Management of Erectile Dysfunction Following Radical Prostatectomy

  • Craig D. Zippe
  • Rupesh Raina
Part of the Current Clinical Urology book series (CCU)


Radical prostatectomy (RP) has been the gold standard treatment for organ/specimen-confined prostate cancer for several decades. Improved surgical techniques have decreased the rate of “total” and stress-induced incontinence to < 10%, but urologists still report that most patients experience erectile dysfunction (ED) following RP (1–3). Although the surgical technique and experience remain the dominant variables in outcome, other factors affecting postoperative ED include the patient’s age, preoperative sexual function, psychological adjustment to a cancer diagnosis, and coexisting medical diseases (i.e., diabetes, hypertension). Other preoperative variables include the stage of disease, preservation of the neurovascular bundles, urinary incontinence, and adjuvant treatments (radiation therapy, hormonal therapy) (3–4).


Erectile Dysfunction Radical Prostatectomy Sexual Satisfaction Erectile Function Neurovascular Bundle 
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  1. 1.
    Schrader-Bogan 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: 1977–1986.CrossRefGoogle Scholar
  2. 2.
    Walsh PC, Marschke P, Ricker D, et al. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000; 55: 58–61.PubMedCrossRefGoogle Scholar
  3. 3.
    McCullough AR. Management of erectile dysfunction following radical prostatectomy. Sexual Dysfunction Med 2000; 2: 2–8.Google Scholar
  4. 4.
    Zippe CD, Raina R, Thukral M, et al. Management of erectile dysfunction following radical prostatectomy. Review article. Curr Urol Rep 2001; 2: 495–503.PubMedCrossRefGoogle Scholar
  5. 5.
    Catalona WP, Basler JW. Return of erections and urinary continence following nerve-sparing radical retropubic prostatectomy. J Urol 1993; 150: 905–907.PubMedGoogle Scholar
  6. 6.
    Quinlan DM, Epstein JI, Carter BS, Walsh P. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol 1991; 145: 998–1002.PubMedGoogle Scholar
  7. 7.
    Sexton WJ, Benedict JF, Jarow JP. Comparison of long-term outcomes of penile prosthesis and intracavernosal injection therapy. J Urol 1998; 159: 811–815.PubMedCrossRefGoogle Scholar
  8. 8.
    Jarow JP, Nana-Sinkam P, Sabbagh M, et al. Outcome analysis of goal directed therapy for impotence. J Urol 1996; 155: 1609–1612.PubMedCrossRefGoogle Scholar
  9. 9.
    Mazur DJ, Merz JF. Older patients’ willingness to trade off urologic adverse outcomes for a better chance at five-year survival in the clinical setting of prostate cancer. J Am Geriatr Soc 1995; 43: 979–984.PubMedGoogle Scholar
  10. 10.
    Talcott JA, Rieker P, Propert KJ, et al. Patient reported impotence and incontinence after nerve-sparing radical prostatectomy. J Natl Cancer Inst 1997; 89: 1117–1123.PubMedCrossRefGoogle Scholar
  11. 11.
    Valdivia Navarro P, Gonzalvo A, Blas Marin M, et al. Quality of life after radical prostatectomy. Actas Urol Esp 1997; 21: 903–908.PubMedGoogle Scholar
  12. 12.
    Raina R, Agarwal A, Goyal K, Zippe CD. Defining erectile dysfunction (ED) and treatment pathways following radical prostatectomy (RP) in a preoperative sexually active population. In: 28th Annual Meeting of the American Society of Andrology, Mar 29–Apr 1, 2003, Phoenix AZ, abstract #116, poster presentation.Google Scholar
  13. 13.
    Dutta TC, Eid JF. Vacuum constriction devices for erectile dysfunction: a long-term, prospective study of patients with mild, moderate, and severe dysfunction. Urology 1999; 54: 891–893.PubMedCrossRefGoogle Scholar
  14. 14.
    Cookson MS, Nadig PW. Long term results with vacuum constriction device. J Urol 1993; 149: 290–294.PubMedGoogle Scholar
  15. 15.
    Turner LA, Althof SE, Levine SB, et al. Twelve-month comparison of two treatments for erectile dysfunction: self-injection versus external vacuum devices. Urology 1992; 39: 139–144.PubMedCrossRefGoogle Scholar
  16. 16.
    Soderdahl DW, Thrasher JB, Hansberry KL. Intracavernosal drug-induced erection therapy versus external vacuum devices in the treatment of erectile dysfunction. Br J Urol 1997; 79: 952–957.PubMedCrossRefGoogle Scholar
  17. 17.
    Gould JE, Switters DM, Broberick GA, deVereWhite RW. External vacuum devices: a clinical comparison with pharmacologic erections. World J Urol 1992; 10: 68–70.CrossRefGoogle Scholar
  18. 18.
    Blackard CE, Borken WD, Lima JS, et al. Use of vacuum tumescence device for impotence secondary to venous leakage. Urology 1996; 41: 225–227.CrossRefGoogle Scholar
  19. 19.
    Sidi AA, Becher EF, Zhang G, Lewis JH. Patient acceptance of and satisfaction with an external negative pressure device for impotence. J Urol 1990; 144: 1154.PubMedGoogle Scholar
  20. 20.
    Raina R, Klepacz H, Agarwal A, Zippe CD. Early use of vacuum constriction device (VCD) following radical prostatectomy (RP) facilitates early sexual activity and potential return of erection. J Urol 2002; 167: 279.CrossRefGoogle Scholar
  21. 21.
    Raina R, Agarwal A, Lakin MM, Zippe CD. Combination therapy: sildenafil citrate enhances sexual satisfaction in vacuum constriction device (VCD) failures following radical prostatectomy (RP). J Urol 2002; 167: 281Google Scholar
  22. 22.
    Wiles PG. Successful non-invasive management of erectile impotence in diabetic men. BMJ (Clin Res Ed) 1988; 296: 161–162.CrossRefGoogle Scholar
  23. 23.
    Padma-Nathan H, Hellstrom WJ, Kaiser FE, et al. Treatment of men with erectile dysfunction with transurethral alprostadil. N Engl J Med 1997; 336: 1–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Costabile RA, Govier FE, Ferrigni RG, et al. Safety of transurethral alprostadil in patients with erectile dysfunction following radical prostatectomy. J Urol 1997; 157: 1424.CrossRefGoogle Scholar
  25. 25.
    Paolone DR, Lankin MM, Ingleright BJ, et al. Intraurethral alprostadil therapy at The Cleveland Clinic Foundation. Abstract submitted to North Central Section AUA for presentation in October, 1998.Google Scholar
  26. 26.
    Raina R, Agarwal A, Zippe CD. Long term efficacy and compliance of MUSE therapy for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis. J Urol 2003.Google Scholar
  27. 27.
    Burnett AL. Nitric oxide in the penis: physiology and pathology. J Urol 1997; 157: 320–324.PubMedCrossRefGoogle Scholar
  28. 28.
    Burnett AL. Nitric oxide regulation of penile erection: biology and therapeutic implications. J Androl 2002; 23: S20 - S24.PubMedGoogle Scholar
  29. 29.
    Ballard SA, Gingell CJ, Tang K, et al. Effects of sildenafil on the relaxation of human corpus cavernosum tissue in vitro and on the activities of cyclic nucleotide phosphodiesterase isoenzymes. J Urol 1998; 159: 2164–2171.PubMedCrossRefGoogle Scholar
  30. 30.
    Nehra, et al. Combination of sildenafil and intraurethral prostaglandin E1 salvaged a selected population of men with ED. Abstract submitted to the AUA for the 95th Meeting of the American Urological Association, May, 2000.Google Scholar
  31. 31.
    Porst H. Transurethral alprostadil with MUSE versus intracavernous alprostadil: a comparative study in 103 patients with erectile dysfunction. Int J Impot Res 1997; 9: 187–192.PubMedCrossRefGoogle Scholar
  32. 32.
    Stakl W, Hasun R, Marberger N. Prostaglandin E-1 in the treatment of erectile dysfunction. World J Urol 1990; 8: 84–86.CrossRefGoogle Scholar
  33. 33.
    Khan MA, Thomson CS, Sullivan ME, et al. The role of prostaglandins in the etiology and treatment of erectile dysfunction. Prostaglandin Leukotr Essent Fatty Acids 1999; 60: 169–174.CrossRefGoogle Scholar
  34. 34.
    Cawello W, Schweer H, Dietrich B, et al. Pharmacokinetics of prostaglandin E1 and its main metabolites after intracavernous injection and short term infusion of prostaglandin E1 in patients with erectile dysfunction. J Urol 1997; 158: 1403–1407.PubMedCrossRefGoogle Scholar
  35. 35.
    Dennis RL, McDougal WS. Pharmacological treatment of erectile dysfunction after radical prostatectomy. J Urol 1988; 139: 775–776.PubMedGoogle Scholar
  36. 36.
    Rodriguez VL, Gonzalvo IA, Bono AA, et al. Erectile dysfunction after radical prostatectomy. Etiopathology and treatment. Actas Urol Esp 1997; 21: 909–921.Google Scholar
  37. 37.
    Lakin MM, Chen RN, Llorens SA, et al. Prostaglandin E1 injection therapy for post-prostatectomy impotence: an outcome analysis. J Urol 1996; 155: 639.CrossRefGoogle Scholar
  38. 38.
    Evans C. Complications of intracavernosal therapy for impotence. In: Carson C, Kirby R, Goldstein I, eds. Textbook of Erectile Dysfunction. Isis Medical Media, Oxford, 1999, pp. 365–370.Google Scholar
  39. 39.
    Mulhall JP, Jahoda A, Cairney M, et al. The causes of patient dropout from penile self-injection therapy for impotence. J Urol 1999; 162: 1291–1294.PubMedCrossRefGoogle Scholar
  40. 40.
    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: 287–299.PubMedCrossRefGoogle Scholar
  41. 41.
    Raina R, Lakin MM, Agarwal A, et al. Long-term efficacy and compliance of Intracavernous injections following radical prostatectomy: SHIM (IIEF-5) analysis. J Impot Res 2003; 15 (5): 318–322.CrossRefGoogle Scholar
  42. 42.
    Bechara A, Casabe A, Cheliz G, et al. Prostaglandin E1 versus mixture of prostaglandin E1 papavereine and phentolamine in non-responders to high papaverine plus phentolamine doses. Urology 1996; 155: 913–914.CrossRefGoogle Scholar
  43. 43.
    Mullhall JP, Daller M, Traish AM, et al. Intracavernosal forskalin: role in management of vasculogenic impotence resistant to 3-agent pharmacotherapy. J Urol 1997; 158: 1752–1758.CrossRefGoogle Scholar
  44. 44.
    Mc Mohan CG. A pilot study of role of intracavernous injection of vasoactive intestinal peptide and phentolamine in the management of erectile failure. Int J Impot Res 1996; 8: 233–236.Google Scholar
  45. 45.
    Buvat J, Costa P, Morlier D, et al. Double blind multicenter study comparing alprostadil alpha-cyclodextrin with moxisylyte chlorohydratein chronic organic erectile dysfunction. J Urol 1998; 159: 116–119.PubMedCrossRefGoogle Scholar
  46. 46.
    Moreland RB, Abdulmaged T, 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 1998; 153: 811–815.Google Scholar
  47. 47.
    Fraiman MC, Lepor H, McCullough AR. Changes in penile morphometrics in men with erectile dysfunction after nerve sparing radical prostatectomy. Mol Urol 1999; 3: 109–115.PubMedGoogle Scholar
  48. 48.
    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 1996; 155: 639.CrossRefGoogle Scholar
  49. 49.
    Raina R, Ausmundson S, Agarwal A, Lakin MM, Zippe CD. Long-term intracavernous (IC) therapy responders can potentially switch to sildenafil citrate after radical prostatectomy (RP). Urology 2003, in press.Google Scholar
  50. 50.
    Willke RJ, Glick HA, McCarron TJ, et al. Quality of life effects of alprostadil therapy for erectile dysfunction. J Urol 1997; 157: 2124–2127.PubMedCrossRefGoogle Scholar
  51. 51.
    Goldstein I, Lue TF, Padma-Nathan H, et al. for the Sildenafil Study Group: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998; 338: 1397–1404.PubMedCrossRefGoogle Scholar
  52. 52.
    Steers WD. Viagra after one year. Urology 1999; 54: 12–17.PubMedCrossRefGoogle Scholar
  53. 53.
    Zippe CD, Thurkal M, Agarwal A, et al. The erectile dysfunction following radical prostatectomy. Indian J Urol 2000.Google Scholar
  54. 54.
    Zippe CD, Jhaveri FM, Klein EA, et al. Role of Viagra after radical prostatectomy. Urology 2000; 55: 241–245.PubMedCrossRefGoogle Scholar
  55. 55.
    Zagaja GP, Mhoon DA, Aikens JE, Brendler CB. Sildenafil in the treatment of erectile dysfunction after radical prostatectomy. Urology 2000; 56: 631–634.PubMedCrossRefGoogle Scholar
  56. 56.
    Lowentritt BH, Scardino PT, Miles BJ, et al. Sildenafil citrate after radical retropubic prostatectomy. J Urol 1999; 162: 1614–1618.PubMedCrossRefGoogle Scholar
  57. 57.
    Leonard S, Duda C, Jdorey J, PB. Treatment of erectile dysfunction with sildenafil. Urology 1999; 53: 19–24.CrossRefGoogle Scholar
  58. 58.
    Jarow JP, Burnett AL, Geringer AM. Clinical efficacy of sildenafil citrate based on etiology and response to prior treatment. J Urol 1999; 162: 722–725.PubMedCrossRefGoogle Scholar
  59. 59.
    Hong EK, Lepor H, McCullough AR. Time dependent patient satisfaction with sildenafil for erectile dysfunction (ED) after nerve sparing radical retropubic prostatectomy. Int J Impot Res 1999; 11: 15–22.CrossRefGoogle Scholar
  60. 60.
    Zippe CD, Kedia S, Kedia AW, Pasqualotto F. Sildenafil citrate (Viagra) after radical retropubic prostatectomy: pro. Urology 1999; 54: 583–586.PubMedCrossRefGoogle Scholar
  61. 61.
    Feng MI, Huang S, Kaptein J, Kaswick J, Aboseif S. Effect of sildenafil citrate on post-radical prostatectomy erectile dysfunction. J Urol 2000; 164: 1935–1938.PubMedCrossRefGoogle Scholar
  62. 62.
    Ajay N, Goldstein I. Sildenafil citrate after radical retropubic prostatectomy: con. Urology 1999; 54: 587–589.CrossRefGoogle Scholar
  63. 63.
    Sadovsky R, Miller T, Moskowitz M, et al. Three-year update of sildenafil citrate ( Viagra) efficacy and safety. Int J Clin Pract 2001; 15–128.Google Scholar
  64. 64.
    Raina R, Lakin MM, Agarwal A, et al. Long-term effect of sildenafil citrate following radical prostatectomy: 3-year follow-up. Urology 2003; 62: 110–115.PubMedCrossRefGoogle Scholar
  65. 65.
    Raina R, Agarwal A, Mascha E, et al. Efficacy and factors associated with successful outcome of sildenafil citrate use following radical prostatectomy. J Urol 2003, submitted.Google Scholar
  66. 66.
    Klotz L, Herschorn S. Early experience with intraoperative cavernous nerve stimulation with penile tumescence monitoring to improve nerve sparing during radical prostatectomy. Urology 1998; 52: 537–542.PubMedCrossRefGoogle Scholar
  67. 67.
    Sunderland S. Nerve grafting and related methods of nerve repair. In: Nerve Injuries and Their Repair: A Critical Appraisal. Churchill Livingstone, Edinburgh, 1991, pp. 467–497.Google Scholar
  68. 68.
    Kim ED, Nath R, Kadmon D, et al. Bilateral nerve graft during radical retropubic prostatectomy: 1 year follow-up. J Urol 2001; 165: 1950–1956.PubMedCrossRefGoogle Scholar
  69. 69.
    Kim N, Vardi Y, Padma-Nathan H, Daley J, Goldstein I, Saenz de Tejada I. Oxygen tension regulates the nitric oxide pathway. Physiological role in penile erection. J Clin Invest 1993; 91: 437.PubMedCrossRefGoogle Scholar
  70. 70.
    Lee MC, El-Sakka A, Bakircioglu E. The effect of vascular endothelial growth factor on a rat model of arterial impotence. J Urol 2000; 163: 198.Google Scholar

Copyright information

© Springer Science+Business Media New York 2004

Authors and Affiliations

  • Craig D. Zippe
  • Rupesh Raina

There are no affiliations available

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