PS 20. Post prostatectomy erectile optimization
The concept of Penile Rehabilitation following radical prostatectomy is neither new, complicated or untested. It is however highly controversial, extensively studied and as of the present time unproven. In fact there exists no definitive long term multicenter double blinded trial which identifies the best approach, agent, patient or methodology to achieve optimal outcomes in this population. It is precisely that information gap and the high incidence of this side effect that drives research into this area. Before reviewing the actual animal and human data targeting potential strategies to enhance post pelvic surgical potency preservation, one must evaluate the impact of surgery in the pelvis on erectile mechanisms.
Consensus based on clinical experience and animal model studies strongly support the idea that a variety of injuries occur to men undergoing pelvic surgery and particularly prostatectomy, independent of whether it is laparoscopic, robotic or open. The predominate injury contributing to erectile dysfunction is believed to be neural in origin with smaller impacts being played by vascular and psychological factors. While the precise timing and extent of the injury can be highly variable, host biological factors likely also play an important role in determining final erectile function.
Complete agreement on the physiologic effects of thermal, percussive and traction injuries has not yet been reached, however varied traumatic injuries to the cavernous nerves and vasculature typically occur during the surgical procedure and may continue to propagate for several weeks. The lack of neural signalling is felt to result in loss of cavernous smooth muscle which manifests in most individuals as permanent erectile dysfunction.
Post-operative strategies aimed at preserving the cavernous muscle, coupled to intra-operative approaches which minimize neural and vascular injury are thought to result in optimal outcomes. These preservation strategies will be highlighted during the talk and include use of phosphodiesterase inhibitors, penile traction devices, intracavernous injections, sexual counselling and other supportive measures.
