Dr Rohit Kaushal, Max Hospital, Saket, New Delhi
Recently the urology community has witnessed tremendous growth of regenerative medicine and related publications in the last decade for treatment of erectile dysfunction. After inclusion of LI-ESWT in the EAU guidelines, Platelet Rich Plasma (PRP) is gaining popularity as a novel therapy showing initial promising results.(1,2) Animal studies have reported that PRP may ameliorate key elements of the pathophysiologic pathways leading to ED through vasculogenic, neuroprotective, neurotrophic, repairative, and anti-inflammatory effects. Recently, a double-blind, sham-controlled RCT by Shaher et al (3) showed that all parameters (IIEF, EHS score, penile duplex parameters) were significantly improved in the PRP group compared with the sham group. None of the trials reported any major adverse events except mild pain and bruising. All these trials were conducted in individuals who had been diagnosed with arteriogenic ED and were refractory to oral PDE5-I and /or ICIVAD. PRP is typically administered as intracaversonal injections marketed as Priapus shot (P shot), along with daily or on demand oral PDE 5 inhibitors /ICIVAD +/LI-ESWT.(4)
Currently there is lack of consensus on the best PRP preparation method, production of high quality PRP (volume, number of platelets, growth factor concentrations) and administration methods. Most studies did not use automated PRP preparation devices, and used centrifugation at different speeds. Closed systems clearly offer several benefits for the standardized preparation of PRP.(5) The ideal number of sessions, the time interval between the treatment sessions, the ideal dosage per session, minimum number of punctures per session are the questions that currently lack a definitive answer. Finally the patient profile (age, ED severity, comorbidities) who would benefit the most from the PRP treatment needs to be defined, and the potential synergistic effect of combinations with other treatment modalities for ED needs further exploration.(6) The most interesting combination treatment seems to be PRP and LI-SWT and the initial results are promising, there is a need for high quality RCTs with more robust data from larger sample sizes and long term follow ups and with standardised protocols.(7)
Table 1: Salient studies on role of PRP in ED
Study | Type | N (age [y]) | Protocol | Mean follow-up (mo) | IIEF-5 baseline (median [range] or mean ± SD) | IIEF-5 end of follow-up (median [range] or mean ± SD) | P value |
Shaher et al (2023)(1) | RCT; placebo controlled | 109 (55 y) | Active group (n = 54) 6 mL PRP injections - 3 sessions with 2 wk interval Placebo group (n = 54) 6 mL normal saline injections 3 sessions with 2-wk interval | 24 | PRP group: 18 (17-22) Placebo group: 19 (17-22) | PRP group: 22 (19.7-24.2) Placebo group: 19 (1-22) | <0.001 |
Poulios et al (2021)(2) | RCT; placebo controlled | 60 (58.5) | Active group 10 mL PRP injections with a 1-mo difference Placebo group 10 mL normal saline injections with a 1-mo difference | 24 | Active group 20.4 ± 2.9 Placebo group: 19.4 ± 3.7 | Active group 21.8 ± 4.8 Placebo group 19.4 ± 4.3 | <.001 |
Zasieda et al (2020) (3) | RCT | 64 (—) | Main group 1 PRP injection per week (6 focuses by 1 mL) + 2 sessions of LIPUS (the first at the same time with the PRP injection) per week for 6 wk (n = 32) Control group + 2 sessions of LIPUS per week for 6 wk (n = 32) | 12 | N/A | N/A | 0.047 |
Figure 2: Mechanism of action of PRP in ED