However, there are side effects to the surgery. One is erectile dysfunction ED. The reason why radical prostatectomy carries this risk is that two tiny cavernous nerves are located along the sides of the walnut-sized prostate.
Normally, these cavernous nerves carry signals to the penis to fill with blood and become erect. During surgery, the doctor may need to remove one or both nerves if they are too close to the cancer. Also, even if the nerves are not removed, they can still be damaged during the surgery. The trauma to the cavernous nerves is one of the main causes of ED after prostate surgery.
If you have been diagnosed with prostate cancer and need surgery, you may want to know what options are available to restore your sexual function after surgery. First, it is important that you talk openly with your doctor about:. You should also talk to your doctor about your overall risk of ED. For example, if you are older, have a chronic condition like diabetes, or already have sexual function problems, then you are more likely to develop ED after the surgery.
While it can be difficult to discuss sensitive topics like sex, remember that your sexual health is a part of your overall health and well-being, and it is definitely worth talking about. If you have a partner, be sure to involve this important person in your recovery since your sexual function affects you both. Since ED is a common complication after prostate surgery, it is a good idea to learn about your treatment options.
It is also important to understand that while ED affects most men after prostate surgery, many men regain the ability to have erections within 2 years of nerve-sparing surgery. This is not as common, though, if the nerves were removed. Your doctor may prescribe medications like sildenafil, vardenafil, or tadalafil after your surgery. These medications work by increasing blood flow to the penis, which may restore the ability to have an erection.
Injecting medication directly into the penis is another option. While this is not as convenient as taking a pill, this option can help produce an erection. A vacuum device is also available. This involves placing a mechanical pump over the penis. This pump creates vacuum pressure, which triggers an erection by causing blood to flow into the penis.
To maintain the erection, a small band is placed around the shaft of the penis. Surgery can also be done to treat ED, as various devices exist that can be implanted into the penis to help you achieve an erection.
With one type, there is a small pump implanted under the skin of the scrotum. When you want to have sex, you squeeze the pump and fluid is sent to cylinders that are implanted in the penis. The OC Hospital's, Dr. Ahlering theorized that cautery near the potency nerve bundles must damage the nerves in some way. Since early , he began a new innovative technique to avoid bleeding without the use of damaging electrocautery, by using small steel clamps routinely used in surgery of the kidney.
These clamps are considered non damaging, and are used for only a short duration of the surgery. He applied this method to prostate surgery and this is the 1st reported use of this technique in robotic prostatectomy, and it was recently published in the Journal Urology in May Ahlering has also recently published the early results of this technique. The study compared men who potency nerves were spared with bipolar electrocautery versus men who nerves were sparred without the use of electrocautery, and whose bleeding around the nerves was controlled by the novel technique of the 'Bulldog Clamp".
The men in the study underwent either bilateral saving the potency nerves on both sides of the prostate or unilateral nerve sparing preserving only one of the nerves. Long-term published data for potency after robotic prostatectomy is limited due to how new the procedure is. Very few surgeons world-wide have been using the da Vinci Robot for more than a few years.
As such, the two year endpoint traditionally used for open robotic prostatectomy is not available. For comparison we show the standard data on open prostatectomy potency very little is published about potency in the first months after prostatectomy :. As one can see, the chance of regaining potency diminishes with age and with the number of nerves damaged. Even though it is usually technically possible to spare the nerves, sometimes the nerves themselves are cancerous and must be removed since the primary goal of the surgeon is to remove the prostate cancer.
If the cancer has not reached the nerves controlling erection, the da Vinci Robot has the visual capabilities and the precision necessary to spare these nerves in most cases, thus it is possible that using the robot may add to the chances of being potent after surgery. However, there is no way to guarantee this due to variability in patient anatomy and condition. It is important to realize that some men never regain the ability to maintain an erection after robotic prostatectomy.
It is still unclear how using the da Vinci robot for prostatectomy will affect potency effects. While, as mentioned above, it would appear that using the robot may increase chances of potency, and research into how all this may translate into earlier return or increased percentage of potency is still ongoing.
It is known that using the robot reduces blood loss during robotic prostatectomy surgery, and length of hospital stay. Presumably this is indicative of a decrease in trauma and inflammation, which leads us to speculate that there may be a higher chance of potency erectile function. Urinary continence at zero pads, bladder capacity, and urinary symptom scores for men with moderate symptoms at three months are all also improved over open surgery results.
The postoperative local hypoxia leads to a decrease in nitric oxide production and furthermore determines the inhibition of prostaglandin release molecule that is strongly implicated in the inhibition of the pro-fibrotic process, inhibiting the accumulation of type I and III collagen in the smooth muscle fibers with fibrotic tissue buildup, that in time will replace the cavernous smooth muscle fibers.
The cavernous nerve fibers are accompanied by vascular structures and together form the neurovascular bundles [ 2 ]. Despite the surgical technique and approach used, various degrees of nerve damage will always exist, even in nerve sparing surgery, due to local trauma and its ischemic effect. The postoperative chronic penile flaccidity caused by neuropraxia leads to fibrotic and apoptotic changes in the erectile tissue, with vascular and cavernous elasticity impairment, changes that are responsible for the appearance of ED [ 4 ].
All things taken into consideration, postoperative penile rehabilitation should be introduced as soon as possible after surgery, to prevent fibrosis and to avoid irreversible structural changes that will determine end-organ damage responsible for the permanent ED. It has been demonstrated that any form of penile rehabilitation is better than doing nothing [ 2 ].
The notion of penile rehabilitation implies any form of treatment or combination of treatments that will lead to the recovery of the erectile function, similar to the preoperative baseline erectile function and furthermore to the ability of having a satisfying sexual intercourse [ 14 ].
In the first months after RP, patients will not be able to have spontaneous nocturnal erections despite the treatment applied. It is estimated that the recovery of a satisfactory sexual function will be achieved in 12 to 24 months after surgery with the help of a penile rehabilitation program [ 15 ]. The aim of the therapeutic approach used in post RP ED penile rehabilitation is to avoid and prevent structural endothelial and smooth muscle changes by improving the cavernous oxygenation.
Therefore, the principle behind the majority of the penile rehabilitation therapies is early tissue oxygenation [ 9 , 14 , 16 ]. The most common treatment used in post RP ED is the phosphodiesterase type 5 inhibitors PDE5i therapy, which is considered the first line treatment due to its ease of use, safe profile, and positive effect on the erectile function. This is followed by intracavernosal injections and vacuum erection devices and, the penile prosthesis implant, a solution with great results, regarded as a third line treatment for the patients with ED reluctant to medical treatment, should also be kept in mind.
PDE5i enhance erectile function by decreasing the breakdown rate of cyclic guanosine monophosphate cGMP , which leads to increased intracellular calcium ions efflux with smooth muscle relaxation and erection, this pathway being potentiated by nitric oxide via cavernous nerves [ 17 - 19 ].
In a randomized study conducted on 76 patients who have undergone bilateral nerve sparing open RP BNSRP and have received sildenafil nightly for 36 weeks or placebo after surgery, Padma Nathan demonstrated that the patients in the sildenafil group have shown increased IIEF-EF scores and improved nocturnal penile erections when compared to the placebo group [ 20 , 21 ].
In a study comparing the efficacy of a nightly 10 mg dose of vardenafil or on demand 10 mg vardenafil or placebo in patients after BNSRP, Montorsi showed that the results with the PDE5i treatment were superior to those with placebo in both groups of vardenafil patients, but it also showed no difference between the two vardenafil groups after a period of two months drug washout [ 22 ]. The lot was divided randomly in three groups and the patients have received 5 mg tadalafil once daily, 20 mg tadalafil on demand and placebo After nine months of treatment, the IIEF- scores have improved in both tadalafil groups, but when compared to the placebo group the results were significantly higher in the daily tadalafil group.
After a six weeks drug free period, no significant differences between the groups were seen. At the end of the study, it was also concluded that the daily use of tadalafil has had an important role in preventing penile length loss [ 23 ]. Avanafil, another PDE5i that was recently released, has shown significant improvements in treating patients with post RP ED, especially those who failed to respond to the treatment with sildenafil, vardenafil, or tadalafil.
In a phase three double blind placebo controlled study regarding the safety and efficacy of avanafil in the treatment of RP ED, Mulhall randomized patients to mg or mg of avanafil or on demand placebo for 12 weeks. Prior to the start of the study, the patients presented erectile dysfunction for six weeks or more, after RP was performed. At the end of the study it was concluded that the avanafil treatment was superior to placebo, with a significant increase of the IIEF score as well as in the Sexual Encounter Profile-question 3 Did your erection last long enough for you to have a successful intercourse?
Until now, no clinical trial has demonstrated the superiority of a daily administration of PDE5i versus on demand administration [ 20 ]. The majority of the clinical trials have demonstrated that the positive effects of the PDE5i regarding the penile rehabilitation program do not seem to persist after a drug free period.
According to literature and keeping in mind the results of the existing clinical studies, it is undoubtedly better to use a PDE5i therapy in post RP penile rehabilitation programs than to neglect the postoperative recovery. Vacuum erection devices VED function by creating a vacuum around the penis and drawing blood into corpus cavernosum by using a manually pump which creates a negative pressure.
A constriction ring can be applied at the base of the penis to prevent the blood outflow, therefore sustaining the erection [ 2 , 9 ]. This is a safe, cheap and with good results therapeutic method for erectile dysfunction, therefore its popularity has grown. There are studies that are in favor of the vacuum erection devices, especially when they are associated with PDE5i.
Due to their simple and early use after RP, low price, safe profile and the fact that they can ensure multiple daily erections, the VED are preferred by numerous patients, but their effect regarding the long term erectile recovery is questionable.
In a study evaluating the efficacy of intraurethral alprostadil suppositories IUA versus nightly sildenafil conducted on patients, McCullough reported no statistically significant differences regarding intercourse success and IIEF scores between the two groups after nine months of treatment.
A significant difference in favor of the IUA has been seen at six months, but this could have been be due to the fact that neuropraxia still existed at six months after surgery and that the PDE5i treatment was not fully effective.
Although IUA therapy can have significant results in the postoperative erectile recovery, the lack of clinical trials and as well as the high price and side effects urethral burning and penile pain make its use limited in the medical community [ 17 ]. Intracavernosal injections ICI represent a form of therapy that can be used in patients who have tried PDE5i and have failed [ 9 ].
The first study regarding the ICI was realized by Montorsi in on 30 patients who were randomized to receive ICI with alprostadil three times a week for three months versus no treatment.
Alprostadil ICI can induce penile pain that may lead to treatment dropout, but the TriMix ICI papaverine, phentolamine, and PGE1 is associated with less pain and therefore it can be well supported by patients [ 2 ].
The combination of these three molecules papaverine, phentolamine, and PGE1 acts as a vasoactive agent increasing the corpus cavernosum blood flow and determining erections and penile engorgement [ 17 ]. Penile prosthesis implantation represents the third line treatment for the post-radical prostatectomy erectile dysfunction.
Since its introduction in the s, it has been improved and due to the evolution of the surgical techniques, it has become an effective treatment for erectile dysfunction, with excellent efficacy and satisfaction rates for both patients and their partners [ 5 ]. Megas compared the efficacy and satisfaction profile between the PDE5 inhibitors therapy and penile prosthesis implantation on a lot of 54 patients who have undergone nerve sparing RP.
The patients included in the study were at six months after RP, were disease free prostatic cancer and all of them suffered from erectile dysfunction. The lot was divided into two groups, one receiving PDE 5 inhibitors and the patients in the second group have undergone penile prosthesis implantation.
Radiation therapy, by contrast, often results in a steady decline in erectile function to a hardly trivial degree over time. Options include pharmacologic and nonpharmacologic interventions. Non-pharmacologic therapies, which do not rely on the biochemical reactivity of the erectile tissue, include vacuum constriction devices and penile implants prostheses.
Men who have undergone nerve-sparing technique should be offered therapies that are not expected to interfere with the potential recovery of spontaneous, natural erectile function. In this light, penile prosthesis surgery would not be considered an option in this select group, at least in the initial 2 year post-operative period, until it becomes evident in some individuals that such recovery is unlikely.
A relatively new strategy in clinical management after radical prostatectomy has arisen from the idea that early induced sexual stimulation and blood flow in the penis may facilitate the return of natural erectile function and resumption of medically unassisted sexual activity. There is an interest in using oral PDE5 inhibitors for this purpose, since this therapy is noninvasive, convenient, and highly tolerable.
However, while the early, regular use of PDE5 inhibitors or other currently available, "on-demand" therapies is widely touted after surgery for purposes of erection rehabilitation, such therapy is mainly empiric. Evidence for its success remains limited. Recent strategies have included cavernous nerve interposition grafting and neuromodulatory therapy. The former, as a surgical innovation meant to reestablish continuity of the nerve tissue to the penis may be particularly applicable when nerve tissue has been excised during prostate removal.
In the modern era of commonly early diagnosed prostate cancer, nerve-sparing technique remains indicated for the majority of surgically treated patients. Neuromodulatory therapy, represents an exciting, rapidly developing approach to revitalize intact nerves and promote nerve growth.
Management of Erectile Dysfunction Oral medications relax the muscles in the penis, allowing blood to rapidly flow in. Alternative Treatments Men who do not recovery erectile function after treatment can try injectable medication that pharmacologically induced an erection. Mechanical Devices The vacuum constriction device creates an erection mechanically by forcing blood into the penis using a vacuum seal.
Surgical Options A three-pieced surgically inserted penile implant includes a narrow flexible plastic tube inserted along the length of the penis, a small balloon-like structure filled with fluid attached to the abdominal wall, and a release button inserted into the testicle. Erectile Dysfunction Following Radical Prostatectomy Assuming the management of erectile dysfunction requires expert diagnosis and treatment.
Burnett's Neuro-Urology Laboratory This topic area was handled thoroughly in an article written by Dr.
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