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Reviewer's Choice 

Zewin TS et al, 2018: Efficacy and safety of low-intensity shock wave therapy in penile rehabilitation post nerve-sparing radical cystoprostatectomy: a randomized controlled trial.

Zewin TS, El-Assmy A, Harraz AM, Bazeed M, Shokeir AA, Sheir K, Mosbah A.
Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt.

Abstract

AIM: To evaluate the role of low-intensity extra corporeal shock wave therapy (LI-ESWT) in penile rehabilitation (PR) post nerve-sparing radical cystoprostatectomy (NS-RCP).
MATERIALS AND METHODS: This study included 152 sexually active men with muscle invasive bladder cancer. After bilateral NS-RCP with orthotopic diversion by a single expert surgeon between June 2014 and July 2016, 128 patients were available categorized into three groups: LI-ESWT group (42 patients), phosphodiesterase type-5 inhibitors (PDE5i) group (43 patients), and control group (43 patients).
RESULTS: Mean age was 53.2 ± 6.5 years. Mean ± SD follow-up period was 21 ± 8 months. During first follow-up FU1, all patients of the three groups had insufficient erection for vaginal penetration; with decrease of preoperative IIEF-EF mean score from 27.9 to 6.9. Potency recovery rates at 9 months were 76.2%, 79.1%, and 60.5% in LI-ESWT, PDE5i, and control groups, respectively. There was statistically significant increase in IIEF-EF and EHS scores during all follow-up periods in all the study groups (p < 0.001). However, there was no significant difference between the three groups during all follow-up periods. Statistical evaluation showed no significant difference in continence and oncological outcomes during all follow-up points among the three groups (p = 0.55 and 0.07, respectively).
CONCLUSIONS: During last follow-up, 16% more patients in LI-ESWT group had recovery of potency as compared to the control group. Although the difference is not statistically significant, but of clinical importance. LI-ESWT is safe as oral PDE5i in penile rehabilitation post nerve-sparing radical cystoprostatectomy.

Int Urol Nephrol. 2018 Sep 19. doi: 10.1007/s11255-018-1987-6. [Epub ahead of print]

 

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Comments 2

Peter Alken on Thursday, 28 March 2019 12:56

To the best of our knowledge, this is the first randomized controlled study that evaluated the use of LI-ESWT as a penile rehabilitation method after NS-RCP and compared it with the use of oral PDE5i.” The preservation of potency close to 80 % in this series is exceptionally high. Patients were assessed at 1, 3, 6, and 9-months postoperatively. Erection was evaluated by questionnaires which is standard but has its limits as patients may report whatever they want. Neither the spouse nor the girl friends were interviewed. But patients were also examined with intracavernous injection of prostaglandin E1 to record the hemodynamic parameters of the cavernosal arteries. The injection also induces an erection and I wonder why the authors did not report on the quality of this pharmacological induced erection.

To the best of our knowledge, this is the first randomized controlled study that evaluated the use of LI-ESWT as a penile rehabilitation method after NS-RCP and compared it with the use of oral PDE5i.” The preservation of potency close to 80 % in this series is exceptionally high. Patients were assessed at 1, 3, 6, and 9-months postoperatively. Erection was evaluated by questionnaires which is standard but has its limits as patients may report whatever they want. Neither the spouse nor the girl friends were interviewed. But patients were also examined with intracavernous injection of prostaglandin E1 to record the hemodynamic parameters of the cavernosal arteries. The injection also induces an erection and I wonder why the authors did not report on the quality of this pharmacological induced erection.
Peter Alken on Monday, 07 January 2019 15:25

All patients suffered from postoperative ED. In the Li-ESWT group patients received 12 sessions of penile within 9 weeks while the PDE5i-group patients had a longer treatment with 50 mg daily for 6 months. The control group had no therapy. At the follow-up examinations at 1, 3, 6, and 9-months postoperatively intracavernous penile injection of prostaglandin E1 was used to objectify the erection status among other examinations. The follow-up was for a mean ± SD of 21 ± 8 months (range 9–34).
There was no significant difference between the three groups during all follow-up periods but the control group had the lowest values during all FU-examinations. With larger groups the differences may become significant and Li-ESWT could be an option for those patients with contraindications to PDE5 inhibitors.

All patients suffered from postoperative ED. In the Li-ESWT group patients received 12 sessions of penile within 9 weeks while the PDE5i-group patients had a longer treatment with 50 mg daily for 6 months. The control group had no therapy. At the follow-up examinations at 1, 3, 6, and 9-months postoperatively intracavernous penile injection of prostaglandin E1 was used to objectify the erection status among other examinations. The follow-up was for a mean ± SD of 21 ± 8 months (range 9–34). There was no significant difference between the three groups during all follow-up periods but the control group had the lowest values during all FU-examinations. With larger groups the differences may become significant and Li-ESWT could be an option for those patients with contraindications to PDE5 inhibitors.
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