cate against its use and we feel the potential benefits

outweigh the cost and time associated with this

treatment. Practically, clinicians may choose to

adopt parts or all of this strategy that optimize the

cost–benefit ratio of the various therapies. In fact,

we encourage clinics to critically challenge this

protocol and report their experience with some or

all of its elements. This will only help refine

approaches in the future and optimize function

outcomes for patients.

Our protocol is premised on daily low-dose PDE-5

inhibitor therapy. There are several reasons for this:

(1) most PDE-5 inhibitor studies have been con-

ducted with this therapy and dosing and efficacy are

clearly established, (2) the oral route of administra-

tion is convenient and comfortable for patients and

(3) the upcoming US patent expiration implies that

this therapy will be far more price competitive in the

future. We recommend patients to take sildenafil on

an empty stomach at least 2 h after their most recent

meal, although this can be impractical. Sildenafil is

used nightly to improve corporal oxygenation.

Sexual intercourse is acceptable if the patient is

healthy enough to engage in activity, but it is not

necessary. It must be stressed that achieving erec-

tions is the goal since it is the clear sign of penile

oxygenation. Patients who do not respond to the

early components of the protocol are quickly

identified and transferred to ICI. Figure 1 presents

a timeline for the introduction of each of the

therapeutic modalities. Quarterly physician visits

are

recommended

ensure

compliance

and

optimize the therapy for the individual patient.

For example, a patient can suggest which thera-

pies are effective and which are bothersome. A

decision of which parts of the protocol to adhere

can be made in consultation with their treating

physician.

Ideally, patients are identified several weeks

before RP and introduced to the protocol. If possible,

patients are started on low-dose (25 mg) nightly

sildenafil and MUSE (250

g) thrice weekly before

surgery. Again, this approach is based on anecdotal

data that are unpublished as of this writing.

Although this drug is avoided the night before

surgery, patients are instructed to resume nightly

25 mg sildenafil 3 days after surgery.

When the foley catheter is removed 7–10 days after

surgery, the patient is advised to resume using

MUSE three times per week. Patients are again started

on 250

g and escalated to their effective dose if

possible. This therapy can often cause urethral

burning in patients, is uncomfortable to administer

for some, and may be very expensive. For this reason,

we recommend its use three times per week and

will even discontinue it in some circumstances.

Approximately 1 month after surgery, the patient

is re-evaluated. At this visit, they are encouraged to

engage in sexual activity. We initiate VED therapy

and advise the patient to use the device for 10 min

daily. At this point, the patient is on as many as

three therapies, although each is distinct in its route

of administration, mechanism and timing.

At 3-month post-RP patients who are not respond-

ing to nightly sildenafil with MUSE are transitioned

to ICI with trimix (phentolamine, papaverine and

PGE1). Similar to MUSE, patients are advised to use

this treatment three times per week for erections.

Patients are trained in our clinic by a physicians’

assistant until they show that they can successfully

inject themselves. This approach to patient educa-

tion helps overcome barriers to non-compliance.

Screening for testosterone deficiency (if suspected)

is performed at this point in addition to regular

prostate-specific antigen testing.

The second office visit is also the time where

hormone replacement can be initiated if necessary.

We recommend that prostate-specific antigen be

followed closely over the ensuing visits because of

concern for recurrence in the setting of testosterone

repletion. Patients are not started on testosterone

until two undetectable prostate-specific antigen

readings are identified and they have documented

symptomatic hypogonadism. Functional erectile

status is assessed and patients are challenged to

attempt less invasive therapies if the current proto-

col is effective.

Subsequent visits are scheduled at 3-month

intervals where compliance and efficacy are tested.

All opportunities to withdraw invasive therapies

are attempted, particularly for patients who are

experiencing recovery of spontaneous erections.

This visit schedule is continued for 18–24 months

after surgery to give the patient ample opportunity

to respond to therapy. Figure 2 presents a graphical

representation of our protocol and providers an

algorithm that can be adopted in any practice.

The comprehensive nature of this protocol sug-

gests further study of the relative contribution of

each of these therapies be studied. While compli-

ance can be a challenge in these patients, especially

because of the out-of-pocket costs associated with

EP, we have found that educating the patient on the

importance of preserving pre-RP erectile function is

the most effective means to overcome non-compli-

ance. Subsequent study of each of these therapies

will help clinicians refine their therapies and

continue to improve on what is already the ‘gold

standard’ for oncologic outcomes.

Conflict of interest

The authors declare no conflict of interest.

References

1 Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer

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