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Persistent Erectile Dysfunction Following Radical Prostatectomy: The Association between Nerve-Sparing Status and the Prevalence and Chronology of Venous Leak


  • Supported by: The Sidney Kimmel Center for Prostate and Urologic Cancers.

John P. Mulhall, MD, Director, Male Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate & Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 353 East 68th street, New York, NY 10065. Tel: 646-422-4359; Fax: 212-988-0768; E-mail:


Introduction.  Failure to recover erectile function after radical prostatectomy (RP) may result from venous leak as a sequela of neuropraxia-induced erectile tissue damage. Venous leak portends a poor prognosis for erections recovery as well as phosphodiesterase type 5 inhibitor (PDE5i) response.

Aims.  To define the impact of RP nerve-sparing status on venous leak prevalence and chronology.

Methods.  Study population: men who underwent RP for localized prostate cancer, had functional erections prior to RP, developed postoperative erectile dysfunction (ED), had a Doppler ultrasonography within 6 months of RP, and did not receive any ED treatment for the first 6 months after RP other than on-demand PDE5i.

Main Outcome Measures.  Venous leak prevalence and erectile function recovery at different time-points.

Results.  Data on 142 patients were analyzed, mean age: 58 ± 16 years. Sixty percent had bilateral nerve-sparing (BNS) surgery, 20% unilateral nerve-sparing (UNS) surgery, and 20% non-nerve-sparing (NNS) surgery. Eleven percent and 21% had venous leak by 3 and 6 months, respectively. Venous leak prevalence by 6 months was 7%, 11%, and 75% for BNS, UNS, and NNS surgery (P < 0.001). Mean end-diastolic velocity was 1.8, 2.1, and 7.2 cm/second for the three groups (P < 0.01). The only patients developing venous leak prior to 3 months were NNS patients, one-third of NNS-associated venous leak occurring before this time-point. At 18 months, the proportion of men having return of unassisted erections was 49%, 42%, and 7% with mean erectile function domain scores of 21, 18, and 12, and PDE5i response rates were 72%, 64%, and 12% for the three groups, respectively.

Conclusions.  Nerve-sparing status impacts heavily upon the prevalence and the chronology of venous leak development post-RP. NNS RP is associated with early development of venous leak, increased prevalence of venous leak, and reduction in return of natural erections. Tal R, Valenzuela R, Aviv N, Parker M, Waters WB, Flanigan RC, and Mulhall JP. Persistent erectile dysfunction following radical prostatectomy: The association between nerve-sparing status and the prevalence and chronology of venous leak. J Sex Med 2009;6:2813–2819.