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Erectile Dysfunction Post Radical Cystectomy. The Role of Early Rehabilitation with Pharmacotherapy in Nerve Sparing and Non-Nerve Sparing Group: A Randomized, Clinical Trial - Beyond the Abstract

No clinical studies testing erectile function (EF) post radical cystectomy (RC) were done. Our study objective was to assess the effect of early pharmacologic therapy after RC using intracorporeal injection (ICI), phosphodiesterase inhibitor (PDE5i), and PDE5i+ICI. In our randomized, double-blinded study, we prospectively enrolled 160 potent male patients with invasive bladder cancer. Patients were operated by RC using the nerve-sparing (NS) or non-nerve sparing (NNS) technique. They were treated for 1 month postoperatively by different regimens (PDE5i vs. ICI vs. ICI+PDE5i). Patients were evaluated using the international index of erectile function questionnaire and were followed up regularly at 1, 3, 6, and 12 months using the same parameters. One month after therapy, the mean of EF domain improved in both NS and NNS groups. In the NNS group, in patients treated with ICI alone and ICI+PDE5i, the EF domain at 12 months moved to the moderate and to the mild category respectively. In patients treated by the NS approach, the mean value remained in the mild category with or without therapy.1


As following other pelvic surgeries, erectile dysfunction (ED) associated with RC can be managed with PDE5i, ICI, transurethral suppositories, or vacuum pump devices. Among patients for whom medical therapy is not effective, surgical management with penile prosthesis placement is an alternative effective.2

Similar to what occurred in surgical prostate cancer, better screening and monitoring protocols for bladder cancer will cause stage migration and provide earlier indications for RC. Removing earlier staged diseases will make more patients eligible for nerve-sparing procedures.3 Also, the type of urinary diversion post RC could affect EF.  In a study, authors find significant differences in EF and sexual desire domains between the ileal conduit and orthotopic ileal neobladder diversion groups. Therefore, orthotopic ileal neobladder is the best option especially in younger patients requiring RC.4 Loh-Doyle et al published the first series to describe the perception of penile length loss after RC. They concluded that the perception of penile length loss is a commonly held belief in patients after RC, and many patients will perceive losses that exceed 1 inch (2.54 cm).5 There is a need for more trials that assess the optimal delivery of care after RC because EF could have a significant impact on the quality of life of patients.

Written by: Mohamad Moussa,1 Mohamad Abou Chakra,2  Athanasios Dellis,3 Athanasios Papatsoris4

  1. Chairman of Surgery&Urology Department, Faculty of Medicine, Lebanese University, Al Zahraa Hospital, Beirut, Lebanon.
  2. Department of Urology, Faculty of Medicine,  Lebanese University, Beirut, Lebanon.
  3. Department of Urology/General Surgery, Areteion Hospital, Athens, Greece
  4. 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece


References:

  1. Moussa M, Papatsoris A, Abou Chakra M, Dellis A. Erectile dysfunction post radical cystectomy. The role of early rehabilitation with pharmacotherapy in nerve sparing and non-nerve sparing group: A randomized, clinical trial. Arch Ital Urol Androl. 2021;93(1):58-64.
  2. Modh RA, Mulhall JP, Gilbert SM. Sexual dysfunction after cystectomy and urinary diversion. Nat Rev Urol. 2014;11(8):445-53.
  3. Zippe CD, Raina R, Massanyi EZ, et al. Sexual function after male radical cystectomy in a sexually active population. Urology. 2004;64(4):682-5; discussion 685-6.
  4. Asgari MA, Safarinejad MR, Shakhssalim N, Soleimani M, Shahabi A, Amini E. Sexual function after non-nerve-sparing radical cystoprostatectomy: a comparison between ileal conduit urinary diversion and orthotopic ileal neobladder substitution. Int Braz J Urol. 2013;39(4):474-83.
  5. Loh-Doyle JC, Han J, Ghodoussipour S. Factors Associated With Patient-Reported Penile Length Loss After Radical Cystoprostatectomy in Male Patients With Bladder Cancer. J Sex Med. 2020;17(5):957-963.


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