In recent years, prostate cancer has emerged from an often trivialized medical condition, relegated to older men and thought to exert little lifetime consequence, to a disease state of major importance. The significance of the disease has increased in large part because of its dramatic stage migration in the modern prostate-specific antigen (PSA) era, and this is typified by increasingly early clinical stage diagnoses and diagnoses made increasingly in young men. As a result, the need exists for improved disease control via effective oncological control while maximally preserving functional outcomes. This matter is most noteworthy in the area of erectile function, particularly as it is viewed that other historical complications of treatment, such as urinary incontinence following radical prostatectomy, have greatly been reduced . Indeed, as patients currently consider the impact of various treatment approaches for prostate cancer on their quality of life, many place paramount importance on the opportunity for retaining natural erectile function .
This chapter provides an assessment of the current literature on the subject of erectile dysfunction following treatment for prostate cancer. It includes a review of the significance and impact of the problem, its causes and associations, and both current and future approaches in its clinical management. Emphasis is appropriately given to the consequences of radical prostatectomy, in which this matter has been most intensively studied. However, it is recognized that all interventions for prostate cancer, including external beam radiotherapy, brachytherapy and hormonal ablation, have the potential to affect penile erections.
SIGNIFICANCE OF THE PROBLEM
Erectile dysfunction has long been known to be a potential consequence of treating prostate cancer, perhaps best associated with radical prostatectomy. Historically, erectile dysfunction was a universal outcome of undergoing this surgery. However, in the past 20 years, with the advent of cavernous nerve-sparing modifications of the surgery, postoperative erectile function rates have improved . The initial descriptions of the course of the cavernous nerves surrounding the prostate and supplying the penis represented a major historical advance . As it is currently understood, anatomic radical prostatectomy refers to an improved understanding of the surgical anatomy of the prostate and its surrounding surgical structures in the deep pelvis, and the implementation of a rational plan for surgical dissection based on circumstances of the oncological presentation . In the current era of nerve-sparing radical prostatectomy, the rates of erectile function recovery satisfactory for sexual intercourse following the surgery as reported at major academic centres staffed by highly experienced surgeons range between 60% and 85%, a dramatic improvement over historical rates [5–7]. Contemporary results generated elsewhere may differ. However, in support of these figures, a subset analysis from the cohort study of Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), representing 29 academic and community-based sites across the USA, recently found a 75% potency rate in men younger than 65 years after ...