Some refreshing truths about erectile function post-surgery

A refreshingly honest article published this year in Translational Andrology and Urology, and reprinted in full on the Medscape web site, offers a somewhat depressing assessment of the state of the art of prevention of erectile dysfunction and/or rehabilitation of erectile function in men undergoing radical prostatectomy.

The article by Salonia et al. — see either here (for the original abstract) or here (for the full article on Medscape) — is a detailed review of issues affecting the prevention and the effective management of erectile dysfunction in association with radical surgery as a treatment for prostate cancer.

Key points made by the authors in their review include a number of well-known factors that are not usually brought to the attention of patients and their spouses and partners in discussions about expectations for sexual and erectile function post-surgery including the following:

  • Sexual and erectile dysfunction is actually very common among patients with prostate cancer after a radical prostatectomy.
  • There long has been, and still is, massive inconsistency from published paper to published paper about the definition of “normal’ erectile function before and after a radical prostatectomy.
  • Researchers need to use well validated psychometric instruments with recognized cut-offs for normalcy and severity of erectile/sexual function before and after surgery … and ideally establish and use consistent definitions and one truly established and validated scale for assessing quality of erectile function.
  • With out such consistent definitions and well-established scales, patients can have no reasonable expectations that what they are being told is actually accurate or based on reasonable expectations. (If your are told you casn expect to have a “normal” erection and “normal” sexual relations after surgery, this should not mean a “stuffable” erection!)
  • A vast range of factors can actually affect the likelihood that a patients will recover meaningfully good erectile function post-surgery, including
    • Patient factors, e.g., age, baseline erectile function, and comorbid conditions status
    • Ability to spare the nerves, e.g., non-nerve-sparing vs. unilateral vs. bilateral nerve-sparing
    • Type of surgery, e.g., intra- vs. inter- vs. extrafascial surgeries
    • Surgical technique, e.g., open, laparoscopic, or robot-assisted laparoscopic
    • Surgeon factors, e.g.., surgical volume and surgical skill) represent the key significant contributors to EF recovery.
  • There is now a good deal of data to support the premise that post-surgical rehabilitation and treatment in due time are beneficial (as opposed to just leaving the erectile tissue to its unassisted postoperative fate).
  • Optimal post-operative outcomes — with specific respect to quality of erectile function — are significantly affected by the careful choice of the correct patient for the correct type of surgery.
  • Rehabilitative approaches should be considered exclusively as potential “strategies”;  incontrovertible evidence of the effectiveness of the wide range of rehabilitative approaches to improvement of natural recovery of good erectile function is limited.
  • Numerous effective therapeutic options are available for the treatment of post-surgical erectile dysfunction, up to and including the use of penile implants.

The bottom line to all this is that — sadly — the onus still remains on the patient to make extremely sure that what he is being told by his potential surgeons is actually accurate as opposed to “magical thinking”. The “New” Prostate Cancer InfoLink is of the opinion that there is a major responsibility on the urology community to be far more forthright and honest with patients about the complications and side effects of radical prostatectomy and most importantly the quality of a man’s erectile function post-surgery. The reality appears to bear little relationship to what most men seem to hear prior to their surgery, and the published literature is rife with data designed to hide the realities.

9 Responses

  1. Sitemaster,

    Are you OK? Tons of typos on this had me concerned that something was up with you.

    Love your site, the scientific bent you bring to all your topics, and the thoughtfulness you bring to discussions. Thank you and please keep it up, sir. And here’s hoping you were just pleasantly drunk.


  2. Sitemaster writes: ‘the onus still remains on the patient to make extremely sure that what he is being told by his potential surgeons is actually accurate as opposed to “magical thinking.”’

    Realistically, this is not possible. Dr. David Samadi boasts that “83% regain normal sexual function” on his website. But a recent survey stated 93% of patients report diminished sexual function at 2 years post-RP. Samadi is either the most gifted surgeon to walk the planet or he’s guilty of magical thinking. How can the patient be “extremely sure”?

  3. It seems to fall to me to give the UK / NHS experience, so here goes:

    Because under the NHS surgeons are not competing for business based on their EF statistics, you are more likely to get a realistic view. I was told very bluntly that I had perhaps a 20% chance of retaining erectile function ahead of my robot surgery, although there was considerable uncertainty because it was not known, until the operation was in progress, how much nerve sparing would be possible. Having read the “statistics” on various US surgeon web sites I was shocked at this bleak outlook from a very skilled and experienced high volume da Vinci centre, and nearly backed out of the whole surgical route.

    In any case, EF is not a binary yes/no, and at age 57 pre-operatively my EF had declined significantly from that of my younger self. In the end, unilateral nerve sparing was possible, and after a year of vacuum pumps, experiments with injections, disappointments with pills, and experimentation with alternative forms of sexual activity, the remaining nerves awoke, and with the help of Viagra the show is back on the road.

  4. Dear Steve:

    Thanks for bringing the typos to my attention. No alcohol was involved … but yesterday had been a long day!

  5. Dear Len:

    I wish I had a good answer to a very good question. All that I can tell you is that I wouldn’t go near a surgeon who made claims that were so clearly out of synch with 90% of his colleagues.

  6. Of course, the best option is to avoid RP, in any form, at all costs.

  7. What surprises (bothers) me is that I provide a reply and it fails to show up here. I used my WordPress identification.

  8. Dear Chuck:

    Your original comment was duly posted on November 11. Please just click here.

  9. Dear Fred:

    However, avoiding an RP “at all costs” may not be the best idea for a whole bunch of men — most particularly those with a high-risk, truly localized cancer. Such patients may be (and arguably should be) a lot more worried about staying alive than about the quality of their erectile function. No one that I am aware of has ever suggested that radical prostatactomy is an “erectile function-sparing” procedure for a man with high-risk prostate cancer.

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