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It is universally understood that the radical prostatectomy (RP) patient who has immediate return to baseline erectile function is a very rare case. The need to wear a catheter for several days to 2 weeks is itself a deterrent to having an erection. Even men who undergo nerve sparing robot-assisted laparoscopic RP can expect a best-case scenario of an erection sufficient for intercourse in less than a month. The more common range for post-RP ED is 6-18 months, with or without the assistance of oral medication, injections or a vacuum erection device. And sadly, some men never regain spontaneous or natural erections.
ED is commonly known because it occurs, even if briefly, after the majority of operations. It happens because the neurovascular bundles that control erection literally adjoin the outer edges of the prostate capsule, so even careful surgeons who can spare the nerves means they still cause disruption as they tug and tease the delicate fibers away from physical contact with the gland. Nerves don’t like to be disturbed, and it may take them a while to regenerate their ability to transmit signals. Nonetheless, informed patients accept the risk of ED as a necessary trade-off for hoping to “get all the cancer out.”
What isn’t often talked about is the less common – but very real – sexual side effects of total gland removal. There is a considerable body of literature on sexually related side effects and the impact they can have on a man’s and his partner’s pleasure.
Aside from ED, published literature on post-prostatectomy identifies the following risks:
- Performance-related urinary incontinence (i.e. embarrassing leakage of urine during arousal or orgasm)
- Different experience of orgasm due to lack of ejaculate
- Inability to have an orgasm (This is usually more psychological than physical because the nerves that control orgasm are located in the spine and not directly affected by gland removal, and men can experience orgasm without a hard-on. However, a surgical trauma that makes orgasm impossible cannot be ruled out)
- Pain during orgasm
- Penile shortening or changed shape
- Peyronie’s disease (a curvature of the penis due to scar tissue in the penile connective tissue; though only about 26 out of 100,000 men are diagnosed with Peyronie’s, it appears more common in RP cases)
These treatment risks seem to happen less frequently than ED, but it is hard to pin down statistics because men may not report such conditions, and doctors might not think to ask. In fact, it may not even occur to patients before surgery that there are other components of their sexuality besides a hard-on which might be affected. There is some consolation in the knowledge that with time, medication, outpatient interventions and exercises to strengthen the Kegel/pelvic floor muscles, most of these effects improve or resolve altogether.
The issue here is that men are not even told about them beforehand, or asked about them afterward. Both the man and his partner should be informed about the potential need to adapt their intimacy practices after RP for some period of time, be it short or long.
The development of focal therapy such as the Sperling Prostate Center’s Focal Laser Ablation (FLA) was a response to the global recognition that prostate cancer is often an overtreated disease. As such, it has left countless men struggling with diminished quality of life and self-image, and often collateral damage to their sexual relationships. The appeal of FLA lies in the middle ground it offers between no treatment (Active Surveillance) and whole gland treatment (RP and radiotherapy) with its side effect risks. In our experience, there is close to zero risk of sexual and urinary harm thanks to the ability to see, track and confirm precise delivery of laser energy to ablate (destroy) the tumor.
Thus, not only do our patients avoid ED, but also the other side effects listed above while gaining verifiable control of their tumor without sacrificing future treatment options. For more information, contact the Sperling Prostate Center.
Copyright by Dan Serling, MD. Reprint permission courtesy of Sperling Prostate Center (New York, Florida), the leading U.S. center for multiparametric detection, diagnosis and image-guided focal treatment of prostate cancer.
Read more in our Prostate Cancer Health Center.
Fode M et al. Sexuality following radical prostatectomy: is restoration of erectile function enough? Sex Med Rev 2017 Jan; 5(1):110-19.