Clinical Conditions

Over the past two decades the number of cases of prostate cancer has soared. Approximately 50,000 new cases were diagnosed in 1981 and in 1997, more than 200,000 new cases were diagnosed. As the overall incidence of prostate cancer increases, the average age at the time of diagnosis has dropped dramatically from 72.2 years in 1983 to 69 years in 1994. These two factors combined have made sexual dysfunction following radical prostatectomy a far more important issue. Most urologists are aware that erectile dysfunction is frequent following radical prostatectomy (RP). Most fail to appreciate and/or fail to inform their patients regarding the other sexual dysfunctions, which include the absence of ejaculation (although orgasm is generally preserved), and also possible penile curvature or length loss. In a questionnaire-based study conducted by Dr. John Mulhall in 1998, 380 men who underwent RP were questioned regarding postoperative orgasm quality and the presence of pain with orgasm (dysorgasmia). In response to this questionnaire, one year postoperatively, 37% of men had not experienced orgasm, 30% of men who had orgasm said that they had significantly diminished quality overall, and 22% of men who experienced orgasm had some degree of orgasmic pain interfering with sexual relations.

In its original form, RP was a non-nerve sparing procedure, which was almost always associated with erectile dysfunction (ED) postoperatively. In 1982, Drs. Walsh and Donker, at Johns Hopkins University, reported on nerve sparing radical prostatectomy. At that time, it was hoped and believed that this approach would dramatically reduce the incidence of ED. At this point in time, this expected improvement has not been fully realized. What is appreciated is that preservation of the cavernous nerves does not necessarily mean the nerves’ function is intact. It is clearly understood that post-RP erectile function preservation is better in men of younger patient age, with cancer confined to the prostate, who have at least one nerve preserved, especially if the patient had normal erections prior to his operation. In 1996, Mulhall and Graydon published data on a group of patients who had pre- and post-RP erection function testing. Patients with post-RP ED underwent repeat testing at 6 and 24 months after surgery. All patients with postoperative erectile dysfunction had significant blood flow changes after surgery, partly explaining the ED rates after nerve-sparing surgery.

The causes of ED after this form of surgery include nerve injury, artery injury or deterioration in erection tissue structure and function after surgery. In 1997, Dr. Montorsi from Milan, Italy completed the first study looking at early postoperative preventive drug therapy for this problem. Immediate therapy after surgery, using penis injections, administered within the first two months of surgery resulted in a 67% incidence of return of a man’s own erections compared to 20% in men who had no treatment after surgery. The concept is that these erections induced after surgery can protect the erection tissue itself and promote the return of a man’s own erections. There is a strong body of opinion that suggests that men with poor erections after radical prostatectomy should be treated with medications to induce erections early after surgery. It is unknown at this time if the administration of sildenafil that fails to cause a rigid erection after radical prostatectomy can increase the chances of a man’s own erections returning.

When patients with prostate cancer present to the Sexual Medicine Program at The New York Presbyterian Hospital prior to undergoing radical prostatectomy surgery, they are counseled regarding all postoperative sexual dysfunctions including ejaculatory and orgasmic problems. During surgery, the urologic oncologists at this institution use techniques to minimize nerve trauma if possible. All patients are encouraged to seek postoperative evaluation and treatment for erection problems within the first 2 months of the procedure. When ED exists, the best approach is believed to be the commencement of early drug therapy in the form of oral agents (currently Viagra®), transurethral alprostadil (MUSE®) or penile injection therapy. When these treatments have failed or the patient is not a candidate for these three options then the use of vacuum erection device therapy or penile implant surgery may be of benefit to some patients. It is important that patients are followed up with on a regular basis to make sure that a successful drug therapy has been identified. The patients are encouraged to obtain 2-3 erections per week and this therapy is continued for 18 months postoperatively before a full idea is possible regarding return of the patient’s own erections.

Reading

  1. Abosall, S et al. Role of penile vascular injury in erectile dysfunction after radical prostatectomy. British Journal of Urology, 73:75-82, 1994.
  2. Breza, J et al. Detailed anatomy of penile neurovascular structures: surgical significance. Journal of Urology, 141:437-443, 1989.
  3. Carrier, S, et al. Regeneration Of Nitric Oxide Synthase-Containing Nerves After Cavernous Nerve Neurotomy In The Rat. Journal of Urology. 153:1722-1727, 1995.
  4. Catalona, WJ et al. Nerve-sparing radical prostatectomy: evaluation of results after 250 patients. Journal of Urology. 143:538, 1990.
  5. Hampell, O et al. Cavernous nerve grafting restores partial erections after radical retropubic prostatectomy. Journal of Urology
  6. Lue, TF et al. Intraoperative electrostimulation of the cavernous nerve: technique, results and limitations. Journal of Urology. 154:1426-1428, 1995.
  7. Montorsi, F et al. Recovery of spontaneous erectile function after nerve sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. Journal of Urology, 158:1408-1410, 1997
  8. Mulhall, JP et al. The Hemodynamics Of Erectile Dysfunction Following Nerve-Sparing Radical Retropubic Prostatectomy. International Journal of Impotence Research, 8:91-94, 1996.
  9. Walsh PC. Radical prostatectomy, preservation of sexual function, and cancer control: the controversy. Urologic Clinics of North America. 14:663, 1987.
  10. Walsh PC et al. Impotence following radical prostatectomy: insight into etiology and prevention. Journal of Urology. 128:492, 1982.
  11. Mulhall, JP et al. Erectile dysfunction following radical prostatectomy: hemodynamic profiles and their correlation with recovery of erectile function. Journal of Urology, 167(3):1371-75, 2002
  12. Wei JT et al. Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. Journal of Clinical Oncology. 20(2):557-66, 2002
  13. Litwin MS et al. Life after radical prostatectomy: a longitudinal study. Journal of Urology. 166(2):587-92, 2001 Aug
  14. Kim ED et al. Bilateral nerve grafting during radical retropubic prostatectomy: extended follow-up. Urology, 58(6):983-7, 2001 Dec.