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Current management strategy of treating patients with erectile dysfunction after radical prostatectomy: a systematic review and meta-analysis

Abstract

The aim of this study is to present a summary of current evidence concerning the various treatments in the management of penile rehabilitation after radical prostatectomy (RP) and provide recommendations for future research. Randomized controlled trials (RCTs) were identified from electronic databases including PubMed, the Cochrane Library, Embase, and Web of Science from inception through March 2020 with no limitation to language. Comparable data from each study were combined in a meta-analysis where possible, otherwise data were synthesized narratively. The data analysis was completed by Review Manager version 5.3. A total of 39 RCTs were included in this study. At present, phosphodiesterase type 5 inhibitors (PDE5is) remain the first-line treatment for patients with erectile dysfunction (ED) after RP. Compared with the placebo group, patients in regular PDE5is group (mean difference (MD): 0.76; 95% confidence interval (CI): 1.69–4.44; p < 0.0001) and on demand group (MD: 3.92; 95% CI: 2.95–4.88; p < 0.00001) had a significantly higher mean Erectile Function domain of the International Index of Erectile Function (IIEF-EF) scores within 3 months after RP. As for the proportion of IIEF-EF ≥ 22, patients in regular PDE5is group and on demand PDE5is group had significantly higher proportion than those in placebo group 6 months after RP, and the odds ratios were 1.87 (95% CI: 1.32–2.66; p = 0.0005) and 2.17 (95% CI: 1.20–3.93; p = 0.01), respectively. No significant difference was observed between regular PDE5is group and on demand group regardless of mean IIEF-EF score or the proportion of IIEF-EF ≥ 22. Intracorporeal injection therapy seemed to have similar efficacy to PDE5is. The International Index of Erectile Function—5 items (IIEF-5) scores were significantly higher in vacuum constriction devices group than control group at 6–9 months after RP (MD: 6.70, 95% CI: 2.30–11.10, p = 0.003) with great between-study heterogeneity (p = 0.06, I2 = 72%). The other therapeutics including low-intensity extracorporeal shockwave therapy, statin therapy, psychotherapy interventions, and pelvic floor muscle training plus electrical stimulation showed certain improvement on erectile function. We found that the combination therapy showed certain advantages over monotherapy. Currently, PDE5is-based combination therapy remains the mainstream treatment for ED after RP. Intracorporeal injection therapy and vacuum therapy could be served as alternative treatments if PDE5is are ineffective and contraindicated.

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Fig. 1: PRISMA flow diagram.
Fig. 2: Methodological quality assessment of risk of bias in this study.
Fig. 3: The forest plot of the mean difference for men with erectile function using PDE5is or placebo at follow-up.
Fig. 4: The meta-analysis results of the proportion of IIEF ≥ 22 and the potency rate for men with erectile function using PDE5is or placebo at follow-up.
Fig. 5: The meta-analysis of erectile function for vacuum therapy and PFMT.
Fig. 6: Management of penile rehabilitation for patients undergoing RP.

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Conception and design: DCF. Administrative support: WRW. Provision of study materials or patients, collection and assembly of data, data analysis and interpretation: DCF and CT. Manuscript writing and final approval of manuscript: all authors.

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Correspondence to Wuran Wei.

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The study was supported by the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (ZY2016104) and Pillar Program from Department of Science and Technology of Sichuan Province (2018SZ0219). The funders had no role in study design, data collection or analysis, preparation of the manuscript, or the decision to publish. The authors declare that they have no conflict of interest.

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Feng, D., Tang, C., Liu, S. et al. Current management strategy of treating patients with erectile dysfunction after radical prostatectomy: a systematic review and meta-analysis. Int J Impot Res 34, 18–36 (2022). https://doi.org/10.1038/s41443-020-00364-w

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