Optimal strategy for penile rehabilitation after
robot-assisted radical prostatectomy based on
preoperative erectile function
Seref Basal*†, Chris Wambi*, Cengizhan Acikel†, Mantu Gupta* and
*Department of Urology, Columbia University Medical Center, New York, NY, USA, and†Department of Urology,
School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
What’s known on the subject? and What does the study add?
• Removing of prostate for the treatment of localized prostate cancer is associated with a variable loss of erectile function
due to injury of the nerves of erection during operation. Some researchers have reported that after nerve-sparing radical
prostatectomy (RP), the natural recovery time of erectile function is at least 2 years. Factors such as thermal damage,
ischaemic injury, mechanically induced nerve stretching and the local inflammatory effects of surgical trauma may also
impair the cavernous nerves during RP. The concept of penile rehabilitation was first studied by Montorsi et al. in 1997.
They showed that the use of any drug or device at or after RP could maximize the recovery of erectile function. Penile
rehabilitation programmes (PRPs) with vasoactive agents, such as oral phosphodiesterase-5 inhibitors (PDE5Is),
intraurethral and intracavernosal vasoactive agents, and vacuum erection devices (VEDs) can protect erectile tissue
integrity and prevent corporal smooth muscle atrophy and diminish collagen formation.
• The present findings are consistent with previous reports that PRPs have a significant beneficial effect on early erectile
function recovery and that preoperative erectile function is one of the important predictors of erectile function after RP.
Patients can be referred for penile rehabilitation if they have any degree of erectile function (mild, moderate or normal)
before operation.We also showed that the combination of PDE5Is and VEDs for PRPs offers the shortest erectile
function recovery period.
• To define the optimal penile rehabilitation programme
(PRP) based on preoperative Sexual Health Inventory for
Men (SHIM) scores after robot-assisted radical
Patients and Methods
• The medical records of 203 patients who underwent
bilateral nerve-sparing RARP between 2007 and
2011 were reviewed for the present retrospective
• According to patients’ preoperative erection status, group
1 (SHIM = 8–16), group 2 (SHIM = 17–21) and group 3
(SHIM = 22–25) were defined.
• After bilateral nerve-sparing RARP, phosphodiesterase-5
inhibitors (PDE5Is), a vacuum erection device (VED),
the combination of PDE5Is and a VED, or none
of them were utilized by all patients for penile
• Treatment success was defined as a rigid erection suitable
for successful sexual intercourse.
• The numbers of patients in groups 1, 2 and 3,
respectively, were 9, 22 and 73, and the mean
erectile function recovery periods (EFRPs) were
15.44 ? 7.73, 12.31 ? 8.12 and 8.73 ? 5.67 months
(P < 0.05).
• Group 3 offered the best results for EFRP. Only PDE5Is
or the combination of PDE5Is and VED use had a
beneficial effect on EFRP (P < 0.05).
• Using PDE5Is and VED together provided the best result,
but there was no difference between PDE5Is and a VED
(P ? 0.05).
• After bilateral nerve-sparing RARP, PRP with PDE5Is,
including the combination of PDE5Is and VED, has a
beneficial effect on erectile function recovery across all
levels of baseline erectile function.
• Further large randomized control studies are needed to
validate these findings.
© 2012 BJU International | 111, 658–665 | doi:10.1111/j.1464-410X.2012.11487.x
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Correspondence: Ketan K. Badani, Department of Urology,
Columbia University Medical Center, 630 West 168th
Street; New York, NY 10032, USA.
Abbreviations: BMI, body mass index; ED, erectile
dysfunction; EFRP, erectile function recovery period; RP,
radical prostatectomy; ES, erection strength; IIEF,
International Index of Erectile Function; NIH, National
Institutes of Health; PED5I, phosphodiesterase-5 inhibitor;
PRP, penile rehabilitation programs; SHIM, Sexual Health
Inventory for Men; RARP, robot-assisted radical
prostatectomy; VED, vacuum erection device.
Penile rehabilitation after robot-assisted radical prostatectomy
© 2012 BJU International