Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China.
West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
Int J Impot Res. 2022 Jan;34(1):18-36. doi: 10.1038/s41443-020-00364-w. Epub 2020 Oct 24.
The aim of this study is to present a summary of current evidence concerning the various treatments in the management of penile rehabilitation after radical prostatectomy (RP) and provide recommendations for future research. Randomized controlled trials (RCTs) were identified from electronic databases including PubMed, the Cochrane Library, Embase, and Web of Science from inception through March 2020 with no limitation to language. Comparable data from each study were combined in a meta-analysis where possible, otherwise data were synthesized narratively. The data analysis was completed by Review Manager version 5.3. A total of 39 RCTs were included in this study. At present, phosphodiesterase type 5 inhibitors (PDE5is) remain the first-line treatment for patients with erectile dysfunction (ED) after RP. Compared with the placebo group, patients in regular PDE5is group (mean difference (MD): 0.76; 95% confidence interval (CI): 1.69-4.44; p < 0.0001) and on demand group (MD: 3.92; 95% CI: 2.95-4.88; p < 0.00001) had a significantly higher mean Erectile Function domain of the International Index of Erectile Function (IIEF-EF) scores within 3 months after RP. As for the proportion of IIEF-EF ≥ 22, patients in regular PDE5is group and on demand PDE5is group had significantly higher proportion than those in placebo group 6 months after RP, and the odds ratios were 1.87 (95% CI: 1.32-2.66; p = 0.0005) and 2.17 (95% CI: 1.20-3.93; p = 0.01), respectively. No significant difference was observed between regular PDE5is group and on demand group regardless of mean IIEF-EF score or the proportion of IIEF-EF ≥ 22. Intracorporeal injection therapy seemed to have similar efficacy to PDE5is. The International Index of Erectile Function-5 items (IIEF-5) scores were significantly higher in vacuum constriction devices group than control group at 6-9 months after RP (MD: 6.70, 95% CI: 2.30-11.10, p = 0.003) with great between-study heterogeneity (p = 0.06, I = 72%). The other therapeutics including low-intensity extracorporeal shockwave therapy, statin therapy, psychotherapy interventions, and pelvic floor muscle training plus electrical stimulation showed certain improvement on erectile function. We found that the combination therapy showed certain advantages over monotherapy. Currently, PDE5is-based combination therapy remains the mainstream treatment for ED after RP. Intracorporeal injection therapy and vacuum therapy could be served as alternative treatments if PDE5is are ineffective and contraindicated.
本研究旨在总结目前关于根治性前列腺切除术（RP）后阴茎康复各种治疗方法的现有证据，并为未来的研究提供建议。从电子数据库（包括 PubMed、Cochrane 图书馆、Embase 和 Web of Science）中检索了从成立到 2020 年 3 月的随机对照试验（RCT），不限制语言。如果可能，将每项研究的可比数据合并到荟萃分析中，否则将按叙述方式进行综合。数据分析使用 Review Manager 版本 5.3 完成。本研究共纳入 39 项 RCT。目前，磷酸二酯酶 5 抑制剂（PDE5i）仍然是 RP 后勃起功能障碍（ED）患者的一线治疗方法。与安慰剂组相比，常规 PDE5i 组（平均差值（MD）：0.76；95%置信区间（CI）：1.69-4.44；p<0.0001）和按需 PDE5i 组（MD：3.92；95%CI：2.95-4.88；p<0.00001）在 RP 后 3 个月内的国际勃起功能指数（IIEF-EF）的勃起功能域的平均评分明显更高。至于 IIEF-EF≥22 的比例，在 RP 后 6 个月时，常规 PDE5i 组和按需 PDE5i 组的 IIEF-EF≥22 的比例明显高于安慰剂组，比值比分别为 1.87（95%CI：1.32-2.66；p=0.0005）和 2.17（95%CI：1.20-3.93；p=0.01）。无论平均 IIEF-EF 评分或 IIEF-EF≥22 的比例如何，常规 PDE5i 组和按需 PDE5i 组之间均未见明显差异。腔内注射治疗似乎与 PDE5i 具有相似的疗效。RP 后 6-9 个月时，真空勃起装置组的国际勃起功能指数-5 项（IIEF-5）评分明显高于对照组（MD：6.70；95%CI：2.30-11.10；p=0.003），且存在较大的异质性（p=0.06，I=72%）。其他治疗方法，包括低强度体外冲击波治疗、他汀类药物治疗、心理治疗干预和盆底肌肉训练加电刺激，对勃起功能均有一定改善。我们发现联合治疗比单一治疗具有一定优势。目前，基于 PDE5i 的联合治疗仍然是 RP 后 ED 的主流治疗方法。如果 PDE5i 无效或禁忌，则腔内注射治疗和真空治疗可作为替代治疗方法。
