patients that responded to treatment with PDE5-Is as potent. Validated instruments, such as the IIEF, should be used before and after RP to document changes in potency status [51] and [52].
PDE5-Is and intracavernosal injections are more commonly used in rehabilitation programs than are other treatment options [55] and [61]. It is not clear whether the results might be different if the prostate and seminal vesicles had been removed from these rats [55].
Cavernosal biopsy was performed before incision for RP and under local anesthesia 6 mo later.
This study demonstrated that at 48 wk, surgery alone was inferior to surgery plus a rehabilitative regimen that included a PDE5-I.
During the single-blind, washout phase and the open-label, on-demand phase, no statistically significant differences were observed in IIEF or SEP-3 scores among groups. We should properly counsel patients preoperatively and offer medical treatment based on the currently available data. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. 67% di ripresa di funzionalita erettile nel gruppo sottoposto a FIC postoperatoria 20% di ripresa di funzionalita senza FIC riabilitativa Limportanza della terapia riabilitativa e dovuta alla ossigenazione postoperatoria dei corpi cavernosi al fine di evitare la fibrosi degli stessi Zelner et al. In addition, patients who received a biologically effective dose (BED) of radiation below 150 Gy had a significantly higher 5-year actuarial rate of EF preservation than those who had a BED of 150 Gy or greater (74% vs. Rats treated with hyperbaric oxygen had higher ratio of intracavernosal pressure (ICP) to mean arterial pressure (MAP) and higher levels of penile nerve growth factor (NGF) and endothelial nitric oxide synthase (eNOS) compared with the control group. Regular use is proffered, starting as early as possible (from the day of catheter removal or during the first month after surgery), although there are no approved guidelines. Though the differences in treatment versus placebo achieved statistical significance, the relatively low numbers enrolled in this study weaken the strength of the result. Unlike the sildenafil study [60], this study did not show that either on-demand vardenafil or nightly vardenafil was more effective in improving erectile function and sexual intercourse completion rates than placebo after the 8-wk washout period. The 4% placebo normalization of erectile function is similar to that seen in the placebo group of the rehabilitation study with sildenafil [60].
Recovery of erectile function after non-nerve-sparing surgery is unlikely but possible.If an erection can be achieved after surgery, the ability to reach orgasm is maintained but these are “dry” orgasms in which little (if any) ejaculate comes out.
PDE5-I use in penile rehabilitation programs is not supported by rigorous level 1 evidence-based medicine. Bannowsky et al [62] suggested that the selection of PDE5-I in rehabilitation programs should only be based on the presence of nocturnal tumescence documented by the Rigiscan device (Timm Medical Technologies, Inc, Eden Prairie, MN). Iacono et al [69] reported that the percentage of connective tissue and the elastic fiber count did not differ significantly before and after RP in 21 patients treated with sildenafil citrate (sildenafil citrate 50mg, 3 times per week for 2 mo). In a subanalysis with 54 patients, there appeared to be a dose-dependent improvement in nocturnal penile tumescence and rigidity (NPTR) using the Rigiscan device in the treatment group with little improvement in the placebo over their postoperative nadir (Fig.
The advantage of the treatment arms over placebo was also not sustained in the open-label phase. The adverse-event profile was typical for sildenafil, while discontinuation rates due to adverse events were similar to the general ED population.
Both vardenafil dosages appeared to be less effective in patients who underwent UNSRP and in patients with increased ED severity at baseline (no statistical data provided). Potency, continence, and complications in 3,477 consecutive radical retropubic prostatectomies. To support this hypothesis, Bannowsky et al treated 23 patients with preserved nocturnal erections with nightly doses of sildenafil 25mg per day for 52 wk and compared them with a control group of 18 patients [63].
However, there was no placebo group in these two studies, and the effect on the return of potency is unknown. This is the largest randomized, placebo-controlled clinical trial of PDE5-I in post-RP ED published so far. Although that is often not a concern, since most men are over 50 years old at the time of diagnosis, you can talk to your doctor about “banking” sperm before the procedure.Radiotherapy. This is the only randomized, placebo-controlled study that presents objective and non–questionnaire-based data on the possible value of penile rehabilitation with the PDE5-Is.
The contrasting results between the sildenafil and vardenafil studies may be secondary to the surgical site selection, agent used, dosing schedule, the dosages used, and the differing end points. Adverse events were consistent with those previously reported for vardenafil in the general ED population, and the discontinuation rates were 1–4% across study groups. The onset of erectile dysfunction following radiotherapy is gradual and usually begins about six months after the treatment.Loss of erectile function is the most common long-term complication of radiotherapy. In the sildenafil group, 47% of patients achieved and maintained a penile erection sufficient for vaginal intercourse, compared with 28% in the control group. But it occurs less frequently when more sophisticated treatments such as radioactive seed implants (brachytherapy), intensity-modulated radiotherapy (IMRT) and 3-D conformal radiotherapy are used.Hormone therapy. With additional doses of sildenafil (50–100mg) on demand, this baseline potency was increased to 86% overall potency in the sildenafil group versus 66% in the control group. These results may prompt reconsideration of the current clinical practice of prescribing a PDE5-I after RP. When hormone therapy is used, erectile dysfunction may occur approximately two to four weeks after the start of therapy. Currently, there are no studies comparing rehabilitation programs, and there is no evidence to support one particular program over another. Experience suggests many men who have had nerves spared on both sides of their prostate will regain erections.
The results are less favourable with men who have had a single nerve spared or no nerves spared.Following radiotherapy. The air is pumped out of the cylinder, which draws blood into the penis, causing an erection. The erection is maintained by slipping a band off the base of the cylinder and on to the base of the penis. Although these devices can be effective, they have generally been less favoured by patients who have undergone surgery for prostate cancer. Many patients dislike having to use the band at the base of their penis and find it uncomfortable.Penile pellets and cream. With this treatment, the patient inserts a pellet into his urinary tube (urethra) using a plastic applicator, or applies a cream to the tip of the penis. Penile implants This option may be considered if the patient has experienced sustained erectile dysfunction following cancer treatment and if non-surgical therapy has either failed or is unacceptable.
An implant, or prosthesis, is an effective form of therapy in many men but it does require an operation to insert the implant into the penis. Surgery can cause problems such as mechanical failure or infection, which may require removal of the prosthesis and another operation.



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