Treatment for erectile dysfunction resisted after radical prostatectomy

San Antonio-Almost half of all patients with erectile dysfunction following radical prostatectomy decide against any form of treatment for ED, Italian investigators reported at the AUA annual meeting here.

Among the therapeutic options chosen by patients, intracavernosal prostaglandin injection achieved the best results in terms of erectile function. On-demand use of phosphodiesterase type-5 inhibitors led to higher erectile function scores compared with daily rehabilitation therapy.

"Almost 50% of the patients decided not to take any drug," said Francesco Montorsi, MD, professor of urology at Universita Vite Salute San Raffaele in Milan. "That is a take-home message that is important to all of us."

Preoperative assessment included the International Index of Erectile Function (IIEF), a clinical mood (depression) scale, and the International Prostate Symptom Index. Patients were followed at 6-month intervals, at which time the preoperative assessments were repeated and additional survey instruments evaluated treatment satisfaction, urinary continence, sexual satisfaction, and other issues.

Since November 2002, 908 patients underwent radical prostatectomy at University Hospital San Raffaele. Dr. Montorsi said 300 of the patients had baseline assessments the day before undergoing bilateral nerve-sparing surgery. In interviews with physicians, they stated they were fully potent. However, the survey results showed that 166 patients (55%) had some degree of erectile dysfunction, including 80 who met criteria for severe erectile dysfunction. The surveys also revealed that 29 patients were considered to have severe erectile dysfunction because they did not attempt intercourse during the 4 weeks prior to surgery.

Questionnaires are needed

"We think the first finding is that these questionnaires are needed," said Dr. Montorsi. "There is a high prevalence of preoperative severe ED and no sexual activity prior to surgery. It is also clear that the emotional impact of the diagnosis of cancer and the decision to undergo treatment have an impact on the attitudes of patients."

Following surgery, all patients were offered rehabilitation therapy with PDE-5 inhibitors, which consisted of daily half-doses of sildenafil citrate (Viagra), tadalafil (Cialis), or vardenafil (Levitra). Alternatively, patients could opt for on-demand therapy with one of the PDE-5 inhibitors.

About 200 patients had complete data collection, including psychometric evaluations. Of those, 47.1% chose to have no ED treatment, and their postoperative scores on the IIEF erectile function domain (IIEF-EF) averaged 10.8. On-demand PDE-5 inhibitor therapy was chosen by 25.6% of patients, who had a mean IIEF-EF score of 18.5 compared with 13.6 for the 21% of patients who chose rehabilitation treatment with a PDE-5 inhibitor (p=.0008). The highest IIEF-EF mean score (21.3) emerged from 6.4% of patients who had intracavernosal prostaglandin injections.

Dr. Montorsi and colleagues performed a multiple regression analysis to identify correlates for the IIEF-EF. Only the clinical depression scale had a significant correlation with erectile function (p=.0361).

Comparing postoperative results

A separate analysis focused on results involving the surgeon with the highest patient volume (126 patients, 99 of whom had complete data). Baseline assessment showed that 47% of the patients had some degree of ED prior to surgery, including 21% who had severe ED (6.4% who had made no attempts at intercourse). The preoperative evaluation showed that the only correlates with IIEF-EF were older age (p=.0119) and greater body mass index (p=.01770).

Multivariate analysis of postoperative parameters demonstrated that only the patient's continence status correlated with IIEF-EF (p=.0453).