Erectile Function in Men Following Radical Prostatectomy for High-Risk Prostate Cancer

Recovery of Baseline Erectile Function in Men Following Radical Prostatectomy for High-Risk Prostate Cancer: A Prospective Analysis Using Validated Measures

Ashwin N. Sridhar, MBBS, MRCS, MS; Paul J. Cathcart, MD, FRCS; Tet Yap, MD, FRCS; John Hines, FRCS; Senthil Nathan, MS, FRCS, FEBU; Timothy P. Briggs, FRCS; John D. Kelly, MD, FRCS; Suks Minhas, MD, FRCS

ONLINE: March 2016 – The Journal of Sexual Medicine

DOI: 10.1016/j.jsxm.2016.01.005


While radical prostatectomy (RP) can be a successful treatment for prostate cancer, many men develop erectile dysfunction (ED) as a result. Neurovascular bundle preservation (NBP) can reduce the likelihood of ED, but research on this procedure has largely focused on men with low- to intermediate-risk prostate cancer, not high-risk disease.

About 20% to 30% of men with localized prostate cancer are in the high-risk category.

Because of safety concerns, few men with high-risk prostate cancer (HRPC) are offered NBP surgery.

This study aimed to determine how well the erectile function of men with HRPC returned to baseline after undergoing robotic radical prostatectomy (RRP). It also considered the factors affecting erectile function after RRP in this population and offers recommendations for clinicians.


Five hundred thirty-one men with HRPC participated in the study. Their mean age was 64 years.

Using the International Index of Erectile Function (IIEF-5) Sexual Health Inventory for Men (SHIM) questionnaire, researchers assessed the men’s erectile function before surgery and again at 3-month, 6-month, 1-year, 2-year, 3-year, and 4-year points after surgery.

All of the men were offered the use of an oral phosphodiesterase type 5 (PDE5) inhibitor after RRP. If maximum doses of PDE5 inhibitors were not effective in improving erectile function after six months, the men had the option of choosing another PDE5 inhibitor or another therapy, such as self-injection, a vacuum pump, or urethral suppositories. If there was still no improvement, men were offered a penile prosthesis after patient counseling.


The researchers found the following:

• Four hundred twenty-three patients completed questionnaires before and after surgery and had 18 months of follow-up data. Analyses are based on results from these men.

• Overall, erectile function returned to baseline levels for 23.5% of the men after 18 months, based on IIEF-5 scores. This rate included men who used aids such as PDE5 inhibitors.

• Of all the men, 9.6% underwent bilateral NBP, 25.4% underwent unilateral NBP and 65.1% underwent non-NBP surgery. NBP was associated with greater chances of a return of baseline function: 69.4% of men in the bilateral group and 43% of men in the unilateral group saw their erectile function go back to baseline levels. 

• Only 4% of the men who underwent non-NBP RRP saw their erectile function return to baseline within three years. Ninety-six percent of the men did not get back to baseline levels, even if they used a PDE5 inhibitor.

• Men who were younger than age 60, had NBP surgery, and had normal erectile function before surgery had better chances of improvement.

• Men who had bilateral NBP had “a higher probability” of recovering their baseline erectile function within 6 to 18 months.

• Men who had unilateral NBP can “probably recover” their baseline erectile function within 24 months of surgery.

• About 72% of the men opted to use PDE5 inhibitors. Approximately 13% went on to second line therapies (vacuum pump or self-injections) and 3.3% received penile prostheses after 18 months. Men who chose second- and third-line therapies saw improvements in their erectile function.

Given the relative low rate of return to baseline function in men with HRPC, particularly among those who undergo non-NBP RRP, the study authors recommended that second- or third-line therapies be considered early, especially if erectile function is a priority. They added that in this study, only 3.5% of the men chose to have a penile implant, a figure they called “surprisingly low.”