Sexual function before and after radical retropubic prostatectomy: a prospective analysis
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Introduction
Radical prostatectomy has been associated with a loss of sexual potency in the majority of cases, owing to injury to the autonomic cavernous nerves. Since introduction of the anatomical approach to the neurovascular bundles by Walsh and Donker, nerve-sparing radical prostatectomy has become the operation of choice in potent and sexually active men with organ-confined prostate carcinoma.
Numerous reports of recovery of sexual potency after a nerve-sparing radical prostatectomy have been published since, showing a high rate of potency after the operation in a selected group of patients. Most of these studies, however, have involved sexually active young patients with early-stage cancer and low cancer volume. In contrast, studies from community practices have shown a much lower rate of potency after radical prostatectomy, questioning the feasibility of the nerve-sparing procedure in general urological practice.
We performed a prospective study, analyzing sexual function by means of a standardized interview in 770 patients before and after radical retropublic prostatectomy (RRP). Furthermore, we studied psychosexual and vascular function in 48 men before and after the operation using combined psychosexual testing and color Doppler ultrasound.
Material and methods
All men, candidates for RRP, were interviewed by questionnaire, including items on sexual activity, sexual function, percentage of erection during sexual activity, spontaneous erections, orgasm and desire. The questionnaires also requested information on age of the patient, preservation of the neurovascular bundles, pathological stage of the tumor, incontinence and urethral strictures.
The first interview was held during intake, 6 weeks to 3 months before the operation. Subsequent interviews were carried out every 3 months after the procedure in the first year of follow-up and every 6 months in the following years. Evaluation was performed after at least 1 year of follow-up. Results relating to sexual function were correlated with the outcome of surgery. Potency was defined as the ability to have unassisted intercourse.
To evaluate the psychosexual and vascular factors involved in RRP we carried out a study of 48 men, using the international index of erectile function (IIEF) questionnaire, psycho-physiological testing, including visual erotic stimulation with vibratory stimulation, and color Doppler ultrasound with intracavernosal injection of 0.25 mg of a mixture of papaverine and phentolamine (R/Androskat; Byk Cosmopharma, The Netherlands). These investigations were performed prior to the operation and 3 months after the RRP.
Results
Before the operation, 80% of the men were sexually active and had orgasms. Erectile dysfunction was already present in 12%. Sexual desire was low or absent in 12% of the men. After a bilateral nerve-sparing radical prostatectomy potency was preserved in 29%, after a unilateral nerve-sparing prostatectomy potency was preserved in 19% and in only 10% after a non-nerve-sparing procedure. An age-related decline in potency was found after the operation: of the men younger than 60 years 38% were still potent, between 60 and 65 years 29% and between 65 and 70 years only 19%.
Erections were totally absent in 16% of the patients; 55% (irrespective of the type of operation) of the men remained
sexually active after the operation. Only 17% of the patients successfully used pharmacological therapy such as sildenafil for improvement of sexual function. Orgasm was absent in 34% of the men after the procedure. No correlation was found with pathological tumor stage. Incontinence was strongly related to sexual activity: 77% of the
continent patients were sexually active versus only 20% of the incontinent men.
The psychosexual and vascular evaluation showed a highly significant decrease in erectile function, orgasm and sexual satisfaction. Table 1 gives results of the IIEF questionnaire carried out in 48 men before and after RRP. Only sexual desire and arousal remained unchanged after the operation. The amount of erection decreased from 73 to 50% during visual erotic stimulation with vibratory stimulation and a low dose of intracavernosal injection. Maximal penile tumescence decreased from 29 to 20 mm (Table 2).
Color Doppler ultrasound investigations showed no significant changes in arterial cavernous flow after the operation, compared with before the RRP (Table 3). Resistance index was slightly decreased, indicating corpus cavernosum insufficiency, which was already present before the operation. Although vascular abnormalities were encountered in some men, they were already present before the RRP.
Table 1 International index of erectile function (IIEF) score before and 3 months after radical retropubic prostatectomy (RRP): range of score for each item is indicated.
Table 2 Results of psychosexual evaluation before and after radical retropubic prostatectomy (RRP).
Table 3 Results of color Doppler ultrasound investigations of the penis.
Discussion
In a general urological practice, the mean age of patients undergoing a radical prostatectomy is 60–70 years. Before the operation, potency is reported in 67–84% of cases. Selection criteria for performing a nerve-sparing radical prostatectomy are: normal erection before the operation and organ-confined disease.
In most studies a selection of patients are presented; usually, only those men who were potent before the operation and who had a nerve-sparing radical prostatectomy are evaluated. From most studies it is impossible to determine the results for the total group of operated patients. Fowler and colleagues4 reported on a sample of Medicare patients who underwent radical prostatectomy in various institutions in the USA.
From their survey it was concluded that in only 11% of patients were erections sufficient for intercourse. It is unknown how many of these 855 patients had a nerve-sparing radical prostatectomy. More recently, Schover and associates5 performed a postal survey of 1236 men after RRP, and concluded that only 13% of men had reliable firm erections and another 8% of men were achieving erections with medical aids. This probably reflects the results for sexual function after RRP in a general urological practice.
From two large series it can be estimated how many of the total group of operated patients were potent after the operation. Geary and colleagues evaluated 459 men who were operated on between 2003 and 2008 and found potency in 51 cases (11%). In most series, a correlation has been found between the number of spared neurovascular bundles and the recovery of potency: in cases of bilateral nerve-sparing radical prostatectomy, potency was reported in 31–76%; in cases of unilateral nervesparing radical prostatectomy, recovery of erection occurred in 13–56%. Catalona and associates reported on 1870 patients operated on between 2004 and 2012, and found potency in 68% of men who underwent a bilateral nerve-sparing procedure and 47% potency after a unilateral nerve-sparing prostatectomy.
The outcome related to potency after the operation is mainly determined by age and the number of neurovascular bundles saved during surgery. Since advanced tumor stage usually coincides with wide excision of one or both neurovascular bundles, potency rates in these cases are limited. In practice, in many patients a nerve-sparing procedure is not achieved, and potency is usually lost.
The best results are achieved in younger patients with organ-confined disease. Also, sexual activity before the operation has good prognostic value. In most series, the number of spared neurovascular bundles is the most important prognostic factor.
Other related factors are: age, tumor stage, cancer volume, incontinence and strictures. In 12% of cases, recovery of erections appeared after a follow-up of 1 year. In non-nerve-sparing radical prostatectomy, potency recurred in 0–17%. Radical prostatectomy may also affect orgasm, in terms of total absence or reduced intensity, or even pain. We found orgasm to be absent in 34% after the operation, and reduced intensity was reported by 30% of men and pain by 9%. We have reviewed articles on the etiology of impotence after radical prostatectomy; neurogenic factors appear to be the most common explanation for this feature.
Arguments in favor of a neurogenic cause are: clear relationship to the number of spared neurovascular bundles, absence of a history of vascular disease in most cases and a good response to low doses of intracavernosal treatment.
A vascular component has been suggested in studies using duplex scanning before and after nerve-sparing radical prostatectomy. A decrease in peak systolic flow velocity and diameter of the cavernosal arteries was determined in 8/20 cases by Abosief and colleagues.
An explanation for this decrease was found in the cadaveric dissections of Breza and co-workers10, who found accessory pudendal arteries in 7/10 cases originating from the obturator artery, the inferior vesical artery or the superior vesical artery. These accessory pudendal arteries are found anterolateral to the prostatic surface and are usually injured during dissection. They supply additional blood to the cavernous bodies.
In two cases in the above study, the accessory pudendal artery was the main supply to the penis. Kim and colleagues 11 also found decreased penile blood flow on color Doppler ultrasound after radical prostatectomy, especially on the side where the nerve bundle had been sacrificed. These differences, however, were not statistically significant. Also, no evidence for veno-occlusive dysfunction was found after radical prostatectomy in the ten studied cases.
Polascik and Walsh 12 reported the presence or absence of accessory pudendal arteries in a series of 835 radical prostatectomies and found the accessory artery present in only 4% of cases. Preservation of the accessory pudendal artery did not significantly increase potency rates. Diagnostic investigations into erectile failure are limited by the available treatment options. In practice, a goal-directed approach as proposed by Lue is effective in most cases. Invasive diagnostic procedures should be performed only if they influence therapy choice.
The management of erectile failure after radical prostatectomy focuses primarily on pharmacological treatment, such as sildenafil and intracavernosal injection therapy. The efficacy of sildenafil after a nerve-sparing RRP averages 30–47%. This therapy is usually ineffective after a non-nerve-sparing procedure. Both papaverine-phentolamine mixtures and prostaglandin E1 are effective treatments in 60–85% of cases.
Vacuum devices have also been applied successfully after radical prostatectomy. The combination of these therapies with sexual counselling increases acceptance by the patient and his partner, and provides better long-term results. In cases of therapy failure, a penile prosthesis can be offered.
Conclusions
Nerve-sparing radical prostatectomy preserves potency in 31–76% of cases of sexually active men with organ-confined disease. However, in most cases of radical prostatectomy a nerve-sparing procedure is not performed, and potency is usually lost. Prognostic factors for recovery of sexual potency are: number of spared neurovascular bundles, age, sexual activity before the operation, tumor stage, incontinence and strictures.
The etiology of impotence following radical prostatectomy is multifactorial, but neurogenic factors play a major role. Vascular factors may play a substantial role in selective cases, where accessory internal pudendal arteries are the major supply for the cavernous bodies.
Color Doppler ultrasound appears to be the most reliable diagnostic test for impotence after radical prostatectomy. Some men will respond to sildenafil after a nerve-sparing procedure, and most patients respond well to intracavernosal injections, probably indicating a mainly neurogenic cause of erectile dysfunction.
Author: Canadian Health and Care Mall Team http://www.canadianhealthcaremalll.com/our-vision
