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Authors: Ksenija B. Stefanovic, MD, PhD John M. Corman, MD Sexual dysfunction is a common problem in both men and women in the United States. Sexual problems become progressively more common with aging, heart disease, high cholesterol, and diabetes. Sexual dysfunction is also a common consequence of cancer treatment. For example, 25 percent of men treated for testicular cancer, leukemia and Hodgkin’s disease suffer from erectile dysfunction. Several types of surgery may directly interfere with erectile function. Notably, radical prostatectomy (RRP) radical cystectomy, abdominal-perineal resection for rectal cancer or total pelvic exenteration, all may damage the nerves and blood flow to the penis. Historically, impotence has been a frequent consequence of radical prostatectomy. However, in 1982, Walsh and Donker made a singular advance when they reviewed the anatomy associated with the surgery and recognized that the etiology of erectile dysfunction was related to autonomic nerve injury which occurred during the course of the dissection of the apex of the prostate and the division of the lateral pedicle of the organ. In their elegant dissections, they were able to trace the course of the autonomic nerves responsible for erection, thus improving our understanding of the neuroanatomy. They recognized that the autonomic branches to the prostate, urethra and corpora travel outside of the prostatic capsule on both sides of the gland and could be spared without adversely impacting disease control. Nerve-sparing prostatectomy is performed if there is no indication of tumor involvement within the extra-prostatic fascia (neurovascular bundle) even if patients have limited preoperative erectile function. The rationale for preserving the neurovascular bundle in patients with compromised preoperative function is twofold. First, if the nerves are left intact, there is a higher likelihood that oral medication such as Viagra (sildenafil) will be successful postoperatively. Second, some literature suggests that leaving the nerves intact results in improved urinary continence. The selection of unilateral or bilateral nerve sparing is made based upon clinical presentation and intra-operative findings. Patients with locally advanced tumors or with an extensive posterior tumor burden are not offered nerve-sparing surgery because of concern regarding cancer margins. When nerve-sparing is performed, restoration of potency is reported in up to 80 percent of patients less than 60 years old who undergo a bilateral procedure. Fewer than 50 percent of such individuals will have spontaneous, adequate erections if a unilateral nerve sparing approach is employed. Other variables are important in predicting the success of nerve-sparing approaches, namely, age and interval since surgery. In several series, men over the age of 70 were unlikely to achieve adequate erections unless both nerves had been spared. The inability of a single nerve bundle to facilitate erection in this group of patients is thought to be secondary to underlying nerve conduction dysfunction associated with other medical issues conditions. Potency also is impacted by the length of time since surgery. In fact, patients continue to note improved erectile function up to 18 months following surgery, as the nerves recover from the operation. Several studies have shown that even with bilateral nerve-sparing surgery, there is often a several month interval before a patient recovers normal erection. There are several potential explanations for this time delay: transient nerve injury, postoperative psychological issues, and transient corpora cavernosa tissue hypoxia secondary to the absence of frequent and rigid erections. We have found that the delay in the return of potency can be improved by several approaches. First, by employing detailed surgical technique with meticulous hemostasis, one is able to minimize potential trauma to the nerves that supply autonomic innervation to the corpora. Second, by providing a comprehensive preoperative counseling program for the patient and his partner one is able to address postoperative concerns and minimize the psychological impacts of surgery. Finally, by providing early, pharmacologic erections, one can avoid long-term cavernous hypoxia and tissue damage, thus expediting the return of spontaneous erectile function. The recovery rate is dependent on time from the surgery. The rate and degree of natural recovery of sexual function can be expedited by early rehabilitation of erectile function. The treatment of erectile dysfunction after RRP is highly successful and has been shown to be superior to a “wait and see” approach. Additionally, early intervention has a positive impact on preservation of penile length post-RRP. The successful recovery of erectile function is highly dependent on the patient and their partner’s education about treatment-related sexual problems. Open sexual communication between partners is essential. Other issues, such as loss of sexual desire, orgasm, ejaculatory problems or sexual pain should also be addressed. Finally, reproductive health, fertility issues, and sperm banking counseling are an integral part of our program. Preoperatively we assess voiding and sexual function based upon baseline sexual function, patient age, risk factors and disease stage. We provide counseling to the prostate cancer patient and his partner about changes in sexual function. We try to predict the likelihood of developing sexual dysfunction with respect to each patient’s personal desires and preferences and to offer early postoperative reassessment and implementation of treatment. We aggressively pursue early recovery of sexual function. The front line treatment options include oral medications, intraurethral suppositories, injectable medications and vacuum erectile devices (VED). Patients with good preoperative erectile performance who have undergone bilateral nerve-sparing RP have a 72 percent likelihood of having erections that are adequate for penetration with the assistance of oral agents. The most common side effects are headache (20 percent), flushing (8 percent), visual disturbance (6 percent) and nasal congestion (6 percent). Intraurethral prostaglaudin therapy is a good alternative for patients with contraindications to oral medications. The “home success” rate is around 55 percent. No UTI, urethral strictures, penile fibrosis or priapism are described in post-RP patients. Vacuum erection device gives high efficacy and satisfaction rates in post-prostatectomy patients. The major disadvantage is that VED does not create natural erections. It also gives best results in men who have a stable sexual relationship. Intracorporal injection therapy is highly effective. Treatments are self-administered and result in a firm, natural-like erection. The best results with such therapy are seen in patient ’s who receive education preoperatively as a part of global management plan. Side effects of treatment are pain with injection (usually mild), penile fibrosis (2-15 percent) and priapism (1 percent). Careful injection technique, education and slow self-titration drastically reduce all complications. Finally, in previously impotent patients in whom oral medication, vacuum erection device, and injection therapy have failed, a prosthesis can be implemented at the time of RRP or in outpatient surgery at any time post-RP. Most studies indicate general satisfaction rate after RP greater than 80 percent. Recovery of sexual function is an important issue for many patients and is a significant addition to improvement of quality of life. Fortunately, post-prostatectomy sexual dysfunction is a problem that can be managed effectively in most men.
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