November 24, 2014

PROSTATE CANCER

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ERECTILE DYSFUNCTION FOLLOWING RADICAL PROSTATECTOMY

Erectile dysfunction following radical prostatectomy for clinically localized prostate cancer is a known potential complication of the surgery. With the advent of the nerve-sparing radical prostatectomy technique, many men can expect to recover erectile function in the current era. However, despite expert application of the nerve-sparing prostatectomy technique, early recovery of natural erectile function is not common. Increasing attention has been given to this problem in recent years with the advancement of possible new therapeutic options to enhance erection function recovery following this surgery. Visit Dr. Burnett's Neuro-Urology Laboratory

This topic area was handled thoroughly in an article written by Dr. Arthur L. Burnett, entitled “Erectile Dysfunction Following Radical Prostatectomy,” published in the Journal of the American Medical Association, June 1, 2005. Using a question and answer format, excerpts from this article are provided below.

A. Lateral view of the male pelvis illustrating the course and distribution of the left cavernous nerve fiber, as part of the left neurovascular bundle within intrapelvic fascia coverings. The cavernous nerve travels from the pelvicplexus proximally to the penis distally, in close anatomical relationship to the seminal vesicle, prostate, striated urethral sphincter, bladder, and rectum.

B. Anterosuperior oblique view of the same anatomical structures.

C. Anterosuperior oblique view illustrating preservation of the cavernous nervesafter bilateral nerve-sparing prostatectomy and bladder neck anastomosis to theurethral stump. The cavernous nerve fibers are preserved by division and clip-ping of small prostatic nerves alongside the prostate. When non-nerve-sparingsurgery is required for cancer eradication either unilaterally or bilaterally, wide excision of periprostatic soft tissue includes the cavernous nerves en block withthe removed surgical specimen.

 

 

 

1. What is the importance of preserved erectile function?

In considering the impact of the various treatment approaches for prostate cancer 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.

2. What are the current expectations with regard to outcomes after radical prostatectomy?

Following a series of anatomical discoveries of the prostate and its surrounding structures about 2 decades ago, changes in the surgical approach permitted the 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 erection recovery with ability to engage in sexual intercourse is regained by most patients with or without oral phosphodiesterase 5 (PDE5) inhibitors within 2 years.

3. Why is there increasing concern at this time regarding erectile dysfunction issues following radical prostatectomy?

The reality of the recovery process after radical prostatectomy today 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.

4. Why does it take so long to recover erections after the very best surgery?

A number of explanations have been proposed for this phenomenon of delayed recovery, including mechanically induced nerve stretching that may occur during prostate retraction, thermal damage to nerve tissue caused by electrocoagulative cautery during surgical dissection, injury to nerve tissue amid attempts to control surgical bleeding, and local inflammatory effects associated with surgical trauma.

5. What determines erection recovery after surgery?

The most obvious determinant of postoperative erectile dysfunction is preoperative potency status. 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 preexisting risk factors that include older age, comorbid disease states (e.g., cardiovascular disease, diabetes mellitus), lifestyle factors (e.g., cigarette smoking, physical inactivity), and the use of medications such as antihypertensive agents that have antierectile effects.

6. Are there any surgical techniques that have been developed to improve erectile function outcomes?

At this time, there are several different surgical approaches to carry out the surgery, including retropubic (abdominal) or perineal approaches as well as laparoscopic procedures with freehand or robotic instrumentation. Much debate but no consensus exists about the advantages and disadvantages of the different approaches. Further study is needed before obtaining meaningful determinations of the success with different new approaches.

7. Is another treatment option better for preservation of erectile function?

The growing interest in pelvic radiation, including brachytherapy, as an alternative to surgery can be attributed in part to the supposition that surgery carries a higher risk of erectile dysfunction. Clearly, surgery is associated with an immediate, precipitous loss of erectile function that does not occur when radiation therapy is performed, although 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.

8. What current options exist to treat erectile dysfunction after radical prostatectomy?

Options include pharmacologic and nonpharmacologic interventions. Pharmacotherapies include the oral PDE-5 inhibitors (sildenafil [Viagra®], tadalafil [Cialis®], and vardenafil [Levitra®]), intraurethral suppositories (MUSE®), and intracavernous injections (prostaglandin E1and vasoactive drug mixtures). 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.

9. Can erection “rehabilitation” be applied to improve erection recovery rates?

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.

10. Are there new strategies in the near future that may be helpful in improving erection recovery after surgery?

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. Therapeutic prospects include neurotrophins, neuroimmunophilin ligands, neuronal cell death inhibitors, nerve guides, tissue engineering/stem cell therapy, electrical stimulation, and even gene therapy.

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