Characteristics and management of erectile dysfunction after various treatments for prostate cancer

Abstract

Currently, there are many well-established therapeutic options for early prostate cancer, and therefore, it is difficult for both urologists and patients to choose the optimal treatment. It is essential for urologists to counsel their patients according to reliable information about the advantages and disadvantages of each therapeutic option. We picked the topic for this issue, “Characteristics and management of erectile dysfunction after various treatments for prostate cancer,” because erectile dysfunction (ED) is one of the most frequent adverse events encountered in the management of prostate cancer. We invited six specialists to review each therapeutic option: radical prostatectomy, laparoscopic radical prostatectomy, robot-assisted laparoscopic radical prostatectomy, external beam radiotherapy, brachytherapy, and androgen deprivation therapy (ADT). Among these modalities, surgical interventions tend to induce a quick drop in erectile function with slow postoperative recovery. Early postoperative rehabilitation has been introduced, aiming at the early recovery of ED. On the contrary, radiation therapy tends to maintain the patient's erectile function for a while after treatment but it gradually decreases. ADT may compromise not only the erectile function but also the libido level, and may result in significant deterioration of the patient's quality of life. We hope these reviews will help urologists to counsel their patients with regards to decision-making in the management of early prostate cancer. Jintetsu Soh md phd Deputy Editor Erectile dysfunction and urinary incontinence are major complications after radical prostatectomy (RP). While general health-related quality of life (QOL) usually recovers within about 6 months, sexual dysfunction remains and deteriorates patient QOL.1 To preserve sexual functions, a nerve-sparing procedure during RP, as initially described by Walsh et al.2 has become widely accepted and performed. In a 5-year follow-up study assessing the impact of nerve sparing on recovery of sexual function conducted in our institution, bilateral nerve-sparing RP is identified as showing better recovery and preservation in postoperative sexual functions than unilateral and non-nerve-sparing RP.1 The first thing we should do to preserve sexual function is thus try to perform nerve-sparing surgery, unless this interferes with oncological outcomes. Unfortunately, however, even when we have successfully performed bilateral nerve-sparing RP, only about 55% of subjects showed full return to baseline sexual function.1 At present, we would have to say that traditional nerve-sparing procedures have certain limits. We have recently reported that nerve fibers distributed on the prostate capsule, particularly those outside the neurovascular bundle, contribute to erection.3 Recent advances in surgical techniques for RP that pay increasing attention to preserving as many nerve fibers responsible for erectile function as possible may change the results of nerve-sparing RP. Penile rehabilitations for erectile dysfunction, such as oral phosphodiesterase type 5 inhibitors (PDE5i), intracavernous vasoactive injections, intra-urethral application of prostaglandin E1 (PGE-1) and vacuum constriction devices, have attracted attention. The purpose of penile rehabilitation is to preserve cavernosal tissue property, and thereby promote the chances of recovery of postoperative erectile ability. In these methods, we have used oral PDE5i as a first-line treatment for patients complaining of erectile dysfunction after RP, although the efficacy of PDE5i in penile rehabilitation programs has not yet been supported by definitive evidence in humans. Between June 2003 and July 2008, a total of 269 patients with newly diagnosed localized prostate cancer (T1–3N0M0) were treated with RP in our institution. Among these, 103 patients who underwent bilateral nerve-sparing RP confirmed by intraoperative electrophysiological testing were recruited (a