Radical prostatectomy, whether performed via open, laparoscopic, or robotic-assisted techniques, is a common treatment for localized prostate cancer. However, one of its most significant postoperative complications is erectile dysfunction (ED), which can impact patients’ quality of life. This article explores the prevalence, mechanisms, and recovery of erectile function following different surgical approaches, highlighting key factors such as nerve preservation, surgical expertise, and rehabilitation strategies.

Prevelance of ED after radical prostatectomy

The prevalence of ED after radical prostatectomy varies depending on surgical technique, nerve-sparing approaches, and patient factors such as age and baseline erectile function.

Prevalence by Surgical Approach:

• Open Radical Prostatectomy (ORP): ED rates range from 60% to 90%, with recovery taking up to 2–3 years if nerve-sparing techniques are used.
• Laparoscopic Radical Prostatectomy (LRP): ED rates are similar to ORP, ranging from 50% to 85%, though some studies suggest slightly better outcomes due to reduced blood loss and improved visualization.
• Robotic-Assisted Radical Prostatectomy (RARP): Reported ED rates range from 30% to 80%, with a potentially faster recovery due to enhanced precision and nerve preservation.

Key factors influencing ED prevalence

There are severeal risk factors influencing ED following radical prostatectomy surgery;

• Nerve-Sparing Surgery: Bilateral nerve-sparing techniques significantly improve erectile function recovery.
• Surgeon Experience: High-volume surgeons tend to achieve better functional outcomes.
• Patient Age & Baseline Function: Younger patients with good preoperative erectile function have higher chances of recovery.
• Postoperative Rehabilitation: Use of phosphodiesterase type 5 (PDE5) inhibitors, vacuum erection devices, and penile rehabilitation programs can improve outcomes.

Overall, while robotic-assisted techniques may offer better erectile function recovery rates, ED remains a common issue post-prostatectomy, emphasizing the importance of preoperative counseling and rehabilitation strategies.

Which method is the best to prevent ED following radical prostatectomy

The best method for preserving erectile function after radical prostatectomy depends on several factors, including surgical technique, nerve-sparing approach, and surgeon experience. However, based on current evidence, RARP is generally considered the most effective approach for preserving erectile function.

Comparison of Surgical Approaches for Erectile Function Preservation:

Why robotic surgery is preferred for erectile function preservation?

While no method completely eliminates the risk of erectile dysfunction, RARP is generally considered the best option for erectile function preservation, provided it is performed by an experienced surgeon using a bilateral nerve-sparing technique. However, patient factors such as age, baseline erectile function, and overall health also play a significant role in post-surgical outcomes.

• Better Visualization & Precision: Robotic systems provide a 3D magnified view, allowing surgeons to carefully preserve the neurovascular bundles responsible for erections.
• Minimal Tissue Trauma: The precision of robotic arms reduces excessive manipulation and damage to erectile nerves.
• Faster Recovery: Studies suggest patients undergoing RARP experience faster return of erectile function compared to open and laparoscopic methods.
• Improved Nerve-Sparing Techniques: The flexibility of robotic instruments allows for more delicate dissection, reducing the risk of nerve injury.

Treatment options for ED after radical prostatectomy

Erectile dysfunction (ED) is a common side effect after radical prostatectomy, regardless of whether the procedure is open, laparoscopic, or robotic-assisted. Recovery depends on factors such as nerve-sparing techniques, patient age, preoperative erectile function, and rehabilitation strategies.

First-Line Therapy: Phosphodiesterase Type 5 (PDE5) Inhibitors

• Drugs: Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), Avanafil (Stendra)
• Effectiveness: Works best if at least one neurovascular bundle is preserved during surgery.
• Usage: Often prescribed for penile rehabilitation (low-dose daily or on-demand).
• Limitations: Less effective if severe nerve damage has occurred.

Second-Line Therapy: Vacuum Erection Devices (VEDs)

• How It Works: Uses a vacuum pump to increase blood flow to the penis.
• Benefits: Can maintain penile tissue health and prevent fibrosis.
• Limitations: Some men find it uncomfortable or unnatural.

Intracavernosal Injections (ICI)

• Drugs Used: Alprostadil, Trimix (Papaverine + Phentolamine + Alprostadil)
• How It Works: Directly relaxes penile smooth muscles, leading to an erection.
• Effectiveness: Highly effective (up to 80% success rate), even when PDE5 inhibitors fail.
• Limitations: Requires self-injection, which some patients may find difficult.

Intraurethral Suppositories (MUSE – Medicated Urethral System for Erection)

• Drug Used: Alprostadil (intraurethral pellet)
• How It Works: Stimulates blood flow when inserted into the urethra.
• Effectiveness: Less effective than injections but useful for some men.
• Limitations: Can cause urethral pain or irritation.

Penile Implants (Prosthesis Surgery) – Last Resort

• Types:
  • Inflatable Implant: Fluid-filled device that mimics a natural erection.
  • Malleable Implant: Semi-rigid rods that allow manual positioning.
• Effectiveness: High satisfaction rates (~90%), especially for severe or permanent ED.
• Limitations: Requires surgery; irreversible.

Lifestyle Modifications & Psychological Support

• Pelvic Floor Therapy: Strengthens muscles involved in erections.
• Regular Exercise: Improves blood circulation and overall health.
• Healthy Diet: A heart-healthy diet benefits erectile function.
• Counseling & Sex Therapy: Helps manage anxiety, depression, and relationship concerns.

Emerging Therapies

• Shockwave Therapy: Low-intensity waves to improve penile blood flow (still experimental).
• Stem Cell Therapy & PRP (Platelet-Rich Plasma): Under research for nerve regeneration.

What is the most effective method to treat ED following radical prostatectomy”?

The most effective treatment for ED after RP depends on the severity of nerve damage and individual patient response. However, penile implants (prostheses) are considered the most effective method for patients with severe or permanent ED.

Best Treatment Options Based on Severity:

Why penile implants are the most effective solution?

For mild to moderate ED, PDE5 inhibitors or injections may be effective, but for severe and persistent ED, penile prosthesis implantation is the most effective and reliable solution.

• High Success & Satisfaction: 90–95% of men report successful sexual function and satisfaction.
• Works Regardless of Nerve Damage: Unlike PDE5 inhibitors, implants do not rely on intact nerves.
• Permanent & Predictable: Provides an erection on demand without requiring medication or external devices.

Summary

ED is a common complication following radical prostatectomy, with prevalence rates varying by surgical technique. RARP generally offers better erectile function preservation compared to ORP and LRP approaches, due to improved nerve-sparing precision.

Treatment Options:

• First-line: PDE5 inhibitors (Viagra, Cialis) – Effective if nerves are preserved.
• Second-line: Vacuum erection devices (VEDs) – Helps maintain blood flow.
• Third-line: Intracavernosal injections (Alprostadil, Trimix) – High success rate even in severe cases.
• Last resort: Penile implants (prostheses) – Most effective long-term solution for permanent ED.

Early penile rehabilitation and a personalized treatment plan can improve erectile function recovery and overall quality of life.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE