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Grand Rounds | Clinician's Corner

Erectile Dysfunction Following Radical Prostatectomy

Arthur L. Burnett, MD
JAMA. 2005;293(21):2648-2653. doi:10.1001/jama.293.21.2648.
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Erectile dysfunction following radical prostatectomy for clinically localized prostate cancer is a known potential complication of the surgery. Because prostate cancer is diagnosed today more frequently than in the past and because the diagnosis is made in increasingly younger men, there is an urgent need to develop effective interventions that preserve erectile function after surgery. In this presentation, a 51-year-old man with adenocarcinoma of the prostate underwent a bilateral nerve-sparing radical prostatectomy, after which he lost natural erectile function for approximately 9 months. The case highlights the fact that following surgery in which the nerve-sparing radical prostatectomy technique is used, between 60% to 85% of men eventually recover erectile function. This constitutes a dramatic improvement over an earlier era, when postprostatectomy erectile dysfunction was the nearly universal rule. The case also emphasizes that despite expert application of the nerve-sparing prostatectomy technique, early recovery of natural erectile function is uncommon. Many patients experience erectile dysfunction for as long as 2 years after the procedure, requiring the use of erectile aids for sexual activity during this period until natural erections recover. Corrective, cause-specific advances such as neuromodulatory therapy offer valuable adjuncts to this surgery.

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Figure. Schematic of the Cavernous Nerves and Their Preservation During Radical Prostatectomy
Graphic Jump Location

A, Lateral view of the male pelvis illustrating the course and distribution of the left cavernous nerve fiber, as part of the left neurovascular bundle within intrapelvic fascia coverings. The cavernous nerve travels from the pelvic plexus proximally to the penis distally, in close anatomical relationship to the seminal vesicle, prostate, striated urethral sphincter, bladder, and rectum. B, Anterosuperior oblique view of the same anatomical structures. C, Anterosuperior oblique view illustrating preservation of the cavernous nerves after bilateral nerve-sparing prostatectomy and bladder neck anastomosis to the urethral stump. The cavernous nerve fibers are preserved by division and clipping of small prostatic nerves alongside the prostate. When non–nerve-sparing surgery is required for cancer eradication either unilaterally or bilaterally, wide excision of periprostatic soft tissue includes the cavernous nerves en bloc with the removed surgical specimen.

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