Postprostatectomy Erectile Dysfunction: A Review

Abstract

In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis.

Penile neurovascular structure revisited: immunohistochemical studies with three‐dimensional reconstruction

“…Although oral phosphodiesterase‐5 (PDE5) inhibitors are generally accepted as an effective therapy for ED, men with ED from diabetes or radical prostatectomy respond poorly to these drugs (Martinez‐Jabaloyas et al ., ; Capogrosso et al ., ). Impairments in production of endogenous NO from severe endothelial dysfunction and peripheral neuropathy are responsible for poor responsiveness to PDE5 inhibitors (Musicki & Burnett, ; Angulo et al ., ).…”

Internal and External Validation of a 90-Day Percentage Erection Fullness Score Model Predicting Potency Recovery Following Robot-assisted Radical Prostatectomy

“…Given their low predicted probability of recovery, these men would be good early candidates for consideration of pre-emptive rehabilitation and/or aggressive interventions. Such interventions are not only more effective when pursued early [20], but early intervention can also significantly improve patient quality of life during the post-RP recovery process [21,22]. Conversely, men reporting 25-100% PEF at 90 d have a significant chance of ESI recovery and it would be logical to manage them accordingly.…”

Application of Dried Human Amnion Graft to Improve Post-Prostatectomy Incontinence and Potency: A Randomized Exploration Study Protocol

“…The postoperative continence rate (no pads) varies between 4% and 31%, mean 16% [2]. Some patients recover from incontinence after rehabilitation, but 10-20% suffer from persistent incontinence and 20-70% from erectile dysfunction [1,3,4]. In addition, continence is not standardized and is defined differently in studies: 1-h or 24-h pad weighing test, pad consumption, social continence [5].…”