Techniques to Improve Sexual Function Following Robot-Assisted Radical Prostatectomy

  • Nicola Fossati
  • Alberto Briganti
  • Giorgio Gandaglia
  • Alexandre Mottrie
  • Francesco MontorsiEmail author


Penile rehabilitation aims at improving cavernosal oxygenation, preserving endothelial structure, and preventing smooth muscle structural changes. The most commonly adopted approaches for penile rehabilitation following robot-assisted radical prostatectomy are represented by phosphodiesterase type-5 inhibitors (PDE5-Is), intra-corporeal injection therapy, vacuum erection devices (VED), and the combination of these treatments. In this chapter, the most relevant studies concerning penile rehabilitation after radical prostatectomy will be analysed and discussed. Nowadays, many strategies have been developed to facilitate the recovery of erectile function. However, clear and validated protocols for penile rehabilitation after robot-assisted radical prostatectomy still have to be defined. A combination of modalities might provide optimal preservation of erectile function. On-going and future studies will elucidate who is the optimal candidate and which is the optimal program for penile rehabilitation. New therapies emerging from pre-clinical studies will improve the clinician’s armamentarium and increase the potential of penile rehabilitation.


Prostatectomy Erectile dysfunction Penile rehabilitation Phosphodiesterase 5 inhibitors 


  1. 1.
    Hatzimouratidis K, Burnett AL, Hatzichristou D, McCullough AR, Montorsi F, Mulhall JP. Phosphodiesterase type 5 inhibitors in postprostatectomy erectile dysfunction: a critical analysis of the basic science rationale and clinical application. Eur Urol. 2009;55:334–47. Scholar
  2. 2.
    Mulhall JP. The role and structure of a postradical prostatectomy penile rehabilitation program. Curr Urol Rep. 2009;10:219–25.CrossRefPubMedGoogle Scholar
  3. 3.
    Mulhall JP, Slovick R, Hotaling J, Aviv N, Valenzuela R, Waters WB, et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol. 2002;167:1371–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Walz J, Burnett AL, Costello AJ, Eastham JA, Graefen M, Guillonneau B, et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol. 2010;57:179–92. Scholar
  5. 5.
    Burnett AL. Rationale for cavernous nerve restorative therapy to preserve erectile function after radical prostatectomy. Urology. 2003;61:491–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Gandaglia G, Suardi N, Cucchiara V, Bianchi M, Shariat SF, Rouprêt M, et al. Penile rehabilitation after radical prostatectomy: does it work? Transl Androl Urol. 2015;4:110–23. Scholar
  7. 7.
    Mulhall JP, Bivalacqua TJ, Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. J Sex Med. 2013;10:195–203. Scholar
  8. 8.
    Teloken P, Mesquita G, Montorsi F, Mulhall J. Post-radical prostatectomy pharmacological penile rehabilitation: practice patterns among the international society for sexual medicine practitioners. J Sex Med. 2009;6:2032–8. Scholar
  9. 9.
    Tal R, Teloken P, Mulhall JP. Erectile function rehabilitation after radical prostatectomy: practice patterns among AUA members. J Sex Med. 2011;8:2370–6. Scholar
  10. 10.
    Li J, Shi Q, Pu C, Tang Y, Bai Y, Yuan H, et al. Phosphodiesterase type 5 inhibitors for the treatment of post-nerve sparing radical prostatectomy erectile dysfunction in men. Sci Rep. 2014;4:5801. Scholar
  11. 11.
    Brock G, Nehra A, Lipshultz LI, Karlin GS, Gleave M, Seger M, et al. Safety and efficacy of vardenafil for the treatment of men with erectile dysfunction after radical retropubic prostatectomy. J Urol. 2003;170:1278–83. Scholar
  12. 12.
    Nehra A, Grantmyre J, Nadel A, Thibonnier M, Brock G. 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;173:2067–71. Scholar
  13. 13.
    Montorsi F, Brock G, Lee J, Shapiro J, Van Poppel H, Graefen M, et al. Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. Eur Urol. 2008;54:924–31. Scholar
  14. 14.
    Montorsi F, Nathan HP, McCullough A, Brock GB, Broderick G, Ahuja S, 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;172:1036–41. Scholar
  15. 15.
    Montorsi F, Brock G, Stolzenburg J-U, Mulhall J, Moncada I, Patel HRH, et al. Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT). Eur Urol. 2014;65:587–96. Scholar
  16. 16.
    Padma-Nathan H, McCullough AR, Levine LA, Lipshultz LI, Siegel R, Montorsi F, et al. Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Int J Impot Res. 2008;20:479–86. Scholar
  17. 17.
    Mulhall JP, Burnett AL, Wang R, McVary KT, Moul JW, Bowden CH, et al. A phase 3, placebo controlled study of the safety and efficacy of avanafil for the treatment of erectile dysfunction after nerve sparing radical prostatectomy. J Urol. 2013;189:2229–36. Scholar
  18. 18.
    Smith WB, McCaslin IR, Gokce A, Mandava SH, Trost L, Hellstrom WJ. PDE5 inhibitors: considerations for preference and long-term adherence. Int J Clin Pract. 2013;67:768–80. Scholar
  19. 19.
    Pavlovich CP, Levinson AW, Su L-M, Mettee LZ, Feng Z, Bivalacqua TJ, et al. Nightly vs on-demand sildenafil for penile rehabilitation after minimally invasive nerve-sparing radical prostatectomy: results of a randomized double-blind trial with placebo. BJU Int. 2013;112:844–51. Scholar
  20. 20.
    Moncada I, de Bethencourt FR, Lledó-García E, Romero-Otero J, Turbi C, Büttner H, et al. Effects of tadalafil once daily or on demand versus placebo on time to recovery of erectile function in patients after bilateral nerve-sparing radical prostatectomy. World J Urol. 2015;33:1031–8. Scholar
  21. 21.
    Virag R. Intracavernous injection of papaverine for erectile failure. Lancet. 1982;2:938.CrossRefPubMedGoogle Scholar
  22. 22.
    Sopko NA, Burnett AL. Erection rehabilitation following prostatectomy–current strategies and future directions. Nat Rev Urol. 2016;13:216–25. Scholar
  23. 23.
    Montorsi F, Guazzoni G, Strambi LF, Da Pozzo LF, Nava L, Barbieri L, 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;158:1408–10.CrossRefPubMedGoogle Scholar
  24. 24.
    Mulhall J, Land S, Parker M, Waters WB, Flanigan RC. The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med. 2005;2:532–40. discussion 540–2. Scholar
  25. 25.
    Raina R, Lakin MM, Thukral M, Agarwal A, Ausmundson S, Montague DK, 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;15:318–22. Scholar
  26. 26.
    Coombs PG, Heck M, Guhring P, Narus J, Mulhall JP. A review of outcomes of an intracavernosal injection therapy programme. BJU Int. 2012;110:1787–91. Scholar
  27. 27.
    Broderick GA, McGahan JP, Stone AR, White RD. The hemodynamics of vacuum constriction erections: assessment by color Doppler ultrasound. J Urol. 1992;147:57–61.CrossRefPubMedGoogle Scholar
  28. 28.
    Raina R, Agarwal A, Ausmundson S, Lakin M, Nandipati KC, Montague DK, et al. Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function. Int J Impot Res. 2006;18:77–81. Scholar
  29. 29.
    Basal S, Wambi C, Acikel C, Gupta M, Badani K. Optimal strategy for penile rehabilitation after robot-assisted radical prostatectomy based on preoperative erectile function. BJU Int. 2013;111:658–65. Scholar
  30. 30.
    Köhler TS, Pedro R, Hendlin K, Utz W, Ugarte R, Reddy P, et al. A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. BJU Int. 2007;100:858–62. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nicola Fossati
    • 1
  • Alberto Briganti
    • 1
  • Giorgio Gandaglia
    • 1
  • Alexandre Mottrie
    • 2
    • 3
  • Francesco Montorsi
    • 1
    Email author
  1. 1.Division of Oncology/Unit of UrologyIRCCS Ospedale San Raffaele, Urological Research InstituteMilanItaly
  2. 2.Department of UrologyOnze-Lieve-Vrouw HospitalAalstBelgium
  3. 3.ORSI AcademyMelleBelgium

Personalised recommendations