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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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