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Neurogenic Vasculogenic
cavernous nerve interruption, transection of the
traction and/or dissection accessory pudendal arteries
Apoptosis
Corporal smooth muscle fibrosis
VED can be used safely with other treatment modalities to achieve better
erectile function results.
Studies on VED for post RP penile rehabilitation
• 28 men with IIEF scores of >11: Early daily VED use- (1m post RP).
Late on-demand VED prior to intercourse- (6m post RP).
• They found that men who had completed early VED use had significantly greater IIEF scores
and a longer stretched penile length (2 cm) compared to the late on-demand group.
• However, at last follow-up (mean 9.5m) there was no significant difference in outcome, and
none of the patients reported unassisted erections sufficient for intercourse.
Another prospective clinical trial of 109 men randomized into using daily VED vs no treatment.
After 9 months, 80% of those using VED had erections sufficient for intercourse and were less
likely to report penile shrinkage (85% vs 23%, respectively).
There is a need to deeper investigate the effect of VED, and for longer rehabilitation periods
The neural pathway regeneration is crucial for successful penile rehabilitation.
• PVS stimulates branches of the pudendal nerves along the penile shaft.
• The stimulation of nerve terminal endings activates a reflex parasympathetic erection -
release of NO -activation of the cGMP /cAMP cycles -cavernosal smooth muscle dilation
and penile engorgement.
• 68 patients were randomized into using PVS+PDE5is vs PDE5is only .
• They were instructed to stimulate the frenulum once daily for at least 1-week before
surgery and after catheter removal for a period of 6 weeks.
• IIEF scores were evaluated at 3, 6, and 12m after surgery.
• Results showed that IIEF scores were higher in the PVS group at all times.
• At 12m, 53% reached a score of at least 18, vs to 32% in PDE5I only group (P = 0.07).
[Sonksen J
Penile Vibratory Stimulation (PVS)
• This study showed that PVS is both acceptable and tolerable for patients.
• Most importantly, it also pioneers the use of PVS as an agent in ED after
nerve-sparing RP.
[Sonksen J
Low-Intensity Shockwave Treatment (LI-ESWT):
low-intensity extracorporeal shockwave
• These studies demonstrate that LI-ESWT may potentially serve as an adjunct to penile
rehabilitation.
Human data have preceded the generation of basic science data.
low-intensity extracorporeal shockwave
• Shockwaves applied to the targeted tissue cause mechanical stress and micro-trauma
that catalyze a set of biological reactions resulting in neovascularization of the tissue.
ED 1000
(1) RC Rosen, KR Allen, X Ni, AB Araujo. Minimal Clinically Important Differences in the Erectile Function Domain of the International Index of Erectile Function Scale. Euro Urol 2011, 60
(5): 1010-6
Results at one month follow-up
• IIEF-EF increased from mean 8.83±2.53 to 9.83±4.04 (p=0.06)
• EHS increased from 1.06±0.96 to 1.41±0.96 (NS)
• FMD (AUC) increased from 308.1±185.1 to 489.1±408.76 (p=0.0031)
• No side effects were registered
Early intervention
Longer treatment course of LI-ESWT
What lies in the future for non-medical RP penile rehabilitation?
All are investigative :
• Impulse magnetic field therapy (PMT)
• affecting the cells’ water content, oxygen uptake
(shafik, 40 men, full erections)
• Tissue engineering: Engineering a biological substitute to
replace injured, diseased or malfunctioning organs (in rabbits)
• Nanoparticles
• Implanted drug delivery device
• Platelet-Rich Plasma (PRP) (three studies in China
and Taiwan-rats)
An exciting future of technological options are just around the corner
Good communication with the patient and expectation management are crucial
for future compliance and satisfaction with any rehabilitation program.