An interest of mine as a robotic surgeon treating prostate cancer is performing nerve sparing prostatectomy (removal of the prostate while preserving the nerves responsible for erectile function). This is perhaps the most difficult portion of the procedure. As described before, this is due to the fact that these nerves are not visible with the naked eye. Even with the magnification offered by robotic surgery, the nerves are only recognized best by the blood vessels that travel along side them.
When a patient presents to my office with a new diagnosis of prostate cancer, several factors must be discussed about the patient's disease to determine whether nerve sparing can be performed. Most often, it is possible, however. The amount of prostate cancer found on prostate biopsy (this is a procedure done to diagnose prostate cancer) and how aggressive the cancer cells appear under the microscope will be a consideration. If there is a large volume of a very aggressive cancer, the surgeon may counsel the patient on the fact that the nerves may not be able to be spared because of the risk of cancer that may be involving the nerves. The goal of the surgery, it must be remembered, is to cure the cancer.
All patients undergoing this type of surgery must be warned of the possibilities of erectile dysfunction. It must also be stressed that it takes time for the nerves to recover function after the operation. A patient cannot assume that they will be back to their sexual baseline a few weeks after surgery. In fact, research has shown that it can take up to TWO YEARS to fully recover erectile function. Most of the battle in dealing with this side effect is understanding the disease and not having false or unreasonable expectations.
There has been a recent body of research to support the use of phosphodiesterase inhibitors (ViagraTM, LevitraTM, and CialisTM) during the recovery period from prostatectomy. The medicines are prescribed to be taken on a regular basis (depending on the medication). The patient will be told not to expect an immediate erection, however. The use of these medications has been shown to hasten the return of nerve function (make it come back faster).
In general, the factors that best determine who will have the best chance of recovering their erectile function following prostatectomy are age, whether one or both nerves were spared, and how good the erections were before the operation. Studies have shown that the younger a patient is at the time of surgery, the better chance they have to recover function. It may be obvious as well that "two is better than one," or that there is "strength in numbers." This means that if both nerves are spared, the patient will have a better chance of recovery versus only one or none being spared. Finally, if erectile function is poor (2 out of 10 on a scale) before the operation, it will not improve and will have a good chance of worsening.