Singhal A. et al., 2025: Low-Intensity Extracorporeal Shock Wave Therapy (LI-ESWT) for Erectile Dysfunction in Patients Post-prostatectomy: A Systematic Review.
Abhinav Singhal 1, Maanya Bhardwaj 2, Gaurika Bhardwaj 3, Keval M Patel 1
1Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR.
2Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR.
3Critical Care, Royal Marsden Hospital, London, GBR.
Abstract
Erectile dysfunction (ED) is a common and distressing complication following radical prostatectomy, significantly affecting patients' quality of life. Low-intensity extracorporeal shock wave therapy (LI-ESWT) has emerged as a non-invasive modality aimed at enhancing erectile function through tissue regeneration and improved neovascularisation. This review aims to systematically evaluate the safety and efficacy of LI-ESWT in the treatment of ED in men following prostatectomy. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed across PubMed, PubMed Central (PMC), MEDLINE, Cochrane Library, and Scopus for studies published between January 2015 and July 2025. Eligible studies included randomised controlled trials (RCTs) and cohort studies evaluating LI-ESWT for post-prostatectomy ED using validated outcome measures such as the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS). Risk of bias was assessed using the Cochrane Risk of Bias (RoB) 2.0 and the Newcastle-Ottawa Scale. Ten studies, of which five were RCTs and five were cohort studies, involving a total of 760 patients met the inclusion criteria. LI-ESWT was associated with statistically significant improvements in erectile function across most studies, particularly when combined with phosphodiesterase-5 inhibitors (PDE5is). IIEF-5 scores improved in both three-monthly and 6-12-monthly follow-ups, and EHS ≥3 was commonly achieved in combination therapy cohorts. No serious adverse events were reported. However, variations in treatment protocols, energy settings, and follow-up durations limited comparability and precluded meta-analysis. The overall certainty of evidence was moderate for efficacy and high for safety. LI-ESWT appears to be a safe and potentially effective treatment for ED following radical prostatectomy, particularly when initiated early and used alongside PDE5is. Despite encouraging results, heterogeneity among studies and treatment protocols, alongside methodological limitations, underscores the need for larger, high-quality RCTs to establish standardised protocols and confirm long-term benefits.
Cureus. 2025 Oct 5;17(10):e93901. doi: 10.7759/cureus.93901. PMID: 41200620;
PMCID: PMC12587078
Comments 1
This systematic presents a thorough examination of the existing literature and highlights both the potential benefits and limitations of this treatment modality. The article addresses a significant complication following radical prostatectomy—erectile dysfunction—which can severely impact a patient's quality of life. The emergence of LI-ESWT as a promising, non-invasive treatment alternative is a relevant topic in current urology. The review aims to evaluate the safety and efficacy of LI-ESWT in treating ED in men post-prostatectomy, following systematic review guidelines (PRISMA)
Methodology
Literature Search: The authors conducted a comprehensive search of multiple databases (PubMed, Cochrane Library, etc.) for studies published from January 2015 to July 2025.
Inclusion Criteria: The review included randomized controlled trials (RCTs) and cohort studies that reported validated outcomes (IIEF-5 and EHS).
Risk of Bias Assessment: Utilization of the Cochrane Risk of Bias 2.0 and the Newcastle-Ottawa Scale to evaluate the quality of included studies.
Results
Ten studies (five RCTs, five cohort studies) met inclusion criteria, encompassing 760 patients.
-Efficacy: Most studies showed statistically significant improvements in erectile function, particularly when LI-ESWT was combined with phosphodiesterase-5 inhibitors (PDE5is).
-Safety: No serious adverse events were reported, indicating a favorable safety profile for LI-ESWT.
- Challenges: Variability in treatment protocols and outcomes, such as energy settings and follow-up durations, limited the ability to conduct a meta-analysis.
Discussion
- Strength of Evidence: The review highlights that RCTs provided stronger evidence compared to observational studies. Significant improvements in erectile function were reported in RCTs, reinforcing the intervention's potential.
- Combination Therapy: Notably, combining LI-ESWT with PDE5is appears to enhance outcomes, which is an important consideration for clinical practice.
- Limitations: The review acknowledges the limitations of heterogeneity in protocols, retrospective study designs, and small sample sizes. The authors stress the need for larger, well-designed studies to confirm findings and establish standardized treatment protocols.
Areas for improvement of the article
1. Detail on Protocol Variability: More discussion on the specific variations in treatment protocols and their potential impact on outcomes could enhance understanding.
2. Visuals and Tables**: Including more visuals (like graphs or flow charts) to summarize data could improve reader comprehension and engagement.
3. Broader Context: A brief comparison with other available treatments for post-prostatectomy ED could provide additional context for clinicians considering LI-ESWT.
Conclusions
The authors conclude that LI-ESWT is a safe and potentially effective treatment for ED in men after radical prostatectomy, particularly when initiated early and used in conjunction with PDE5is. They call for further research with larger, multi-center RCTs to solidify the evidence base and optimize treatment strategies.
Overall, this systematic review provides valuable insights into the use of LI-ESWT for erectile dysfunction in post-prostatectomy patients. While the findings are promising, the call for further high-quality studies is essential to validate the therapeutic approach and establish best practices for its implementation in clinical settings. Most importantly, the timing of the treatment should be focused more intensively.
Jens Rassweiler