Erectile dysfunction and penile rehabilitation after robot-assisted radical prostatectomy

Abstract

Radical prostatectomy is one of the treatments of choice in patients with clinically localized prostate cancer and a life expectancy >10 years according to international guidelines. Although this surgical approach is characterized by excellent oncologic outcomes at long-term follow-up, one of the most common complications after radical prostatectomy is represented by erectile dysfunction (ED) (Potosky et al., J Natl Cancer Inst 96:1358-1367, 2004). Refinements in the surgical technique such as the introduction of nerve-sparing approaches helped physicians to reduce the incidence of post-operative ED. However, the prevalence of this condition still ranges between 20 and 80% at long-term follow-up (Potosky et al., J Natl Cancer Inst 96:1358-1367, 2004; Tal et al., J Sex Med 6:2538-2546, 2009; Woo et al., J Endourol 28:172-177, 2014). Of note, variations in reported erectile function (EF) recovery rates after surgery depend on several factors such as EF recovery definition, baseline characteristics of patients undergoing surgery, preoperative EF, the follow-up duration and the surgical approach adopted. For example, over the last few years several authors demonstrated that baseline characteristics and preoperative functional status play a major role in the subsequent recovery of EF after radical prostatectomy. Similarly, the adoption of minimally invasive surgical techniques might have an impact on postoperative functional outcomes. Nonetheless, the proportion of patients who fail to recover EF after radical prostatectomy is still not negligible. As such, the concept of penile rehabilitation was introduced as a way to maximize the recovery of EF and, in turn, to reduce the risk of post-surgical ED in prostate cancer patients undergoing radical prostatectomy (Montorsi et al., J Urol 158:1408-1410, 1997). In particular, penile rehabilitation is defined as the adoption of any possible intervention in combination or alone that can help patients to achieve an erection sufficient for a satisfactory sexual intercourse and, possibly, to return to preoperative EF levels. Possible approaches for penile rehabilitation range from the use of mechanical devices to the administration of pro-erectile drugs such as phosphodiesterase type 5 inhibitors (PDE5-I). However, despite a number of investigators focused on ED after surgery, no standard universal treatment algorithm or specific guideline is available to date for penile rehabilitation after radical prostatectomy. The aim of the present chapter is to critically review the current management options for EF recovery after radical prostatectomy with a special focus on the use of PDE5-I.