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Dr. Arthur L. Burnett, of Johns Hopkins University, wrote an article on Erectile Dysfunction Following Radical Prostatectomy for the Journal of American Medicine, June 1, 2005. He has allowed QUEST to reprint parts of his article.

Which Patients Are Concerned?

Our improved diagnostic capabilities have led to the fact that many prostate cancer patients receive their diagnoses at relatively young ages. In considering the impact of the various treatment approaches on their quality of life, many patients place paramount importance on the possibility of retaining natural erectile function.

This matter is frequently important to young men who by age status are more likely to have intact erectile function than older men; however, for all men having normal preoperative erectile function irrespective of age, preservation of this function is understandably important postoperatively.

What is the prognosis for physical recovery, continence and potency after a radical Prostatectomy?

"Following a successful, nerve-sparing radical prostatectomy, most men will have return of erections but will not be able to have children by natural means."
­ Dr. William J. Catalona

The development of nerve-sparing surgery permitted the RRP procedure to be performed with significantly improved outcomes.

Now after the surgery, expectations are that physical capacity is fully recovered in most patients within several weeks, return of urinary continence is achieved by more than 95% of patients within a few months, and erectile recovery with ability to engage in sexual intercourse is regained by most patients with or without oral phosphodiesterase type 5 (PDE 5) inhibitors – pharmaceutical assistance – within two years.

What is nerve sparing surgery?

Preservation of the cavernous nerves – the so-called nerve-sparing technique – offered many men opportunities to regain erectile function.

These nerves…course along the lateral aspects of the prostate and rectum providing innervation (nerve connections) to the proximal penis in the deep pelvis. The severing of the cavernous nerves (during surgery) was and is the common basis for erectile dysfunction.

What is the time-line for return of function after surgery?

Despite expert application of the nerve-sparing prostatectomy technique, early recovery of natural erectile function is uncommon.

The reality of the recovery process…is that erectile function recovery lags behind functional recovery in other areas. Patients are understandably concerned about this issue and, following months of erectile dysfunction, become skeptical of reassurances that their potency will return.

Even when the nerve-sparing surgery is performed with immaculate technique, patients do not recover erectile function as quickly as they do urinary continence. In fact, the cavernous nerves are typically functionally inactive for as long as 2 years after surgery, even when nerve-sparing technique is used.

Message From a Patient: Delayed Return of Erections

Dr. Catalona wants to share this message he received from a patient.

  I am approximately 18 months post nerve sparing radical prostatectomy.   My erectile function is just now beginning to return to near my

pre-operation level.  I was able to achieve penetration and go to completion using a 20 mg Cialis dose for the first time last week.

I’d like to share a suggestion from my experience: Patients should learn about using a vacuum pump and/or a "cocktail" injection to allow sexual activity after an RRP.  

I began my post radical process of attempting to recover erectile function by taking Viagra three times per week with sexual stimulation.   While I was able to achieve a "soft off" this way, it did not produce any noticeable erectile function.

Nine months post surgery, unhappy that I could not achieve an erection and concerned that not having an erection would produce long term atrophy, I tried both the vacuum pump and a “cocktail” injection.   

Both methods have pluses and minuses.

The cocktail produces a great erection, but also produces discomfort and lasts up to three hours.

The vacuum pump is hard to manipulate successfully; the ring is a bit unwieldy; and the erection is harder to maintain.

But in both cases, the ability to have sexual success is a great cure for the frustration of not being able to produce an erection and also made me feel like the atrophy problem was being addressed. I was at least actively doing something that felt like it was working.

Post radical prostatectomy patients should be encouraged to use these methods for both psychological and potential physiological reasons.

Why does it take so long to recover?

A number of explanations have been proposed for this phenomenon of delayed recovery, including mechanically induced nerve stretching that may occur (during the operation), thermal damage to nerve tissue caused by cauterization during surgical dissection, injury to nerve tissue amid attempts to control surgical bleeding, and local inflammatory affects associated with surgical trauma.

Why don’t all men recover erectile function after nerve-sparing surgery?

The most obvious determinant of postoperative erectile dysfunction is preoperative potency.

Some men may experience a decline in erectile function over time, as an age-dependent process. Furthermore, postoperative erectile dysfunction is compounded in some patients by preexsisting risk factors that include: older age, cardiovascular disease, diabetes, cigarette smoking, physical inactivity and taking of some medications.

The impact of these risk factors on patients’ eventual outcomes has led to the acknowledgment that rating erection recovery potential after surgery should involve…relevant risk factors.

Does the treatment affect the outcome?

Several surgical advances can improve functional outcomes. For example, optical magnification and avoidance of tissue destructive energy sources in the vincinity of the cavernous nerves is recommended.

A growing interest in pelvic radiation, including brachytherapy, as an alternative to surgery can be attributed in part to the idea that surgery carries a higher risk of erectile dysfunction…..Surgery is associated with an immediate loss of erectile function that does not occur with radiation therapy.

But with surgery, recovery is possible in many with appropriately extended follow-up. Radiation therapy, by contrast, often results in a steady decline in erectile function to a hardly trivial degree over time.

What is available for Erection Rehabilitation After a RRP?

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.

This relatively new strategy of rehabilitation in clinical management after an RRP comes 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.

In this respect, an early strategy is injection therapy, although its application has not occurred widely, mostly because of patient reluctance to perform needle insertion into the penis on a regular basis.

The interest in using oral PDE 5 inhibitors is not surprising since this therapy is noninvasive, convenient, and highly tolerable. However, while the early, regular use of PDE 5 inhibitors or other currently available “on demand” therapy is widely touted after surgery for purposes of erection rehabilitation, evidence for its success remains llimited.

Patients should involve their doctors in all plans for erection rehabilitation.

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