Efficacy of Medical Interventions for Erectile Dysfunction after Prostate Cancer Treatment: A Systematic Review and Network Meta-Analysis.

PURPOSE: Erectile dysfunction (ED) is a prevalent and distressing consequence of radical prostatectomy (RP) and radiotherapy (RT) for prostate cancer, profoundly impacting quality of life. Despite a wide array of available interventions, their comparative effectiveness remains uncertain in the absence of head-to-head trials. MATERIALS AND METHODS: We conducted a systematic review and network meta-analysis (NMA) of studies evaluating medical interventions for ED following RP or RT. MEDLINE, Embase, and Scopus were searched for eligible studies. Risk of bias (RoB) was assessed using the Cochrane RoB 2 and ROBINS-I tools. A random-effects NMA was performed, with efficacy expressed as odds ratios (ORs) and 95% confidence intervals (CIs). The certainty of evidence was evaluated using the GRADE framework. The primary outcome was recovery of erectile function, assessed using validated measures or the proportion achieving successful intercourse. RESULTS: Forty-one studies (n=4,157 participants) met inclusion criteria. Following RP, combination therapies were most effective: tadalafil plus intraurethral alprostadil gel (OR 24.8), tadalafil plus vacuum erection device (OR 12.3), and tadalafil plus low-intensity shockwave therapy (OR 8.2) demonstrated the highest odds of functional recovery versus placebo. Following RT, on-demand tadalafil was the most effective intervention (OR 8.0). Pooled analysis of RP studies showed a significant mean improvement in International Index of Erectile Function scores favouring active interventions over control (mean difference 4.5, 95% CI: 2.4-6.5, I²=62%), with longer intervention duration associated with greater improvement. Overall certainty of evidence was low to very low due to RoB, imprecision, and inconsistency. CONCLUSIONS: Combination therapies appear most effective for ED recovery after RP, while on-demand phosphodiesterase type 5 inhibitors are most efficacious after RT. These findings provide novel comparative evidence; however, cautious clinical application and further high-quality research are warranted.