Prospective analysis of penile length changes after radical prostatectomy

Advancing Precision in Penile Length Measurement: Evidence-based Synthesis of Stretched Penile Length INdicator Technique (SPLINT)

Purpose

The purpose of this study was to synthesize evidence and propose a technique for estimation of stretched penile length (SPL) applicable to children.

Materials and Methods

This review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. PubMed, Embase, and Scopus databases were queried on penile length (PL) measurement techniques in humans published from 1990 onward. The devices and the techniques used for PL measurement, state of the penis, the habitus of the participants, proximal and distal landmarks for measurement, handling the foreskin and pubic pad of fat, optimal stretching of the penis, and other factors (including the environment) which should be accounted for in the technique were identified from the study cohort (90895 participants across 145 included studies).

Results

PL has been represented through flaccid (33.79%), stretched (81.3%), and erect (12.41%) PLs as well as the greatest corporeal length (1.4%). Following devices have been used to measure the PL in the study cohort: rulers [54.68%], calipers [9.7%], measuring tapes [14.5%], coloured measuring strips [2.06%], spatulas/tongue depressors [11.03%], FitKit, syringe [1.4%], cotton swab (and ruler), titan cylinders, slide gauge and ultrasonography [1.37%]. The factors relevant to SPL measurement have been incorporated into the proposed SPL INdicator Technique (SPLINT) which is essentially a holistic extension of the "Conventional PL Measurement" technique.

Conclusions

There is a wide range of heterogeneity in the technique for estimation of PL across the study cohort; the underlying factors have been identified along with the respective variables, and the SPLINT for SPL has been described.

Worldwide Temporal Trends in Penile Length: A Systematic Review and Meta-Analysis

PURPOSE

Normative male genital measurements are clinically useful and temporal changes would have important implications. The aim of the present study is to characterize the trend of worldwide penile length over time.

MATERIALS AND METHODS

A systematic review and meta-analysis using papers from PubMed, Embase, and Cochrane Library from inception to April 2022 was performed. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Pooled means and standard deviations for flaccid, stretched, and erect length were obtained. Subgroup analyses were performed by looking at differences in the region of origin, population type, and the decade of publication. Metaregression analyses were to adjusted for potential confounders.

RESULTS

Seventy-five studies published between 1942 and 2021 were evaluated including data from 55,761 men. The pooled mean length estimates were flaccid length: 8.70 cm (95% CI, 8.16-9.23), stretched length: 12.93 cm (95% CI, 12.48-13.39), and erect length: 13.93 cm (95% CI, 13.20-14.65). All measurements showed variation by geographic region. Erect length increased significantly over time (QM=4.49, df=2, p=0.04) in several regions of the world and across all age groups, while no trends were identified in other penile size measurements. After adjusting for geographic region, subject age, and subject population; erect penile length increased 24% over the past 29 years.

CONCLUSIONS

The average erect penis length has increased over the past three decades across the world. Given the significant implications, attention to potential causes should be investigated.

Robot assisted laparoscopic radical prostatectomy with maximal urethral length preservation technique preserves penile length

Penile shortening is a recognized but neglected side effect of prostate cancer treatment. In this study we explore the effect of maximal urethral length preservation (MULP) technique on penile length preservation after robot assisted laparoscopic prostatectomy (RALP). In an IRB approved study, we prospectively evaluated the stretched flaccid penile length (SFPL) pre and post RALP in subjects with a diagnosis of prostate cancer. The multiparametric MRI (MP-MRI) was utilized for surgical planning if available preoperatively. Repeated measures t-test, linear regression and 2-way ANOVA analyses were performed. A total of 35 subjects underwent RALP. Mean age was 65.8 yr (SD: 5.9), preoperative SFPL was 15.57 cm (SD: 1.66) and postoperative SFPL was 15.41 cm (SD: 1.61) p = 0.68. No change in the postoperative SFPL was recorded among 27 subjects (77.1%) while 5 subjects (14.3%) had 0.5 cm shortening, and 3 subjects (8.6%) had 1 cm shortening. Pathologic stage, preoperative MP-MRI and body mass index (BMI) were significant predictors of postoperative SFPL on linear regression analysis, p = 0.001. Among 26 subjects with pathologic stage 2 disease, no statistical difference was seen in repeated measures t-test between pre and postoperative SFPL, 15.36 vs 15.3 cm, p = 0.08. All subjects were continent by 6 months postoperatively, with no complications. We demonstrate that incorporating MULP technique and preoperative MP-MRI preserves SFPL in subjects undergoing a RALP.

Penile Rehabilitation after Prostate Cancer Treatment: Which Is the Right Program?

The management of sexual complications after treatment of localized prostate cancer, such as erectile dysfunction, changes in the length of the penis, pain during sexual intercourse, and lack of orgasm, is still an unsolved problem with an important impact on patients’ quality of life. In this review, we summarize the current scientific literature about the rehabilitation of erectile dysfunction after prostate cancer treatment. The therapy for penile rehabilitation includes different types of treatments: the combination of phosphodiesterase type 5 inhibitors (PDE5-I) and the vacuum erectile device (VED) are considered first-line treatment options. When therapy begins, the duration of treatment, the dosage and the drug used all play very important roles in the treatment outcome. Intracavernous injection (ICI) therapy represents the second-line option for patients ineligible for PDE5-I therapy. Technological development has led to the emergence of devices for the stimulation of the penis without the use of drugs, such as penile vibratory stimulation (PVS) for stimulation of ejaculation in spinal cord injury and low-intensity extracorporeal shockwave therapy (LIESWT). The rapid diffusion of the latter, thanks to its easy use, attains good results without side effects. The panorama of penile rehabilitation after PC treatments is vast and many studies are needed, especially on new technologies, to find the best therapeutic regimen possible, personalized to the patient’s characteristics and the type of treatment for PC.

Impact of Pelvic Anatomical Changes Caused by Radical Prostatectomy

Simple Summary

After radical prostatectomy, the pelvic anatomy is altered such that the postoperative structure differs from the preoperative one, resulting in a variety of complications. In this review, the complications and mechanisms of pelvic anatomical changes associated with radical prostatectomy, as well as countermeasures, are outlined. An analysis of the anatomical mechanisms that cause complications after radical prostatectomy using imaging and other modalities is in progress. In addition, many surgical techniques that ensure the prevention of postoperative complications have been reported, and their usefulness has been evaluated. The preservation of as much periprostatic tissue and periprostatic structures as possible may lead to favorable postoperative functions, as long as the cancer condition permits.

Abstract

During radical prostatectomy, the prostate is removed along with the seminal vesicles, and the urinary tract is reconstructed by dropping the bladder onto the pelvic floor and suturing the bladder and urethra together. This process causes damage to the pelvic floor and postoperative complications due to the anatomical changes in the pelvic floor caused by the vesicourethral anastomosis. Urinary incontinence and erectile dysfunction are major complications that impair patients’ quality of life after radical prostatectomy. In addition, the shortening of the penis and the increased prevalence of inguinal hernia have been reported. Since these postoperative complications subsequently affect patients’ quality of life, their reduction is a matter of great interest, and procedural innovations such as nerve-sparing techniques, Retzius space preservation, and inguinal hernia prophylaxis have been developed. It is clear that nerve sparing is useful for preserving the erectile function, and nerve sparing, urethral length preservation, and Retzius sparing are useful for urinary continence. The evaluation of pre- and postoperative imaging to observe changes in pelvic anatomy is also beginning to clarify why these techniques are useful. Changes in pelvic anatomy after radical prostatectomy are inevitable and, therefore, postoperative complications cannot be completely eliminated; however, preserving as much of the tissue and structure around the prostate as possible, to the extent that prostate cancer control is not compromised, may help reduce the prevalence of postoperative complications.

Mapping the prevalence and use of questionnaires to detect the neglected sexual side effects after prostate cancer treatment: a scoping review

BACKGROUND

Early prostate cancer (PCa) treatment interventions may leave men with debilitating sexual side effects, especially when not diagnosed or present at initial follow-up treatment. Men are often embarrassed to disclose their sexual dysfunction. This may lead to sexual side effects related to PCa treatment remaining untreated, adding to their burden of disability. This study was conducted to map the evidence on the prevalence of neglected sexual side effects (NSSE) after radical prostatectomy (RP) surgery or radiation treatment (RT) for PCa treatment and the reported use of questionnaires to identify such side effects.

METHODS

This systematic scoping review's search strategy involved searching MEDLINE/PubMed, Science Direct and Google Scholar databases. Guided by eligibility criteria, two independent reviewers conducted title, abstract and full-text screening. Data from the included studies were extracted. The review team explored the implications of the findings in relation to the research question and aims of the study. The Mixed Method Appraisal Tool was used to appraise the quality of the included studies. This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

Searches of the databases identified 1369 articles, with 23 eventually included for review. The prevalence of NSSE ranged between 0 and 78% in studies reporting on early PCa treatment of RP and RT patients. Orgasmic dysfunction (5-78%), penile curvature changes (10-15.9%) and penile length shortening (0-55%) similarly showed a low to moderate prevalence. Climacturia had low prevalence (4-5.2%) after RT and moderate prevalence (21-38%) after RP, whilst anejaculation had low to high prevalence (11-72%) after RT. No validated questionnaire was used to detect any NSSE after early PCa treatment. Studies mainly modified other questionnaires, and two studies used non-validated questionnaires to identify some NSSE. Participants in the included studies reported being inadequately informed about the possible sexual side effects of their treatment.

CONCLUSION

This study showed a low to a high prevalence of NSSE in men after RP and RT for early PCa treatment. Questionnaires helped detect individual NSSEs after PCa treatment but there is currently no evidence of a valid, reliable and comprehensive questionnaire to detect the NSSE collectively.

SCOPING REVIEW REGISTRATION

N/A.

Oncosexology: Sexual Issues in the Male Cancer Survivor

Oncosexology is a multidisciplinary field composed of physicians, nurses, psychologists, and other health care professionals focusing on sexual issues in patients with cancer. Although any cancer diagnosis or treatment can be associated with sexual dysfunction, pelvic malignancies (such as prostate, bladder, or colorectal cancer) have the highest rates of sexual dysfunction in men. This includes erectile dysfunction, testosterone deficiency, ejaculatory dysfunction, orgasmic dysfunction, sexual incontinence, and penile shortening. Testicular cancer and hematologic malignancies also have a significant impact on patients' sexual function. Health care providers should address sexual dysfunction with their patients, including any adverse effects of potential treatment options.

A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy

BACKGROUND

Although the concept of penile rehabilitation after radical prostatectomy (RP) has been advocated for decades, there is little definitive evidence regarding its utility or the best strategy to optimize patient outcomes.

AIM

The goal of this study is to analyze the ability of 3 different pharmacological strategies to preserve the ability of men to achieve spontaneous (non-medication assisted) erections after bilateral nerve-sparing RP.

METHODS

This IRB- and FDA-approved study studied penile rehabilitation in a 3-arm fashion with a target enrollment of 200 patients. (i) Control arm: nightly placebo with sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (ii) nightly sildenafil arm: nightly sildenafil 50 mg and sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (iii) combination therapy arm: nightly sildenafil 50 mg (5 nights/week) plus intracavernosal injections twice/week. Inclusion criteria included bilateral nerve-sparing surgery, normal serum total testosterone, and good preoperative baseline erectile function as measured by the erectile function domain score of the IIEF (EFD) (≥24). Patients were followed with a medication use diary and the IIEF questionnaire at 6 weeks, 3 m, 6 m, 12 m, 18 m and 24 m.

OUTCOMES

A difference was seen in the IIEF-EFD scores between the 3 groups at 24 months after RP. Secondary end points include the time to return of spontaneous functional erections, the time for patients to respond to oral erectogenic therapy, and the proportion of patients who have normalization of their IIEF-EFD scores.

RESULTS

The study was interrupted because of failure to recruit the target study population in a reasonable timeframe. A total of 76 subjects with median age of 57 (IQR: 51, 63) years and mean IIEF-EFD of 29 (IQR: 27, 30) were initially randomized, but at 24 months, the sample sizes by group were (i) n = 4; (ii) n = 18; and (iii) n = 10, with median IIEF-EFD 24 (IQR: 18, 28), 24 (IQR: 18, 28), and 21 (IQR: 9, 26), respectively. There was no statistical difference among the groups in the final analysis.

CLINICAL IMPLICATIONS

Definitive evidence for the ability of different pharmacological rehabilitation strategies to improve long-term EF outcomes might never be available.

STRENGTHS & LIMITATIONS

This was a well-designed randomized and 3-arm designed trial intended to provide decisive evidence regarding the utility of penile rehabilitation. Failure to recruit the target population is the main limitation.

CONCLUSION

The limited number of patients in the present trial precludes definitive interpretation. However, results indicate how challenging it is to conduct true rehabilitation studies. Miranda EP, Benfante N, Kunzel B, et al. A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy. J Sex Med 2021;18:423-429.

Neglected side effects to curative prostate cancer treatments

In this narrative review we summarize neglected side effects of curative intended treatment for prostate cancer. They include climacturia, arousal incontinence (AI), orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia), ejaculatory dysfunction, and morphological penile alterations in the form of shortening and deformity. Even though they have not received as much interest as erectile dysfunction (ED) or urinary incontinence, these side effects have been shown to negatively impact patient's quality of life. They are common and rates of climacturia after radical prostatectomy (RP) range from 20% and 45%, less after external beam radiation therapy (EBRT). Decreased orgasmic sensation ranges from 3.9% to 60% after RP and between 36-57% after EBRT. Dysorgasmia ranges from 9.5-15% for both RP and EBRT. Anejculation after EBRT ranges from 11-71% and rates of penile shortening are reported between 0 and 100%. There are no internationally validated questionnaires that adequately asses these side effects. This is necessary if we are to align patient and partner expectations properly and consequently manage them optimally. Neglected side effects should be discussed with patients and their partners preoperatively, as they are associated with bother and may lead to patient's avoiding sexual activity.

Adding a vacuum erection device to regular use of Tadalafil improves penile rehabilitation after posterior urethroplasty

This study aimed to evaluate whether adding a vacuum erection device (VED) to regular use of Tadalafil could achieve better penile rehabilitation following posterior urethroplasty for pelvic fracture-related urethral injury (PFUI). Altogether, 78 PFUI patients with erectile dysfunction (ED) after primary posterior urethroplasty were enrolled and divided into two treatment groups: VED combined with Tadalafil (Group 1, n = 36) and Tadalafil only (Group 2, n = 42). Changes in penile length, testosterone level, International Index of Erectile Function-5 (IIEF-5) questionnaire, Quality of Erection Questionnaire (QEQ), and nocturnal penile tumescence (NPT) testing were used to assess erectile function before and after 6 months of ED treatment. Results showed that the addition of VED to regular use of Tadalafil preserved more penile length statistically (0.4 ± 0.9 vs −0.8 ± 0.7 cm, P < 0.01). IIEF-5 score and QEQ score in Group 1 were higher than Group 2 (both P < 0.05). After treatment, 21/36 (58.3%) Group 1 patients and 19/42 (45.2%) Group 2 patients could complete vaginal penetration. Group 1 patients also had markedly improved testosterone levels (P = 0.01). Unexpectedly, there was no significant difference in NPT testing between two therapies. For PFUI patients with ED after posterior urethroplasty, the addition of VED to regular use of Tadalafil could significantly improve their conditions – improving erection and increasing penile length – thus increasing patient satisfaction and confidence in penile rehabilitation.

Comparative analysis of penile implants in patients with vasculogenic erectile dysfunction versus postradical prostatectomy erectile dysfunction

Penile prosthesis is the treatment of choice for erectile dysfunction (ED) refractory to medical treatment; vasculogenic ED and ED postradical prostatectomy (PRP) are the main aetiologies. Few studies have compared surgical outcomes of penile prosthesis placement for vasculogenic versus PRP severe erectile dysfunction. This study includes 117 cases corresponding to virgin implants for ED of either vasculogenic aetiology or PRP (58 for PRP and 59 for vasculogenic cases). We analysed data corresponding to: age, comorbidity, type of prosthesis, presence of fibrosis that hinders dilation, need for modelling, size of implanted cylinders and complications (intra and postoperative). In the results the rate of hypertension, diabetes, dyslipidaemia and ischemic heart disease was higher in vasculogenic ED. All of the prostheses were hydraulic; 24.1% of two components and 75.9% of three in the PRP group; 39% components of two and 61% of three in the vasculogenic group. With regard to the presence of cavernous fibrosis and need for modelling, no significant differences were found. However, significant differences were observed in the size of the implanted cylinders; PRP of 18.30 ± 2.11 cm versus 19.21 ± 1.71 cm in vasculogenic ED (p = 0.01643). There were no significant differences between the groups in infection rates, mechanical failure or extrusion. In conclusion the implantation of penile prosthesis in ED after PRP is associated with a shorter cylinder length compared with vasculogenic origin. Although there was a certain non-significant tendency to the need for modelling manoeuvres in PRP, there were no significant differences in postoperative outcomes including infection or mechanical failure.

Changes in penile length after radical prostatectomy: effect of neoadjuvant androgen deprivation therapy

Although reports have shown evidence for penile length (PL) shortening after radical prostatectomy (RP), the association between neoadjuvant androgen deprivation therapy (NADT) and PL after RP has yet to be determined. This study evaluates chronological changes in PL after NADT and RP. Stretched PLs (SPLs) of 143 patients, 41 of whom had undergone NADT, were measured before, 10 days after, and 1, 3, 6, 9, 12, 18, and 24 months after RP. Chronological erectile function and testosterone levels were then evaluated. SPL was shortest 10 days after RP in both the NADT (-) and NADT (+) groups and gradually recovered in length thereafter. SPL in the NADT (-) group was significantly longer than that in the NADT (+) group before RP. However, no significant differences in SPLs were found between both groups 6 months after RP. Although all subjects in the NADT (+) group had testosterone levels of <50 ng/dL before RP, such levels increased after RP. Before RP, the NADT (-) group was found to have significantly better erectile function than the NADT (+) group. However, differences in erectile function between the NADT (-) and NADT (+) groups after RP were not significant. This report is the first to show that among patients with prostate cancer, those who underwent NADT had greater PL recovery after RP than those who did not. Data regarding PL recovery after NADT and RP obtained in this study could be useful for patients with prostate cancer who plan to undergo such procedures.

Inflatable penile prosthesis implant length with baseline characteristic correlations: preliminary analysis of the PROPPER study

Background

“Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration” (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length.

Methods

Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length.

Results

From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=−0.18; P<0.01), history of RP (r=−0.13; P<0.01), PD as comorbidity (r=−0.16; P<0.01), venous leak (r=−0.08; P<0.01), and presence of stress incontinence (r=−0.13; P<0.01). Analyses showed weak positive correlations with Black/AA (r=0.32; P<0.01), CV disease as primary ED etiology (r=0.08; P<0.01) and pre-operative stretched penile length (r=0.18; P<0.01). There is a moderate correlation with pre-operative flaccid penile length (r=0.30; P<0.01).

Conclusions

Implanted penile prosthesis length is negatively correlated with some ethnic groups, prostatectomy, and incontinence. Positive correlates include CV disease, preoperative stretched penile length, and flaccid penile length.

The controversy surrounding penile rehabilitation after radical prostatectomy

Radical prostatectomy (RP) techniques have been refined in the last few decades. Despite nerve-sparing surgery, erectile dysfunction (ED) still seems to be affecting more than half of patients undergoing RP. Penile rehabilitation consists of understanding the mechanisms that affect erectile function (EF) and utilizing pharmacologic agents, devices or interventions to promote male sexual function before and after any insult to the penile erectile physiologic axis. There currently is a limited amount of clinical trials that assess treatments with the goal of recovering post-prostatectomy EF. The goal of this article is to assess a contemporary series of trials that study penile rehabilitation. Although the current evidence lacks to prove its irrefutable effectiveness, advancements in research and technology forecast a promising future in penile rehabilitation management.

Vacuum therapy in penile rehabilitation after radical prostatectomy: review of hemodynamic and antihypoxic evidence

Generally, hypoxia is a normal physiological condition in the flaccid penis, which is interrupted by regular nocturnal erections in men with normal erectile function.1 Lack of spontaneous and nocturnal erections after radical prostatectomy due to neuropraxia results in persistent hypoxia of cavernosal tissue, which leads to apoptosis and degeneration of cavernosal smooth muscle fibers. Therefore, overcoming hypoxia is believed to play a crucial role during neuropraxia. The use of a vacuum erectile device (VED) in penile rehabilitation is reportedly effective and may prevent loss of penile length. The corporal blood after VED use is increased and consists of both arterial and venous blood, as revealed by color Doppler sonography and blood gas analysis. A similar phenomenon was observed in negative pressure wound therapy (NPWT). However, NPWT employs a lower negative pressure than VED, and a hypoperfused zone, which increases in response to negative pressure adjacent to the wound edge, was observed. Nonetheless, questions regarding ideal subatmospheric pressure levels, modes of action, and therapeutic duration of VED remain unanswered. Moreover, it remains unclear whether a hypoperfused zone or PO₂ gradient appears in the penis during VED therapy. To optimize a clinical VED protocol in penile rehabilitation, further research on the mechanism of VED, especially real-time PO₂ measurements in different parts of the penis, should be performed.

Penile rehabilitation following prostate cancer treatment: review of current literature

Radical prostatectomy (RP) and radiotherapy (RT) are highly effective in improving prostate cancer survival. However, both have a detrimental effect on erectile function (EF). Penile rehabilitation consists of understanding the mechanisms that cause erectile dysfunction (ED) and utilizing pharmacologic agents, devices or interventions to promote male sexual function. For the past decade, many researchers have pursued to define effective treatment modalities to improve ED after prostate cancer treatment. Despite the understanding of the mechanisms and well-established rationale for postprostate treatment penile rehabilitation, there is still no consensus regarding effective rehabilitation programs. This article reviews a contemporary series of trials that assess penile rehabilitation and explore treatment modalities that might play a role in the future. Published data and trials related to penile rehabilitation after RP and RT were reviewed and presented. Although recent trials have shown that most therapies are well-tolerated and aid in some degree on EF recovery, we currently do not have tangible evidence to recommend an irrefutable penile rehabilitation algorithm. However, advancements in research and technology will ultimately create and refine management options for penile rehabilitation.

Effect of Tadalafil Once Daily on Penile Length Loss and Morning Erections in Patients After Bilateral Nerve-sparing Radical Prostatectomy: Results From a Randomized Controlled Trial

OBJECTIVE

To report penile integrity measures, including stretched penile length (SPL), from a randomized, double-blind, double-dummy, placebo-controlled trial evaluating treatment with tadalafil initiated after nerve-sparing radical prostatectomy (nsRP).

METHODS

Patients aged ≤ 68 years were randomized after nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg once daily (OaD), 20-mg tadalafil on-demand ("pro-re-nata"; PRN), or placebo, followed by 6-week drug-free washout and 3-month open-label OaD treatment. Secondary outcome measures included the change in SPL from pre-nsRP to the end of DBT (analysis of covariance adjusting for treatment, country, baseline, age, and nerve-sparing score), responses to Sexual Encounter Profile (SEP) questions 1-3 (mixed models for repeated measures adjusting for treatment, country, visit, visit-treatment-interaction, age), and Standardized Morning Erection Question (Cochran-Mantel-Haenszel test adjusted for age and country).

RESULTS

Four hundred twenty-three patients were randomized to tadalafil OaD (N = 139), tadalafil PRN (N = 143), and placebo (N = 141). Greater retainment of SPL was observed with tadalafil OaD vs placebo at the end of DBT (least-square mean [95% confidence interval] difference OaD vs placebo, 4.1 mm [0.4 to 7.8 mm]; P = .032). No significant effects on SPL were found for tadalafil PRN vs placebo, or for the nerve-sparing score. Penile tumescence (SEP1) and ability for vaginal insertion (SEP2) significantly improved vs placebo at the end of double-blind and open-label treatment for patients randomized to tadalafil OaD only. The ability for successful sexual intercourse (SEP3) significantly improved with tadalafil OaD vs placebo only during DBT. The distribution of Standardized Morning Erection Question responses was different at the end of DBT (P = .045); 34.2% of patients on tadalafil OaD, 50.0% on tadalafil PRN, and 56.5% on placebo reported absence of morning erections.

CONCLUSION

These data suggest the early initiation of tadalafil OaD protects from penile length loss and may contribute to protection from structural cavernosal changes after nsRP.

Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT)

BACKGROUND

The potential rehabilitative and protective effect of phosphodiesterase type 5 inhibitors (PDE5-Is) on penile function after nerve-sparing radical prostatectomy (NSRP) remains unclear.

OBJECTIVE

The primary objective was to compare the efficacy of tadalafil 5mg once daily and tadalafil 20mg on demand versus placebo taken over 9 mo in improving unassisted erectile function (EF) following NSRP, as measured by the proportion of patients achieving an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score ≥ 22 after 6-wk drug-free washout (DFW). Secondary measures included IIEF-EF, Sexual Encounter Profile question 3 (SEP-3), and penile length.

DESIGN, SETTING, AND PARTICIPANTS

Randomised, double-blind, double-dummy, placebo-controlled trial in men ≤ 68 yr of age with adenocarcinoma of the prostate (Gleason ≤ 7) and normal preoperative EF who underwent NSRP at 50 centres from nine European countries and Canada.

INTERVENTIONS

1:1:1 randomisation to 9 mo of treatment with tadalafil 5mg once daily, tadalafil 20mg on demand, or placebo followed by a 6-wk DFW and 3-mo open-label tadalafil once daily (all patients).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression, mixed-effects model for repeated measures, and analysis of covariance, adjusting for treatment, age, and country, were applied to IIEF-EF scores ≥ 22, SEP-3, and penile length.

RESULTS AND LIMITATIONS

Four hundred twenty-three patients were randomised to tadalafil once daily (n=139), on demand (n=143), and placebo (n=141). The mean age was 57.9 yr of age (standard deviation: 5.58 yr); 20.9%, 16.9%, and 19.1% of patients in the tadalafil once daily, on demand, and placebo groups, respectively, achieved IIEF EF scores ≥ 22 after DFW; odds ratios for tadalafil once daily and on demand versus placebo were 1.1 (95% confidence interval [CI], 0.6-2.1; p=0.675) and 0.9 (95% CI, 0.5-1.7; p=0.704). At the end of double-blind treatment (EDT), least squares (LS) mean IIEF-EF score improvement significantly exceeded the minimally clinically important difference (MCID: ΔIIEF-EF ≥ 4) in both tadalafil groups; for SEP-3 (MCID ≥ 23%), this was the case for tadalafil once daily only. Treatment effects versus placebo were significant for tadalafil once daily only (IIEF-EF: p=0.016; SEP-3: p=0.019). In all groups, IIEF-EF and SEP-3 decreased during DFW but continued to improve during open-label treatment. At month 9 (EDT), penile length loss was significantly reduced versus placebo in the tadalafil once daily group only (LS mean difference 4.1mm; 95% CI, 0.4-7.8; p=0.032).

CONCLUSIONS

Tadalafil once daily was most effective on drug-assisted EF in men with erectile dysfunction following NSRP, and data suggest a potential role for tadalafil once daily provided early after surgery in contributing to the recovery of EF after prostatectomy and possibly protecting from penile structural changes. Unassisted EF was not improved after cessation of active therapy for 9 mo.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01026818.