Emerging concepts in erectile preservation following radical
prostatectomy: a guide for clinicians
, BJ Miles
, LI Lipshultz
and M Khera
Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA and
Columbia Business School,
New York, NY, USA
Radical prostatectomy (RP) is a commonly performed procedure for the management of prostate
cancer. While documented oncologic outcome for early stage disease is excellent, functional
impairments such as incontinence and erectile dysfunction (ED) are common after the procedure.
Recent evidence has implicated cavernous nerve damage and subsequent corporal oxygen
deprivation, as well as corporal inflammation, in the pathogenesis of post-RP ED. Targeted
therapies such as oral phosphodiesterase-5 inhibitors, mechanical vacuum erection devices, local
alprostadil delivery and testosterone replacement (for hypogonal patients) have demonstrated some
efficacy in the management of post-RP ED. This review aggregates much of the recent data in
support of these therapies and critically reviews them. The article then presents tools to assess
patients and partner sexual function to aid in identifying and monitoring post-RP ED. Finally, the
article describes a protocol in use at Baylor College of Medicine as a guide toward the development
of a protocol for erectile preservation (EP). The purpose of this work is to educate clinicians on
emerging concepts in EP and provide an implementable protocol for use in practice.
International Journal of Impotence Research
published online 23 June 2011
pharmacologic studies in sexual function; vacuum devices; oral vasoactive agents;
intraurethral and intracavernosal therapy; pelvic cancer treatments and sexual dysfunction
Prostate cancer, the most common non-dermato-
logical malignancy in men in the United States with
an annual incidence of approximately 220 000, is
responsible for almost 30% of cancer diagnoses and
9% of cancer-related mortality in US men.
tive therapeutic strategies include radical prosta-
tectomy (RP) and radiation therapy. The number of
RPs performed per annum is estimated at 110 000 in
the United States alone.
Recent advances in screen-
ing and early detection of prostate cancer have
yielded excellent oncologic outcomes for low-risk
patients and shifted the focus of surgeons to
enhance functional outcomes for patients under-
Such functional outcomes include
recovery of urinary continence and erectile function.
While several factors influence post-RP erectile
function recovery, pre-operative erectile function
and nerve sparing (NS) status are critical predictors.
Tal and coworkers identified the aggregate recovery
rate of erectile function after surgery at approxi-
mately 60%. Even within this fraction of patients, a
large variability in the quality of erections likely
exists because of the subjective nature of assigning
a binary response to the presence of satisfactory
In general, erectile dysfunction (ED) and reduced
sexual satisfaction have a negative impact on quality
Various studies assessing the efficacy of
interventions to treat ED include quality of life
measures as secondary outcomes. Importantly, stu-
dies have consistently indicated that erectile func-
outcomes in patients.
Perhaps an even higher
impact observation is that the quality of erectile
function correlates with emotional well being.
patients after RP remain fragmented and inconsis-
tent. A study of French urologist’s suggests that
only a minority actually provide formal post-RP
therapy directed at sexual function outcomes.
The questionnaire-based study found that only 38%
for patients despite the fact that the overwhelming
Received 17 December 2010; revised 15 April 2011;
accepted 1 May 2011; published online 23 June 2011
Correspondence: Dr M Khera, Scott Department of
Urology, Baylor College of Medicine, 6620 Main Street,
Suite 1325, Houston, TX 77030, USA.
International Journal of Impotence Research (2011) 23,
2011 Macmillan Publishers Limited
All rights reserved