Non-surgically Related Causes of Erectile Dysfunction After Bilateral Nerve-sparing Radical Prostatectomy

G Gandaglia; G Lista; N Fossati; N Suardi; A Gallina; M Moschini; L Bianchi; MS Rossi; R Schiavina; SF Shariat; A Salonia; F Montorsi; A Briganti


Prostate Cancer Prostatic Dis. 2016;19(2):185-190. 

In This Article

Materials and Methods

Study Population

We performed a retrospective study evaluating 716 patients with clinically localized PCa treated with BNSRP between January 2006 and August 2013 at a single tertiary referral center. Patients included in the study underwent either an open or robot-assisted approach performed by six experienced surgeons, as previously described.[11,12] In particular, three surgeons performed exclusively open surgery, two surgeons performed robotic cases and one surgeon performed both open and robotic RPs. Indication for bilateral neurovascular bundles preservation was based on disease characteristics at diagnosis and on the clinical judgment of each treating physician, regardless of preoperative EF status. Exclusion criteria consisted of neoadjuvant hormonal therapy, salvage RP or missing values.


All patients had complete functional and clinical preoperative data available such as age, body mass index, Charlson comorbidity index (CCI), PSA, biopsy Gleason score and clinical stage. All patients had data available on preoperative depressive status assessed by the Center for Epidemiologic Studies-Depression (CES-D) scale. Depression was defined as a CES-D score of ≥16.[13] Preoperative EF and postoperative EF were assessed by the International Index of Erectile Function-EF domain (IIEF-EF). Baseline EF was assessed the day before surgery. Patients were stratified as follows: severe (IIEF-EF: 1–10), moderate and mild-to-moderate (IIEF-EF: 11–21), mild (IIEF-EF: 22–25) and no ED (IIEF-EF ≥26).[14] Patients were categorized according to the use of phosphodiesterase type-5 inhibitors (PDE5-Is) within 2 years after surgery in three groups: no PDE5-Is, on-demand and chronic use as previously described.[15] Salvage radiotherapy (sRT) was defined as RT delivered at the time of biochemical recurrence before the onset of clinical metastases. aRT was defined as RT administered within 6 months after surgery without evidence of PSA progression. aRT was administered to patients with aggressive pathologic characteristics (positive margins, non-organ confined disease, pathologic Gleason score 8–10 and/or lymph-node invasion) according to the clinical judgment of the treating physician. All patients included in the aRT group received a three-dimensional conformal approach: the clinical target volume was drawn on computed tomography images by the physicians and included the prostatic fossa and periprostatic tissue. The planned volume was defined as the clinical target volume plus a 1-cm margin. All patients received irradiation of the prostatic bed only to a median dose of 70.2 Gy. The seminal vesicles bed was always irradiated regardless of the pathologic stage (pT2, pT3a or pT3b) with a median dose delivered to the seminal vesicles bed of 60–61 Gy.


Patients were evaluated every 3 months during the first year after surgery and every 6 months thereafter. During each visit, postoperative EF was assessed through IIEF-EF questionnaire. EF recovery was defined as an IIEF-EF score of ≥22.[16]

Statistical Analysis

Medians and interquartile ranges (IQRs) were reported for continuous non-normally distributed variables. Frequencies and proportions were reported for categorical variables. The Mann–Whitney and chi-square tests were used to compare medians and proportions between groups, respectively. Kaplan–Meier analyses assessed the impact of the preoperative functional status, depression and aRT on the time to EF recovery. Multivariable Cox regression models were used to test the impact of preoperative IIEF-EF, depression and aRT on EF recovery after accounting for age, CCI, body mass index, surgical approach (open vs robot-assisted surgery), use of PDE5-Is and sRT.

Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS, Chicago, IL, USA) version 21.0, with a two-sided significance level set at P<0.05.