Sidney Glina Faculdade de Medicina do ABC Instituto H. Ellis Editor-in-Chief of the International Brazilian Journal of Urology

Transcription

1 Sidney Glina Faculdade de Medicina do ABC Instituto H. Ellis Editor-in-Chief of the International Brazilian Journal of Urology (

2 Conflict of Interest: In the last 2 years I have been: - Speaker for Besins, Lilly, Aché, Eurofarma - Member of Advisory Board of Aché, Besins, EMS and Lilly

3 What Is True Rate of ED After Radial Prostatectomy? Literature Review Studies with 50 patients Limited to English Language ED Range % Burnett et al. J Urol 2007; 178:

4 Erectile function after radical prostatectomy Patient selection Low tumor volume Younger and pre-op potent patients Surgical technique

5 Erectile dysfunction in robotic radical prostatectomy Preservation of erectile function rates varied from 40% to 92.3% (SHIM > 21) in series of RALP. Whelan P, Ekbal S, Nehra A. Indian J Urol Oct;30(4):

6 Penile periferic neuroanatomy Campbell s 2002

7 Penile periferic neuroanatomy Campbell s 2002

8 Pathophysiology of ED after RP Neuropraxia of cavernous nerves(direct trauma, inflammation, heating, and ischemia) chronic absence of erections persisting flaccidity increased expression of TGF-β1, ET-1, NGF, and HIF- 1α) smooth muscle apoptosis and fibrosis impairment of the venous occlusive mechanism ED Fode M, Ohl DA, Ralph D, Sønksen J BJU Int Nov; 112(7):

9 Pathophysiology of ED after RP During (nocturnal) erections penis oxygenation rises from to mmhg. Arterial oxygenation levels are essential to keep production of NO Mulhall JP Curr Opin Urol Nov; 18(6):

10 Nocturnal erections after RP Rigiscan on the first night after catheter removal (14 o p.o.): Decrease of nocturnal erections of patients submitted to uni/bilateral nerve sparing RP Absence of nocturnal erections on patients submitted to non-nerve sparing RP Bannowsky A, Schulze H, van der Horst C, Hautmann S, Jünemann KP. BJU Int. 2008;101(10):

11 Erectile function after radical prostatectomy: an evolutionary phenomena.most men can not have an erection immediatelly after radical prostatectomy..many men require more than 2 years to satisfactorily recover erectile function. Rabbani F, Schiff J, Piecuch M, Yunis LH, Eastham JA, Scardino PT, Mulhall JP J Sex Med Dec; 7(12):

12 Penile Rehabilitation after Radical Prostatectomy Concept of rehabilitation: Maintenance of cavernous oxygenation Preservation of endothelial structure Prevention of smooth muscle structural alterations. Gandaglia G, Suardi N, Cucchiara V, Bianchi M, Shariat SF, Roupret M, Salonia A, Montorsi F, Briganti A. Transl Androl Urol. 2015;4(2):

13 Penile Rehabilitation after Radical Prostatectomy Penile rehabilitation is defined as the use of any intervention with the objective to achieve erections sufficient for satisfactory sexual intercourses (to return erectile function to preoperative levels). Gandaglia G, Suardi N, Cucchiara V, Bianchi M, Shariat SF, Roupret M, Salonia A, Montorsi F, Briganti A. Transl Androl Urol. 2015;4(2):

14 Ideal Penile Rehabilitation after Radical Prostatectomy Early reestablishment of daily erections! Intracavernosal PGE1 periodically (Everyday? Every other day?)

15 Intracavernous PGE1 after RP 30 patients with NSRP 30 p.o.: A-15 pts: PGE1 3x/w for 3 months B-15 pts: observation A: 67% recovered spontaneous erection. B: 20% recovered spontaneous erection Montorsi F et al Int J Impotence Res 1998

16 Intracavernous injections Disadvantadges Injection (high dropout rate) Pain (mainly post RP) Fibrosis

17 Penile Rehabilitation after Radical Prostatectomy: the case for PDE5-is Benefits of PDE-5is on penile rehab: Chronic administration of PDE5-Is to rats undergoing cavernous nerve injury might decrease erectile tissue fibrosis and apoptosis of smooth muscle Sildenafil administration has been found to affect the expression of several genes involved in smooth muscle preservation and to reduce oxidative stress Gandaglia G, Suardi N, Cucchiara V, Bianchi M, Shariat SF, Roupret M, Salonia A, Montorsi F, Briganti A. Transl Androl Urol. 2015;4(2):

18 Penile Rehabilitation after Radical Prostatectomy: the case for PDE5-is Benefits of PDE-5is on penile rehab: Prevention the degeneration of nervous tissue and stimulate neuroregeneration Increased amount of nerves has been observed after cavernous nerve injury in rats treated with sildenafil compared to their counterparts left untreated Gandaglia G, Suardi N, Cucchiara V, Bianchi M, Shariat SF, Roupret M, Salonia A, Montorsi F, Briganti A. Transl Androl Urol. 2015;4(2):

19 Clavell-Hernandez J, Wang R. Asian J Androl ;17(6):916-22

20 Efficacy and safety of phosphodiesterase type 5 (PDE5) inhibitors in treating erectile dysfunction after bilateral nerve-sparing radical prostatectomy Cui Y, Liu X, Shi L, Gao Z. Andrologia Feb;48(1):20-8.

21 Post-Radical Prostatectomy Pharmacological Penile Rehabilitation: Practice Patterns Among the International Society for Sexual Medicine Practitioners 301 physicians 41 countries (questionnaire) 82% urologists 65% Formal sexual medicine specialty training 44% Uro-oncology specialty training 60% Performed RPs. 87% performed some form of rehabilitation. (First Strategy) 95% PDE5-i 75% Intracavernosal injections 30% Vacuum device 9.9% Intraurethral prostaglandin. 54% immediately/just after urethral catheter removal 37% within the first 4 months after RP Teloken P, Mesquita G, Montorsi F, Mulhall J. J Sex Med 2009