Recovery of Baseline Erectile Function in Men Following Radical Prostatectomy for High-Risk Prostate Cancer: A Prospective Analysis Using Validated Measures Ashwin N. Sridhar, MBBS, MRCS, MSc, 1 Paul J. Cathcart, MD, FRCS, 2 Tet Yap, MD, FRCS, 1 John Hines, FRCS, 3 Senthil Nathan, MS, FRCS, FEBU, 1 Timothy P. Briggs, FRCS, 1 John D. Kelly, MD, FRCS, 1,4 and Suks Minhas, MD, FRCS 1 ABSTRACT Introduction: Recovery of baseline erectile function (EF) after robotic radical prostatectomy in men with high- risk prostate cancer is under-reported. Published studies have selectively reported on low-risk disease using non- validated and poorly defined thresholds for EF recovery. Aim: To assess return to baseline EF in men after robotic radical prostatectomy for high-risk prostate cancer. Materials: Five hundred thirty-one men underwent robotic radical prostatectomy for high-risk prostate cancer from February 2010 through July 2014. Pre- and postoperative EF was prospectively assessed using the International Index of Erectile Dysfunction (IIEF-5) questionnaire. Multivariate logistic regression analysis determined the effect of age, preoperative function, comorbidities, body mass index, prostate-specific antigen level, cancer stage or grade, nerve-sparing status, adjuvant therapy, and continence on EF return (defined as postoperative return to baseline EF with or without use of phosphodiesterase type 5 inhibitors). Kaplan-Meier analysis and log-rank test were used to analyze return over time. Mann-Whitney U-test was used to compare IIEF-5 scores. Main Outcome Measures: Pre- and postoperative EF was assessed using the IIEF-5 Sexual Health Inventory for Men at 3 months, 6 months, 1 year, 2 years, 3 years, and 4 years postoperatively. Results: Overall, return of EF was seen in 23.5% of patients at 18 months. This was significantly increased in men no older than 60 years (P ¼ .024), with a preoperative IIEF-5 score of at least 22 (P ¼ .042), and after undergoing neurovascular bundle preservation (34.9% of patients, P < .001). There was no significant change in IIEF-5 scores from 3 to 36 months in patients who were treated with phosphodiesterase type 5 inhibitors in the non-neurovascular bundle preservation group (P ¼ .87), although there was significant improvement in those receiving second- or third-line therapies (P ¼ .042). Other than preoperative hypertension (P ¼ .03), none of the other comorbidities predicted return of EF. Conclusion: In this study, 23.5% of men recovered to baseline EF. Of those who underwent bilateral neurovascular bundle preservation robotic radical prostatectomy, 70% recovered baseline EF; however, this accounted for only 9.6% of all patients. Only 4% of men who underwent non-neurovascular bundle preservation had baseline recovery with phosphodiesterase type 5 inhibitors up to 36 months. There was significant improvement after use of second- or third-line therapies, indicating the need for earlier institution of these treatment modalities. J Sex Med 2016;13:435e443. Copyright Ó 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. Key Words: Prostatic Neoplasm; Prostatectomy; Robotic; Recovery of Function; Erectile Dysfunction; Counseling INTRODUCTION High-risk prostate cancer (HRPC; stage T2c, prostate-specific antigen level >20 ng/mL, or Gleason score 8e10 indicating dis- ease 1 ) accounts for approximately 20% to 30% of patients pre- senting with localized disease. 2 Cancer-specific mortality with watchful waiting in this group has been shown to be 17% to 20% at 10 years. 3,4 Radical prostatectomy (RP) has been found to lower the risk of PC death, with an absolute risk decrease of 17% vs watchful waiting in men younger than 65 years at 10 years of follow-up. 5 Received September 27, 2015. Accepted January 12, 2016. 1 Department of Urology, University College London Hospital, London, UK; 2 Department of Urology, Guy’ s and St. Thomas hospital, London, UK; 3 Department of Urology, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK; 4 Division of Surgery and Interventional Science, University College London, London, UK Copyright ª 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsxm.2016.01.005 J Sex Med 2016;13:435e443 435