madman
Super Moderator
Erectile Dysfunction, Surgical and Regenerative Therapy (2022)
Carlo Bettocchi, Fabio Castiglione, Omer Onur Cakir, Ugo Falagario, and Anna Ricapito
5.1 Erectile Dysfunction: Surgical Therapy
5.1.1 Introduction
Erectile dysfunction (ED) is defined as the failure to achieve and/or maintain a penile erection that is satisfactory for sexual intercourse [1]. It is postulated that more than 40% of men between the ages of 40 and 80 could suffer from different grades of ED [2]. The causes of ED are numerous but only in very few cases, ED is truly curable, such as the psychogenic one. In most cases, ED is only treatable [2].
Regardless of the cause, chronic ED is characterized by anatomical and functional alterations in the erectile cavernous tissue characterized by fibrosis [3]. Historically, the concept of penile fibrosis has been entirely linked to Peyronie’s disease and urethral stricture [4]. On the other hand, corpus cavernosum (CC) fibrosis was considered a rare disorder that was only seen after a penile fracture or after prolonged erection [5].
However, recently, several studies have demonstrated that CC fibrosis is a common pathological sign underlying most cases of vasculogenic and/or neurogenic ED. The penile erection is regulated by a complex mechanism that involves the synergy of the nitrergic and adrenergic neuronal system, endothelium, and smooth muscle cells of the CC. Pathological disorders affecting one or more of these elements could cause CC fibrosis [6]. An impaired elasticity of the CC due to fibrosis leads to a diminished filling of the sinusoids and inadequate compression of the subtunical venules. This lack of compression will result in blood leaking out of the CC during an erection, which makes the penis incapable to become entirely erected.
ED treatment has been standard for many years, and it was characterized by a limited range of therapeutic agents. The first-level approach consists of lifestyle modification followed by medical therapy with phosphodiesterase-5 (PDE5i) inhibitors. For refractory patients or those with intolerable side effects, European guidelines [7] suggest second- and third-level treatments such as vacuum devices, self-administered intracavernous injection of erectogenic substances, intraurethral creams, and placement of penile prostheses [8]
5.1.2 History of Penile Prosthesis
5.1.3 Penile Prosthesis Implant
5.1.4 Types of Devices and Differences
5.1.5 Surgical Approach
5.1.6 Comparison Between the Three Techniques
5.1.7 Complications
5.1.7.1 Intraoperative Complications
5.1.7.2 Postoperative Complications
5.2 Regenerative Therapies for Erectile Dysfunction
5.2.1 Introduction
Over the last decades, there has been an increasing interest in the hypothesis of “regenerative” cures for ED aimed at decreasing fibrosis of the CC and rebuilding their normal biological architecture. These new regenerative treatments include stem cell injections, platelet-rich plasma, and low-intensity shock wave therapy (Li-SWT). There are numerous data obtained on animal models of ED that indicate that these methods can result in angiogenesis and reduce fibrosis, thus “restoring” dysfunctional CC tissue [23].
To date, there are limited clinical data to support regenerative therapies as a first-line treatment for ED. However, evidence is growing every year, and these regenerative therapies are becoming a reality in the ED treatment clinical scenario.
5.2.2 Li-SWT for Erectile Dysfunction
5.2.2.1 Mechanism of Action
5.2.2.2 Type of Li-SWT Machine
5.2.2.3 Efficacy
5.3 Platelet-Rich Plasma for Erectile Dysfunction
5.3.1 Mechanism of Action
5.3.2 Effectiveness
5.4 Stem Cells for Erectile Dysfunction
5.4.1 Introduction
In the context of ED, the effects of stem cells from a broad range of sources have been reported, including adipose-derived stem cells (ADSCs), bone marrow stem cells (BMSCs), embryonic stem cells (ESCs), endothelial progenitor cells (EPCEPCs), urine-derived stem cells (USCs), skeletal muscle-derived stem cells (SkMSCs), and a stromal vascular fraction (SVF) (Table 5.4). In the past decade, several studies have evaluated the effect of stem cell therapy on the recovery of erectile function in several animal models of aging, diabetes mellitus, and cavernous nerve injury [41]. More important several phase 1 and phase 2 studies have evaluated the safety and the efficacy of stem cell-based therapy in men suffering from ED [42–47].
5.4.2 Mechanism of Action
5.4.3 Efficacy
Carlo Bettocchi, Fabio Castiglione, Omer Onur Cakir, Ugo Falagario, and Anna Ricapito
5.1 Erectile Dysfunction: Surgical Therapy
5.1.1 Introduction
Erectile dysfunction (ED) is defined as the failure to achieve and/or maintain a penile erection that is satisfactory for sexual intercourse [1]. It is postulated that more than 40% of men between the ages of 40 and 80 could suffer from different grades of ED [2]. The causes of ED are numerous but only in very few cases, ED is truly curable, such as the psychogenic one. In most cases, ED is only treatable [2].
Regardless of the cause, chronic ED is characterized by anatomical and functional alterations in the erectile cavernous tissue characterized by fibrosis [3]. Historically, the concept of penile fibrosis has been entirely linked to Peyronie’s disease and urethral stricture [4]. On the other hand, corpus cavernosum (CC) fibrosis was considered a rare disorder that was only seen after a penile fracture or after prolonged erection [5].
However, recently, several studies have demonstrated that CC fibrosis is a common pathological sign underlying most cases of vasculogenic and/or neurogenic ED. The penile erection is regulated by a complex mechanism that involves the synergy of the nitrergic and adrenergic neuronal system, endothelium, and smooth muscle cells of the CC. Pathological disorders affecting one or more of these elements could cause CC fibrosis [6]. An impaired elasticity of the CC due to fibrosis leads to a diminished filling of the sinusoids and inadequate compression of the subtunical venules. This lack of compression will result in blood leaking out of the CC during an erection, which makes the penis incapable to become entirely erected.
ED treatment has been standard for many years, and it was characterized by a limited range of therapeutic agents. The first-level approach consists of lifestyle modification followed by medical therapy with phosphodiesterase-5 (PDE5i) inhibitors. For refractory patients or those with intolerable side effects, European guidelines [7] suggest second- and third-level treatments such as vacuum devices, self-administered intracavernous injection of erectogenic substances, intraurethral creams, and placement of penile prostheses [8]
5.1.2 History of Penile Prosthesis
5.1.3 Penile Prosthesis Implant
5.1.4 Types of Devices and Differences
5.1.5 Surgical Approach
5.1.6 Comparison Between the Three Techniques
5.1.7 Complications
5.1.7.1 Intraoperative Complications
5.1.7.2 Postoperative Complications
5.2 Regenerative Therapies for Erectile Dysfunction
5.2.1 Introduction
Over the last decades, there has been an increasing interest in the hypothesis of “regenerative” cures for ED aimed at decreasing fibrosis of the CC and rebuilding their normal biological architecture. These new regenerative treatments include stem cell injections, platelet-rich plasma, and low-intensity shock wave therapy (Li-SWT). There are numerous data obtained on animal models of ED that indicate that these methods can result in angiogenesis and reduce fibrosis, thus “restoring” dysfunctional CC tissue [23].
To date, there are limited clinical data to support regenerative therapies as a first-line treatment for ED. However, evidence is growing every year, and these regenerative therapies are becoming a reality in the ED treatment clinical scenario.
5.2.2 Li-SWT for Erectile Dysfunction
5.2.2.1 Mechanism of Action
5.2.2.2 Type of Li-SWT Machine
5.2.2.3 Efficacy
5.3 Platelet-Rich Plasma for Erectile Dysfunction
5.3.1 Mechanism of Action
5.3.2 Effectiveness
5.4 Stem Cells for Erectile Dysfunction
5.4.1 Introduction
In the context of ED, the effects of stem cells from a broad range of sources have been reported, including adipose-derived stem cells (ADSCs), bone marrow stem cells (BMSCs), embryonic stem cells (ESCs), endothelial progenitor cells (EPCEPCs), urine-derived stem cells (USCs), skeletal muscle-derived stem cells (SkMSCs), and a stromal vascular fraction (SVF) (Table 5.4). In the past decade, several studies have evaluated the effect of stem cell therapy on the recovery of erectile function in several animal models of aging, diabetes mellitus, and cavernous nerve injury [41]. More important several phase 1 and phase 2 studies have evaluated the safety and the efficacy of stem cell-based therapy in men suffering from ED [42–47].
5.4.2 Mechanism of Action
5.4.3 Efficacy
