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Updated analysis of training attempts in men using intracavernosal injection therapy after radical prostatectomy
Cara Cimmino, MD, Nelson Bennett, Jr., MD.
Lahey Clinic Medical Center, Burlington, MA, USA.

BACKGROUND: Intracavernosal injection therapy has been important in the treatment of erectile dysfunction for those men whom oral agents have been ineffective or contraindicated. Additionally, intracavernosal injections (ICI) have been successful as part of a penile rehabilitation regimen after radical pelvic surgery. Various reports have suggested that the attrition rate of ICI is linked to how quickly a satisfactory erection can be obtained. The objective of this study is to report the number of intracavernosal injections required to titrate to a satisfactory erection in the post-radical retropubic prostatectomy (RRP) setting.
METHODS: Men requesting ICI in the post-prostatectomy setting were included. Patient demographics, co-morbidity and nerve-sparing information was compiled. Those patients who were non-functional with or without PDE5 inhibitors constituted the study population. All patients underwent a comprehensive 2-hour ICI training session using Trimix (papaverine 30mg/ml, phentolamine 1mg/ml, prostaglandin E1 10mcg/ml) and subsequently instructed contact the office after using a prescribed dose of Trimix. Dose titration was performed via telephone. Functionality as assessed by a score of 4 or 5 on IIEF Q3 (ability to penetrate) was assessed at office follow-up. Bimix (papaverine 30mg/ml, phentolamine 1mg/ml) and Super-Trimix (papaverine 60mg/ml, phentolamine 1mg/ml, prostaglandin E1 20mcg/ml) was used when indicated. Patients that discontinued injections for greater than 1 month were excluded.
RESULTS:Data exists on 384 patients. All patients recorded a 0, 1, or 2 on Q3 of the IIEF prior to initial consultation. Mean patient age was 59.8±6.8 years. All had bilateral nerve sparing surgery. Subjects were 15.5±28.1 months post-prostatectomy with 92% <12 months post-RRP. Co-morbidities included diabetes (4%), hypertension (25%), hyperlipidemia (48%), and coronary artery disease (8%). Baseline IIEF EFD was 11±4. Men required 2.9±2.2 penile injections in addition to two office-based ‘training’ penile injections to titrate to a satisfactory penetration quality erection. 32.7 % (125/384) needed 3 or fewer total injections and 39.% (150/384) needed 4 or 5 total injections. 1.7% (7/384) required 10 or more injections. Pearson correlation coefficient between months after RRP and total number of titration ICI was -0.06. Of those that required <5 injections (72.9%), IIEF EFD was 27±3. One patient experienced a priapic episode of greater than 90 minutes and was treated promptly.
CONCLUSIONS: Over two-thirds of men needed less than 5 intracavernosal training injections to titrate to a satisfactory penetration quality erection. There was no correlation between elapsed time after RRP and the number of penile training injections required to attain a ‘hard’ erection.


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