Non-surgically Related Causes of Erectile Dysfunction After Bilateral Nerve-sparing Radical Prostatectomy

G Gandaglia; G Lista; N Fossati; N Suardi; A Gallina; M Moschini; L Bianchi; MS Rossi; R Schiavina; SF Shariat; A Salonia; F Montorsi; A Briganti


Prostate Cancer Prostatic Dis. 2016;19(2):185-190. 

In This Article

Abstract and Introduction


Background: Erectile dysfunction (ED) represents one of the most common long-term side effects in prostate cancer (PCa) patients treated with bilateral nerve-sparing radical prostatectomy (BNSRP). The aim of our study was to assess the influence of non-surgically related causes of ED in patients treated with BNSRP.

Methods: Overall, 716 patients treated with BNSRP were retrospectively identified. All patients had complete data on erectile function (EF) assessed by the Index of Erectile Function-EF domain (IIEF-EF) and depressive status assessed by the Center for Epidemiologic Studies-Depression (CES-D) questionnaire. EF recovery was defined as an IIEF-EF of ≥22. Kaplan–Meier analyses assessed the impact of preoperative IIEF-EF, depression and adjuvant radiotherapy (aRT) on the time to EF recovery. Multivariable Cox regression models were used to test the impact of aRT on EF recovery after accounting for depression and baseline IIEF-EF.

Results: Median follow-up was 48 months. Patients with a preoperative IIEF-EF of ≥22 had substantially higher EF recovery rates compared with those with a lower IIEF-EF (P<0.001). Patients with a CES-D of <16 had significantly higher EF recovery rates compared to those with depression (60.8 vs 49.2%; P=0.03). Patients receiving postoperative aRT had lower rates of EF compared with their counterparts left untreated after surgery (40.7 vs 59.8%; P<0.001). These results were confirmed in multivariable analyses, where preoperative IIEF-EF (P<0.001), depression (P=0.04) and aRT (P=0.03) were confirmed as significant predictors of EF recovery.

Conclusions: Preoperative functional status and depression should be considered when counseling PCa patients regarding the long-term side effects of BNSRP. Moreover, the administration of aRT has a detrimental effect on the probability of recovering EF after BNSRP. This should be taken into account when balancing the potential benefits and side effects of multimodal therapies in PCa patients.


The main goal of radical prostatectomy (RP) in patients with clinically localized prostate cancer (PCa) is to obtain optimal long-term cancer control without functional impairments.[1] This is particularly true when considering the increasing proportion of young patients diagnosed with localized disease.[1–3] Erectile dysfunction (ED) represents one of the most common sequelae after RP in PCa patients.[2,4] Of note, this side effect significantly affects health-related quality of life.[4,5] The rates of ED after surgery vary between 10 and 70%.[2,6–8] This is mainly related to differences in the surgical approach, ED definition, as well as preoperative patient characteristics and rehabilitation protocols.[9] Particularly, the concept of an anatomic bilateral nerve-sparing RP introduced by Walsh almost 35 years ago revolutionized PCa treatment.[10] The authors demonstrated that the preservation of neurovascular bundles was associated with acceptable functional outcomes. Nonetheless, postoperative erectile function (EF) recovery after RP nowadays remains a challenge for the urologist and a certain proportion of patients experience ED even in the presence of a meticulously performed sparing RP (BNSRP).[7,8] This applies also to patients treated with minimally invasive surgery, where the adoption of robot-assisted approaches might result into better outcomes in terms of EF recovery.[7,8] We hypothesized that non-surgically related aspects may affect the optimal recovery of EF after surgery. In particular, both preoperative status (that is, depression and preoperative EF) and the administration of postoperative treatments such as adjuvant radiotherapy (aRT) might have a significant impact on the probability of recovering EF after surgery.