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
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
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data that are unpublished as of this writing.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
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.
1 Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer
CA Cancer J Clin
Review and treatment protocol: erectile preservation for RP patients
International Journal of Impotence Research