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Erectile Dysfunction After Radical Prostatectomy: The Importance of Baseline Function and Surgical Techniques

This article explores the impact of radical prostatectomy on erectile function and the importance of considering baseline function and surgical techniques for better outcomes. It also discusses the neglected side effects and needs of patients, as well as the use of pills and penile rehabilitation. The overall worldwide change in surgical approach is highlighted, which has led to significant modifications in patient characteristics.

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Erectile Dysfunction After Radical Prostatectomy: The Importance of Baseline Function and Surgical Techniques

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  1. Disfunzione erettile dopo prostatectomia radicale TUTTO DA RIFARE? Andrea Salonia, MD, PhD, FECSM Università Vita-Salute San Raffaele Direttore, URI-Urological Research Institute Divisione di Oncologia Sperimentale/Unità di Urologia, IRCCS Ospedale San Raffaele

  2. THE SUSPICION-DIAGNOSIS-TREATMENT MODEL Salonia A & Montorsi F, ESSM 2012

  3. Preop normal Erectile Function: 101/234 (43%) Salonia A, et al. Eur Urol, 50:360-365, 2006

  4. Clinical experience suggests that patients view EF recovery as getting back to their baseline erectile functioning without the use of medication “BACK TO BASELINE” CONCEPT Mulhall JP, et al. J Sex Med, 7:1687-1698, 2010

  5. The vast majority of patients will regain Erectile function sufficient to engage in intercourse following LRP • Only a fraction, however, will return to their preoperative level of sexual function Levinson AW, et al. World J Urol, 29:29-34, 2011

  6. Brajtbord JS, et al. J Urol, 192:396-401, 2014

  7. SCANDINAVIAN PROSPECTIVE STUDY (vs AGE-MATCHED HEALTHY CONTROLS) 50% 34% 23% 26% Johansson et al. Lancet Oncol, 12:91–99, 2011

  8. Nubra Valley, Ladakh, 2006

  9. Efficacy of Sildenafil Citrate in Men With Erectile Dysfunction Following Radical Prostatectomy: A meta-analysis Overall response rates (and 95% CI) to sildenafil treatment after RP 35% Montorsi F, et al. J Sex Med 2:658-67, 2005

  10. p<0.0001 Montorsi F, et al, J Urol 172: 1036-42, 2004

  11. Safety and efficacy of vardenafil for the treatment of men with erectiledysfunctionafter radical retropubicprostatectomy p<0.0001 Brock G et al. J Urol, 170:1278-1283, 2003

  12. 298 men with ED ≥ 6 mo after RP treated with avanafil on demand (100 or 200mg) vs placebo for 30 wk After 12 weeks there were significantly greater increases in SEP2 and SEP3 and change in mean IIEF-EF domain score with 100 and 200 mg avanafil vs placebo (p:0.01) Mulhall JP, et al. J Urol 2013;189:2229-36

  13. TADALAFIL 20mg: 12 compresse

  14. TX group characteristics throghout the 18-mo FU ACCEPTANCE OF RATE: ONLY 51%!!!! OVERALL DISCONTINUATION RATE: 72.6% Salonia A, et al. Eur Urol 53:564-570, 2008

  15. 1 out of 5 patients discontinued the treatment Polito M, et al. BJU Int, 110:E954-7, 2012

  16. SURGICAL TECHNIQUE

  17. Moncada I, et al.. World J Urol, 33:1031-8, 2015

  18. REACTT – Tadalafil OaD contributes to the recovery of EF after RP Time to recovery • 25 % of patients achieved IIEF-EF ≥ 22 within 5.8 months with TAD OaD, 9.0 months for TAD PRN, and 9.3 months for placebo • The use of tadalafil OaD can significantly shorten the time to EF-recovery post-nsRP compared with placebo Moncada I, et al. World J Urol, 33:1031-8, 2015

  19. Functional & topographic anatomy of the prostate: what has changed? Walz J, et al. Eur Urol , 57:179-92, 2010 Salonia A, et al. Eur Urol, 62:261-72, 2012

  20. Systematic review and meta-analysis on functional outcomes after RARP The prevalence of ED according to different definitions was 47.8% after RRP and 24.2% after RARP The cumulative analysis showed a statistically significant advantage in favor of RARP (OR: 2.84; 95% CI, 1.48–5.43; p = 0.002) Ficarra V, et al, Eur Urol, 62:418-430, 2012

  21. PCa treatment – Robotic vs Open surgery • The vastmajority of data regarding EF recoverycomes from RCTsincludingmainlypatientstreated with ORP • Isroboticsurgerychanging the landscape in terms of rates and recovery from sexualdysfunctionafter RP? • Do weneed to reconceptualizedpenilerehabilitationin a new patientsetting? Capogrosso P & Salonia A, ESSM 2015; AUA2015; SIA2015; SIU2015

  22. ORGASMIC DYSFUNCTION AFTER ROBOT-ASSISTED VERSUS OPEN RADICAL PROSTATECTOMY Cox-regression analysis assessing predictors of recovery from climacturia Capogrosso P, et al. Eur Urol, 2015

  23. Kaplan-Meier curves predicting recovery from CLIMACTURIA in the overall population (1) and within treatment groups (2) • The log-rank test indicates the statistically significant difference across each group (p<0.01) • Kaplan-Meier curves predicting recovery from PAINFUL ORGASM in the overall population (a) and within treatment groups (b). • The log-rank test indicates a non statistically significant difference across each group (p=0.3) Capogrosso P, et al. Eur Urol, 2015

  24. ORGASMIC DYSFUNCTION AFTER ROBOT-ASSISTED VERSUS OPEN RADICAL PROSTATECTOMY • These findings showed that one third of patients submitted to RP reported climacturia • Recovery from climacturia was greater and faster following RARP than RRP, in • - patients undergoing a bilateral NS procedure • - patients who recovered satisfactory erectile functioning and urinary continence Capogrosso P, et al. Eur Urol, 2015

  25. SUM-UP • Baseline EF concept • Neglected side effects • Neglectedpatientsneeds • Pills & Nota 75 • Overallworldwidechange in surgicalapproachhaspromotesignificantoverallworldwidemodifications in patientscharacteristics

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