Erectile Function Preservation and Rehabilitation

Abstract

Despite modified surgical techniques including nerve-sparing procedures radical prostatectomy (RP) is a significant source of long-term erectile function impairment which can be caused by cavernous nerve trauma, insufficient arterial inflow, hypoxia-related and neuropraxia-associated damage to erectile tissue resulting in veno-occlusive dysfunction. An increasing understanding of the pathophysiological mechanisms leading to post-RP erectile dysfunction (ED) has provided concepts for prophylaxis and rehabilitation of erectile function. Penile rehabilitation is the term given to the concept that we can use medications to prevent the structural damage that erectile tissue undergoes after radical pelvic surgery, while nerve recovery occurs. Rehabilitation revolves around two strategies, regular phosphodiesterase type 5 inhibitor (PDE5i) use and early postoperative erectile regeneration. The reason and the logical background to use the PDE5i drug category as prophylaxis for erectile function preservation after RP are not fully understood yet. Supported by experimental and clinical data the postulate is that PDE5i might have a positive effect on endothelial protection, neurogenesis, and cavernosal smooth muscle protection involving neuronal and endothelial regeneration, lowering apoptosis, and recovery of nocturnal erections thus inducing cavernosal oxygenation in an effort. to protect the erectile tissue. The current literature also sustains data that an early postoperative erection may optimize the functional rehabilitation by improving cavernosal oxygenation and preventing hypoxia-induced corporal fibrosis. Besides the oral use of PDE5i alternatives are available including transurethral suppositories, vacuum erection devices, and intracavernosal injections complementing the rehabilitation strategies. Based on the current evidence from human and animal studies there is a strong signal for a positive effect of a prophylactic penile rehabilitation after RP which may translate into greater preservation of erectile function. However, a formal analysis of what the optimal rehabilitation program represents, remains unsettled to date. Large prospective multi-center, randomized, placebo-controlled studies in the future will hopefully be able to answer question about an optimal dosing, a time frame for the application, duration and form of the use, and maybe differences between the different medications. Further, supportive managements including cavernous nerve reconstruction and neuroprotection stratagems are under investigation finding their place of value in the future. Comprehensively, for a sufficient erectile rehabilitation after RP it needs a well-informed patient who is highly motivated to follow a medical regimen and is willing to pay for it to maintain sexual quality of life after a potential curative cancer treatment.