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Penile rehabilitation after radical prostatectomy

Nature Clinical Practice Urology volume 3, pages 400–401 (2006)Cite this article

Postprostatectomy erectile dysfunction (ED) is a common quality-of-life issue that affects 14–84% of men who undergo radical prostatectomy for localized prostate cancer. Improvements in our understanding of the pathophysiology of postprostatectomy ED have paved the way for pharmacologic regimens aimed at improving early postoperative corporeal blood filling. The absence of early postoperative erections is associated with poor corporeal oxygenation, which could facilitate the development of corporeal fibrosis and lead to veno-occlusive dysfunction. Preventing penile ischemia after surgery could promote the preservation of erectile function. Montorsi et al.1 showed that intracorporeal injections of alprostadil soon after bilateral nerve-sparing radical prostatectomy increased the recovery rate of spontaneous erections compared with observation alone. Brock et al.2 have also shown that long-term treatment with intracavernosal alprostadil injections significantly improves penile hemodynamics, and promotes the return of spontaneous erections (either partial or total), in patients with arteriogenic ED. These data confirm a potential curative role for this therapeutic modality in patients treated with radical prostatectomy, which is often associated with postoperative penile vascular compromise (including insufficiency of the cavernous arteries) and various degrees of neural damage. Mulhall et al.3 recently showed that postoperative intracorporeal injections of alprostadil in patients not responding to oral sildenafil resulted in higher rates of spontaneous functional erections and erectogenic drug responses 18 months after nerve-sparing radical prostatectomy than did no rehabilitation. Early postoperative use of a vacuum constriction device has also been proposed as a penile rehabilitation strategy, with the aim of promoting adequate cavernosal oxygenation and thereby preventing postoperative penile fibrosis.4

Phosphodiesterase-type-5 (PDE5) inhibitors have revolutionized the treatment of ED. Recent studies have elucidated some potential mechanisms that might explain the rehabilitative action of these drugs.5,6,7 Montorsi et al. showed that when sildenafil 100 mg is taken at bedtime by patients with ED of various etiologies, the overall quality of nocturnal erections, as recorded with the RigiScan® device (Endocare, Irvine, CA), is significantly better than that obtained with placebo.5 Moreover, early use of sildenafil at high doses after radical prostatectomy seems to be associated with preservation of smooth-muscle content within human corpora cavernosa.6 Experimental data regarding the potential mechanisms involved in chronic administration of sildenafil as a rehabilitative treatment have been reported.7 One study, conducted in male rats, examined the effects of an 8-week course of sildenafil (subcutaneous dose of 60 mg/kg/day) on electrically-induced erectile responses in vivo, before and after an acute injection of sildenafil (intravenous dose of 0.3 mg/kg). Endothelial-dependent and endothelial-independent relaxations of strips of corpus cavernosum were examined in vitro, and compared with cavernosal strips from untreated rats. Interestingly, acetylcholine-induced endothelial-dependent relaxation was significantly enhanced in rats treated chronically with sildenafil, compared with untreated rats. This indicates that either muscarinic receptors or the transduction mechanisms leading to the activation of endothelial nitric oxide synthase are upregulated by chronic sildenafil treatment. Moreover, functional in vivo evaluations showed that chronic administration of sildenafil significantly enhanced frequency-dependent erectile responses, and was associated with a greater response to an acute injection of sildenafil, in treated rats compared with controls. This study provides the first experimental data to support the idea that chronic use of sildenafil is associated with a higher rate of erectile-function recovery after radical prostatectomy.

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  1. the Department of Urology at Università Vita Salute San Raffaele, Milan, Italy

    Alberto Briganti & Francesco Montorsi

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  1. Alberto Briganti
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  2. Francesco Montorsi
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Correspondence to Francesco Montorsi.

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Briganti, A., Montorsi, F. Penile rehabilitation after radical prostatectomy. Nat Rev Urol 3, 400–401 (2006). https://doi.org/10.1038/ncpuro0555

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