Erectile dysfunction following prostatectomy: prevention and treatment

Abstract

Radical prostatectomy (RP) remains the standard treatment for men with clinically localized prostate cancer, despite the range of alternative treatment modalities. Even with significant advances in surgical technique and superb results for cancer control and preservation of urinary function, erectile dysfunction (ED) following RP is a common complication. This is mainly attributed to temporary cavernous nerve damage (neuropraxia) resulting in penile hypoxia, smooth muscle apoptosis, fibrosis and veno-occlusive dysfunction. One of the most promising new approaches is the concept of early penile rehabilitation, which is thought to prevent ED after RP by countering post-RP pathophysiological changes during the period of neural recovery. Various treatments, such as vacuum constriction devices, intraurethral and intracorporal alprostadil, and phosphodiesterase type 5 (PDE5) inhibitors, might serve to facilitate recovery of erectile function. PDE5 inhibitors are considered as the first-line treatment for early penile rehabilitation, with superior erectile function outcomes compared to placebo. Definitive conclusions regarding the success of penile rehabilitation cannot be drawn at this time because of differences in study design, data acquisition, and definitions of potency. Continued prospective, rigorous study is needed to develop and bring forward this important field and to establish the best evidence basis for counseling and treating patients suffering from ED after RP.

Bilateral nerve sparing robotic-assisted radical prostatectomy is associated with faster continence recovery but not with erectile function recovery compared with retropubic open prostatectomy: The need for accurate selection of patients

“…Patient selection and surgical technique are the major determinants of post-operative erectile function (2). The shift from open to laparoscopic surgery represented a completely new experience for surgeons, who were exposed to surgical anatomy through a different perspective and were required to learn new surgical procedures and to deal with new surgical tools (2).…”

Nightly sildenafil use after radical prostatectomy has adverse effects on urinary convalescence: Results from a randomized trial of nightly vs on-demand dosing regimens

“…While the effects of better nerve-sparing on improving early urinary outcomes after RP in previously potent men have been suggested in the literature, [10][11][12] it has not been shown that early PDE5i use after RP may adversely affect early urinary health-related quality of life. It is known that PDE5i therapy improves erections during the convalescence from nerve-sparing RP; 13 its effects on penile rehabilitation with daily use after RP are less clear. A number of RCTs have reported on the effects of daily PDE5i use on postoperative erectile function with discordant results.…”

Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates

“…The rationale for this treatment is the high, virtually immediate effectiveness of the drug in terms of erectile function and especially of hardness, a factor often considered critical to patient satisfaction [ 9,10 ] . In fact, even after nerve-sparing RP, neuroapraxia involves a period of functional insuffi ciency of nerve fi bres of up to 24 months, limiting the effectiveness of the use of PDE-5 inhibitors [ 11,12 ] .…”