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Pharmacological Penile Rehabilitation Following Radical Prostatectomy: Where Do We Stand Today?
High survival rates in men undergoing radical prostatectomy (RP) have increased the attention given to and the perceived significance of erectile dysfunction (ED) in this population. ED has a significant negative impact on the patient's quality of life and self-esteem. A number of pathophysiologic mechanisms have been implicated in ED following RP, and nerve-sparing techniques do not appear to be sufficient to prevent sexual impairment. Even among men in whom bilateral nerve sparing is achieved, erectile function may take up to 24 months to return. Aiming to decrease the time to recovery of spontaneous erections after RP, Montorsi and colleagues in 1997 pioneered the use of early intracavernosal injections of alprostadil for penile rehabilitation. The overall concept of penile rehabilitation is to prevent cavernous tissue damage during neural recovery, in part by providing adequate oxygenation to the cavernous tissues. The Montorsi study prompted further interest in early intervention to ensure the recovery of penile erections, and the next logical step was to look at oral pharmacotherapy to restore nocturnal erections as another way to increase oxygenation of the cavernosal bodies. Although evidence from studies on penile rehabilitation after RP supports the tissue oxygenation concept, the rationale and mechanism for its use in penile rehabilitation programs has not been fully elucidated nor have results been replicated in large multicenter placebo-controlled trials.
Additional studies are currently being conducted to assess the ability of locally administered alprostadil to increase tissue oxygenation, decrease the time required for return of erectile function, and particularly restore function to a level close to that experienced presurgery.
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