Erections after prostatectomy surgery: does Viagra still work?

In this blog for a non-medical audience, Alastair Lamb, Senior Fellow in Robotic surgery and Consultant Urologist at Oxford University Hospitals, and Altan Omer, Pelvic GU-Oncology fellow, look at the evidence for use of PDE5 inhibitors (Viagra, Cialis & Levitra) for penile rehabilitation after prostate cancer surgery.

What is the problem?

Some 6,500 radical prostatectomies are performed every year in the UK (British Association of Urological Surgeons, 2019).  While approximately half of these men have pre-existing erectile dysfunction, over 50% of the other half can expect to lose natural erections after prostatectomy surgery, especially if their cancers are locally advanced and require wide clearance to ensure removal of the whole tumour.

Are these erections lost for good?

There’s pretty good evidence to show that men can continue to recover erectile function up to two years after prostatectomy surgery (Montorsi et al., 2014), which we believe is partly because it takes time for the bruising and scar tissue after surgery to settle down. But if spontaneous erections do not recover by this point then it is unlikely that they will do so thereafter. Conversely, there is good evidence that drugs such as Viagra can be used to enhance erections after surgery and that, even if such drugs do not work – for example if the nerves have been removed to maximise cancer clearance – mechanical devices such as vacuum pumps, cavaject injections into the side of the penis or MUSE therapy (small tablets inserted into the end of the urethra) are effective.

Use it or lose it?

The question therefore remains as to whether longer term recovery of spontaneous erections can be assisted by such devices and particularly by the use of PDE5 inhibitors. This is a process generally known as “penile rehabilitation”. The concept is that men need to ‘use’ their penises in order to speed up recovery of the blood vessels and nerves that are essential for erections, indeed that lack of use may inhibit recovery. This Cochrane review pulled together randomised trials testing the effect of PDE5i on erectile function after radical prostatectomy (Philippou et al., 2018). There were eight randomised trials including 1699 men and the drugs used were either Viagra (sildenafil), Cialis (tadalafil) or Levitra (vardenafil). The review found no evidence to support penile rehabilitation, defined as an improvement in erectile function, off drug, at the end of the period of follow up (one to two years) compared to a control group who had not received any drug. The authors did note however that the quality of evidence was poor, mainly because of a lack predefined outcomes and inconsistency in reporting standards (varying definitions of potency, different follow-up durations, multiple modes of assessment including both physician and patient-reported outcomes etc).

How important is nerve-sparing?

The short answer is very. All men in these studies had some form of nerve-sparing performed during their surgery so this review was not able to assess the effect of nerve-sparing on subsequent recovery of erections as there was no control group to compare to. Previous studies have convincingly demonstrated the critical nature of nerve-sparing (Patel et al., 2011). The decision to undertake nerve-sparing is made in advance by the surgeon and depends on the extent of cancer. Robotic surgery has allowed more precise and meticulous surgical dissection of the surrounding layers of the prostate. Indeed, 80% of UK prostatectomies are now completed with a da Vinci robot, the remainder split evenly between laparoscopic and open surgery. The outer layers of the prostate are a bit like an onion with several layers. The layer containing the nerves is like the brown skin on the onion and the surgeon can choose to cut inside this layer to leave the brown skin (or nerve layer) in place.

The outer layers of the prostate are a bit like an onion with several layers. The layer containing the nerves is like the brown skin on the onion and the surgeon can choose to cut inside this layer to leave the brown skin (or nerve layer) in place.

However, when there is a lot of cancer there is a real possibility of leaving some cancer cells behind if this close approach is taken, and so the surgeon instead chooses intentionally to take this outer layer with the prostate – the brown skin stays on the onion. So, while it may increase the risk of prostate tissue being left behind (which incidentally, is one of the reasons why the PSA may remain high post-operatively), sparing the nerves is a critical step for preservation of erectile function, and men who undergo an intentional non-nerve-sparing procedure should always be warned of the inevitability of erectile dysfunction after surgery. Of course, for those men who have already have erectile dysfunction before surgery, no amount of nerve sparing will return natural erections.

Isn’t Viagra very expensive?

Viagra is indeed rather expensive. A box of four 100mg tablets (Viagra, Pfizer) will cost the NHS or you (by private prescription) £23.50 per box. However, since December 2017 in the US, and amazingly since June 2013 in the UK, it has been legal for other drug manufacturers to make generic sildenafil and so, with a private prescription you can now pick up a box of 4 x 100mg sildenafil citratetables for as little as 79p (https://bnf.nice.org.uk/medicinal-forms/sildenafil.html), a thirty-fold price reduction. It’s almost as cheap as paracetamol! The NHS is slowly waking up to this but still official NHS guidance only permits one packet of four tables per month for those who meet strict erectile dysfunction criteria. We hope this will change soon, given that 11 boxes could be purchased for the £8.80 standard NHS prescription charge! Furthermore, Cialis also came off patent in December 2018 in the US and we can therefore expect generic tadalafil, which currently costs £54.99 for a box of 28 x 2.5mg – cialis is generally taken daily due to its longer half-life – to come down to similar prices.

Mr. Altan E. Omer MD FEBU is a Pelvic Uro-Oncology and Robotic Surgery Fellow at the Churchill Hospital, Oxford.

Where does this leave you?

Increasing availability of these previously expensive drugs is a tremendous help for men who have undergone radical prostate surgery. Despite the uncertainty regarding penile rehabilitation, there is no doubt that real-time erections often improve while on Viagra (or Cialis or Levitra etc) and so straightforward access to these drugs is essential for a speedy return to a functioning sex life after cancer, for those who want it.

Join in the conversation on Twitter with @CochraneUK or leave a comment on the blog.

References may be found here.

Alastair Lamb and Altan Omer have nothing to disclose.


Alastair Lamb

About Alastair Lamb

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Mr Alastair D Lamb, MA(Oxon), MBChB, PhD(Cantab), FRCS(Urol) is a Cancer Research UK Clinician Scientist, Senior Fellow in Robotic Surgery and Honorary Consultant Urologist at the Nuffield Department of Surgery, University of Oxford and Oxford University Hospitals NHS Foundation Trust, UK. My clinical focus is to deliver excellent and timely prostate cancer care to men referred to our team from the Oxford regional area, focussing on state-of-the-art diagnostics with multiparametric MRI and targeted transperineal biopsies, followed by robotic-radical prostatectomy (RARP) or indeed active surveillance where appropriate. I have a particular interest in pushing the boundaries of minimal access surgery (MIS), for example to performing cytoreductive radical prostectomy in locally advanced or metastatic disease and RARP in fit, older men where such approaches are deemed safe and evidence-based. My research goal is to provide a robust molecular platform for accurate decision-making in early stage prostate cancer.

5 Comments on this post

  1. Avatar

    Tadalafil isn’t always taken once daily. It’s also available as PRN does of 10mg and 20mg as well as daily doses of 2.5mg and 5mg.
    The long half-life isn’t the reason it’s given daily!

    Robert / Reply
  2. Avatar

    Mr Lamb,
    What do you think of the Menon precision prostatectomy technique described by Dr Mani Menon in the link below: early results on the first 50 patients are said to yield a much higher recovery of erectile function (said to be about 95%) compared to the usual robot assisted radical prostatectomy, whether retzius sparing or traditional? Of course, one could not apply the MPP technique to every case (eg where cancer has invaded the cap of the prostate); but one would think that there must be a significant subset of patients for whom Dr Menon’s suggested technique may reasonably be considered. Early days yet in relation to proof of this new technique, of course, but looks promising.
    http://manimenon.com/menon-precision-prostatectomy/

    Ian / Reply
    • Avatar

      Thank you for your comment Ian. Mani Menon is a legend in our field and I want to learn everything I can from him! However, I do have reservations about his proposed technique, just as I have reservations about any focal therapy in prostate cancer. We know that approx 70% of prostate cancer occurs in the “peripheral zone” of the prostate – the “cap” you refer to in your comment. And this is precisely the zone that Dr Menon chooses to leave behind. We also know that up to 30% of negative MRI scans/prostate biopsies actually harbour clinically significant prostate cancer. I am concerned about doing an operation which, by it’s nature, precludes further radical surgery, but which involves the very real possibility of leaving behind prostate tissue harbouring lethal prostate cancer. Until we can precisely determine the presence or absence of small quantities of lethal prostate cancer cells at diagnosis I will not be offering these treatments to my patients. Instead I think we should put our efforts and fundraising into basic scientific endeavour to identify such “lethal clones” in the prostate (http://www.nds.ox.ac.uk/team/alastair-lamb). I am also very encouraged by the potential of “retzius-sparing” prostatectomy techniques, using both posterior and anterior approaches, early results of which seem to offer very promising erectile function and continence results without compromising radical treatment (several abstracts to be presented this year at EAU19 and AUA19 https://eaucongress.uroweb.org/scientific-programme/.

  3. Avatar

    yes it does work, viagra should be first consulted by the doctor in this case before consumption.

    Hansel / Reply
  4. Avatar

    Mr Lamb, it’s very impressive that you’ve attended Mani Menon’s recent presentation at AUA19 on 5 May of the Menon Precision Prostatectomy technique, aimed at reducing ED. Plainly, one should not just MRI the area of the PZ to be left in situ, but also biopsy it too. Yes, there is a risk that the sliver of PZ which is left in situ may generate CaP. But in any event, even if you did a full RARP, traditional or Retzius-sparing, my understanding is that the patient will still be taking some risk of biochemical reoccurrence in some circumstances, even if there are “clear” margins at the finish of the operation. It seems to me that it is for the patient to choose what level of risk he’d prefer – and whether he’s willing to take some CaP risk to have a better chance of continued normal erectile function, given that he is, as I understand it, already taking at least some risk of biochemical reoccurrence anyway. So it seems to me that surgeons, in principle, ought to be prepared to have the technical capacity to “do it the patient’s way” provided that the patient understands and signs up to any extra risk, rather than the surgeon saying ab initio that no sliver at all of PZ can be left and imposing a decision on the patient of greater ED risk when the patient might prefer a better chance of erectile function and be willing to tradeoff some CaP risk, at least if it is found that there is negative MRI report AND a negative biopsy in the area. Any views you have are of great interest. Someone needs spend a little time with Menon in the USA and bring the learning over the Atlantic because there are lots of men who’d prefer to have this chance if MPPs can be done in a way that makes sense.

    Ian / Reply

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