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The role of vacuum erection devices in penile rehabilitation after radical prostatectomy

International Journal of Impotence Research volume 21, pages 158–164 (2009)Cite this article

Abstract

Even nerve-sparing radical prostatectomy damages the cavernous nerves and leads to temporary erectile dysfunction (ED) in men recovering from prostate cancer surgery. Historically, patients recovering from prostate cancer surgery have been advised that the return of erectile function (EF) can take from 6 to 18 months, or even longer. Unfortunately, the return of sexual function in these patients remains variable, but is generally thought to be dependent on the individual patient's pre-surgery EF, as well as the degree of cavernous nerve disruption during prostate removal. Recently, there has been a growing movement to proactively treat patients postoperatively for presumed nerve damage to stimulate nerve recovery and possibly reduce the degree of irreversible damage. This would reduce the on-demand therapy these patients would require, and hopefully remove the requirement for an implantable prosthesis. The underlying hypothesis is that the artificial induction of erections shortly after surgery facilitates tissue oxygenation, reducing cavernosal fibrosis in the absence of nocturnal erections, potentially increasing the likelihood of preserving EF. Vacuum erection devices (VED), because of their ability to draw blood into the penis regardless of nerve disturbance, have become the centerpiece of penile rehabilitation protocols. This review will discuss the pathophysiology of radical prostatectomy induced ED and the rationale for rehabilitation. It will then discuss current protocols, including those involving the VED.

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References

  1. Jamal A, Murray T, Ward E, Samuels A . Cancer statistics, 2005. Cancer J Clin 2005; 55: 10–30.

    Article  Google Scholar 

  2. Jones GW, Mettlin C, Murphy GP, Guinan P, Herr HW, Hussey DH et al. Patterns of care for carcinoma of the prostate gland: results of a national survey of 1984 and 1990. J Am Coll Surg 1995; 180: 545–554.

    CAS  PubMed  Google Scholar 

  3. Walsh PC, Donker PJ . Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 1982; 128: 492.

    Article  CAS  PubMed  Google Scholar 

  4. Walsh PC, Marschke P, Ricker D, Burnett AL . Patient reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000; 55:58–61: following radical prostatectomy. J Urol 1993; 150: 905–907.

    Article  Google Scholar 

  5. Catalona WP, Basler JW . Return of erections and urinary continence following nerve-sparing radical retropubic prostatectomy. J Urol 1993; 150: 905–907.

    Article  CAS  PubMed  Google Scholar 

  6. Quinlan DM, Epstein JI, Cater BS, Walsh PC . Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol 1991; 145: 998–1002.

    Article  CAS  PubMed  Google Scholar 

  7. Rabbani F, Stapleton AM, Kattan MW, Wheeler TM, Scardino PT . Factors predicting recovery of erections after radical retropubic prostatectomy. Urology 1995; 45: 1000–1006.

    Article  Google Scholar 

  8. Penson DF, Litwin MS . Quality of life after treatment for prostate cancer. Curr Urol Rep 2003; 4: 185.

    Article  PubMed  Google Scholar 

  9. Mullerad M, Donohue JF, Li PS, Scardino PT, Mulhall JP . Functional sequelae of cavernous nerve injury in the rat: is there model dependency. J Sex Med 2006; 3: 77–83.

    Article  PubMed  Google Scholar 

  10. Fraiman MC, Lepor H, McCullough AR . Changes in penile morphometrics in men with erectile dysfunction after nerve-sparing radical prostatectomy. Mol Urol 1999; 3: 109–115.

    CAS  PubMed  Google Scholar 

  11. Gontero G, Galzerano M, Bartoletti R, Magnani C, Tizzani A, Frea B et al. New Insights into the pathogenesis of penile shortening after radical prostatectomy and the role of postoperative sexual function. J Urol 2007; 178: 602–607.

    Article  PubMed  Google Scholar 

  12. Padma-Nathan H, McCullough A, Forest C . Erectile dysfunction secondary to nerve-sparing radical retropubic prostatectomy: comparative phosphodiesterase-5 inhibitor efficacy for therapy and novel prevention strategies. Curr Urol Rep 2004; 5: 467–471.

    Article  PubMed  Google Scholar 

  13. Zippe CD, Raina R, Thukral M, Lakin MM, Klein EA, Agarwal A . Management of erectile dysfunction following radical prostatectomy. Curr Urol Rep 2001; 2: 495–503.

    Article  CAS  PubMed  Google Scholar 

  14. Zippe CD, Jhaveri FM, Klein EA, Kedia S, Pasqualotto FF, Kedia A et al. Role of Viagra after radical prostatectomy. Urology 2000; 55: 241–245.

    Article  CAS  PubMed  Google Scholar 

  15. Raina R, Pahlajani G, Agarwal A, Zippe CD . Early penile rehabilitation following radical prostatectomy: Cleveland clinic experience. Int J Impot Res 2008; 20: 121–126.

    Article  CAS  PubMed  Google Scholar 

  16. Raina R, Agarwal A, Ausmundson S, Lakin M, Nandipati KC, Montague DK et al. Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile dysfunction. Int J Impot Res 2006; 18: 77–81.

    Article  CAS  PubMed  Google Scholar 

  17. Kohler TS, Pedro R, Hendlin K, Utz W, Ugarte R, Reddy P et al. A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. Brit J Urol 2007; 100: 858–862.

    Article  Google Scholar 

  18. Burnett AL . Rationale for cavernous nerve restorative therapy to preserve erectile function after radical prostatectomy: results from CaPSURE. J Urol 2004; 171: 703–708.

    Article  Google Scholar 

  19. Zealer DL, Hamdan AL, Rainey CL . Effects of denervation on posterior cricoarytenoid muscle physiology and histochemistry. Ann Otol Rhinol Laryngol 1994; 103: 780–788.

    Article  Google Scholar 

  20. Klein LT, Miller MI, Buttyan R, Raffi AJ, Burchard M, Devris G et al. Apoptosis in the rat penis after penile denervation. J Urol 1997; 158: 626–630.

    Article  CAS  PubMed  Google Scholar 

  21. Polasek CA, Gonzalez CM, Zelner DJ, Jiang HB, Mckenna KE, McVary KT . Analysis of NOS isoform changes in a post radical prostatectomy model of erectile dysfunction. Int J Impot Res 2001; 13: S1–S15.

    Article  Google Scholar 

  22. Iacono F, Giannella R, Somma P, Manno G, Fusco F, Mirone V . Histological alterations in cavernous tissue after radical prostatectomy. J Urol 2005; 173: 1673–1676.

    Article  PubMed  Google Scholar 

  23. Mulhall JP, Slovick R, Hotaling J, Aviv N, Valenzuela R, Waters WB et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with recovery of erectile function. J Urol 2002; 167: 1371–1375.

    Article  PubMed  Google Scholar 

  24. Kim N, Vardi Y, Padma-Nathan H, Daley J, Goldstein I, Saenz de Tejada I . Oxygen tension regulates the nitric oxide pathway: physiological role in penile erections. J Clin Invest 1993; 91: 437–442.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Fischer DC, Gross J, Zuch J . Cycle of penile erections synchronous with dreaming (REM) sleep: preliminary report. Arch Gen Psychiatry 1965; 12: 29.

    Article  Google Scholar 

  26. Leungwattanakij S, Bivalacqua TJ, Usta MF, Yang DY, Hyun JS, Champion HC et al. Cavernous neurotomy causes hypoxia and fibrosis in rat corpus cavernosum. J Androl 2003; 24: 239–245.

    Article  PubMed  Google Scholar 

  27. Granchi S, Vannelli GB, Vignozzi L, Crescioli C, Ferruzzi P, Mancina R et al. Expression and regulation of endothelin-1 and its receptors in human penile smooth muscle cells. Mol Hum Reprod 2002; 8: 1053–1064.

    Article  CAS  PubMed  Google Scholar 

  28. Sakuda H, Nakashima Y, Kuriyama S, Sueishi K . Media conditioned by smooth muscle cells cultured in a variety of hypoxic environments stimulates in vitro angiogenesis: a relationship to transforming growth factor-beta 1. Am J Pathol 1992; 14: 1507–1516.

    Google Scholar 

  29. Saenz de Tejada I, Moreland RB . Physiology of erection, pathophysiology of impotence, and implications of PGE1 in the control of collagen synthesis in the corpus cavernosum. In: Goldstein I, Lue TF (eds). The Role of Alprostadil in the Diagnosis and Treatment of Erectile Dysfunction. Excerpta Medica: Princeton, 1993 pp 3–16.

    Google Scholar 

  30. Christ GJ, Lerner SE, Kim DC, Melman A . Endothelin-1 as a putative modulator of erectile dysfunction I: characteristics of contraction of isolated corporal tissue strips. J Urol 1995; 153: 1998–2003.

    Article  CAS  PubMed  Google Scholar 

  31. Moreland RB, Traish A, McMillin MA, Smith B, Goldstein I, Saenz de Tejada I . PGE1 suppresses the induction of collagen synthesis by transforming growth factor B1 in human corpus cavernosum smooth muscle. J Urol 1995; 153: 826–835.

    Article  CAS  PubMed  Google Scholar 

  32. Wessells H, Lue T, McAninch J . Penile length in the flaccid and erect states: guildelines for penile augmentation. J Urol 1996; 156: 995–999.

    Article  CAS  PubMed  Google Scholar 

  33. Munding MD, Wessells HB, Dalkin BL . Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy. Urology 2001; 58: 567–569.

    Article  CAS  PubMed  Google Scholar 

  34. Mulhall JP, Graydon RJ . The hemodynamics of erectile dysfunction following nerve-sparing radical retropubic prostatectomy. Int J Impot Res 1996; 169: 1462–1464.

    Google Scholar 

  35. Breza J, Aboseif SR, Orvis BR, Lue TF, Tanagho EA . Detailed anatomy of penile neurovascular structures: surgical significance. J Urol 1989; 141: 437.

    Article  CAS  PubMed  Google Scholar 

  36. Teloken PE, Mesquita GG, Montorsi F, Mulhall JP . Post-radical prostatectomy pharmacological penile rehabilitation: current practice status. J Sex Med 2006; 3 (Suppl 5): 394.

    Google Scholar 

  37. Montorsi F, Guazzoni G, Strambi LF, Da Pozzo LF, Nava L, Barbieri L et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol 1997; 158: 1408–1410.

    Article  CAS  PubMed  Google Scholar 

  38. Mulhall J, Land S, Parker M, Waters WB, Flanigan RC . The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med 2005; 2: 532–540.

    Article  CAS  PubMed  Google Scholar 

  39. Wang R, Huber N, Madsen L, Wood C, Babaian R . Compliance to penile rehabilitation program following radical prostatectomy: one year data. J Sex Med 2006; 3 (2 Supp): 151.

    Google Scholar 

  40. McCullough A . The effect of low dose intraurethral alprostadil (MUSE) on corporal oxygenation after nerve sparing radical prostatectomy. J Sex Med 2007; 4 (1 Suppl): 89.

    Google Scholar 

  41. Padma-Nathan H, McCullough AR, Levine LA, Lipschultz LI, Siegel R, Montorsi F et al. Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Int J Impot Res 2008; 20: 479–486.

    Article  CAS  PubMed  Google Scholar 

  42. Levine LA, McCullough AR, Padma-Nathan H . Longitudinal randomized placebo-controlled study of the return of nocturnal erections after nerve-sparing radical prostatectomy in men treated with nightly sildenafil citrate (abstract). J Urol 2004; 231: 171.

    Google Scholar 

  43. Sharabi FM, Daabees TT, El-Metwally MA, Senbel AM . Effect of sildenafil on the isolated rat aortic rings. Fundam Clin Phamacol 2005; 19: 449–456.

    Article  CAS  Google Scholar 

  44. Montorsi F, Brock G, Lee J, Shapiro JA, Van Poppel H, Graefen M et al. Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. Eur Urol 2008; 54: 924–931.

    Article  CAS  PubMed  Google Scholar 

  45. Nadig PW, Ware JC, Blumoff R . Non-invasive device to produce and maintain an erection-like state. Urology 1986; 27: 126–131.

    Article  CAS  PubMed  Google Scholar 

  46. Witherington R . Vacuum constriction device for management of erectile dysfunction. J Urol 1989; 141: 320–322.

    Article  CAS  PubMed  Google Scholar 

  47. Nadig PW . Six years experience with the vacuum constriction device. Int J Impot Res 1989; 1: 55–58.

    Google Scholar 

  48. Lewis RW, Witherington R . External vacuum therapy for erectile dysfunction: use and results. World J Urol 1997; 15: 78–82.

    Article  CAS  PubMed  Google Scholar 

  49. Sidi AA, Becher EF, Zhang G, Lewis JH . Patient acceptance of and satisfaction with an external negative pressure device for impotence. J Urol 1990; 144: 1154–1156.

    Article  CAS  PubMed  Google Scholar 

  50. Meinhardt W, Lycklama a Nijeholt AAB, Kropman RF, Zwartendijk J . The negative pressure device for erectile disorders: when does it fail? J Urol 1993; 149: 1285–1287.

    Article  CAS  PubMed  Google Scholar 

  51. Dutta TC, Eid JF . Vacuum constriction devices for erectile dysfunction: a long-term, prospective study of patients with mild, moderate, and severe dysfunction. Urology 1999; 54: 891–893.

    Article  CAS  PubMed  Google Scholar 

  52. Turner LA, Althof SE, Levine SB, Bodner DR, Kursh ED, Resnick MI . Twelve-month comparison of two treatments for erectile dysfunction: self-infection versus external vacuum devices. Urology 1992; 39: 139–144.

    Article  CAS  PubMed  Google Scholar 

  53. Marmar JL, DeBenedictis TJ, Praiss DE . The use of a vacuum constrictor device to augment a partial erection following an intracavernous injection. J Urol 1988; 14: 975–979.

    Article  Google Scholar 

  54. Chen J, Sofer M, Kaver I, Matzkin H, Greenstein A . Concomitant use of sildenafil and a vacuum entrapment device for the treatment of erectile dysfunction. J Urol 2004; 171: 292–295.

    Article  PubMed  Google Scholar 

  55. Chen J, Godschalk MF, Katz PG, Mulligan T . Combining intracavernous injection and external vacuum as treatment for erectile dysfunction. J Urol 1995; 153: 1476.

    Article  CAS  PubMed  Google Scholar 

  56. Moul MW, McLeod DG . Negative pressure devices in the explanted penile prosthesis population. J Urol 1989; 142: 729–731.

    Article  CAS  PubMed  Google Scholar 

  57. Colombo F, Cogni M, Deiana G, Mastromarino G, Vecchio D, Patelli E et al. Vacuum therapy. Arch Ital Urol Nefrol Androl 1992; 64: 267–269.

    CAS  PubMed  Google Scholar 

  58. Bosshardt RJ, Farwerk R, Sikora R, Sohn M, Jakse G . Objective measurement of the effectiveness, therapeutic success and dynamic mechanisms of the vacuum device. Brit J Urol 1995; 75: 786–791.

    Article  CAS  PubMed  Google Scholar 

  59. Raina R, Agarwal A, Ausmundson S, Lakin M, Nandipati KC, Montague DK et al. Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function. Int J Impot Res 2006; 18: 77–81.

    Article  CAS  PubMed  Google Scholar 

  60. Dalkin BL, Christopher BA . Preservation of penile length after radical prostatectomy: early intervention with a vacuum erection device. Int J Impot Res 2007; 19: 501–504.

    Article  CAS  PubMed  Google Scholar 

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  1. Department of Surgery, Division of Urology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    T Lehrfeld & D I Lee

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Lehrfeld, T., Lee, D. The role of vacuum erection devices in penile rehabilitation after radical prostatectomy. Int J Impot Res 21, 158–164 (2009). https://doi.org/10.1038/ijir.2009.3

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