Medline on treating male impotence after severing the nerves to the prostate

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Hi All,

 

I wrote:

> Normal erection is due to autonomically controlled vascular congestion

> of the penile vessels and corpora cavernosa. With no functional

> autonomic control, [normal] erections are not possible. Temporary

> compression of venous return may give a partial erection but the

> methods needed would discourage most men. Viagra ...

 

I sent the earlier mail without commenting on the role of Viagra

(sildenafil) and other WM treatments of male impotence. SOME

impotent men can get benefit from high-tech WM treatment post-

surgery.

 

A scan of Medline abstracts suggests:

 

(1) Some men with prostate enlargement (esp prostate cancer that

needs radical resection) are impotent BEFORE surgery. A test of

Viagra, or other WM drugs, (for example intrapenile injections, or

medicated urethral system for erection (MUSE)) can be done to see if

these can give erections sufficient for normal intercourse.

 

Some men who can achieve reasonable erections in that way have a

good prognosis for post-surgical potency, even after radical (non-nerve-

sparing) prostate surgery:

 

2) However, even with WM intervention, the boost of erectile strength

(even in those men who have some degree of erection) is modest.

Therefore, expert counselling of the men AND their partners in Master-

Class sexual technique is likely to improve matters. For example, a

partner who shows loving interest, expressed by active and expert

sexual stimulation of the impotent male, can expect a better response

to male medication than one who offers an orifice but proceeds to

snore, or who clearly would prefer no sexual contact.

 

Some relevant abstracts follow. For more detail, see Medline abstracts

for the profile (viagra AND erection AND radical prostat*) at

http://tinyurl.com/9szkc:

 

Trinchieri A, Nicola M, Masini F, Mangiarotti B. (2005) Prospective

comprehensive assessment of sexual function after retropubic non

nerve sparing radical prostatectomy for localized prostate cancer.Arch

Ital Urol Androl. Dec;77(4):219-23. Urology Unit Ospedale A. Manzoni

Lecco, Italy. a.trinchieri OBJECTIVES: This

prospective study was undertaken to assess sexual function according

to a multidisciplinary comprehensive approach in patients with localized

prostate cancer who were treated with radical prostatectomy.

MATERIALS AND METHODS: Patients with localized prostate cancer

scheduled to undergo retropubic radical non nerve sparing

prostatectomy participated to the study. International Index of Erectile

Function (IIEF) and Self-rating Depression Scale (SDS) questionnaires

were administered and patients were interviewed by a psychologist

about their sexualfunction before and 1 month and 3 months after

surgery and underwent nocturnal penile tumescence (NPT) monitoring

for 3 nights before and 3 months after radical prostatectomy. After

surgery patients were offered sexual counselling and were encouraged

to experiment with oral treatment for erectile dysfunction. At 24 month

follow up patients were interviewed asking for information PSA value,

continence and sexual status. RESULTS: At basal IIEF score showed

erectile dysfunction at various degree in 40%, SDS score demonstrated

a mild depression in 10% and NPT tests showed a number or erectile

episodes less than 3 in 30%, a total time of erection less than 60

minutes in 43% and a degree of rigidity less than 70% in 66%. IIEF

scores were inversely related to SDS scores (r = -0.43, p < 0.012) and

SDS scores were inversely related to time of erection at NPT (r = -0.44,

p = 0.016). The mean basal IIEF score was significantly higher than the

1-month IIEF (p = 0.000) and 3-month IIEF score (p = 0.001) and the

mean basal SDS score was significantly higher than the 3-month SDS

score (p = 0.011). The mean degree of erections (p = 0.000), total time

of erection (p = 0.004) and degree of erection (p = 0.003) at basal were

significantly higher than at 3-month follow up. At 24 month follow up five

patients replied that they were not able to achieve any erection (group

A), 4 were able to achieve an erection only after intracorporeal injection

of prostaglandins (group B), 3 were able to achieve erection after oral

treatment with sildenafil and only one stated to be able to achieve

spontaneously an erection sufficient to sexual intercourse (group C).

The mean values of basal IIEF and SDS score at basal and the degree

of erection at basal were not significantly different in the three groups

whereas the mean number of erections and the mean total time of

erection at basal NPT tests were significantly higher in group C than in

group A and B. CONCLUSION: Severe erectile dysfunction was

observed in most patients after retropubic radical non nerve sparing

prostatectomy, but 50% of candidates for radical treatment presents

with abnormal erectile function before surgery when appropriately

studied. Patients who will recover erectile function could be identified by

NPT test before surgery. Depression associated with the fear for

intervention is related with erectile dysfunction measured by IIEF scores

before surgery, but depression index scores improve after surgery

showing that the role of depression in the maintenance of erectile

dysfunction is marginal. Sexual counselling and oral treatment facilitate

recovery after surgery in patients with optimal erectile function before

treatment. PMID: 16444937 [PubMed - in process]

 

Montorsi F, McCullough A. (2005) Efficacy of sildenafil citrate in men

with erectile dysfunction following radical prostatectomy: a systematic

review of clinical data. J Sex Med. Sep;2(5):658-67. Department of

Urology, Universita Vita Salute San Raffaele, Via Olgettina 60, Milan

20132, Italy. montorsi.francesco INTRODUCTION: Radical

prostatectomy is a frequently used treatment option for prostate cancer;

however, prostatectomy is often associated with significant morbidity,

including erectile dysfunction (ED). AIM: To analyze the efficacy of

sildenafil citrate in treating ED after radical prostatectomy. MATERIALS

AND METHODS: MEDLINE and CANCERLIT (1998 to January 2004)

were searched for English language articles using the key words

prostatectomy, sildenafil, and phosphodiesterase inhibitors. Eleven

studies fulfilled the inclusion criteria: primary, discrete data sets of

postprostatectomy patients with ED treated with sildenafil monotherapy.

RESULTS: Sample sizes ranged from 13 to 198 (mean age, 61 +/- 3

years). Treatment durations were 4 weeks (or more than four doses) to

1 year, and sildenafil dosing was in the recommended range (25-100

mg). Seven studies reported a response rate (range, 14%-53%) for an

end point consistent with the primary analysis outcome (erection

sufficient for vaginal intercourse); the combined estimate of probability

of response was 35% (95% confidence interval [CI], 24%-48%). There

was strong evidence for a lower response rate after non-nerve-sparing

(range, 0%-15%) versus nerve-sparing surgery (range, 35%-75%;

combined odds ratio [OR] = 12.1; 95% CI, 5.5-26.6) but not after

unilateral (range, 10%-80%) versus bilateral nerve-sparing surgery

(range, 46%-72%; combined OR = 2.21; 95% CI, 0.75-6.54).

CONCLUSIONS: The results of these studies demonstrate that with

sildenafil, more than one third of patients with postprostatectomy ED

achieved erection sufficient for intercourse. The odds of responding

improved 12-fold with preservation of at least one neurovascular

bundle. Early treatment failure does not necessarily imply lack of

efficacy in the future, and patients should be encouraged to continue

trying sildenafil, titrating up to 100mg as needed. PMID: 16422824

[PubMed - in process]

 

Raina R, Nandipati KC, Agarwal A, Mansour D, Kaelber DC, Zippe CD.

(2005) Combination therapy: medicated urethral system for erection

enhances sexual satisfaction in sildenafil citrate failure following nerve-

sparing radical prostatectomy.J Androl. Nov-Dec;26(6):757-60. Center

for Advanced Research in Human Reproduction, Infertility, and Sexual

Function, Cleveland Clinic Foundation, OH 44105, USA.

rraina The objective of our study was to assess the

effectiveness of combining medicated urethral system for erection

(MUSE) with sildenafil citrate in men unsatisfied with the sildenafil

alone. Baseline and follow-up data from 23 patients (mean age, 62.5 +/-

5.23 years) unsatisfied with the use of the sildenafil citrate alone for the

treatment of erectile dysfunction following nerve-sparing radical

prostatectomy (mean use, 4 attempts/100-mg dose) was obtained. All

patients started oral sildenafil citrate more than 6 months after radical

prostatectomy. Combination therapy was initiated using 100 mg

sildenafil citrate orally 1 hour prior to intercourse. Patients used

combination therapy for a minimum of 4 attempts prior to assessment

with the Sexual Health Inventory of Men (International Index for Erectile

Function-5) and visual analog scale to gauge rigidity (0-100). The effect

of therapy on the total International Index for Erectile Function (IIEF)

score and penile rigidity score was assessed. Of the 23 patients, 4

(17%) had no improvement with the addition of medicated urethral

system for erection and discontinued the drug, while 19 (83%) reported

improvement with the penile rigidity and sexual satisfaction. The IIEF

scores of these 19 patients showed significant improvements in each

sexual domain, and the patients reported that erection was sufficient for

vaginal penetration 80% of the time. Rigidity scores on a scale of 0-100

with sildenafil alone averaged 38% (23-53) for men and 46% (26-67) for

their partners. With the addition of MUSE, scores increased to 76% for

men and 62% for their partners. We conclude that the addition of MUSE

to sildenafil improved sexual satisfaction and penile rigidity in patients

unsatisfied with sildenafil alone. PMID: 16291971 [PubMed - in process]

 

Stephenson RA, Mori M, Hsieh YC, Beer TM, Stanford JL, Gilliland FD,

Hoffman RM, Potosky AL. (2005) Treatment of erectile dysfunction

following therapy for clinically localized prostate cancer: patient reported

use and outcomes from the Surveillance, Epidemiology, and End

Results Prostate Cancer Outcomes Study. J Urol. Aug;174(2):646-50;

discussion 650. Division of Urology, Univ of Utah School of Medicine,

Salt Lake City, Utah 8411132, USA. robert.stephenson

PURPOSE: Erectile dysfunction (ED) persists for years following

curative therapies for clinically localized prostate cancer. We report use

and treatment outcomes in a 5-year interval in a population based

cohort from the Surveillance, Epidemiology, and End Results Prostate

Cancer Outcomes Study. MATERIALS AND METHODS: A sample of

1,977 men with localized prostate cancer who received external beam

radiation therapy or radical prostatectomy in 1994 to 1995 were

surveyed for 5 outcome measures of ED treatment, namely treatment,

perceived helpfulness, erectile sufficiency, sexual activity frequency and

erection maintenance. Subjects were surveyed 6, 12, 24 and 60 months

after prostate cancer diagnosis. RESULTS: Overall 50.5% of men ever

used ED treatment. The use of ED treatments increased during the

study course. Subject age, regular sexual partner and baseline sexual

activity were factors positively associated with ED treatments. While it

was used uncommonly (1.9%), a penile prosthesis was perceived as

the most helpful ED treatment (helped a lot in 52% of respondents).

Sildenafil helped a lot in 12% of respondents. Erectile fullness, erection

maintenance and sexual activity frequency were modestly improved in

men using ED treatment compared with those in men not using ED

treatment. CONCLUSIONS: Approximately 50% of patients in this

population based cohort of men used ED treatment during the 5 years

after prostate cancer diagnosis. Men using ED treatments had modest

improvement in sexual function compared with men that in who did not

receive ED treatment at 60 months. More effective treatments for ED

following local therapy for prostate cancer are needed. PMID: 16006930

[PubMed - indexed for MEDLINE]

 

Porpiglia F, Ragni F, Terrone C, Renard J, Musso F, Grande S, Cracco

C, Ghignone G, Scarpa RM. (2005) Is laparoscopic unilateral sural

nerve grafting during radical prostatectomy effective in retaining sexual

potency? BJU Int. Jun;95(9):1267-71. Division of Urology, Department

of Clinical and Biological Sciences, University of Turin 'San Luigi'

Hospital, Turin, Italy. porpiglia OBJECTIVES: To present a

pilot study of laparoscopic unilateral sural nerve grafting during radical

prostatectomy, with the aim of preserving sexual potency. PATIENTS

AND METHODS: Because they had localized prostate cancer, 29 men

had a laparoscopic radical prostatectomy with deliberate wide unilateral

neurovascular bundle resection and preservation of the contralateral

bundle. Fifteen men (group A) had an interposition sural nerve graft on

the sectioned bundle, and 14 (group B) had laparoscopic radical

prostatectomy with preservation of the unilateral bundle only. The men

were also involved in a rehabilitation programme, and erectile function

was evaluated after surgery, and at 3, 8, 12 and 18 months, using the

five-item version of the International Index of Erectile Function (IIEF-5)

questionnaire. RESULTS: The two groups had similar clinical

characteristics (age, prostate-specific antigen level, body mass index,

prostate volume, clinical stage, Gleason score before and after surgery,

postoperative stage). The follow-up was complete for 12 men in group

A and 10 in group B. Group A had significantly higher erectile function

scores on the IIEF-5 at 12 and 18 months than immediately after

surgery (P < 0.01), whereas in group B the improvement was not

statistically significant. Overall, by 18 months after surgery five of 12

men in group A had achieved spontaneous unassisted erection or

erection assisted with sildenafil, while three of 10 in group B achieved

an erection assisted with sildenafil (not significant). CONCLUSIONS:

These data suggests that laparoscopic sural nerve grafting during

radical prostatectomy is feasible and safe; nevertheless we cannot

conclude that sural nerve grafting is more effective than preserving the

neurovascular bundle alone in retaining sexual potency. More research

is required to validate the effectiveness of this technique. Publication

Types: Evaluation Studies PMID: 15892814 [PubMed - indexed for

MEDLINE]

 

 

Best regards,

 

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