We Have Questions: Prostatectomy and Sexual Function

For people with localized prostate cancer—or cancer that hasn't spread beyond the prostate gland—surgery is a common treatment.

The primary type of surgery for prostate cancer is a radical prostatectomy, a procedure in which the urologist or urologic oncologist removes the entire prostate gland, according to Scott Shelfo, M.D., the medical director of urology at City of Hope Atlanta.

There are two different approaches to prostatectomies. In the first, called an open prostatectomy, a surgeon makes an incision in the wall of the lower abdomen or in the perineum, the area between the scrotum and anus.

In the second, more common approach, called a laparoscopic prostatectomy, a surgeon makes smaller incisions and removes the prostate gland using a tube-like instrument called a laparoscope. The surgeon either holds the laparoscope with their own hands or with robotic arms by using a control panel. The latter method is known as robotic prostatectomy, which accounts for about 67 percent of radical prostatectomies in the United States.

Research suggests that a radical prostatectomy results in a substantial reduction in deaths among prostate cancer patients. However, the procedure is not without side effects, some of which can be fairly serious.

After a prostatectomy, many patients experience urinary incontinence. Nearly all patients experience erectile dysfunction (ED), or the inability to achieve or maintain an erection, Shelfo said.

ED, though common early after surgery, often improves over time. Within two years, about 40 percent to 50 percent of patients regain their pretreatment erectile function.

The return of erectile function depends on whether nerves are damaged during the procedure, according to Shelfo. A surgeon who properly performs nerve-sparing techniques can improve the chances of the patient's erectile function being restored.

In a Q&A with Giddy, Shelfo explains who should get a prostatectomy, how it can impact a person's sex life and what can be done to help recover erectile function.

Editor's note: This interview has been edited for length and clarity.

Who should get a radical prostatectomy?

Shelfo: A radical prostatectomy is intended for patients who have localized prostate cancer.

What alternative treatment options are available?

Prostate cancer patients often have a choice between a prostatectomy or radiation therapy to the prostate as potential treatment options. While some low-grade, slow-growing prostate cancers are managed with active surveillance and monitoring with regular checkups, intermediate- or high-grade cancers are usually treated with either surgery or radiation.

How can a patient decide which treatment is right for them?

The decision to proceed with surgery versus radiation is based on each individual, taking into account their disease, age and health status, as well as patient preference. The patient is always actively involved in choosing the best treatment option for him with his doctor.

What are the common outcomes of a radical prostatectomy?

Oncological outcomes are often very good, with high chances of resulting in no evidence of disease.

How does the prostate's removal affect sexual health?

Both surgery and radiation can have side effects on the quality of life for men. A prostatectomy can affect the man's urinary habits; specifically, he may develop stress urinary incontinence. It can also affect the man's sexual health, such as the ability to attain and maintain erections. In certain patients, we can perform a nerve-sparing technique at the time of prostatectomy that may decrease this side effect.

What can be done to help men who experience erectile dysfunction and other sexual side effects?

If the patient does experience erectile dysfunction postoperatively, there are many treatment options, including oral medication, vacuum erection devices and point injection therapy, as well as surgical implantation of a penile prosthesis.