Rho BY et al., 2022: Efficacy of Low-Intensity Extracorporeal Shock Wave Treatment in Erectile Dysfunction Following Radical Prostatectomy: A Systematic Review and Meta-Analysis
Rho BY, Kim SH, Ryu JK, Kang DH, Kim JW, Chung DY.
Department of Urology, Inha University School of Medicine, Incheon 22212, Korea.
Erectile dysfunction (ED) is a well-known complication of radical prostatectomy (RP). Oral 5-phosphodiesterase inhibitors are currently the most widely used penile rehabilitation treatment for ED following RP, but they are less effective than for those with general ED. Low-intensity extracorporeal shock wave treatment (LI-ESWT), causing a biological change that induces neovascularization, has recently been used as a treatment for ED. Therefore, we conducted a systematic review and meta-analysis to investigate the efficiency of LI-ESWT in ED following RP. PubMed, Embase, and the Cochrane Library were searched up until December 2021. The endpoint was the change in IIEF scores after LI-ESWT. Five papers (460 patients) were included in the final analysis. In IIEF scores performed 3-4 months after LI-ESWT, the group receiving LI-ESWT showed statistically significantly better results than the control (WMD = -2.04; 95% CI, -3.72 to -0.35; p = 0.02). However, there were a total of two studies that measured the results after 9-12 months. There was no statistical difference between the two groups (WMD = -5.37; 95% CI, -12.42 to 1.69; p = 0.14). The results of this analysis indicate that LI-ESWT showed a statistically significant effect on early recovery in penile rehabilitation of ED following RP. However, the level of evidence was low. Therefore, careful interpretation of the results is required.
J Clin Med. 2022 May 14;11(10):2775. doi: 10.3390/jcm11102775. PMID: 35628901. FREE ARTICLE
Erectile Dysfunction is one of the remaining side-effects of radical prostatectomy (RP) for patients with localized prostatic cancer. Oral 5-phosphodiesterase inhibitors (PDE5Is) are currently the most widely used penile rehabilitation treatment for ED after RP, however, the response rate to the currently available PDE5Is is much lower in men with ED following RP than in the general ED population. Other options such as intracavernous injection or the use of penile pumps are inconvenient for the patients.
Based on the excellent results of Low-intensity extracorporeal shock wave therapy (Li-ESWT) in case of vasculogenic erectile dysfunction, recently the use of Li-ESWT in a penile rehabilitation program has been evaluated. The exact mechanism of LI-ESWT in ED following RP remains unknown. In summary, it is thought that stimulation by shockwave microbubbles causes neo-angiogenesis by activating vascular endothelial growth factor release and endothelial progenitor cells, which also causes stem cell recruitment and Schwann cell activation, leading to nerve regeneration.
The authors present a meta-analysis on the existing data of Li-ESWT for this interesting indication. They could include 5 studies with a total of 460 patients in their analysis. Most of the studies focused on the results after 3-4 months, two studies also had a longer follow-up up to 12 months. In all studies, the study population was comparable and the results always favored Li-ESWT leading to a significant better early rehabilitation of erectile dysfunction documented by the IIEF-score.
The authors also clearly discuss the limitation of their study reflecting the actual clinical situation:
- There was no a standard Li-ESWT protocol. The number of shock waves differed (1500 – 4000 per session) as well as the applied energy density (0.09 – 0.15 mJ/mm2)
- The number of a total of five studies is low.
It would be really good, that the interested groups in Europe would define treatment protocols for future trials. Since in the penile rehabilitation several factors play a role, such as stimulation of nerve-regeneration, improvement of the quality of the cavernous muscle, and improvement of micro-angiopathy, the use of energy density might be crucial.
Moreover, there is the question of timing and duration of such a rehabilitation program with Li-ESWT. At least, there have been no side effects reported in all these studies. Early responders could probably continue with PDE-5-inhibitors, whereas poor responders show continue with Li-ESWT.
Evidently, there a many future studies necessary to finally establish the role of Li-ESWT for this very interesting indication.