ERECTION REHABILITATION AFTER RADICAL PROSTATECTOMY

General Information

• Nerve-Sparing Radical Prostatectomy
• Erectile Function Recovery Outcomes
• Current Erectile Dysfunction Management
• Erection Rehabilitation Strategies
• Clinical Programs
  

Nerve-Sparing Radical Prostatectomy

Pioneering anatomic discoveries by Dr. Patrick Walsh approximately 25 years ago revolutionized prostate cancer surgery.  Because of innovations in radical prostatectomy, rates of postoperative recovery of erectile function sufficient for sexual intercourse have improved dramatically from that of the previous era.  However, delayed postoperative recovery of erection for as long as two years is common.  This complication occurs even with nerve-sparing techniques, and it is known that the nerves regulating penile erection are traumatized to some extent even while they are preserved during surgery.  The risk of this complication exists for any form of radical prostatectomy, whether it is done with an open surgical approach or by any of the more recently described laparoscopic or robotic approaches.

Consistent with our mission to serve patients with the very best clinical care, we recognize current realities of the surgery with regard to its impact on erectile function.  It is our commitment to perform the surgery with the greatest precision possible and to develop new strategies to hasten postoperative recovery of erectile function. 

Surgical Objectives.  Several variables importantly determine the success of radical prostatectomy.  First, performance of the surgery requires surgeon understanding of the detailed surgical anatomy of the prostate and its surrounding structures in the pelvis.  In performing the surgery today, surgeons must appreciate anatomical landmarks including the course of the nerves regulating penile erection.  Current understanding is that these nerves are contained at specific locations coursing around the prostate from deep within the pelvis toward the base of the penis internally.  Second, the surgeon must proficiently achieve the proper dissection planes that maximally preserve the nerves without compromising proper removal of the prostate for cancer control. 

Surgical Technique.  In the tradition of Dr. Walsh’s contributions, we have advanced concepts in understanding and performing the surgery at the highest possible level.  Our ongoing anatomical studies and that of other investigators have led to a heightened understanding of the distributions of erection-producing nerves coursing adjacent to the prostate and male urinary sphincter.  Refinements of the surgical approach include the application of a “high anterior release” modification of the “classic” interfascial dissection:  the gentle release and preservation of fascia (connective tissue layers) containing erection-producing nerves early during the surgical dissection and at specific locations surrounding the prostate.  The technical maneuver seems to protect the fragile nerves while allowing the prostate and its immediately surrounding fascia to be removed completely.  This form of the surgical dissection supposedly affords the best opportunity for erection recovery and prostate cancer control. 
 
Several remarks are made regarding the open surgical approach done today.  The surgery is frequently performed with a minimal incision at the low aspect of the abdomen in the midline of approximately 3-4 inches (Fig.).  This incision provides enough exposure for direct examination of the prostate and careful dissection while also minimizing discomfort that may be associated with a larger incision.  The surgery may also be performed with special surgical eyeglasses called optical loupes (which resemble telescopes) that may enhance visualization of anatomical structures.  These recent modifications of the open surgery have allowed the surgery to be performed with the very best success.

Figure Legend:  Modern open radical retropubic prostatectomy can be done by highly specialized surgeons with a lower midline abdominal incision, sufficient for dissection and removal of the prostate gland (see left).  For comparative purposes, laparoscopic or robotic approaches require several small upper abdominal incisions as entry ports for instruments used to dissect the prostate gland and a small lower midline abdominal incision for prostate gland removal (see right).

Postoperative Expectations.  Improvements in the surgery and anesthesia surrounding radical prostatectomy in recent years have led to improved functional recovery than what was known in the prior era.  Length of hospitalization is one to two days.  Recovery of diet and activity is rapidly met irrespective of the surgical approach.  Because of the anatomic nature of the surgical incision, most patients experience only a short interval of postoperative pain which is managed by intravenous patient-controlled analgesia.  Long-term postoperative recovery is also quite rapid today with all surgical approaches.

Erectile Function Recovery Outcomes

Reported rates of erectile function recovery range between 60% and 85% at major academic centers staffed by highly experienced surgeons.  It is recognized that controversies persist regarding the exact level of erectile function recovery achieved with surgery, as demonstrated by various conflicting reports available in the literature.  Surgeon experience and the volume of surgeries performed are conceivably the dominant factors governing outcomes.  Methodologic factors, such as imprecise documentation of presurgical erectile function status, nonuniform use of outcome questionnaires for assessing potency, insufficient follow-up intervals after surgery to assess outcomes, lack of prospective assessment, bias in obtaining data, and failure to differentiate erection response with and without use of erection-enhancing medication, have all contributed to variations in reported erectile function recovery outcomes after the surgery.

With regard to erection recovery following treatment, a pertinent question is how radical prostatectomy compares with other interventions for clinically localized prostate cancer.  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, which appears to contrast with the results of radiation therapy.  However, with appropriately extended follow-up, erectile dysfunction does occur with radiation therapy owing to a steady decline of this function because of radiation effects.  Several studies, including the Prostate Cancer Outcomes Study, have demonstrated that erectile dysfunction rates for radical prostatectomy and external beam radiation therapy are similar after two years of follow-up. 

Current Erectile Dysfunction Management

Several options are currently available for managing erectile dysfunction following radical prostatectomy.  These options include both pharmacologic (use of medications) and nonpharmacologic (devices or mechanical methods) interventions (see table).   These options are understood to be conventional management options or erection aids.  It is acknowledged that these options generally produce temporary, repetitive means for an erectile response and would seem artificial.  Nevertheless, they do permit the opportunity for sexual intercourse for men who experience incomplete or delayed recovery of erectile function following the surgery. 

Rehabilitation Strategies

In keeping with the notion that normal erectile function is spontaneous and natural, such a level of recovery would be ideally achieved following radical prostatectomy.  The new charge for managing erectile dysfunction after radical prostatectomy is to recover spontaneous and natural erectile function.  Several medical and surgical approaches have been recently explored with this objective in mind.  These options include cavernous nerve interposition grafting, pharmacologic rehabilitation therapy, and neuromodulatory therapy. 

Cavernous Nerve Interposition Grafting.  This strategy has been promoted as an option to facilitate the recovery of erectile function in men undergoing radical prostatectomy.  The consideration is based on the use of nerve grafting elsewhere to recover reconnection of nerve tissue that has been damaged.  Nerve grafting procedures have been done successfully with radical prostatectomy and reportedly have caused minimal adverse consequences.  However, the benefit of this intervention remains uncertain.  Current data show that the approach may have limited success and should be offered only to a small proportion of men undergoing the surgery who are certainly not eligible for nerve-sparing techniques.  Further clinical trials are necessary to know whether this approach is truly beneficial. 

Pharmacologic Rehabilitation.  This strategy is based on the concept that early-induced sexual stimulation and blood flow in the penis might facilitate the return of natural erectile function and resumption of medically unassisted sexual activity.  The major approaches that have been explored for this strategy include intracavernosal injection therapy and use of oral medications such as Viagra, Cialis, and Levitra.  Enormous interest has been given to the use of oral medications lately because of the appeal of a non-invasive, convenient, and highly tolerable intervention.  Many practitioners have proposed regimens using oral medications following radical prostatectomy considering that they may offer some benefit.  However, the precise role of these therapies remains undefined.  Additional controlled trials are needed to determine their true therapeutic benefit. 

Neuromodulation.  This strategy follows recent scientific progress in the field suggesting that treatments which protect and preserve the health of penile nerves may enable better preservation of erectile function postoperatively.  Extensive investigation has taken place in this area using animal models, suggesting the feasibility of this strategy.  However, much more work is needed in this area at the human level to demonstrate benefit. 

Clinical Programs

Currently at the Brady Urological Institute, we are actively initiating and evaluating various treatments which may have potential benefit in facilitating erectile function recovery after radical prostatectomy.  Management strategies are available beyond conventional therapeutic management of erectile dysfunction following this surgery.  The use of oral medications (PDE-5 inhibitors) can be offered and should follow a discussion with each treating surgeon regarding the advantages, disadvantages and preferred regimen of treatment to be used.  In addition, we offer several clinical trials which may be of interest to patients undergoing radical prostatectomy who would otherwise expect to experience some delay in recovering erections with any standard currently available surgical approach.  These clinical trials include both pharmacologic and nonpharmacologic strategies (see Clinical Trials).  In all, these programs indicate our commitment to explore the next level of interventions for improving erectile function recovery outcomes following radical prostatectomy.