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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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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