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Keywords:

  • erectile dysfunction;
  • radical prostatectomy;
  • treatment;
  • predictive factors

Abstract

  1. Top of page
  2. Abstract
  3. Preoperative Factors: Importance of Patient Selection
  4. Intraoperative Factors: The Importance of Surgical Technique
  5. Postoperative Factors: The Importance of Drug Administration
  6. Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence
  7. Conflict of Interest Disclosures
  8. References

Radical prostatectomy (RP) is a commonly used procedure in the treatment of clinically localized prostate cancer. For this report, the authors critically analyzed the factors associated with recovery of erectile function after surgery. A systematic review of the literature using the Medline and CancerLit databases was conducted. Keywords for the literature search included prostate cancer, radical prostatectomy, erectile dysfunction, impotence, treatment, and prophylaxis. Accurate patient selection (based on patient age, preoperative erectile function, and comorbidity profile) and adequate surgical technique (ie, the preservation of neurovascular bundles) were the major determinants of postoperative erectile function. Moreover, better results were achieved when an appropriate pharmacologic treatment using either oral or local approaches was given. Therefore, the authors concluded that, if patients are stratified correctly according to preoperative, intraoperative, and postoperative factors, then a satisfactory functional recovery may be expected after surgery. For these reasons, an ideal multivariate model predicting the restoration of erectile function after surgery should include patient, surgeon, and postsurgical treatment variables. The authors also concluded that the stratification of patients with regard to their risk of developing erectile dysfunction after surgery was feasible based on several parameters, which should be taken into account for correct patient treatment and counseling. To address this objective, accurate tools for predicting the likelihood of complete functional recovery after surgery are needed. Cancer 2009;115(13 suppl):3150–9. © 2009 American Cancer Society.

Radical prostatectomy (RP) is used increasingly as a therapeutic option for patients who have clinically localized prostate cancer and a life expectancy ≥10 years. The pioneering work by Walsh and Donker1 contributed significantly to our understanding of the surgical anatomy of the prostate and represented the basis for the subsequent development of the anatomic RP technique. The objective of this surgical approach is complete excision of the prostate to provide optimal cancer control while maintaining the integrity of the anatomic structures devoted to the functions of urinary continence and sexual potency.2-4 Since the initial reports on this technique, increasing numbers of studies have reported satisfactory postoperative rates of urinary continence, whereas the preservation of erectile function after surgery has remained a major challenge for most urologists.5-8 These findings led to an increasing interest in elucidating the pathophysiology of postoperative erectile dysfunction (ED) and on its potential prophylaxis and treatment.9 The objective of the current review was to critically evaluate the predictive factors associated with recovery of erectile function after RP. For this purpose, we stratified the factors associated with postoperative erectile function into preoperative, intraoperative, and postoperative predictors.

A systematic review of the literature using the MEDLINE and CancerLit databases was conducted. Electronic searches were limited to the English language using the keywords prostate cancer, radical prostatectomy, erectile dysfunction, impotence, treatment, prophylaxis. All of the keywords are within the Medical Subject Headings database, which represents the controlled vocabulary used for indexing articles for MEDLINE and PubMed. The articles with the highest level of evidence were selected. Overall, 61 articles related to the topics of ED and RP were identified and peer reviewed by the authors.

Preoperative Factors: Importance of Patient Selection

  1. Top of page
  2. Abstract
  3. Preoperative Factors: Importance of Patient Selection
  4. Intraoperative Factors: The Importance of Surgical Technique
  5. Postoperative Factors: The Importance of Drug Administration
  6. Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence
  7. Conflict of Interest Disclosures
  8. References

Accurate patient selection is key for a satisfactory sexual outcome after RP.8 First, the anatomic nerve-sparing approach to the prostate is considered for patients who have clinically localized prostate cancer. Patients who have tumors classified as clinical T1 and T2, as determined by digital rectal examination and/or transrectal ultrasonography of the prostate, are the best candidates. Because clinical stage often is correlated with both prostate-specific antigen (PSA) value and biopsy Gleason sum, it has been suggested that a nerve-sparing approach may be considered for patients who have a PSA value <10 ng/mL and a Gleason sum ≤7.10 Also, it has been demonstrated that several key preoperative factors are associated significantly with erectile status after surgery.8, 9 These factors include patient and partner age, preoperative erectile function (including preoperative use of phosphodiesterase type 5 inhibitors [PDE5-I]), and comorbidity status at the time of surgery (Table 1).

Table 1. Factors Associated With Erectile Function Recovery After Radical Prostatectomy
Preoperative Factors (References)Intraoperative Factors (References)Postoperative Factors (References)
  1. ED indicates erectile dysfunction.

1. Patient age at surgery (Rabbani 2000,11 Ayyathurai 2008,12 Kundu 2004,13 and Eastham 200814)1. Surgical approach: Volume of neural tissue preserved (Rabbani 2000,11 Ayyathurai 2008,12 Kundu 2004,13 Eastham 2008,14 and Michl 200616)1. Time of erectile function assessment after surgery (Mulhall 200547)
2. Partner age (Descazeaud 200615)2. Nerve-sparing technique (Montorsi 2005,23 Masterson 2008,24 Nielsen 2008,25 Menon 2005,26 and Rogers 200432)2. ED prophylaxis and treatment (Montorsi 1997,46 Mulhall 2005,47 Raina 2006,48 Padma-Nathan 2008,49 McCullough 2008,50 Bannowsky 2008,51 and Montorsi 200852)
3. Preoperative erectile function (Rabbani 2000,11 Ayyathurai 2008,12 Kundu 2004,13 Eastham 2008,14 and Michl 200616)3. Surgical expertise (Ayyathurai 200812) 
4. Comorbidity profile (Montorsi 200417)  

Patient and partner age

The age of patient at the time of surgery is key in determining erectile function recovery after surgery. Several trials have indicated that the best postoperative potency rates are obtained in the younger patient population.11-14 Younger patients are more likely to have better preoperative erectile function and to be more interested in sexual recovery after surgery.11-14 Patients between ages 40 years and 49 years reported rates of erectile function recovery as high as 92%.13 In addition to patient age, it recently was demonstrated that a difference in age between a patient and their partner is associated linearly with better sexual outcome after RP.15 A difference in patient and partner age as great as 20 years was associated with a roughly 3.5-fold increased erectile function recovery rates compared with patients who were the same age as their partners (90% vs 25%; P < .001). This was true regardless of proerectile drug administration after surgery. These data reinforce the need for sexual counseling that includes both patients and their partners.

Preoperative erectile function

Preoperative erectile function represents another key factor associated with the recovery of erectile function after surgery.11-14, 16 Ideally, patients who are being considered for nerve-sparing RP (NSRP) should be potent before the procedure.17 This is of major importance, because patients who report some degree of ED and patients who already use a PDE5-I before the procedure are more likely to develop severe ED postoperatively, regardless the surgical technique used.17 The use of validated questionnaires, such as the International Index of Erectile Function (IIEF), is mandatory in the diagnostic approach of patients before surgery.18 However, a key issue that remains controversial is the best timing for the administration of these instruments.19 Indeed, proportions of patients do not engage in sexual activity at all after a diagnosis of prostate cancer because of psychogenic issues. Therefore, the evaluation of sexual function at the time of hospitalization may not provide realistic results. For these reasons, such an assessment ideally should be done before prostate biopsy, at the time of the first visit.

Cormorbidity profile

Comorbid conditions also seem to affect the recovery of spontaneous erections postoperatively, because such conditions may have an impact on baseline penile hemodynamics. For instance, a concomitant diagnosis of diabetes mellitus, hypertension, ischemic heart disease, or hypercholesterolemia or history of cigarette smoking identified at the time of the preoperative patient assessment should be taken into account as a potential negative predictive factor for potency before and after surgery.17

Intraoperative Factors: The Importance of Surgical Technique

  1. Top of page
  2. Abstract
  3. Preoperative Factors: Importance of Patient Selection
  4. Intraoperative Factors: The Importance of Surgical Technique
  5. Postoperative Factors: The Importance of Drug Administration
  6. Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence
  7. Conflict of Interest Disclosures
  8. References

In suitable candidates, radical excision of the prostate should be performed with the objective of achieving total cancer control, ie, removing all cancer present in the prostatic tissue, while maintaining the integrity of the anatomic structures on which urinary continence and erectile function are based.2 Namely, the corpora cavernosa receives the innervation responsible for erections through the cavernosal nerves, which branch out from the pelvic plexus. This latter structure is located adjacent to the tip of the seminal vesicles on the anterolateral wall of the rectum and may be damaged during RP. The cavernous nerves course adjacent to small vessels that form the so-called neurovascular bundle (NVB) along the posterolateral margin of the prostate bilaterally and are located between the visceral layer of the endopelvic fascia and the prostatic fascia. Several studies have demonstrated that the surgical approach is key for maintaining erectile function after RP.11-14 Indeed, the volume of neural tissue preserved is associated linearly with the quality of erection after surgery. Patients with both NVBs preserved are more likely to recover erectile function after surgery (Table 1).11-14, 16 In 2000, Rabbani and colleagues, using a rigorous statistical method, demonstrated for the first time that the volume of neural tissue preserved is crucial for postoperative potency.11 Several other studies have confirmed those results.12-14, 16 In addition, many recent reports have demonstrated that the course of the NVB may be more complex than what was believed historically.20-22 It is well known that neuronal fibers gathered in the NVB are located at the rectolateral side of the prostate. These fibers, after piercing the urogenital diaphragm, enter the corpora cavernosa. However, several reports have indicated that the nerve fibers of the NVB are spread around the prostatic capsule and contribute to the innervation of several anatomic structures other than the corpora cavernosa. Eichelberg et al20 elegantly demonstrated that approximately 1 in 4 of these nerves can be observed along the ventral circumference of the prostatic capsule. Tewari et al21 also described additional, small nerve fibers ramifying in the prostatic and Denonvillier fascia outside the main bundles of the NVB. Moreover, an elegant insight into the anatomy of the NVB has been provided by Costello et al,22 who demonstrated that the nerves running in the NVB innervate not only the corpora cavernosa but also the rectum, prostate, and levator ani musculature. All constituents of the NVB are organized into 3 functional compartments that have a different course according to the area innervated. The neurovascular supply to the rectum generally is located in the posterior and posterolateral sections of the NVB, whereas the levator ani neurovascular supply is located in the lateral section of the NVB. Conversely, the cavernosal nerves and the prostatic neurovascular supply descend along the posterolateral surface of the prostate, and location of the prostatic neurovascular supply is the most anterior.

The results from those studies clearly have revealed a more complex course of the fibers of the NVB, which contribute to create a widely spread neural network instead of a real neural bundle. However, the exact function of all of the nerve fibers described in the periprostatic space is still to be demonstrated. On the basis of the findings of these studies, some authors have advocated a modification of the standard nerve-sparing approach aimed at maximizing nerve fiber preservation.23-25 Montorsi et al23 have suggested a technique using a high anterior incision of the levator and prostatic fasciae (1 and 11 o'clock positions) over the prostate. This allows development of the plane between the prostatic capsule and prostatic fascia (intrafascial approach) to displace the neurovascular network located between the 2 fasciae laterally and to preserve nerve fibers located on the ventral part of the prostate. In a small cohort of 42 patients who underwent surgery with an intrafascial nerve-sparing approach, the rate of full erectile function recovery (defined as an IIEF-erectile function [IIEF-EF] domain score ≥26) was as high as 52% at 6-month follow-up.23

Recently, Masterson and collegues24 conducted a retrospective, nonrandomized comparison of functional outcome associated with a standard nerve-sparing technique compared with a modified nerve-sparing approach. In the modified technique, the NVB was mobilized completely off the prostate from the apex to above the seminal vesicles, including incision of Denonvillier fascia, before urethral division and mobilization of the prostate off the rectum. It is noteworthy that the 6-month erectile function recovery rate was significantly higher in patients who underwent the modified technique compared with patients who underwent a standard nerve-sparing approach (67% vs 45%, respectively; P = .01). Similar results were reported recently by Nielsen et al in a high-volume, single-surgeon series.25 These data seem to replicate what was reported previously in a comparative trial of robotic RPs in which only 17% of patients who underwent a standard nerve-sparing technique achieved medically unassisted, normal erections (defined as a Sexual Health Inventory for Men score >21) compared with 51% of patients who underwent prostatic fascia-preserving RP at 1-year follow-up (P < .0001).26 Table 2 shows the erectile function outcomes reported in the major, available, open laparoscopic and robotic series.

Table 2. Single-center Studies Assessing Erectile Function Outcomes in Retropubic, Laparoscopic, and Robotic Radical Prostatectomy Series
StudyNo. of PatientsBaseline ED, %Technique UsedTreatment AdministeredPostoperative EF DefinitionOutcome
  1. ED indicates erectile dysfunction; EF, erectile function; NSRRP, nerve-sparing radical retropubic prostatectomy; PDE5-I, phosphodiesterase type 5 inhibitors; IIEF-EF, International Index of Erectile Function erectile function domain; SHIM, Sexual Health Inventory for Men; IC, intracavernous; RRP, radical retropubic prostatectomy; ICI, intracavernous injection; BNS, bilateral nerve sparing; NS, nerve sparing.

Montorsi 200523520NSRRP with high incision of the levator and prostatic fasciaeWith or without PDE5-IIIEF-EF score ≥2652% At 6 mo
Masterson 200824371Not reportedEarly release of neurovascular bundles (n=97) vs standard nerve-sparing technique (n=275)Not reportedPresence of full erections using a 5-point scale67% Vs 45% at 6 mo
Nielsen 2008251670High anterior release of the levator fascia (n=74) vs standard NSRRP (n=92)Not reportedSHIM score ≥2270% Vs 54% at 12 mo
Menon 200526580Preservation of the prostatic fascia (n=35) vs standard nerve-sparing (n=23), robotic prostatectomyWith or without PDE5-ISHIM score ≥2297% Vs 74% at 1 y
Montorsi 199746300Standard NSRRPIC Alprostadil 3 times/wk for 12 wk vs observationSpontaneous erection sufficient for sexual intercourse67% Vs 20% at 6 mo
Mulhall 2005471320RRPSildenafil or ICI (3 times/wk) vs observationPercentage of patients with normal EF domain scores22% Vs 6% at 18 mo
Kaul 20065415427Intrafascial nerve-sparing robotic prostatectomyWith or without PDE5-ISHIM score ≥2271% At 1 y
Rozet 200555890BNS extraperitoneal laparoscopic prostatectomyICI vs tadalafil 10 mg every 2 dSexual intercourse rates64% Vs 43% at a median follow-up of 6 mo
Chien 20055620Not reportedBNS robotic prostatectomyWith or without PDE5-IAbility to have sexual intercourse with or without PDE5-I50%
Michl 20061627558.8%Bilateral NSRRPNot reportedSHIM score ≥1936.7%
Kundu 20041317700Bilateral NSRRPNot reportedErections sufficient for intercourse76%
Toujier 2008572940Laparoscopic (n=130) vs open (n=164) radical prostatectomyNot reportedErections hard enough for penetration >50% of the time, almost always, or always56% Vs 58.5%
Rodriguez 200958580Bilateral and unilateral NS robotic prostatectomyNot reportedSHIM score ≥2246%
Rabbani 20000112290Bilateral and unilateral NSRRPNot reportedPresence of full erections using a 5-point scale55% At 12 mo

Moreover, in properly selected patients, some authors advocate an advantage in favor of a partial excision of the seminal vesicles to reduce the risk of damaging the pelvic plexus and to minimize injury to the cavernosal innervation27 However, such an approach remains controversial because of the lack of long-term data assessing disease recurrence and survival. Moreover, recent data have questioned the applicability of previously validated criteria for selecting patients who are suitable for a seminal vesicle-sparing approach.28 For these reasons, the role of a standardized seminal vesicle-sparing technique on functional and oncologic outcomes needs to be addressed further in prospective, randomized trials.

Another issue that has been a matter of intense debate is the significance of preserving the accessory pudendal artery (APA) during surgery. The prevalence of the APA varies from 4% to 75%, depending on whether the APA was identified during surgery,29 angiography,30 or autopsy.31 Despite the lack of a clear significance of the APA in the pathophysiology of ED, accumulating evidence supports the concept that APA preservation may contribute to the recovery of erectile function after surgery. Indeed, after an early assessment indicating that there was no association between erectile function recovery and APA preservation during NSRP,29 a group of investigators at Johns Hopkins observed that APA preservation resulted in a 2-fold greater likelihood of postoperative potency recovery.32 On the basis of those results, the authors concluded that preservation of the APA may favorably influence the recovery of sexual function after NSRP. This may be related to the finding that the APA represented the dominant source of blood supply to the penis in approximately 50% of patients who had an accessory artery identified.30 Taken together, these data suggest the need for intraoperative APA sparing when technically feasible.33 However, larger functional studies will be needed in the future to clarify this issue.

Finally, with regard to oncologic outcomes after RP, surgical expertise plays a key role in the preservation of postoperative erectile function (Table 1). In a large retrospective series of 1620 RPs, Ayyathurai et al12 observed that, in a large, single-surgeon series, the surgeon's experience was an independent predictor of erectile function recovery after surgery along with patient age and nerve-sparing technique. Despite the large number of patients evaluated, that study was limited by the lack of a stringent definition of full erectile function after surgery. Conversely, when multiple surgeons at a high-volume center were evaluated, no difference in sexual outcome was reported.34 The authors concluded that surgical expertise cannot be measured simply by the number of such operations that a surgeon performs. However, no mention was made in the report about differences in surgical approaches among surgeons. Therefore, larger trials assessing both surgical volume and surgical technique are needed to evaluate the correlation between surgeon and functional outcome after NSRP.

Postoperative Factors: The Importance of Drug Administration

  1. Top of page
  2. Abstract
  3. Preoperative Factors: Importance of Patient Selection
  4. Intraoperative Factors: The Importance of Surgical Technique
  5. Postoperative Factors: The Importance of Drug Administration
  6. Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence
  7. Conflict of Interest Disclosures
  8. References

A key postoperative factor associated with erectile function improvement after RP is represented by the administration of proerectile drugs. Several trials have demonstrated higher rates of erectile function recovery after surgery in patients who received any drug for ED (Table 1).

Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence

  1. Top of page
  2. Abstract
  3. Preoperative Factors: Importance of Patient Selection
  4. Intraoperative Factors: The Importance of Surgical Technique
  5. Postoperative Factors: The Importance of Drug Administration
  6. Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence
  7. Conflict of Interest Disclosures
  8. References

Rationale for penile rehabilitation

A better understanding of the pathophysiology of postprostatectomy ED, including the concept of tissue damage induced by poor corporeal oxygenation, has paved the way for the application of pharmacologic regimens aimed at improving early postoperative corporeal blood filling, thus increasing penile oxygenation and decreasing penile fibrosis. The rationale for penile rehabilitation has been elucidated in several animal and human studies. Chronic PDE5-I administration in cavernous nerve crush injury animal models increased the content of smooth muscle cells and decreased the deposition of collagen in the penile tissue compared with controls.35, 36 Moreover, chronic sildenafil use was associated with a significant reduction in the apoptotic indices and with a greater density of myelinized fibers in rats that underwent cavernous nerve injury.37 Furthermore, chronic use of PDE5-I contributed to the enhanced expression of nitric oxide synthase in rat corpora cavernosa.38 Therefore, the rationale for chronic PDE5-I administration relies on several structural and functional changes induced by continuous administration of the drug.

Similar preservation of erectile tissue morphology after chronic PDE5-I treatment also was described in a clinical investigation. Schwartz et al analyzed a cohort of 21 potent patients with localized prostate cancer who underwent retropubic RP at a single institution. Those patients subsequently received sildenafil at a dose of either 50 mg (Group 1) or 100 mg (Group 2) every other night for 6 months starting from the day of catheter removal.39 Patients underwent percutaneous penile biopsy both preoperatively (under general anesthesia before surgical incision) and 6 moths after surgery (using local anesthesia). It is noteworthy that, although, in Group 1, there was no statistically significant difference in the mean intracavernosal smooth muscle content between the preoperative and postoperative measurements (51.1% and 52.6%, respectively), in Group 2, a statistically significant increase in the mean smooth muscle content after surgery (42.8% vs 56.8%; P < .05) was observed. Thus, a daily high-dose administration of PDE-5 inhibitors may be a key factor in cavernosal smooth muscle preservation, thus reinforcing the idea of the clinical application of sexual pharmacologic prophylaxis after surgery. Finally, chronic treatment with PDE5-I has been associated with ameliorated endothelial function in both animal and human models.40-43 Several mechanisms seem to be involved in the improvement of endothelial function after chronic PDE5-I administration. These include increased endothelial nitric oxide synthase activity,44 decreased apoptotic cell death,45 and an increased amount of circulating endothelial progenitor cells.43

Penile rehabilitation after nerve-sparing radical prostatectomy: Clinical evidence

Despite all the evidence in favor of chronic treatment with PDE5-I, only a few trials have assessed the role of penile rehabilitation in men who underwent RP.46-52 Montorsi et al46 demonstrated that, by using intracorporeal injections of alprostadil early after bilateral NSRP (BNSRP), the rate of recovery of spontaneous erections was significantly higher than the rate with observation alone. Those data also recently were confirmed by Mulhall et al,47 who demonstrated that the prophylactic use of intracorporeal injections of alprostadil in patients who did not respond to oral sildenafil resulted in higher rates of spontaneous functional erections and erectogenic drug response 18 months after NSRP. In this context, the prophylactic administration of a vacuum constriction device also has been proposed recently as an early penile rehabilitation approach aimed at promoting adequate cavernosal oxygenation and, thus, preventing penile fibrosis after surgery.48 The advent of PDE5-I in the treatment of ED clearly has revolutionized the management of this medical condition. The rationale for the use of these drugs as prophylaxis is based mainly on oxygenation of the corpora cavernosa, thus maintaining a vital cavernosal structure. Padma-Nathan et al49 reported on the prospective administration of sildenafil at doses of 50 mg and 100 mg versus placebo, daily and at bedtime, in patients who underwent BNSRP and were potent preoperatively. Four weeks after surgery, the patients were randomized to receive either sildenafil or placebo for 36 weeks. Responders were defined as those who had a combined score ≥8 for questions 3 and 4 on the IIEF and a positive response to the question, “Were erections good enough for satisfactory sexual activity?.” It is noteworthy that 27% of the patients in that study who received sildenafil were responders compared with 4% in the placebo group (P = .0156). Postoperative nocturnal penile tumescence assessments were supportive of the sildenafil group.50 Recently, Bannowsky et al evaluated the effect of daily sildenafil 25 mg in a small cohort of patients who underwent NSRP and who maintained nocturnal erections early after surgery.51 Patients assigned nonrandomly to receive either daily sildenafil 25 mg or no treatment after surgery. In that study, the patients who received nightly sildenafil had higher mean IIEF-5 scores and a shorter time to recovery of erectile function (P < .001) compared with the patients who remained untreated after surgery (potency rate, 86% vs 66%, respectively). However, despite the enthusiasm associated with chronic administration of PDE5-I after surgery, results from a recent, well designed, prospective, randomized, double-blind study appear to support the on-demand use of PDE5-I after BNSRP over a daily dosing regimen.52 The study included a total of 628 preoperatively potent patients who underwent BNSRP and were randomized to receive either vardenafil 10 mg nightly or flexible-dose, on-demand vardenafil or placebo for 9 months. This large and rigorous study demonstrated that on-demand use of vardenafil during the treatment period was associated with significantly greater IIEF-EF domain scores and significantly better Sexual Encounter Profile 3 (SEP3) success rates (defined as a positive answer to the question: “Did your erections last enough to have successful intercourse?”) compared with placebo (all P < .001). In addition, the proportion of patients that achieved IIEF-EF domain scores ≥22 at the end of study period was greater for the on-demand vardenafil group than for the nightly vardenafil and placebo groups. However, when patients were reassessed at the end of the 2-month open-label phase when they received on-demand vardenafil, no difference was reported in terms of erectile function recovery (defined as an IIEF-EF domain score ≥22) or in terms of SEP3 outcomes. Therefore, the results of that trial indicated that there was no difference in sexual outcomes between the 3 groups of patients. However, several flaws may have biased the results of that prospective, randomized trial. The major problem was the inclusion of patients who were recruited at 87 different centers. The mean number of patients treated at each site was <5. The large number of treating surgeons raises the issues of heterogeneity of surgical quality and nerve-sparing status of the population. This was confirmed indirectly by the low response to vardenafil at the end of the single-blind phase (approximately 40%). Moreover, no data were given with regard to the number of pills taken during the treatment phase between the 2 groups (namely, nightly vardenafil and on-demand vardenafil). Some patients who were randomized to receive nightly vardenafil may not have used it every night. Therefore, patients who were randomized to receive on-demand vardenafil may have taken a similar amount of the drug compared with their nightly counterparts. Furthermore, the duration of the trial also has been questioned.53 Indeed, a 9-month study may not be long enough to correctly assess the beneficial effects of PDE5-I on postoperative erectile function recovery. A continuous improvement in erectile function up to 2 years after surgery has been reported.47 Despite these limitations, the trial is 1 of the few addressing the role of chronic PDE5-I administration in patients who underwent bilateral NSRP.

In conclusion, RP is performed increasingly in patients with prostate cancer. Because the mean age of this patient subgroup has declined progressively since the advent of PSA testing and prostate cancer screening programs, the demand for optimal postoperative quality of life has become more important. Erectile function after RP depends strictly on several preoperative, intraoperative, and postoperative factors that must be taken into account for adequate patient stratification and counseling. Indeed, when patients are selected properly and managed adequately after surgery, the expected rate of recovery of optimal erectile function is high.

References

  1. Top of page
  2. Abstract
  3. Preoperative Factors: Importance of Patient Selection
  4. Intraoperative Factors: The Importance of Surgical Technique
  5. Postoperative Factors: The Importance of Drug Administration
  6. Pharmacologic Prophylaxis of Postoperative Erectile Dysfunction: Rationale and Clinical Evidence
  7. Conflict of Interest Disclosures
  8. References