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Sighinolfi M. et al., 2022: Low-intensity Extracorporeal Shockwave Therapy for the Management of Postprostatectomy Erectile Dysfunction: A Systematic Review of the Literature

Sighinolfi MC, Eissa A, Bellorofonte C, Mofferdin A, Eldeeb M, Assumma S, Panio E, Calcagnile T, Stroppa D, Bozzini G, Gaia G, Terzoni S, Sangalli M, Micali S, Rocco B.
Urology Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy.
Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt.
Urology Unit, Columbus Clinic Center, Milan, Italy.
Urology Department, University of Modena & Reggio Emilia, Modena, Italy.
Urology Department, ASST Lariana, Como, Italy.
Gynecology Department, ASST Santi Paolo e Carlo, Milan, Italy.

Abstract

Context: Erectile dysfunction (ED) following radical prostatectomy is a concern for patients and their partners. Low-intensity extracorporeal shockwave therapy (LI-ESWT) can potentially enhance tissue repair and regeneration. The aim of the current study was to systematically review the literature to assess the role of LI-ESWT in the management of patients with postprostatectomy ED.

Evidence acquisition: Two authors independently performed a systematic search of the PubMed and Web of Science databases to identify all relevant articles. Non-English reports, case reports, reviews, letters, and editorials were excluded. Risk of bias was assessed according to the GRADE guidelines.

Evidence synthesis: Nine articles met the inclusion criteria and were included in the qualitative analysis. All the studies included were published between 2015 and 2022 and the majority of them compared phosphodiesterase type 5 inhibitors (PDE5Is) alone versus a combination of LI-ESWT and PDE5Is. Only three studies were randomized controlled trials (RCTs). In general, there is no standardized protocol for LI-ESWT for postprostatectomy ED. In comparisons of LI-ESWT + PDE5Is versus PDE5Is alone, some authors found a statistically significant improvement in erectile function with LI-ESWT + PDE5Is. The starting time for LI-ESWT differed among the studies, ranging from 3 d to 6 mo after surgery. The main limitations of the review are the scarcity of studies, small sample sizes, high risk of bias, and high heterogeneity among studies.

Conclusions: There is currently limited evidence on the use of LI-ESWT either alone or in combination with PDE5Is in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow-up show that LI-ESWT could potentially play a role in the management of postprostatectomy ED in the future. Further RCTs with larger sample sizes are needed.

Patient summary: Despite limited reports in the literature, low-intensity shockwave therapy after removal of the prostate is a promising noninvasive treatment for dealing with erectile dysfunction after surgery.
Eur Urol Open Sci. 2022 Jul 30;43:45-53. doi: 10.1016/j.euros.2022.07.003. eCollection 2022 Sep. FREE ARTICLE

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Comments 1

Jens Rassweiler on Wednesday, 04 January 2023 09:30

Erectile dysfunction (ED) following radical prostatectomy is a concern for patients and their partners. Low-intensity extracorporeal shockwave therapy (LI- ESWT) can potentially enhance tissue repair and regeneration. The aim of the current study was to systematically review the literature to assess the role of LI-ESWT in the management of patients with postprostatectomy ED.

Nine articles out of 26 met the inclusion criteria and were included in the qualitative analysis. All the studies included were published between 2015 and 2022 and the majority of them compared phosphodiesterase type 5 inhibitors (PDE5Is) alone versus a combination of LI-ESWT and PDE5Is. Only three studies were randomized controlled trials (RCTs).

The authors found, that there is no standardized protocol yet of LI-ESWT for postprostatectomy ED. In comparisons of LI-ESWT + PDE5Is versus PDE5Is alone, some authors found a statistically significant improvement in erectile function with LI-ESWT + PDE5Is. The starting time for LI-ESWT differed among the studies, ranging from 3 d to 6 mo after surgery.

From their analysis, the authors concluded, that there is currently limited evidence on the use of LI-ESWT either alone or in combination with PDE5Is in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow-up showed that LI-ESWT could potentially play a role in the management of postprostatectomy ED in the future. Further RCTs with larger sample sizes are needed.

The situation of the current evidence concerning the efficacy of Li-ESWT is very well reflected by this meta-analysis. Due to the low number of studies and patients included in the three RCTs not even recommendations about the treatment regimen can be given. However, I would recommend to use the well-established protocols for vasculogenic ED (ie. 3000 SW, 0.1-0.2 mJ/mm2; 3-4 Hz, 6 weekly sessions). One might add some shocks via the perineum to stimulate nerve regeneration of the neurovascular bundles. If one takes the recent RCT by Motil et al., which is not included in this meta-analysis, one could expect a positive role ofLi-ESWT particular in the early postoperative phase, whereas the effect diminishes after 6 months, mainly due to the “natural rehabilitation” of the erectile dysfunction. It is evident, that we all should put a lot of effort in evaluating this promising treatment option in the future.

Jens Rassweiler

Erectile dysfunction (ED) following radical prostatectomy is a concern for patients and their partners. Low-intensity extracorporeal shockwave therapy (LI- ESWT) can potentially enhance tissue repair and regeneration. The aim of the current study was to systematically review the literature to assess the role of LI-ESWT in the management of patients with postprostatectomy ED. Nine articles out of 26 met the inclusion criteria and were included in the qualitative analysis. All the studies included were published between 2015 and 2022 and the majority of them compared phosphodiesterase type 5 inhibitors (PDE5Is) alone versus a combination of LI-ESWT and PDE5Is. Only three studies were randomized controlled trials (RCTs). The authors found, that there is no standardized protocol yet of LI-ESWT for postprostatectomy ED. In comparisons of LI-ESWT + PDE5Is versus PDE5Is alone, some authors found a statistically significant improvement in erectile function with LI-ESWT + PDE5Is. The starting time for LI-ESWT differed among the studies, ranging from 3 d to 6 mo after surgery. From their analysis, the authors concluded, that there is currently limited evidence on the use of LI-ESWT either alone or in combination with PDE5Is in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow-up showed that LI-ESWT could potentially play a role in the management of postprostatectomy ED in the future. Further RCTs with larger sample sizes are needed. The situation of the current evidence concerning the efficacy of Li-ESWT is very well reflected by this meta-analysis. Due to the low number of studies and patients included in the three RCTs not even recommendations about the treatment regimen can be given. However, I would recommend to use the well-established protocols for vasculogenic ED (ie. 3000 SW, 0.1-0.2 mJ/mm2; 3-4 Hz, 6 weekly sessions). One might add some shocks via the perineum to stimulate nerve regeneration of the neurovascular bundles. If one takes the recent RCT by Motil et al., which is not included in this meta-analysis, one could expect a positive role ofLi-ESWT particular in the early postoperative phase, whereas the effect diminishes after 6 months, mainly due to the “natural rehabilitation” of the erectile dysfunction. It is evident, that we all should put a lot of effort in evaluating this promising treatment option in the future. Jens Rassweiler
Monday, 17 June 2024