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The success rates of treatment are based on factors including the type of
surgery (nerve sparing or non-nerve sparing), the age of the patient, and
whether the patient received hormone therapy prior to surgery or additional
therapies such as radiation therapy either prior to or after the surgery.
Drug therapy
There are currently three oral drugs available that have been used in
patients who have had radical prostatectomy for prostate cancer. These three
drugs are Viagra, Levitra, and Cialis. While success rates have varied to some
extent it is fair to say that those patients who are likely to respond to any of
these medications are patients who have had bilateral nerve sparing radical
prostatectomy. Up to 70% of these patients may respond to these three drugs.
Some patients may respond to one drug better than another and this is probably
an individual or idiosyncratic response that we see with any group of
medications. Success is less likely in patients who have had only a single nerve
spared and very unlikely in those patients who have had no nerves spared at the
time of the surgery. Success rates are also better with oral therapy in younger
patients and are probably better in patients who do not have other risk factors
that might be implicated in erectile dysfunction such as cigarette smoking,
hypertension, high cholesterol and coronary artery disease.
When oral medications are unsuccessful these are the following alternatives.
#1 vacuum constriction devices
Vacuum constriction devices consist of an acrylic cylinder that is placed
over the penis. A lubricant is used to create a good seal between the body and
the cylinder and a pump mechanism is used to create a vacuum inside the cylinder
allowing a patient to achieve an adequate erection. If an adequate erection can
be achieved a band or ring is then placed over the base of the penis (the part
of the penis closest to the body) and this is used to help maintain the
erection. These devices have been helpful to some men in facilitating
intercourse after radical prostatectomy. Many men, however, find the band at the
base to be uncomfortable or find the device to be somewhat cumbersome. This
tends to limit the number of men who choose this therapy following radical
prostatectomy.
#2 intracavernous or penile injections
In those patients who do not respond to oral therapy this is probably the
most wildly used non-surgical method and certainly is the most widely used
method amongst patients who have had a radical prostatectomy. This method will
work in patients regardless of the nerve sparing status. It does not however,
work in all patients and is probably successful in approximately 80% of those
patients who choose to try it. The patients do need to inject each time they
want to have sex and the material is injected directly into the erection tissue.
If the technique is learned properly pain is, in most cases, not a significant
problem. Complications that can occur with injection therapy include the
possibility of producing a drug induced prolonged erection which would require
injecting additional medication into the penis to make it flaccid or soft again
and the possibility of scar tissue which may result in curvature of the penis.
Drug induced prolonged erections are fortunately rare. Scar tissue development
seems to relate to some extent to the frequency with which one injects and the
length of time one utilizes this therapy. Although this is a successful therapy
there is a significant drop out rate with time.
#3 intraurethral therapy
This involves placing into the urethra (or tube that carries the urine), a
suppository or pellet that is deposited by means of an applicator system. The
applicator is placed into the urethra. The insertion is usually not
uncomfortable and the applicator length is relatively small so that it is placed
only into the tip of the penis.
The medication contained in the pellet is one of the medicines that we use
for injection therapy but contains fifty to one hundred times more medication.
This is because the medication has to be absorbed by the urethra and travel to
the erection chamber.
While this medication can at times produce an adequate erection, in most men
the erection produced is generally felt to be unsatisfactory. In addition, the
higher amount of medication that needs to be inserted and absorbed may result in
a considerable degree of discomfort in many men. This is therefore not an
attractive treatment alternative in the large majority of men who are post
prostatectomy. This method at times been combined with oral medication in some
men who fail to respond to either one of these treatment modalities. The number
of patients, however, who respond to this combination are relatively few and the
combination is quite expensive.
#4 penile implants or prostheses
Clinical studies have demonstrated a high degree of patient satisfaction
with a penile prosthesis. In patients who have had bilateral or unilateral nerve
sparing surgery, however, we generally counsel them to wait a period of
approximately one to two years to see if some degree of recovery is going to
occur or if enough recovery combined with one of the non-surgical methods is
sufficiently satisfactory so that surgery is felt to be undesirable.
Some patients fail to respond to any non-surgical therapy or find the therapy
unacceptable even if they do get a response. Such patients are certainly
reasonable candidates for a penile prosthesis. Problems that can occur with
prosthetic devices include: infections in which case the device needs to be
removed and a new one inserted or device malfunction which also results in the
necessity to remove the device and consider inserting a new device.
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