Page 3 - Algorithm for erectile rehabilitation following prostate cancer treatment

consensus: algorithm for erectile rehabilitation after Pca treatment

Table 1. Pro-erectile therapy algorithm
Patient preference Low invasiveness High invasiveness
Patient goal Long-term penile health Short-term erectile function
PCa treatment status BNS UNS NNS BNS UNS NNS
Surgery Pharmaceutical Daily and PRN PRN use of full-dose MUSE ICI ICI ICI
approach full-dose PDE5i PDE5i
Mechanical VED VED VED VED VED VED
approach
Radiation Pharmaceutical Daily and PRN full-dose PDE5i ICI
approach
Mechanical VED VED
approach
Baseline recommendation for all patients: Regular sexual activity (at least once a week). When applicable, patient’s partners should be included in the treatment plan. BNS: bilateral nerve
sparing; ICI: intracavernous injection; NNS: non-nerve sparing; PC: prostate cancer; PDE5i: phosphodiesterase type 5 inhibitors; UNS: unilateral nerve sparing; VED: vacuum erection devices.

and non-biomedical approaches, however, as this strategy is 3). More research is needed to determine the timeline for
often reserved later in the treatment trajectory (beyond two patients treated with RT. 38
years) to allow sufficient time for natural recovery and suffi-
cient retrial with first-line treatments, it is not presented in the Discussion
algorithm. Patient preferences are also taken into account
35
in terms of tolerance of degree of treatment invasiveness Developing a treatment plan for ED after PCa involves bal-
and the patient’s goals for erectile recovery (articulated fur- ancing a number of factors, including different trajectories
ther below). In addition to the specific recommendations for for radiation vs. surgical treatment, nerve-sparing status,
pro-erectile therapy, patients are recommended to maintain and the degree of invasiveness of various pro-erectile ther-
regular sexual activity (at least weekly), whether penetrative apies, along with determining patient and partner’s goals
or non-penetrative, and/or masturbation. Clinicians may also for erectile recovery. 20-23 Other patient-related factors must
consider combination therapies if necessary, depending on all be considered to ensure that pro-erectile therapies are
the patient’s desire to challenge ED over time. 36,37 optimally successful, including patient expectations of pro-
erectile therapy and timeline of recovery; the role of the
Section 2: Patient goals for erectile recovery and psychosocial considerations partner in erectile recovery; and the patient’s sexual beliefs,
As a supplemental document to the algorithm, Table 2 masculine values, possible grief in response to sexual losses,
outlines patient values and goals for erectile rehabilita - and potential performance anxiety. 39-41
tion and should be used as a resource to guide treatment Sub-algorithms were proposed for each group of patients
planning. The panel agreed that there were essentially two (e.g., those treated with radiation vs. surgery), as the panel
pathways that the patient might choose. The primary goals recognized advantages to more accurately capture between-
of “long-term penile health” (i.e., optimizing changes for group differences, such as different trajectory of impact of PCa
natural recovery of erections with a relatively non-invasive treatment on erectile function. Consensus on structures of the
approach) vs. “short-term erectile function” were identified sub-algorithms was achieved; the structure would include
in the algorithm. Clinicians are encouraged to assess the consideration for timeline benchmarks, long-term penile
patient’s goals for outcomes, as this may change with time. health vs. short-term erectile function, as well as additional
Furthermore, partners may also wish to provide input into sexual concerns, all while integrating patient preferences.
these goals. Suggested timeline benchmarks for the sub-algorithms
were 1‒3, 6, 12, 18, and 24 months from baseline, for
Section 3: Benchmarking and normalization surgical outcomes only. The suggested benchmarks were
In addition to the algorithm based on patient treatment based on historical practice adopted in clinical trials and
and preference for ED rehabilitation (pharmaceutical vs. the expected success rates of relevant treatment approaches.
mechanical), the panel noted the importance of provid - However, a significant limitation is the limited empirical
ing patients with a point of reference for their progress in evidence due to heterogeneity in treatment timelines and
terms of expected timeline of erectile function recovery. a low risk of external validity in clinical studies. Further
This attempt at typical response benchmarking is intended discussion is required to establish outcome benchmarks for
to help patients manage their expectations and normalize patients with a delayed response to treatment and also for
their recovery process. The panel determined that sufficient patients receiving RT.
empirical evidence for typical response benchmarking was The sub-algorithm structure for penile rehabilitation (i.e.,
only available for the post-RP patient population (Table long-term care of penile health) was designed to focus on

CUAJ • August 2019 • Volume 13, Issue 8 241