Sexual Function After Surgery for Prostate or Bladder Cancer

Alejandro J. Miranda-Sousa, MD; Hugo H. Davila, MD; Jorge L. Lockhart, MD; Raul C. Ordorica, MD; Rafael E. Carrion, MD

Disclosures

Cancer Control. 2006;13(3):179-187. 

In This Article

Therapy for Sexual Dysfunction

Male Erectile Dysfunction

Several treatment modalities are available to manage sexual dysfunction ( Table 2 ). First-line therapies include patient education, lifestyle modification, psychotherapy, oral therapy, and the use of a vacuum device. Second- line therapies include intraurethral alprostadil and intracavernous injection therapy, and third-line options include penile prosthesis implantation.

One group of oral agents is composed of the selective inhibitors of phosphodiesterases type-5 (PDE-5), the enzyme that breaks down the intracellular second messenger of erection,cGMP. When nitric oxide enters a vascular smooth-muscle cell, it triggers a cascade of reactions leading to the production of cGMP and subsequent smooth-muscle relaxation. The breakdown of these second messengers (cAMP and cGMP) is regulated by the set of enzymes known as PDEs (Fig 2). Thus, these oral agents enhance the natural effects of nitric oxide on corporal arterial and sinusoidal smooth muscle by inhibiting catabolism of cGMP by PDE-5.[13,64]

For neurogenic causes of erectile dysfunction, the nerve-sparing techniques and PDE-5 inhibitors have been shown to improve the degree of erectile function. One study[65] evaluated sexual function in a series of patients who underwent a variety of nerve-sparing radical prostatectomies. Then, if indicated, they received either of two different doses of sildenafil citrate postoperatively. The authors reported that successful treatment of erectile dysfunction with sildenafil citrate after radical prostatectomy was dependent on the presence of the neurovascular bundles. Patients who underwent bilateral nerve-sparing techniques performed better than those undergoing unilateral or no nerve-sparing procedures. The response to sildenafil citrate was not related to the interval between the surgery and initiation of drug therapy but was related to dose.[65] Other studies have reported preservation of sexual function in 70% to 80% of patients treated with sildenafil citrate following radical prostatectomy.[66,67] Vardenafil after nerve-sparing radical retropubic prostatectomy improved erection in 71.1% and 59.7% of patients taking 20 mg and 10 mg of vardenafil, respectively, during 12 weeks compared with 11.5% in the placebo group.[68] A study evaluating tadalafil in the postprostatectomy patient showed similar efficacy.[69]

A recent study by Schwartz et al[70] evaluated the histologic effects of adding sildenafil citrate during the postoperative course in prostatectomy patients. Sildenafil was given to 40 potent volunteers who were given either 50 mg or 100 mg of sildenafil citrate every other night for 6 months beginning the day of Foley catheter removal after radical retropubic prostatectomy. A statistically significant increase in mean smoothmuscle content was seen in the high-dose group (56.85%) compared with the low-dose group (42.82%) (P < .05). The authors concluded that at higher doses following retropubic prostatectomy, sildenafil may increase smooth-muscle content. The effect on the return of potency is not known, but maintaining the pro-erectile ultrastructure is an integral part to rehabilitating erectile function following retropubic prostatectomy.[70] Therefore, it is appropriate to consider use of any of these oral agents to preserve the pro-erectile cyto-ultrastructure before and after surgery for bladder and prostate cancer.[71]

Intraurethral therapy with alprostadil, the synthetic formulation of prostaglandin PGE1), involves inserting a vasodilatory agent into the urethra. The drug diffuses from urethra to the corpus spongiosum and then to the corpus cavernosum through venous channels. To assess the role of postoperative alprostadil in patients following prostatectomy, a study from the Walter Reed Medical Center[72] evaluated prostatectomy patients who received doses of transurethral alprostadil in the clinic. Patients for whom a suitable dose was determined received treatment at home with active drug or placebo for 3 months. Of the 384 patients in whom radical prostatectomy was identified as a cause of erectile dysfunction, 70.3% had an erection believed sufficient for intercourse in the clinic, and 57.1% on active medication had sexual intercourse at least once at home. The overall success rate (ie, the likelihood of active treatment to lead to intercourse at home) was 40.1%. A more recent study[73] reported consistent efficacy of medicated urethral system for erection in the postprostatectomy patients regardless of the nervesparing status.

Intracavernous injections involve direct injections of papaverine, phentolamine, and alprostadil separately or in combination. The molecular mechanism of action is through inhibition of PDE-5, leading to increased cAMP and cGMP in penile erectile tissue. Advantages are high efficacy and stability at room temperature. Disadvantages include priapism (0% to 35%) and corporeal fibrosis (1% to 33%, mainly due to papaverine). Montorsi et al[74] evaluated the recovery of sexual function with postoperative intracavernosal injections of PGE-1 in prostatectomy patients. The recovery rate of spontaneous erections in patients who had early institution of postoperative PGE-1 injections was higher than those who did not. This small study prompted investigators to seek other erectile rehabilitation regimens in order to maximize the return of normal sexual function following radical prostatectomy and radical cystectomy. The concept of penile or erectile rehabilitation involves managing patients on a long-term basis involving one or more of the treatment modalities described.

The vacuum constriction device (also known as vacuum erection device, VED) consists of a plastic cylinder connected directly to a vacuum-generating source (manual or battery-operated pump). After the penis is engorged by the negative pressure, a constricting ring is applied to the base to maintain the erection. Combining intracorporeal injection with the VED may enhance the degree of tumescence.[75] A study evaluating the use of VED after radical prostatectomy showed that 92% responded to the VED (with an erection sufficient for vaginal penetration), but only 14% agreed to continue it at home.[76]

The penile prosthesis remains one of the most effective treatments for all types of erectile dysfunction, especially after cavernosal nerve damage. Patient and partner satisfaction rates with the penile prostheses generally range from 60% to 80%,[77] but a common postoperative complaint is inadequate penile length. Other disadvantages of this treatment modality are the invasiveness of the procedure and inherent surgical risks.

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