UroToday - AUA 2008 - Penile Rehabilitation in the Radical Prostatectomy Patient

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Monday, 26 May 2008

ORLANDO, FL

(UroToday.com) - Dr. Sharlip moderated a debate on penile rehabilitation. A

consequence of radical prostatectomy (RP) is ED and its prevalence is reported

between 9-93%. How penile rehabilitation is given and whether it works is

debated. The purpose of penile rehabilitation is to provide oxygen to the

corpora cavernosa for both prevention and recovery in post-RP patients.

Dr.

Mulhall said the purpose of penile rehabilitation is to prevent structural

alterations to maximize chance of a man returning to his preoperative sexual

performance. Minor neuropraxia results in vascular, neural and smooth muscle

injury. The erect penile state and oxygenation turns off TGF-beta and decreases

collagen production. Hyperbaric oxygen and cavernosal nerve injury had improved

return of erectile function compared to controls in a rat experiment. The later

men present with their ED post-RP the worse their venous leak problem and

resultant structural changes and fibrosis in the penis. Early use of PDE5

inhibitors preserves penile processes in animal models. In 3 clinical trials

injection therapy and sildenafil improved erectile response. Biopsies of penile

tissue at 6 months post-RP in men treated with PDE5 inhibitors had preservation

of smooth muscle content. Smooth muscle preservation in both the corpora and

endothelium are the reasons that penile rehabilitation makes sense, he

concluded.

Dr.

Donatucci argued that the body of evidence supporting penile rehabilitation may

not be presently available. Effect in animals does not equate with the same

response in humans, and only focuses on a specific mechanism not the entire

system. Nerve sparing is not a standardized event and there is a lack of

standardized algorithms. Outcomes at specific centers can not be translated to

general populations. He showed clinical trials that were not positive between

on-demand and daily use of PDE5 drugs. There are 7 ongoing trials for penile

rehabilitation. Most are single investigator and not multi-center. Some are in

radiotherapy patients and not surgical series. He stated that there is not

enough evidence to support penile rehabilitation in an evidence-based fashion

at the present time.

Dr.

Mulhall rebuttaled that the lack of level 1 evidence based medicine does not

mean that we shouldn’t practice penile rehabilitation. Most studies in ED

are a translation from animal models, so he refuted that. ED is associated with

depression and reduced QOL and the practice is used by 87% of the members of

the Society of Sexual Medicine.

Dr.

Donatucci countered that we must be careful about the nuances of how our

literature is interpreted by the public. Outcomes of specific trials can not be

translated to all affected patients, he concluded.

Moderated

by Ira D. Sharlip, MD, at the Annual Meeting of the American Urological

Association (AUA) - May 17 - 22, 2008. Orange

County Convention

Center - Orlando,

Florida, USA.