Standard Operating Procedure for the Preservation of Erectile Function Outcomes after Radical Prostatectomy


  • John P. Mulhall MD,

    Corresponding author
    1. Sexual & Reproductive Medicine, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
    • John P. Mulhall, MD, Sexual & Reproductive Medicine, Urology Service, Memorial Sloan Kettering Cancer Center, 353 E 68th Street, New York, NY 10021, USA. Tel: (212) 639-4359; Fax: 212-988-0768; E-mail:

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  • Trinity J. Bivalacqua MD, PhD,

    1. The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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  • Edgardo F. Becher MD, PhD

    1. Division of Urology, Hospital de Clínicas “José de San Martín,” University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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Introduction.  Prostate cancer is common, and, thus, more men are being treated surgically. Long-term functional outcomes are of significant importance to the patient and their partners. Erectile function (EF) preservation (rehabilitation) has gained significant traction worldwide, despite the absence of definitive evidence supporting its use.

Aim.  To review the effectiveness of specific pharmacological therapies and other erectogenic aids in the treatment of post-radical prostatectomy (RP) erectile dysfunction.

Methods.  A systematic literature review of original peer-reviewed manuscripts and clinical trials reported in Medline.

Main Outcome Measure.  This review focused on the evaluation of interventions that aimed to improve EF recovery following RP.

Results.  Although well documented in animal models, studies supporting the rehabilitation with phosphodiesterase type 5 inhibitors in humans are scarce. Daily sildenafil has been used in trials (only one randomized placebo-controlled trial) with a significant improvement in erection recovery when compared to placebo or no rehabilitation but with a low return to baseline rates (27% vs. 4% placebo). Nightly vardenafil vs. on demand vs. placebo has been studied in the Recovery of Erections: INtervention with Vardenafil Early Nightly Therapy trial with no difference in erection recovery following RP. Intracavernosal injections, although widely used and attractive from a rehabilitation standpoint, does not yet have definitive supporting its role in rehabilitation. Vacuum erection devices use following RP has been reported, but there are no data to support its role as monotherapy. Intraurethral alprostadil was also studied vs. sildenafil in a multicenter, randomized, open-label trial, and no superiority was found.

Conclusions.  At this time, we are unable to define what represents the optimal rehabilitation program in regard to strategies utilized, timing of intervention, or duration of treatment. Mulhall JP, Bivalacqua TJ, and Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. J Sex Med **;**:**–**.