Prostate Cancer Expert Forum
Post Prostatectomy
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Post Prostatectomy

I had a radical prostatectomy June 9, catheter removal and incontinence is fading away, five ports are healing, no pain.  Stream very strong yet there seems to be some dribbling.  Is it normal not to get an erection witll I need an ED drug?
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Thank you for your question. It is good to know that your recovering well after your surgery. I can understand your concerns regarding sexual function recovery.

Varying degrees of erectile dysfunction (ED) and urinary incontinence are quite common in men following prostatectomy. In fact, many studies indicates that it may take up to 4 years for men who have had a nerve-sparing radical prostatectomy to recover their erectile function. Of course, many factors affect a man's recovery of potency after a nerve-sparing radical prostatectomy such as the position and extent of the cancer, the anatomy and health of the man, and the experience of his surgeon [1-3].

Surgery can affect this process in four main ways:

•           Nerves can become traumatized or damaged. Traumatized nerves can recover, but neural trauma as well as nerve damage can lead to structural changes in erectile tissue. The most severe change is called denervation apoptosis.
•           Arteries (the accessory pudendal arteries) may become damaged, which will reduce blood flow to the penis.
•           Veins may leak, which can cause fibrosis or scarring of the penis as well as affect erectile function.
•           Psychological effects include the impact of a cancer diagnosis on relationships and anxiety centered on the resumption of intimacy after surgery.

Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of post-operative erectile function. Pharmacological treatment of post-operative ED, using either oral or local approaches, is effective and safe. Moreover, recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments, for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in case of properly selected young patients treated with a bilateral nerve-sparing approach by experienced surgeons. In this context, pharmacological prophylaxis may potentially have a significant expanding role in future strategies aimed at preserving post-operative erectile function. According to Padmanathan et al men who took sildenafil nightly, beginning four weeks after they had undergone a nerve-sparing radical prostatectomy, were more likely to recover normal spontaneous erections at 48 weeks after surgery [4-8].

However, there are also numerous reports of patients having erections even with catheter still in and without the need of ED drugs.

http://www.nytimes.com/2010/02/14/health/14robot.html?pagewanted=2

Data from some studies have shown 87% return in sexual function in selected patients after 1 year of follow-up with bilateral nerve sparing and athermal technique [9-13] .

http://www.paactusa.org/paactvol26-2.pdf

As, you have just had the surgery, you should give sufficient time for sexual function recovery. Meanwhile, you should also discuss these issues with your urologist and get an idea about numerous alternatives for post-prostatectomy ED.
  
Sincerely,

Ash K. Tewari, MD

www.nycrobotics.com

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References

1.     Walsh PC, Donker PJ (1982) Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 128:492–497
2.     Rabbani F, Stapleton AM, Kattan MW, et al (2000) Factors predicting recovery of erections after radical prostatectomy. J Urol 164:1929–1934
3.     Meuleman EJ, Mulders PF (2003) Erectile function after radical prostatectomy: a review. Eur Urol 43:95–101
4.     Mulhall J, Land S, Parker M, Waters WB, Flanigan RC (2005) The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med 2:532–545
5.     Padma-Nathan E, McCullough AR, Giuliano F, et al (2003) Postoperative nightly administration of sildenafil citrate significantly improves the return of normal spontaneous erectile function after bilateral nerve-sparing radical prostatectomy. J Urol 4(Suppl):375
6.     Zagaja GP, Mhoon DA, Aikens JE, Brendler CB (2000) Sildenafil in the treatment of erectile dysfunction after radical prostatectomy. Urology 56:631
7.     Raina R, Lakin MM, Agarwal A, Mascha E, Montagne DK, Klein E, Zippe C (2004) EYcacy and factors associated with successful outcome of sildenafil citrate use for erectile dysfunction after radical prostatectomy. Urology 63:960–966
8.     Alberto Briganti · Andrea Salonia · Andrea Gallina, Felix K.-H. Chun · Pierre I. Karakiewicz · Markus Graefen, Hartwig Huland · Patrizio Rigatti · Francesco Montorsi: Management of erectile dysfunction after radical prostatectomy in 2007
9.     Tewari A, Rao S, Martinez-Salamanca JI, Leung R, Ramanathan R, Mandhani A, Vaughan ED, Menon M, Horninger W, Tu J et al.: Cancer control and the preservation of neurovascular tissue: how to meet competing goals during robotic radical prostatectomy. BJU Int, 2008.
10.  Takenaka A, Tewari A, Hara R, Leung RA, Kurokawa K, Murakami G and Fujisawa M: Pelvic autonomic nerve mapping around the prostate by intraoperative electrical stimulation with simultaneous measurement of intracavernous and intraurethral pressure. J Urol. 177: 225-9; discussion 229, 2007.
11.  Tewari A, Takenaka A, Mtui E, Horninger W, Peschel R, Bartsch G and Vaughan ED: The proximal neurovascular plate and the tri-zonal neural architecture around the prostate gland: importance in the athermal robotic technique of nerve-sparing prostatectomy. BJU Int. 98: 314-23, 2006.
12.  Leung RA, Kim TS and Tewari AK: Future directions of robotic surgery: a case study of the Cornell athermal robotic technique of prostatectomy. ScientificWorldJournal. 6: 2553-9, 2006.
13.  El-Hakim A, Leung RA and Tewari A: Robotic prostatectomy: a pooled analysis of published literature. Expert Rev Anticancer Ther. 6: 11-20, 2006.

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