Andrology update: Timing of PDE-5 inhibitors
The Andrology Update 2016 during Thematic Session 5 exclusively featured state-of-the-art lectures including one that highlighted erectile dysfunction (ED) treatment after radical prostatectomy (RP) and how to choose the right method for the right patient.
Despite excellent oncologic outcomes, RP is associated with disability functional impairments, such as urinary incontinence and ED. “Up to 70% of patients still experience postoperative ED, even when a bilateral nerve-sparing approach is performed. Also, younger patients have higher rates of ED than older patients,” said Dr. G. Gandaglia (IT).
ED is multifactorial and psychological factors in particular, should not be ignored as they have a high impact. Treatment options are many of which PDE-5 inhibitors take centre stage, according to Gandaglia. He emphasized that penile rehabilitation – defined as the use of any intervention or combination with the goal of restoring erectile function (EF) pretreatment levels – should not be overlooked. Although some randomized controlled trials have been conducted with PDE-5 inhibitors, there are some concerns with regard to the timing of drug administration, short follow-up periods and selection criteria.
Gandaglia: “A recent study showed that patients at intermediate risk of ED after surgery are the ones who benefit most from use of PDE-5 inhibitors and they are the ones that should be targeted.”
Other options to treat ED are vacuum erection devices (“cost-effective compared to other treatments, suitable for use in combination with PDE-5 inhibitors”), and intracorporeal injection therapy which can be effective as second- line option for patients who failed to respond to oral treatment. Finally, penile prosthesis implantation is a third- line option after failure of less invasive treatments or non-compliance to conservative management. “They have a low rate of complications and implant failure,” Gandaglia said. “But the best timing – early versus delayed implantation – is still not clear.”
Optimal management for Peyronie’s disease (PD) – which does not affect the patient solely on a physical level but perhaps even more psychologically – consists of various options, according to Dr. E. Zacharakis (GB). “There have been many oral treatments for PD, most of which are not effective, apart from pentoxifylline and L-Arginine/PDE-5 inhibitors. There is limited evidence that interferon and verapamil are effective, whereas the evidence for collagenase is Grade A/Level 1,” he said. Furthermore, topical treatment with verapamil gel is not recommended; topical energy treatment seems to have limited benefit whereas shock wave therapy has none.
Recommendations for surgery depend on the specific characteristics of the disease. Zacharakis emphasized that detailed consent is imperative as well as following published algorithms. Plication/Nesbit is indicated for deformity < 60° and borderline ED. If the patient has a deformity > 60° and an experienced surgical team is available, then grafting is a treatment option. Patients with refractory ED and PD are eligible for prosthesis placement with manipulation.