Patients with clinically localized prostate cancer and a life expectancy of at least ten years are candidates for radical prostatectomy. Erectile dysfunction (ED) and urinary incontinence are the two most frequently encountered sequelae of radical prostatectomy. While most of the series reported in this field show low postoperative urinary incontinence rates, the proportion of patients complaining of ED postoperatively is reported by most centers as being significantly higher, affecting 10% to 100% of patients.

Since the development of nerve-sparing radical prostatectomy, the incidence of post-operative erectile dysfunction has decreased. Solid data show that bilateral nerve-sparing surgery is better, in terms of retaining erectile function, than unilateral nerve sparing, which in turn is better than surgery without nerve sparing. However, despite this technical improvement, a significant number of men continue to experience some degree of erectile dysfunction.

This is due to the fact that, although the nerve-sparing technique has been well defined and clearly associated with satisfactory results, many different variables are implicated in the postoperative preservation of the erectile function. For instance, the use of magnifying loops (3.8x prismatic lenses in our experience) is particularly important during dissection of the prostate.

The surgeon's experience is critical. To get this experience, a surgeon has to perform a large number of these procedures. Surgeons reporting good postoperative potency usually perform two radical prostatectomies per week.

Patient selection also plays an important role. Men of 50 or younger who plan to have a nerve-sparing procedure should have normal preoperative erectile function, and should be very motivated regarding the preservation of erectile ability. They should report spontaneous erections within the first postoperative year; if there are none, there is probably a technical problem. As the age of patients increases, the risk of postoperative ED also increases. In our experience is not reasonable to even discuss a nerve-sparing procedure with a patient over 65 years.

Beside the surgeon's skill and the strict selection of the patients who are interested in a nerve-sparing procedure, postoperative management has been reported to have a great influence in improving erectile function after surgery. We believe that close patient follow-up helps in the process of recovery of erectile function. It's important to talk with the patients one month after the procedure and then every three months, to stimulate them to try and engage in sex with confidence. The use of a transparent gel to lubricate the penis prior to intercourse or the placement of a gentle elastic band round the base of the penis may help in some patients. More important, many publications have shown that an early or immediate rehabilitation of the corpus cavernosum after surgery, based on the use of injection therapy (e.g. alprostadil), oral sildenafil, or the newer PDE-5 inhibitors (vardenafil, tadalafil), is often associated with a high successful rate, when compared to "watchful and waiting".

For these reasons, patients are advised to have prophylactic intracavernous injections of alprostadil, twice a week for at least 3 months following surgery, starting soon after removal of the catheter. This is done in order to stimulate corporeal blood filling and to reduce the risk of corporeal fibrosis; moreover, with intracavernous injections patients can enjoy full rigid erections soon after surgery. Sildenafil on demand is usually given from the third postoperative month.

Sildenafil, as well as the new drugs soon to be available - tadalafil and vardenafil - have been reported to have a high successful rate in term of erectile function and overall satisfaction after surgery, especially in younger patients who undergo a bilateral nerve-sparing procedure. These drugs can also be tried with bed-time administration in order to facilitate corporeal oxygenation and to avoid the fibrosis subsequent to prolonged ischemia in the corpus cavernosum; currently, randomized studies are being performing to verify this hypothesis.

In patients in whom a bilateral nerve-sparing technique cannot be performed, sural nerve graft seems to offer positive results. This procedure is an established medical practice that has not yet had widespread application in urology. Animal data support the idea that grafting a segment of nerve in this area may allow the recovery of spontaneous erections, although many discordant opinions have been raised about this procedure in the clinical practice. In most patients today, nerve grafts are not indicated, especially if the tumor is impalpable (T1c), low grade (Gleason less than 7), and the prostate specific antigen is less than 10 ng/ml. Recovery of spontaneous erections is usually reported 12 months after nerve grafting, and during this period the penis should be stimulated as described above.

In conclusion, the prevalence of erectile dysfunction has been reported to be significantly decreased since development of the bilateral nerve-sparing procedure, although its total abolition has not been achieved. However the current and future availability of new and selective drugs will help the management of erectile dysfunction after radical prostatectomy, so this remains a topic of major importance for the practicing urologist.