A Strategic Approach to Erection Recovery after Radical Prostatectomy

Radical prostatectomy has evolved over the past 30 years with improved surgical technique including optimal methods to spare erection-producing autonomic nerves located deeply within the pelvis adjacent to the prostate gland. These surgical advances have improved erectile function recovery rates after surgery. However despite current surgical proficiency for radical prostatectomy, many men still do experience delayed or incomplete recovery of erectile function status postoperatively. Thus, interest continues to better understand the basis for erectile function loss after surgery and develop strategies to promote erectile function recovery after radical prostatectomy.

A. Lateral view of the male pelvis illustrating the course and distribution of the left cavernous nerve fiber, as part of the left neurovascular bundle within intrapelvic fascia coverings. The cavernous nerve travels from the pelvicplexus proximally to the penis distally, in close anatomical relationship to the seminal vesicle, prostate, striated urethral sphincter, bladder, and rectum.  B. Anterosuperior oblique view of the same anatomical structures.  C. Anterosuperior oblique view illustrating preservation of the cavernous nervesafter bilateral nerve-sparing prostatectomy and bladder neck anastomosis to theurethral stump. The cavernous nerve fibers are preserved by division and clip-ping of small prostatic nerves alongside the prostate. When non-nerve-sparingsurgery is required for cancer eradication either unilaterally or bilaterally, wide excision of periprostatic soft tissue includes the cavernous nerves en block withthe removed surgical specimen.

Evidence supports the likely basis of erectile dysfunction associated with radical prostatectomy to relate to traumatic injury of the erection producing cavernous nerves even when they are gently dissected and preserved at the time of surgery. It is certainly clear that the very best surgical technique is needed as the first-line approach of "neuroprotection." The next frontier in this arena involves strategies directed to maximally restoring cavernous nerve function. Various strategies have been studied in this regard including nerve grafting techniques, nerve stimulation techniques, as well as application of "nerve growth factors" that may revitalize the nerve supply to the penis. Ongoing scientific work at the basic science research laboratory level is fundamental to the achievement of progress in this field. New scientific concepts will next be "translated" to the human condition applying rigorously conducted clinical trials.

 
At the Brady Urological Institute, our focus continues in an integrative manner to perform the surgery in the most proficient manner while also offering scientifically grounded options to recover erectile function at the time of surgery and in the early postoperative interval. We employ a number of strategies to improve erectile function for our patients:

• A thorough preoperative assessment of function and counseling regarding the expectations after surgery.
• Clinical trials involving experimental therapies to preserve erectile function at the time of surgery.
• "Penile rehabilitation" that can be performed at the discretion of your surgeon or as part of the post-prostatectomy recovery clinic.

We believe this integrative approach offers men the best opportunity for erectile function recovery after radical prostatectomy.

This blog was written by Arthur L. Burnett, MD, MBA, FACS, Patrick C. Walsh Distinguished Professor of Urology; Director, Basic Science Laboratory in Neurourology; Director, Sexual Medicine Fellowship Program; and Faculty Member, Cellular and Molecular Medicine Graduate Training Program.