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

OBJECTIVE: To report experience with combined therapy using intracorporal injection (ICI) of alprostadil and oral phosphodiesterase 5 (PDE-5) inhibitors for the minimally invasive treatment of erectile dysfunction (ED) after radical prostatectomy (RP), as PDE-5 inhibitors are effective but a few patients may have a suboptimal response. PATIENTS AND METHODS: In a retrospective study, 34 men (aged 46-66 years) had a nerve-sparing retropubic RP and subsequent ED. Patients were titrated on sildenafil citrate or vardenafil to maximum doses. All had a suboptimal response after a maximum of eight doses of oral therapy and were then treated with ICI therapy using 15 or 20 microg alprostadil. Erectile function was assessed with the Sexual Health Inventory for Men (SHIM). RESULTS: Of the 32 patients who continued combined therapy, 22 (68%) had an improvement in erectile function after ICI therapy, as assessed by the SHIM score. On follow-up, 36% of these patients used ICI therapy only intermittently, instead of regularly, as they felt that this was adequate enough for good results. CONCLUSIONS: PDE-5 oral pharmacotherapy is the most commonly used effective therapy for ED but may not be as effective in patients who have radical surgery; the addition of testosterone patches may have side-effects or be considered a risk in patients with a history of prostate cancer. The use of ICI therapy as an adjunct or maintenance therapy to their oral medication may be another alternative in these patients.     

Erektionsstatus nach nervenerhaltender radikaler Prostatektomie

The time lapse before recovery of erectile function after nerve-sparing radical prostatectomy is still under debate. Several pathophysiologies are postulated for postoperative erectile function rehabilitation. In prospective studies we measured nocturnal penile tumescence (NPTR) in the acute phase during the first night after catheter removal subsequent to nerve-sparing radical prostatectomy to assess the neuronal organic erectile integrity.Eighteen sexually active patients suffering from local prostate cancer underwent bilateral and unilateral nerve-sparing retropubic radical prostatectomy. All patients completed an IIEF-5 questionnaire concerning erectile function preoperatively. The transurethral catheter was removed 14 days after surgery, and nocturnal penile tumescence was measured with an erectometer (Rigi-Scan) in each patient during the following night. None of these patients received any comedication interacting with erectile function.The preoperative IIEF score was >18 in all patients. After catheter removal, 17 of 18 patients (95%) had nocturnal penile radial rigidity >70% that persisted for >10 min during one night. In a control of four patients without a nerve-sparing procedure, no nocturnal erections were recorded.The measurement of NPTR in the acute phase after nerve-sparing radical prostatectomy showed retained erectile function even during the "first" night after catheter removal. Our findings are important for an appropriate choice of pharmacotherapy for optimal recovery of erectile function. In cases of early penile erections, the cavernous nerve had been well preserved during surgery providing good neuronal integrity, and PDE-5 inhibitors can support organic rehabilitation of the corpus cavernosum. In the absence of early penile erections, the neuronal integrity of the cavernous nerve is presumed to be impaired. In this case, additional injection therapy should be chosen to support recovery of spontaneous erectile function.     

Factors predicting recovery of erections after radical prostatectomy

PURPOSE: Because preservation of functioning penile erections is a major concern for many patients considering treatment for localized prostate cancer, we analyzed various factors determined before and after radical retropubic prostatectomy to identify those significantly associated with recovery of erectile function. MATERIALS AND METHODS: Our prospective database of patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy was used to determine factors predictive of erection recovery after radical prostatectomy. The study included 314 consecutive men with prostate cancer treated with radical retropubic prostatectomy between November 1993 and December 1996. Preoperative potency satisfactory for intercourse and degree of neurovascular bundle preservation during the operation were documented. RESULTS: Patient age, preoperative potency status and extent of neurovascular bundle preservation but not pathological stage were predictive of potency recovery after radical prostatectomy. At 3 years after the operation 76% of men younger than age 60 years with full erections preoperatively who had bilateral neurovascular bundle preservation would be expected to regain erections sufficient for intercourse. Compared to the younger men, those 60 to 65 years old were only 56% (95% confidence interval [CI] 37 to 84) and those older than 65 years were 47% (95% CI 30 to 73) as likely to recover potency. Patients with recently diminished erections were only 63% (95% CI 38 to 100) as likely to recover potency as men with full erections preoperatively, and those with partial erections were only 47% (95% CI 23 to 96) as likely to recover potency. Resection of 1 neurovascular bundle reduced the chance of recovery to 25% (95% CI 10 to 61) compared to preserving both nerves. CONCLUSIONS: Knowledge of preoperative erectile function and patient age before the operation and the degree of neurovascular bundle preservation afterward may aid in patient counseling regarding potency recovery after radical prostatectomy.     

Erectile dysfunction following treatment of prostate cancer: new insights and therapeutic options

Prostate cancer remains the most common cancer in adult men. Its treatment usually results in compromised or absent erectile function. This article will review the treatment options available to resume sexual activity following prostate cancer therapy and will focus on non-surgical treatment options. In addition, intracavernosal injection therapy has been shown to enhance recovery of spontaneous, unassisted erections when started shortly after nerve-sparing radical prostatectomy. Most recently, oral treatment with sildenafil citrate begun shortly after surgery was shown in a placebo-controlled trial to encourage return of normal erections. Presumably this occurs by promoting nocturnal erections which appear to prevent the permanent neurovascular damage to the penis following radical prostate surgery.     

Erectile dysfunction after surgical treatment

Erectile dysfunction is a recognized complication of prostate and bladder radical surgery, although there is significant variation in the reported risk, much of this variability is related to the retrospective nature of most previous studies. Undoubtedly, the quality of life of bladder and prostate cancer patients would be much improved if both normal micturition and potency are preserved, which is the subject of this article. Quality of life studies can delineate sexual function after radical prostatectomy, including the use of sexual aids. Penile erection is a neurovascular event modulated by neurotransmitters and hormonal status. The penis is innervated by autonomic and somatic nerves. Both surgery and radiation therapy appear to affect such a mechanism. Radiation is thought to produce Erectile Dysfunction (ED) by accelerating microvascular angiopathy causing cavernosal fibrosis or stenosis of the pelvic arteries and by accelerating existing arteriosclerosis, leading to vascular impotence. Years may elapse before clinically significant ED occurs. Criteria that influence recovery of erections after surgery include younger patient age, stronger erections before operation, preservation of the neurovascular bundles, and attention to fine details in the surgical technique. Recovery of erections occurs in 68% of preoperatively potent men treated with bilateral nerve-sparing surgery and in 47% of those treated with unilateral nerve-sparing surgery.     

Interposition of sural nerve restores function of cavernous nerves resected during radical prostatectomy

PURPOSE: The permanent loss of erectile function when both neurovascular bundles are widely resected at radical prostatectomy as well as the successful use of autologous nerve grafts in reconstructive surgery led us to perform bilateral nerve grafts in an effort to restore erectile function in potent patients treated for prostate cancer who underwent radical retropubic prostatectomy and resection of both neurovascular bundles. MATERIALS AND METHODS: Radical retropubic prostatectomy with deliberate resection of both neurovascular bundles was recommended for high grade, locally extensive prostate cancer in 9 select, sexually active men who reported normal erectile function. After the prostate was removed but before vesicourethral anastomosis an autologous sural nerve graft was interposed between the divided ends of the cavernous nerves bilaterally. Erectile function was monitored by patient interview, questionnaire and nocturnal penile tumescence testing after the operation. RESULTS: Four to 5 months postoperatively patients noticed slowly improving spontaneous erections, as manifested by mild tumescence regularly every several hours. Nocturnal penile tumescence testing with the RigiScan device at 4 to 6 months in 2 cases revealed erections that approached minimal criteria for normalcy. Approximately 14 months after surgery a rigid erection sufficient for penetration and intercourse developed in 1 patient. He described this event as "an erection of substance-hard, not just fluffy." CONCLUSIONS: We have developed a technique using sural nerve grafts to restore continuity of the cavernous nerves, which are resected during radical prostatectomy. The early return of spontaneous partial erections in our patients suggests that interposition nerve grafts may enhance the recovery of erectile function when the neurovascular bundles are resected.     

Prostatakarzinom und erektile Dysfunktion

The quality of life of patients after radical prostatectomy is mainly influenced by erectile dysfunction (ED) and incontinence. New criteria for treatment and patient selection give us the opportunity to restore sexual function in more patients.When ED is present, we should not wait for 24 months for natural restitution. PDE-5-inhibitors, intracavernosal self injection therapy and the vacuum constriction device are effective and conform to both patient and economic preference.Therefore, every urologists should be able to offer his patients an individual and successful approach to the therapy of ED after prostate cancer.     

Urinary continence and erectile function: a prospective evaluation of functional results after radical laparoscopic prostatectomy

OBJECTIVES: To evaluate prospectively functional results (urinary continence and erectile function) after laparoscopic radical prostatectomy. METHODS: From 1998 to 2001, 235 patients underwent laparoscopic radical prostatectomy for localized prostate cancer. All of them completed a confidential, self-administered questionnaire regarding urinary continence and erectile function before, and 1, 3, 6, and 12 months after surgery. Results were analyzed separately for day and night for urinary continence and status of neurovascular bundles as well as age for erectile function. RESULTS: To date, 100 consecutive patients have completed all questionnaires. Diurnal and nocturnal urinary continence have increased to 90% and 97% one year after surgery. Overall, 49.3% of the 77 patients, who were potent preoperatively, and did not receive any form of adjuvant therapy, had erections sufficient for intercourse one year after surgery. Potency rates were 38.4%, 53.8% and 58.8% after no, unilateral, and bilateral nerve bundle preservation, respectively. For younger patients (<60 years) with unilateral and bilateral neurovascular bundle preservation, potency rates were 75% and 83.3%, respectively. CONCLUSION: One year after laparoscopic radical prostatectomy, urinary continence rate is 90% during the day and 97% during the night. Overall potency rates after bilateral preservation of neurovascular bundles are 58.8% and 83.8% for the subgroup of younger patients (<60 years).     

Testosterone and erectile dysfunction

Aging is associated with a decline in several important health factors in men, including libido. Serum testosterone concentrations also decrease with age, and many age-related clinical features are closely associated with androgen deficiency, including erectile function (ED). Approximately 70% of ED is of organic origin, with the major risk factors being diabetes mellitus, hypercholesterolemia, smoking and chronic medical illnesses. These are also established risk factors for atherosclerosis, which is the predominant predisposing factor of vasculogenic ED. The introduction of phosphodiasterase-5 (PDE-5) inhibitors for the treatment of ED made a significant impact both in terms of clinical efficacy, and increasing the awareness of the condition. In spite of this, some patients fail to respond to PDE-5 inhibitors alone. Both animal and clinical studies indicate that testosterone therapy improves both erectile function and the response to PDE-5 inhibitors in patients with ED and hypogonadism. Indeed, interventional studies demonstrate that testosterone replacement therapy improves erectile function in hypogonadal men who have previously failed to respond to PDE-5 inhibitors alone. Furthermore, it has been demonstrated that the full therapeutic potential of PDE5 inhibitors will only become manifest in a eugonadal state. Recent studies have demonstrated a close relationship between testosterone and ED and suggest that testosterone therapy may be a valuable option for an increasing number of affected men. European guidelines recommend that all men presenting with ED should have their testosterone concentrations measured.     

Bilateral nerve grafting during radical retropubic prostatectomy: extended follow-up

Objectives. To confirm the benefit of using an interposition sural nerve graft at the time of radical retropubic prostatectomy in an extended series of men with at least 1 year of follow-up. We previously reported the return of erectile function after resection of both cavernous nerves.Methods. Twenty-eight potent men with clinically localized prostate cancer underwent radical retropubic prostatectomy with deliberate wide bilateral neurovascular bundle resection and the placement of bilateral nerve grafts. Erectile dysfunction questionnaires and patient interviews were completed at 6-month intervals. A minimum of 12 months of follow-up (mean 23 ± 10 months) was obtained for 23 men (mean age 58 ± 6 years). A control group of 12 men who underwent bilateral nerve resections, but declined nerve graft placement, was also followed up.Results. Of the 23 men, 6 (26%) had spontaneous, medically unassisted erections sufficient for sexual intercourse with vaginal penetration. An additional 6 men (26%) described “40% to 60%” spontaneous erections (fullness, no rigidity, not able to penetrate). Ten men (43%) had intercourse with sildenafil. No demonstrable erections occurred before 5 months postoperatively. The greatest return of function thus far was observed at 18 months after surgery.Conclusions. This surgical technique continues to show promise as an advance in prostate cancer surgery. The results of this study demonstrated recovery of erectile function in men who underwent bilateral nerve graft placement during radical retropubic prostatectomy when both cavernous nerves were deliberately resected.     

Update on erectile dysfunction in prostate cancer patients

PURPOSE OF REVIEW: Evolution in the management of prostate cancer includes increased attention being paid to patient quality of life after treatment, specifically with issues related to sexual function. Erectile dysfunction is one of the major concerns of patients undergoing treatment for prostate cancer. There are several recognized factors that determine the postoperative incidence of erectile difficulties, including patient age, degree of cavernosal nerve sparing during surgery, cancer stage, and associated vascular comorbidities. Early initiation of rehabilitation protocols after radical prostatectomy has been advocated to promote the speed and degree of recovery of erectile function. The aim of this communication is to review recent initiatives in erectile dysfunction restoration after prostate cancer therapy. RECENT FINDINGS: In recognition of the neurogenic basis of erectile dysfunction after radical prostatectomy, new strategies have been devised to initiate the rehabilitation process. Type 5 phosphodiesterase inhibitors, vacuum erection devices, and intracavernosal and intraurethral application of vasoactive agents have all been reported in a positive light in recent studies. Developments in cavernous nerve graft interposition procedures, perioperative neuroprotection measures, and postoperative neurotrophic treatments aim to preserve prostate cancer patients' qualities of life. SUMMARY: Data generated from a number of clinical investigations document that pharmacologic rehabilitation programs provide a higher rate of recovery of erectile function following radical prostatectomy. Both intracavernosal and intraurethral applications of vasoactive agents and vacuum devices can speed the recovery period for return of erectile function. Various neuroprotective and neurotrophic approaches are thought to provide integral roles for the maintenance of sexual function in men undergoing prostate cancer therapy.     

The role of testosterone replacement therapy following radical prostatectomy

Hypogonadism is highly prevalent in older men and men who have prostate cancer. The symptoms of hypogonadism, such as depression, decreased libido, erectile dysfunction, and decreased bone mineral density, can significantly impair a man's quality of life. Moreover, we know that testosterone plays an important role in erectile preservation and in the growth and function of cavernosal and penile nerves. There are compelling data to suggest that testosterone replacement therapy (TRT) in normal and high-risk men does not increase the risk for prostate cancer. In the few studies of men treated with TRT after a radical prostatectomy, there have been no biochemical recurrences. Based on these data, it is difficult to justify withholding TRT following a radical prostatectomy. If we do not lower the testosterone levels of eugonadal men after a radical prostatectomy, how can we justify not replacing testosterone levels in hypogonadal men to make them eugonadal following a radical prostatectomy?     

5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study

PURPOSE: Prior studies of postoperative outcomes following radical prostatectomy have been limited by selection bias and short-term followup. In this study we assessed temporal changes in urinary and sexual function up to 5 years following radical prostatectomy in a population based cohort. MATERIALS AND METHODS: A sample of 1,288 men with localized prostate cancer who underwent radical prostatectomy and completed a baseline survey within 6 to 12 months of diagnosis were included in the analysis. Two and 5-year functional and quality of life data were collected, as was information on the use of erectile aids. Temporal functional changes and potentially confounding or modifying factors were assessed using longitudinal regression models. RESULTS: Of these men 14% reported frequent urinary leakage or no urinary control 60 months after diagnosis, which was slightly higher than the 10% reporting incontinence at 24 months (p = 0.007). At 60 months 28% of the men had erections firm enough for intercourse compared with 22% at 24 months (p = 0.003). Sildenafil was the most commonly used erectile aid (43% ever used) and 45% of users reported that it helped "somewhat" or "a lot." CONCLUSIONS: Urinary and sexual dysfunction were common 5 years following radical prostatectomy in this large, community based cohort of prostate cancer survivors. While a small minority of subjects experienced changes in urinary or sexual function between years 2 and 5 after prostatectomy, functional outcomes remained relatively stable in the majority of participants.     

Nervenerhaltende radikale Prostatektomie mit niedrig dosiertem Sildenafil

Objective

The purpose of this study was to evaluate the effect of low-dose sildenafil (25 mg) for rehabilitation of erectile function after nerve-sparing radical prostatectomy.

Patients and methods

In a prospective study, 43 sexually active patients underwent nerve-sparing retropubic radical prostatectomy. Rigiscan® measurement of nocturnal penile tumescence and rigidity (NPTR) was carried out 7–14 days after surgery. A group of 23 patients with preserved nocturnal erections received sildenafil 25 mg/day at night to support recovery of erectile function. A control group of 18 patients underwent follow-up without PDE-5 inhibitors. Evaluation using the IIEF-5 questionnaire was performed 6, 12, 24, 36, 52 and 78 weeks after the operation.

Results

Of 43 patients, 41 (95%) showed 1–5 erections during the first night after catheter removal. In the group receiving daily sildenafil, the mean IIEF-5 score decreased or increased from 20.8 preoperatively to 3.6 at 6 weeks, 3.8 at 12 weeks, 5.9 at 24 weeks, 9.6 at 36 weeks, 14.1 at 52 weeks and 19.3 at 78 weeks after prostatectomy. In the control group, the mean preoperative IIEF-5 score of 21.2 decreased or increased to 2.4 at 6 weeks, 3.8 at 12 weeks, 5.3 at 24 weeks, 6.4 at 36 weeks, 9.3 at 52 weeks and 13.2 at 78 weeks. Statistical evaluation showed significant differences regarding the IIEF-5 score and recovery period of erectile function between the groups (p<0.001), with potency rates of 92 vs 68%.

Conclusion

The measurement of NPTR after nerve-sparing radical prostatectomy showed erectile function as early as the first night after catheter removal. In cases of early penile erections, daily low-dose PDE-5 inhibitors lead to a significant improvement/acceleration of erectile function recovery.     

Efficacy of unilateral nerve sparing in radical perineal prostatectomy

AIM: We determine the efficacy of unilateral nerve-sparing radical perineal prostatectomy in preserving the sexual function. PATIENTS AND METHODS: Ninety-two patients with histologically confirmed unilateral prostate cancer were scheduled for contralateral nerve preservation. The perioperative morbidity was assessed using the patients' chart reviews. Postoperative health-related quality of life, urinary continence, and potency were evaluated prospectively with questionnaires provided before surgery and then after 6, 12, and 24 months. RESULTS: Unilateral nerve preservation was performed in 88 of the 92 patients. Due to extensive scarring or prostatic size, the procedure was terminated as regular radical prostatectomy in 4 other patients. The perioperative complication rate was low and of minor significance, except in 1 patient who experienced a significant myoglobulinuria due to a prolonged procedure. Blood transfusions were necessary in 5 (5.4%) patients. Ureteral reimplantation was performed in 1 patient because of ureteral stricture. Positive surgical margins were present in 12 (18%) of 67 pT2 patients and in 8 (35%) of 23 pT3 patients. A proportion of 48% (15/31) of the patients followed for more than 24 months and who had a good erectile function prior to surgery reported unassisted sexual intercourse. However, only 4 of these patients were completely satisfied with all aspects of sexual performance, as asked in a short version of the International Index of Erectile Function questionnaire. CONCLUSIONS: Unilateral nerve-sparing radical perineal prostatectomy is technically feasible and yields excellent results in terms of potency preservation for prostates <60 ml. However, the quality of erections is decreased, even in patients with erections sufficient for intercourse. Hence, appropriate sexual counseling in conjunction with medical therapy should be offered to all patients.     

The 5-year functional outcomes after radical prostatectomy： a real-life experience in Korea

We investigated the functional outcomes regarding erectile function and urinary continence up to 5 years following radical prostatectomy （RP） in a cohort of Korean men. We retrospectively analyzed the clinicopathologic data of 85 Korean men who received open uni- or bilateral nerve-sparing RP for clinically localized prostate cancer and were followed up for at least 5 years postoperatively. From medical records, patients＇ status regarding urinary and erectile function at baseline and postoperative followups after RP was assessed. At 24 and 60 months after RP, proportions of subjects continent （no pads used） were 89.4% and 97.6%, respectively （P = 0.007）. Excluding subjects （n = 24） who preoperatively reported having severe erectile dysfunction or lacked relevant informations, proportions of subjects capable of having vaginal intercourse regardless of erectile aid usage were 47.5% and 37.7% at 24 and 60 months from RP, respectively （P = 0.022）. Patient＇s age at surgery （P = 0.047） and salvage radiation therapy （P = 0.026） were observed to be significant predictors of having erections sufficient for intercourse at 60 months from RP in multivariate analysis. Our results showed that while patients＇ postoperative status regarding urinary continence at 2 years from RP is generally maintained or improved at 5 year point, erectile function was observed to significantly declined from 2 years to 5 years following RP. Such decline in erectile function following RP may be more significant among men who were relatively older at surgery or those who received salvage therapy during postoperative follow-ups.     

Incidence rate of prostate cancer in men treated for erectile dysfunction with phosphodiesterase type 5 inhibitors: retrospective analysis

The purpose of this study was to determine the incidence rate of prostate cancer among men with erectile dysfunction (ED) treated with phosphodiesterase type 5 inhibitors (PDE-5i) over a 7-year period vs. men with ED of the same age and with similar risk factors who were not treated with PDE-5i. In a retrospective review of electronic medical records and billing databases between the years 2000 and 2006, men with ED between the ages of 50 and 69 years and no history of prostate cancer prior to 2000 were identified. These individuals were divided into two groups: 2362 men who had treatment with PDE-5i, and 2612 men who did not have treatment. Demographic data in each group were compared. During the study period, 97 (4.1%) men with ED treated with PDE-5i were diagnosed with prostate cancer compared with 258 (9.9%) men with ED in the non-treated group (P<00001). A higher percentage of African Americans were treated with PDE-5i vs. those who were not (10.5% vs. 7.1% P<0.0001). The PDE-5i group had lower documented diagnosis of elevated prostate-specific antigen (10.0% vs. 13.1% P=0.0008) and higher percentage of benign prostatic hyperplasia (38.4% vs. 35.1% P=0.0149). Men with ED treated with PDE-5i tended to have less chance (adjusted odds ratio: 0.4; 95% confidence intervals: 0.3–0.5; P<0.0001) of having prostate cancer. Our data suggest that men with ED treated with PDE-5i tended to have less of a chance of being diagnosed with prostate cancer. Further research is warranted.     

机器人辅助腹腔镜前列腺癌根治术后性功能恢复的研究进展

前列腺癌(Prostate cancer,PCa)现已成为老年男性常见的恶性肿瘤之一,严重威胁老年男性的生命健康。目前,前列腺癌根治术(Radical prostatectomy,RP)仍为局部前列腺癌的主要治疗手段。因受手术创伤及围手术期等因素影响,术后往往会出现明显的性功能障碍,主要表现为患者勃起功能障碍(Erectile dysfunction,ED),导致患者生活质量下降。近年来,机器人辅助腹腔镜前列腺癌根治术(Robot-assisted laparoscopic radical prostatectomy,RALP)在前列腺癌根治方面成效显著,不但降低了患者术后肿瘤复发率且术后性功能恢复明显。本文就机器人辅助腹腔镜前列腺癌根治术后性功能恢复做一综述,为前列腺癌患者术后性功能的恢复带来新的诊疗思路。     

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate erectile dysfunction (ED), 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.     

Effects of testosterone on erectile function: implications for the therapy of erectile dysfunction

Sexual potency declines with age, as does the efficiency of erection. Many studies show that different patterns of erectile dysfunction (ED), varying from occasional inability to obtain a full erection, impairment throughout intercourse and total absence of erectile response, might not be triggered by psychological factors only. Recent research indicates that ED relies on organic causes, and has challenged the development of new therapies. One therapeutic approach in patients who have testosterone deficiency is based on androgen therapy. Thus, we reviewed data on testosterone-induced effects relative to erectile function, summarizing the results from studies reported in 1991-2006 on testosterone therapy in patients with ED and hypogonadism, with a special focus on men not responding to phosphodiesterase-5 (PDE-5) inhibitors. We searched several computerized databases parallel with printed bibliographic references. Many studies have established animal models, which confirm that testosterone is important in modulating the central and peripheral regulation of ED. Testosterone deprivation has a strong negative impact on the structure of penile tissues and erectile nerves, which can be prevented by androgen administration. Combined therapy regimens with PDE-5 inhibitors and testosterone might improve ED in patients with hypogonadism of different causes. Thus, androgen treatment in hypogonadic patients, including those unresponsive to PDE-5 inhibitors, often results in an improvement of ED. Testosterone therapy is safe and convenient, while rapidly correcting low testosterone levels.