Skip to main content

Advertisement

SpringerLink
Log in

Erectile Dysfunction Following Radical Retropubic Prostatectomy

Epidemiology, Pathophysiology and Pharmacological Management

  • Therapy in Practice
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Radical prostatectomy has been the time-honoured and standard treatment option for prostate cancer. Erectile dysfunction (ED) is one of the common quality-of-life issues following radical prostatectomy. The recovery of potency following radical prostatectomy varies from 16% to 86%. Although major modifications in surgical technique appear to be promising, the reported ED rates are still high. The time period required for the recovery of erectile function after surgery varies from 6 to 24 months. During this period of neuropraxia lack of natural erections produces cavernosal hypoxia. This cavernosal hypoxia has been implicated as one of the most important factors in the pathophysiology of ED. Cavernosal hypoxia predisposes to cavernosal fibrosis, ultimately producing venous leak and long-term ED. Interruption of this cascade of events has been the major challenge for physicians. Physicians have several options available for the treatment of ED. However, oral treatment options have quickly become established as first-line treatment options. Sildenafil has been most extensively studied in the radical prostatectomy population. In patients who do not respond to oral therapy alone, standard treatment options (intracavernosal injections, vacuum constriction devices and intraurethral alprostadil) are useful. Use of penile prostheses is one of the oldest treatment options available for the treatment of ED but is used only as a last resort. Initial attempts to promote the earlier recovery of erectile function appear to be promising. However, further confirmatory studies are essential. The roles of gene transfer and growth factors are still in experimental stages. In this review we discuss the epidemiology, pathophysiology and treatment options available for ED following radical prostatectomy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Fig. 1
Table II
Table III
Table IV
Table V

Similar content being viewed by others

References

  1. Landis SH, Murray T, Bolden S, et al. Cancer statistics, 1999. CA Cancer J Clin 1999; 49(1): 8–31, 1

    Article  PubMed  CAS  Google Scholar 

  2. Shrader-Bogen CL, Kjellberg JL, McPherson CP, et al. Quality of life and treatment outcomes: prostate carcinoma patients’ perspectives after prostatectomy or radiation therapy. Cancer 1997; 79(10): 1977–86

    Article  PubMed  CAS  Google Scholar 

  3. Walsh PC, Marschke P, Ricker D, et al. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000; 55(1): 58–61

    Article  PubMed  CAS  Google Scholar 

  4. Walsh PC, Partin AW, Epstein JI. Cancer control and quality of life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol 1994; 152 (5 Pt 2): 1831–6

    PubMed  CAS  Google Scholar 

  5. Mulcahy JJ. Erectile function after radical prostatectomy. Semin Urol Oncol 2000; 18(1): 71–5

    PubMed  CAS  Google Scholar 

  6. Catalona WJ, Carvalhal GF, Mager DE, et al. Potency, continence and complication rates in 1870 consecutive radical retropubic prostatectomies. J Urol 1999; 162(2): 433–8

    Article  PubMed  CAS  Google Scholar 

  7. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 1982; 128(3): 492–7

    PubMed  CAS  Google Scholar 

  8. Quinlan DM, Epstein JI, Carter BS, et al. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol 1991; 145(5): 998–1002

    PubMed  CAS  Google Scholar 

  9. Sexton WJ, Benedict JF, Jarow JP. Comparison of long-term outcomes of penile prostheses and intracavernosal injection therapy. J Urol 1998; 159(3): 811–5

    Article  PubMed  CAS  Google Scholar 

  10. Litwin MS, Lubeck DP, Stoddard ML, et al. Quality of life before death for men with prostate cancer: results from the CaPSURE database. J Urol 2001; 165(3): 871–5

    Article  PubMed  CAS  Google Scholar 

  11. Rabbani F, Stapleton AM, Kattan MW, et al. Factors predicting recovery of erections after radical prostatectomy. J Urol 2000; 164(6): 1929–34

    Article  PubMed  CAS  Google Scholar 

  12. Catalona WJ, Basler JW. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol 1993; 150(3): 905–7

    PubMed  CAS  Google Scholar 

  13. Geary ES, Dendinger TE, Freiha FS, et al. Incontinence and vesical neck strictures following radical retropubic prostatectomy. Urology 1995; 45(6): 1000–6

    Article  PubMed  CAS  Google Scholar 

  14. Penson DF, McLerran D, Feng Z, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol 2005; 173(5): 1701–5

    Article  PubMed  Google Scholar 

  15. Nandipati KC, Raina R, Agarwal A, et al. Five-year potency status after radical prostatectomy: role of oral therapy in erectaids [abstract no. 270]. In: 100th Annual Meeting of American Urological Association; 2005 May 21–26; San Antonio (TX). J Urol Suppl 2005; 173: 4

    Google Scholar 

  16. Breza J, Aboseif SR, Orvis BR, et al. Detailed anatomy of penile neurovascular structures: surgical significance. J Urol 1989; 141(2): 437–43

    PubMed  CAS  Google Scholar 

  17. Polascik TJ, Walsh PC. Radical retropubic prostatectomy: the influence of accessory pudendal arteries on the recovery of sexual function. J Urol 1995; 154(1): 150–2

    Article  PubMed  CAS  Google Scholar 

  18. Rogers CG, Trock BP, Walsh PC. Preservation of accessory pudendal arteries during radical retropubic prostatectomy: surgical technique and results. Urology 2004; 64(1): 148–51

    Article  PubMed  Google Scholar 

  19. Mulhall JP, Graydon RJ. The hemodynamics of erectile dysfunction following nerve-sparing radical retropubic prostatectomy. Int J Impot Res 1996; 8(2): 91–4

    PubMed  CAS  Google Scholar 

  20. Mulhall JP, Slovick R, Hotaling J, et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol 2002; 167(3): 1371–5

    Article  PubMed  Google Scholar 

  21. Moreland RB, Traish A, McMillin MA, et al. PGE1 suppresses the induction of collagen synthesis by transforming growth factor-beta 1 in human corpus cavernosum smooth muscle. J Urol 1995; 153 (3 Pt 1): 826–34

    Article  PubMed  CAS  Google Scholar 

  22. Daley JT, Brown ML, Watkins T, et al. Prostanoid production in rabbit corpus cavernosum: I. regulation by oxygen tension. J Urol 1996; 155(4): 1482–7

    Article  PubMed  CAS  Google Scholar 

  23. Zippe CD, Raina R, Thukral M, et al. Management of erectile dysfunction following radical prostatectomy. Curr Urol Rep 2001; 2(6): 495–503

    Article  PubMed  CAS  Google Scholar 

  24. Moreland RB. Is there a role of hypoxemia in penile fibrosis: a viewpoint presented to the Society for the Study of Impotence. Int J Impot Res 1998; 10(2): 113–20

    Article  PubMed  CAS  Google Scholar 

  25. Leungwattanakij S, Bivalacqua TJ, Usta MF, et al. Cavernous neurotomy causes hypoxia and fibrosis in rat corpus cavernosum. J Androl 2003 Mar–Apr; 24(2): 239–45

    PubMed  Google Scholar 

  26. User HM, Hairston JH, Zelner DJ, et al. Penile weight and cell subtype specific changes in a post-radical prostatectomy model of erectile dysfunction. J Urol 2003; 169(3): 1175–9

    Article  PubMed  Google Scholar 

  27. Iacono F, Giannella R, Somma P, et al. Histological alterations in cavernous tissue after radical prostatectomy. J Urol 2005; 173(5): 1673–6

    Article  PubMed  Google Scholar 

  28. De Luca V, Pescatori ES, Taher B, et al. Damage to the erectile function following radical pelvic surgery: prevalence of venoocclusive dysfunction. Eur Urol 1996; 29(1): 36–40

    PubMed  Google Scholar 

  29. Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol 1997; 158(4): 1408–10

    Article  PubMed  CAS  Google Scholar 

  30. Ogura K, Ichioka K, Terada N, et al. Role of sildenafil citrate in treatment of erectile dysfunction after radical retropubic prostatectomy. Int J Urol 2004; 11(3): 159–63

    Article  PubMed  CAS  Google Scholar 

  31. Feng MI, Huang S, Kaptein J, et al. Effect of sildenafil citrate on post-radical prostatectomy erectile dysfunction. J Urol 2000; 164(6): 1935–8

    Article  PubMed  CAS  Google Scholar 

  32. Zippe CD, Jhaveri FM, Klein EA, et al. Role of Viagra after radical prostatectomy. Urology 2000; 55(2): 241–5

    Article  PubMed  CAS  Google Scholar 

  33. Raina R, Lakin MM, Agarwal A, et al. Long-term effect of sildenafil citrate on erectile dysfunction after radical prostatectomy: 3-year follow-up. Urology 2003; 62(1): 110–5

    Article  PubMed  Google Scholar 

  34. Raina R, Nandipati KC, Agarwal A, et al. Five-year efficacy of sildenafil citrate after radical prostatectomy [abstract no. 737]. In: 100th Annual Meeting of American Urological Association; 2005 May 21–26; San Antonio (TX). J Urol Suppl 2005; 173: 4

    Google Scholar 

  35. Raina R, Lakin MM, Agarwal A, et al. Efficacy and factors associated with successful outcome of sildenafil citrate use for erectile dysfunction after radical prostatectomy. Urology 2004; 63(5): 960–6

    Article  PubMed  Google Scholar 

  36. Zagaja GP, Mhoon DA, Aikens JE, et al. Sildenafil in the treatment of erectile dysfunction after radical prostatectomy. Urology 2000; 56(4): 631–4

    Article  PubMed  CAS  Google Scholar 

  37. El-Galley R, Rutland H, Talic R, et al. Long-term efficacy of sildenafil and tachyphylaxis effect. J Urol 2001; 166(3): 927–31

    Article  PubMed  CAS  Google Scholar 

  38. Padma-Nathan H, McMurray JG, Pullman WE, et al. On-demand IC351 (Cialis) enhances erectile function in patients with erectile dysfunction. Int J Impot Res 2001; 13(1): 2–9

    Article  PubMed  CAS  Google Scholar 

  39. Corbin JD, Francis SH. Pharmacology of phosphodiesterase-5 inhibitors. Int J Clin Pract 2002 Jul–Aug; 56(6): 453–9

    PubMed  CAS  Google Scholar 

  40. Crowe SM, Streetman DS. Vardenafil treatment for erectile dysfunction. Ann Pharmacother 2004; 38(1): 77–85

    Article  PubMed  CAS  Google Scholar 

  41. Carson CC, Rajfer J, Eardley I, et al. The efficacy and safety of tadalafil: an update. BJU Int 2004; 93(9): 1276–81

    Article  PubMed  CAS  Google Scholar 

  42. Montorsi F, Nathan HP, McCullough A, et al. Tadalafil in the treatment of erectile dysfunction following bilateral nerve sparing radical retropubic prostatectomy: a randomized, double-blind, placebo controlled trial. J Urol 2004; 172(3): 1036–41

    Article  PubMed  CAS  Google Scholar 

  43. Keating GM, Scott LJ. Vardenafil: a review of its use in erectile dysfunction. Drugs 2003; 63(23): 2673–703

    Article  PubMed  CAS  Google Scholar 

  44. Brock G, Nehra A, Lipshultz LI, et al. Safety and efficacy of vardenafil for the treatment of men with erectile dysfunction after radical retropubic prostatectomy. J Urol 2003; 170 (4 Pt 1): 1278–83

    Article  PubMed  CAS  Google Scholar 

  45. Nehra A, Grantmyre J, Nadel A, et al. Vardenafil improved patient satisfaction with erectile hardness, orgasmic function and sexual experience in men with erectile dysfunction following nerve sparing radical prostatectomy. J Urol 2005; 173(6): 2067–71

    Article  PubMed  CAS  Google Scholar 

  46. Nandipati KC, Raina R, Agarwal A, et al. Efficacy and treatment satisfaction of PDE-5 inhibitors in management of erectile dysfunction following radical prostatectomy: SHIM analysis [abstract no. 99]. Thirteenth annual meeting with American Society of Andrology; Mar 29–Apr 4; Seattle; Washington, DC, 2005

  47. Jeremy JY, Ballard SA, Naylor AM, et al. Effects of sildenafil, a type-5 cGMP phosphodiesterase inhibitor, and papaverine on cyclic GMP and cyclic AMP levels in the rabbit corpus cavernosum in vitro. Br J Urol 1997; 79(6): 958–63

    Article  PubMed  CAS  Google Scholar 

  48. Lee LM, Stevenson RW, Szasz G. Prostaglandin E1 versus phentolamine/papaverine for the treatment of erectile impotence: a double-blind comparison. J Urol 1989; 141(3): 549–50

    PubMed  CAS  Google Scholar 

  49. Leungwattanakij S, Flynn Jr V, Hellstrom WJ. Intracavernosal injection and intraurethral therapy for erectile dysfunction. Urol Clin North Am 2001; 28(2): 343–54

    Article  PubMed  CAS  Google Scholar 

  50. Raina R, Lakin MM, Thukral M, et al. Long-term efficacy and compliance of intracorporeal (IC) injection for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis. Int J Impot Res 2003; 15(5): 318–22

    Article  PubMed  CAS  Google Scholar 

  51. Lakin MM, Montague DK, VanderBrug Medendorp S, et al. Intracavernous injection therapy: analysis of results and complications. J Urol 1990; 143(6): 1138–41

    PubMed  CAS  Google Scholar 

  52. Dennis RL, McDougal WS. Pharmacological treatment of erectile dysfunction after radical prostatectomy. J Urol 1988; 139(4): 775–6

    PubMed  CAS  Google Scholar 

  53. Mulhall JP, Jahoda AE, Cairney M, et al. The causes of patient dropout from penile self-injection therapy for impotence. J Urol 1999; 162(4): 1291–4

    Article  PubMed  CAS  Google Scholar 

  54. Purvis K, Egdetveit I, Christiansen E. Intracavernosal therapy for erectile failure: impact of treatment and reasons for dropout and dissatisfaction. Int J Impot Res 1999; 11(5): 287–99

    Article  PubMed  CAS  Google Scholar 

  55. Mulhall JP, Jahoda AE, Ahmed A, et al. Analysis of the consistency of intraurethral prostaglandin E(l) (MUSE) during at-home use. Urology 2001; 58(2): 262–6

    Article  PubMed  CAS  Google Scholar 

  56. Padma-Nathan H, Hellstrom WJ, Kaiser FE, et al. Treatment of men with erectile dysfunction with transurethral alprostadil. Medicated Urethral System for Erection (MUSE) Study Group. N Engl J Med 1997; 336(1): 1–7

    Article  PubMed  CAS  Google Scholar 

  57. Costabile RA, Spevak M, Fishman IJ, et al. Efficacy and safety of transurethral alprostadil in patients with erectile dysfunction following radical prostatectomy. J Urol 1998; 160(4): 1325–8

    Article  PubMed  CAS  Google Scholar 

  58. Porst H. Transurethral alprostadil with MUSE (medicated urethral system for erection) vs intracavernous alprostadil: a comparative study in 103 patients with erectile dysfunction. Int J Impot Res 1997; 9(4): 187–92

    Article  PubMed  CAS  Google Scholar 

  59. Raina R, Agarwal A, Ausmundson S, et al. Long-term efficacy and compliance of MUSE for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis. Int J Impot Res 2005; 17(1): 86–90

    Article  PubMed  CAS  Google Scholar 

  60. Levine LA, Dimitriou RJ. Vacuum constriction and external erection devices in erectile dysfunction. Urol Clin North Am 2001; 28(2): 335–41, ix

    Article  PubMed  CAS  Google Scholar 

  61. Cookson MS, Nadig PW. Long-term results with vacuum constriction device. J Urol 1993; 149(2): 290–4

    PubMed  CAS  Google Scholar 

  62. Chen J, Sofer M, Kaver I, et al. Concomitant use of sildenafil and a vacuum entrapment device for the treatment of erectile dysfunction. J Urol 2004; 171(1): 292–5

    Article  PubMed  Google Scholar 

  63. Raina R, Agarwal A, Allamaneni SS, et al. Sildenafil citrate and vacuum constriction device combination enhances sexual satisfaction in erectile dysfunction after radical prostatectomy. Urology 2005; 65(2): 360–4

    Article  PubMed  Google Scholar 

  64. Nehra A, Kulaksizoglu H. Combination therapy for erectile dysfunction: where we are and what’s in the future. Curr Urol Rep 2002; 3(6): 467–70

    Article  PubMed  Google Scholar 

  65. Mydlo JH, Volpe MA, Macchia RJ. Initial results utilizing combination therapy for patients with a suboptimal response to either alprostadil or sildenafil monotherapy. Eur Urol 2000; 38(1): 30–4

    Article  PubMed  CAS  Google Scholar 

  66. Raina R, Nandipati KC, Agarwal A, et al. Combination therapy using medicated urethral system for erection enhances sexual satisfaction in sildenafil citrate failure following nerve-sparing radical prostatectomy. J Androl 2005; 26(6): 757–60

    Article  PubMed  CAS  Google Scholar 

  67. Shabsigh R, Padma-Nathan H, Gittleman M, et al. Intracavernous alprostadil alfadex (EDEX/VIRIDAL) is effective and safe in patients with erectile dysfunction after failing sildenafil (Viagra). Urology 2000; 55(4): 477–80

    Article  PubMed  CAS  Google Scholar 

  68. Shabsigh R, Anastasiadis AG. Erectile dysfunction. Annu Rev Med 2003; 54: 153–68

    Article  PubMed  CAS  Google Scholar 

  69. Escrig A, Marin R, Mas M. Repeated PGE1 treatment enhances nitric oxide and erection responses to nerve stimulation in the rat penis by upregulating constitutive NOS isoforms. J Urol 1999; 162(6): 2205–10

    Article  PubMed  CAS  Google Scholar 

  70. Mydlo JH, Viterbo R, Crispen P. Use of combined intracorporal injection and a phosphodiesterase-5 inhibitor therapy for men with a suboptimal response to sildenafil and/or vardenafil monotherapy after radical retropubic prostatectomy. BJU Int 2005; 95(6): 843–6

    Article  PubMed  CAS  Google Scholar 

  71. Buvat J, Montorsi F. Safety and tolerability of apomorphine SL in patients with erectile dysfunction. BJU Int 2001; 88Suppl. 3: 30–5

    Article  PubMed  CAS  Google Scholar 

  72. Mulhall JP, Bukofzer S, Edmonds AL, et al. An open-label, uncontrolled dose-optimization study of sublingual apomorphine in erectile dysfunction. Clin Ther 2001; 23(8): 1260–71

    Article  PubMed  CAS  Google Scholar 

  73. Schwartz EJ, Wong P, Graydon RJ. Sildenafil preserves intracorporeal smooth muscle after radical retropubic prostatectomy. J Urol 2004; 171 (2 Pt 1): 771–4

    Article  PubMed  Google Scholar 

  74. Padma-Nathan H, McCullough AR, Giuliano F, et al. Postoperative nightly administration of sildenafil citrate significantly improves the return of normal spontaneous erectile function after bilateral nerve-sparing radical prostatectomy [abstract no. 1402]. In: 98th Annual Meeting of American Urological Association; 2002 Apr 26–May 1; Chicago (IL). J Urol Suppl 2003; 169: 375

    Google Scholar 

  75. Gallo L, Perdona S, Autorino R, et al. Recovery of erection after pelvic urologic surgery: our experience. Int J Impot Res 2005; 17(6): 484–93

    Article  PubMed  CAS  Google Scholar 

  76. Raina R, Agarwal A, Nandipati KC, et al. Interim analysis of the early use of MUSE following radical prostatectomy (RP) to facilitate early sexual activity and return of spontaneous erectile function [abstract no. 737]. In: 100th Annual Meeting of American Urological Association; 2005 May 21–26; San Antonio (TX). J Urol Suppl 2005; 173: 4

    Google Scholar 

  77. Nandipati KC, Raina R, Agarwal A, et al. Early combination therapy: intracavernosal injections and sildenafil following radical prostatectomy (RP) increases sexual activity and the return of natural erections. Int J Impot Res. In press

  78. Small MP, Carrion HM. Penile prosthesis: new implant for management of impotence. J Fla Med Assoc 1975; 62(10): 21–5

    PubMed  CAS  Google Scholar 

  79. Gerstenberger DL, Osborne D, Furlow WL. Inflatable penile prosthesis: follow-up study of patient-partner satisfaction. Urology 1979; 14(6): 583–7

    Article  PubMed  CAS  Google Scholar 

  80. McLaren RH, Barrett DM. Patient and partner satisfaction with the AMS 700 penile prosthesis. J Urol 1992; 147(1): 62–5

    PubMed  CAS  Google Scholar 

  81. Montague DK, Angermeier KW. Contemporary aspects of penile prosthesis implantation. Urol Int 2003; 70(2): 141–6

    Article  PubMed  Google Scholar 

  82. Montague DK, Angermeier KW. Current status of penile prosthesis implantation. Curr Urol Rep 2000; 1(4): 291–6

    Article  PubMed  CAS  Google Scholar 

  83. Filippi S, Crescioli C, Vannelli GB, et al. Effects of NCX 4050, a new NO donor, in rabbit and human corpus cavernosum. Int J Androl 2003; 26(2): 101–8

    Article  PubMed  CAS  Google Scholar 

  84. Kalsi JS, Kell PD, Cellek S, et al. NCX-911, a novel nitric oxide-releasing PDE5 inhibitor relaxes rabbit corpus cavernosum in the absence of endogenous nitric oxide. Int J Impot Res 2004; 16(2): 195–200

    Article  PubMed  CAS  Google Scholar 

  85. Lee MC, El-Sakka Al, Graziottin TM, et al. The effect of vascular endothelial growth factor on a rat model of traumatic arteriogenic erectile dysfunction. J Urol 2002; 167 (2 Pt 1): 761–7

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.

Author information

Authors and Affiliations

  1. Glickman Urological Institute and Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

    Kalyana C. Nandipati, Rupesh Raina, Ashok Agarwal &  Craig D. Zippe

  2. Department of Internal Medicine and Pediatrics, Case Western Reserve University (MHMC), Cleveland, Ohio, USA

    Rupesh Raina

Authors
  1. Kalyana C. Nandipati
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rupesh Raina
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ashok Agarwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Craig D. Zippe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Craig D. Zippe.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nandipati, K.C., Raina, R., Agarwal, A. et al. Erectile Dysfunction Following Radical Retropubic Prostatectomy. Drugs Aging 23, 101–117 (2006). https://doi.org/10.2165/00002512-200623020-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-200623020-00002

Keywords

Search

Navigation