Do you ever regret a decision that turns out to have a bad outcome? This is the situation for many prostate cancer (PCa) patients who chose radical prostatectomy (RP). A 2017 study found that 15% of PCa patients regret their treatment choice, with twice as many patients ruing the day they opted for RP or radiation vs. those who chose Active Surveillance (AS).^[i] What was the biggest reason for their regret?

They lost their erections.

Why does ED happen after RP?

ED after PCa surgery, including robotic, is due to nerve damage. The nerves that carry arousal messages from the brain and spinal cord to the spongy tissue in the penis (called the corpus cavernosa, that needs to fill with blood to make the penis hard) lie adjacent to the gland. During a nerve-sparing RP, they are carefully teased away from the gland capsule—but nerves are fussy. They don’t take kindly to being disturbed and stretched. They can easily go into a kind of paralysis, as if they have been traumatized.

Of course, nerves can recover. “Waking up” from their catatonic state can take just a few weeks, or as long as 18+ months later. If they were physically damaged, they can regenerate (regrow nerve fibers), but this is slow and unpredictable. Meanwhile, the loss of erections impacts a man’s self-esteem and quality of life. His partner may also have feelings over the loss of familiar lovemaking.

Despite improvements in imaging, instruments and surgical techniques, “Previously published series have shown EF recovery rates after robot?assisted RP (RARP) ranging between 40% and 90% of patients at 12 months, postoperatively… [S]ome authors have reported that patients undergoing minimally invasive RP have experienced even more ED on comparison.”^[ii]

How do you get it back when you’ve lost it?

Many post-RP patients take 2 or more years to regain erections hard enough for intercourse—and some lose it permanently. How can they regain it? There are many available treatments. Men are always advised to not give up, and if one treatment doesn’t work, to move on to the next. The most common are pills, injections, vacuum pumps, and penile implants. While hoping for a return to spontaneous, natural erections, most men eventually adapt to using whatever helps Mother Nature along.

But now there’s big news! An improved surgical approach to transplanting a nerve from the leg to the groin area can restore erections with or without medication, even if more than a decade has passed. Surgeons from Melbourne, Australia have modified a minimally invasive treatment for post-surgery RP called end-to-side nerve grafting.^[iii] You can think of it as analogous to successfully growing new apples by taking a budding branch from a parent apple tree and physically joining it into a compatible rootstock; as the tree heals, the new branch grows its fibers into it, becoming part of the rootstock’s life.

Similarly, the end-to-side grafting procedure performed by the Australian team involved removing two sural nerves from the legs (not required for full leg function) and attaching one end of each to the side of the femoral nerve in the thigh, where it joins the groin; the other end of each sural nerve is attached into the corpus cavernosa within the penis:

The sural nerve then acts as a scaffolding (conduit), similar to an extension cord, to deliver regenerating nerve fibres from the femoral nerve to the corpus cavernosa. After around 12 months, new nerve endings in the corpus cavernosa release neurotransmitter (acetylcholine) which help initiate an erection.^[iv]

The Australian paper followed 17 patients (average age 64) who had ED after prostatectomy, and who underwent the nerve graft roughly 2 years after their RP. As new nerve fibers grew along the graft, 12 men (71%) regained sexual function, sufficient for intercourse, from 6-12 months. By the end of the year, all had improved symptoms, and 7 were able to achieve sexual penetration without the use of drugs. The authors noted that “94% had clinically relevant improvements in sexual [quality of life]” and two of the participants had “their first erection in 12 years.”^[v]

The Melbourne team modified a post-RP end-to-side nerve graft procedure that, after years of research in lab animals, had been used by Brazilian surgeon Fausto Viterbo and others for restoring erections in post-prostatectomy patients.^[vi] The modification enhanced nerve regeneration by inducing minor injury to the femoral nerve to stimulate regeneration, in hopes that this approach would provide more nerve axons (message conductors) to the penis.^[vii]

The Melbourne study is an example of a larger body of research aimed at encouraging nerve regeneration for men who experience moderate to severe ED after PCa treatment. Needless to say, the patients in Melbourne who benefitted from the surgery are thrilled, and we join with the authors in expressing hope that this procedure will be internationally embraced on behalf of RP patients, so they need not have any regrets over their treatment choice.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Hoffman RN, Lo M, Clark JA, Albertsen PC et al. Treatment decision regret among long-term survivors of localized prostate cancer: results from the prostate cancer outcomes study. J Clin Onc. 2017 Jul 10; 35(20):2306-14.
[ii] Isgoren AE, Saitz TR, Serefoglu EC. Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy: Is It Superior to Open Retropubic or Laparoscopic Approach? Sex Med Rev. 2014 Jan;2(1):10-23.
[iii] Reece JC, Dangerfield DC, Coombs JC. End-to-side Somatic-to-autonomic Nerve Grafting to Restore Erectile Function and Improve Quality of Life After Radical Prostatectomy. Eur Urol. 2019 Aug;76(2):189-196.
[iv] “Improved Procedure for Cancer Related Erectile Dysfunction.” Science Daily, Apr. 12, 2019. https://www.sciencedaily.com/releases/2019/04/190412094731.htm
[v] Reece, Ibid.
[vi] Trindade JC, Viterbo F, Trindade AP, Favaro W, Trindade-Filho JC. Long-term follow-up of treatment of erectile dysfunction after radical prostatectomy using nerve grafts and end-to-side somatic-autonomic neurorraphy: a new technique. BJU Int. 2017 Jun;119(6):948-954
[vii] “Improved Procedure for Cancer Related Erectile Dysfunction.” Ibid.