A prospective randomized controlled study on scheduled PDE5i and vacuum erectile devices in the treatment of erectile dysfunction after nerve sparing prostatectomy

Cavernous nerve injury is an important cause of erectile dysfunction(ED).Although protective nerve technology has been widely used in nerve-sparing radical prostatectomy(nsRP),the incidence of ED is still very high after surgery.The purpose of our study was to evaluate erectile function(EF)and penile length in the non-erectile state(PLNES)following scheduled phosphodiesterase 5 inhibitor(PDE5i),vacuum erectile device(VED)treatment,and combination therapy after nsRP.One hundred patients with localized prostate cancer and normal EF were randomized to scheduled PDE5i group,VED treatment group,a combined treatment group,and the control group without any intervention.The International Index of Erectile Function-5(IIEF-5)scores and PLNES were evaluated after 6 months and 12 months of treatment.Sexual Encounter Profile(SEP-Question 2 and SEP-Question 3)were evaluated after 12 months of treatment.Ninety-one of the 100 randomized patients completed the study.We found that the 5 mg tadalafil once a day(OaD)combined with VED can help improve IIEF-5 scores in nsRP patients after both 6 months and 12 months.VED alone or combined with tadalafil OaD can help patients maintain PLNES.VED combined with tadalafil OaD can improve the rate of successful penetration(SEP-Question 2)after 12 months.There were no significant differences in the return to target EF after 12 months among the groups.No significant correlation was noted between the variables and return to target EF(IIEF≥17),and between the variables and effective shortening of the patient’s penis(shortening≥1 cm)after 12 months of intervention.

Combination therapy for erectile dysfunction： an update review

The introduction of oral phosphodiesterase-5 inhibitors （PDE51s） in the late 1990s and early 2000s revolutionized the field of sexual medicine and PDE51s are currently first-line monotherapy for erectile dysfunction （ED）. However, a significant proportion of patients with complex ED will be therapeutic non-responders to PDE51 monotherapy. Combination therapy has recently been adopted for more refractory cases of ED, but a critical evaluation of current combination therapies is lacking. A thorough PubMed and Cochrane Library search was conducted focusing on the effectiveness of combination therapies for ED in therapeutic non-responders to PDE51 therapy. Journal articles spanning the time period between January 1990 and December 2010 were reviewed. Criteria included all pertinent review articles, randomized controlled trials, cohort studies and retrospective analyses. References from retrieved articles were also manually scanned for additional relevant publications. Published combination therapies include PDE51 plus vacuum erectile device （VED）, intraurethral medication, intracavernosal injection （ICI）, androgen supplement, a-blocker or miscellaneous combinations. Based on this review, some of these combination treatments appeared to be quite effective in preliminary testing. Caution must be advised, however, as the majority of combination therapy articles in the last decade have numerous limitations including study biases and small subject size. Regardless of limitations, present combination therapy research provides a solid foundation for future studies in complex ED management.

Value of phosphodiesterase 5 inhibitors as a combination therapy for treating erectile dysfunction:A literature review

Erectile dysfunction(ED)is increasing in prevalence,with estimates that 50%of men between 40 and 70 years of age suffer from the disease.Due to a wide array of available medical interventions,significant focus has been put on combination therapies that can treat ED refractory to first-line treatments such as phosphodiesterase 5 inhibitors(PDE5is).However,reviews evaluating monotherapy noninferiority and patient satisfaction of monotherapy versus combination therapy are lacking.A thorough PubMed search was performed to evaluate combination therapy in ED treatment.Articles published between January 2008 and June 2023 were reviewed,including randomized control trials,retrospective analyses,and cohort studies.Combination therapies included PDE5i plus another PDE5i,testosterone supplementation,α-blockers,vacuum erectile devices,intracavernosal injections,and low-intensity shockwave therapy.Based on this review,PDE5i monotherapy is not inferior to combination therapy and has increased satisfaction,convenience,and ease of use for patients with ED.Limitations of current literature on combination therapy include small sample size,limited data on patient satisfaction,possible biases,and limited follow-up time.Further studies will need larger randomized control trials with follow-up times greater than 1 year.

Vacuum therapy in penile rehabilitation after radical prostatectomy： review of hemodynamic and antihypoxic evidence

Generally, hypoxia is a normal physiological condition in the flaccid penis, which is interrupted by regular nocturnal erections in men with normal erectile function.1 Lack of spontaneous and nocturnal erections after radical prostatectomy due to neuropraxia results in persistent hypoxia of cavernosal tissue, which leads to apoptosis and degeneration of cavernosal smooth muscle fibers. Therefore, overcoming hypoxia is believed to play a crucial role during neuropraxia. The use of a vacuum erectile device （VED） in penile rehabilitation is reportedly effective and may prevent loss of penile length. The corporal blood after VED use is increased and consists of both arterial and venous blood, as revealed by color Doppler sonography and blood gas analysis. A similar phenomenon was observed in negative pressure wound therapy （NPWT）. However, NPWT employs a lower negative pressure than VED, and a hypoperfused zone, which increases in response to negative pressure adjacent to the wound edge, was observed. Nonetheless, questions regarding ideal subatmospheric pressure levels, modes of action, and therapeutic duration of VED remain unanswered. Moreover, it remains unclear whether a hypoperfused zone or PO2 gradient appears in the penis during VED therapy. To optimize a clinical VED protocol in penile rehabilitation, further research on the mechanism of VED, especially real-time PO2 measurements in different parts of the penis, should be performed.