ORIGINAL ARTICLE Erectile dysfunction after radical prostatectomy: the impact of nerve-sparing status and surgical approach N Koehler 1 , S Holze 1,2 , L Gansera 1 , U Rebmann 3 , S Roth 4 , H-J Scholz 5 , D Fahlenkamp 6 , R Thiel 7 and E Braehler ,1 The core question of the study was whether the nerve-sparing status and surgical approach affected the patients’ sexual life in the first year after surgery. In addition, determinants of erectile function (EF) and the extent of sexual activity were investigated. We conducted a multicentric, longitudinal study in seven German hospitals before, 3, 6 and 12 months after radical prostatectomy (RP). A total of 329 patients were asked to self-assess the symptoms associated with erectile dysfunction (ED). These symptoms were assessed using the International Index of Erectile Function and EORTC QLQ-PR25 questionnaires. A multiple regression model was used to test the influence of clinical, socio-demographic and quality-of-life-associated variables on the patients’ EF 1 year after RP. Before surgery, 39% of patients had a severe ED (complete impotence). At 3, 6 and 12 months after surgery, it was 80, 79 and 71%, respectively. Although the surgical approach had no significant effect on EF, patients who had undergone nerve-sparing surgery had significantly lower ED rates. Nevertheless, 1 year after RP, 66% of these patients had severe ED. Age, nerve-sparing status and the burden of urinary symptoms had the greatest impact on the patients’ EF. Regardless of nerve-sparing status and surgical approach, postsurgical improvement of EF does not mean a full convalescence of presurgical EF. Instead, it may rather reduce the degree of postsurgical ED in time. Consequently, urologists should disclose to the patient that ED is a likely side effect of RP. International Journal of Impotence Research (2012) 24, 155--160; doi:10.1038/ijir.2012.8; published online 3 May 2012 Keywords: erectile dysfunction; prostatectomy; quality-of-life INTRODUCTION In many Western countries, prostate cancer has become the most frequently diagnosed cancer in the male population. In Germany, the current incidence is about 60 000 cases per year. 1 Since the introduction of prostate cancer screening, prostate cancer-specific incidence rates have doubled from approx. 50 per 100 000 in 1980 to approx. 100 in 2006. 2 Moreover, there has been a trend towards earlier-stage disease at presentation. 3,4 If detected in a localised state, the most common treatment for prostate cancer is radical prostatectomy (RP). RP can be performed in several ways. The classical approach is open retropubic prostatectomy. Furthermore, RP can be performed in a minimal- invasive laparoscopic way. Both surgical approaches have excellent survival outcomes. In Germany, the 5-year relative survival rate for prostate cancer is between 83 and 94%. 1 However, there are also strong side effects of RP, for example, erectile dysfunction (ED). 5 Depending on the surgical technique, patient age and other socio- demographic and clinical factors, ED rates differ a lot. Even 1 year after RP, ED occurs in about 12--83% of patients. 5--8 The current study is the first prospective multicentre study to compare the functional results of patients who underwent either radical retropubic prostatectomy (RRPE) or endoscopic extraper- itoneal radical prostatectomy (EERPE). In this paper, we report data related to the patients’ sexual life before (t baseline ), 3 months (t 3m ), 6 months (t 6m ) and 1 year (t 1yr ) after prostatectomy. The core question of the study was whether the nerve-sparing status and surgical approach had an effect on the patients’ sexual life in the first year after surgery. The preservation of neurovascular bundles is considered a prerequisite for regaining sexual function after surgery. 9,10 Thus, we expect significantly better sexual functioning in patients who had undergone nerve-sparing vs non-nerve-sparing surgery. As studies comparing RRPE with transperitoneal laparoscopic radical prostatectomy (a surgical approach similar to EERPE) suggest that there are no differences between both surgical techniques in terms of functional results, 11 we do not expect significant differences between RRPE and EERPE regarding sexual function either. In addition, the prevalence of ED before RP, determinants of erectile function (EF) and the extent of sexual activity (not restricted to sexual intercourse) were investigated. MATERIALS AND METHODS We conducted a multicentre, longitudinal study in seven German hospitals (located in the federal states of Saxony, Saxony--Anhalt and North Rhine- Westphalia). Patients received a questionnaire 1 day before surgery in the hospital and subsequently 3, 6 and 12 months after surgery by mail. Presurgical data collection was carried out between February 2008 and May 2009, and the subsequent data collection (1 year after surgery) was completed in June 2010. Recruitment In five participating centres, patients received the questionnaires from physicians, and in two centres patients were recruited by interviewers. EERPE was performed at two hospitals and RRPE was performed at five Received 21 September 2011; revised 20 January 2012; accepted 25 March 2012; published online 3 May 2012 1 Department of Medical Psychology and Medical Sociology, University of Leipzig, Germany; 2 Department of Urology, University of Leipzig, Germany; 3 Diakonissenkrankenhaus Dessau, Dessau, Germany; 4 Helios Klinikum Wuppertal, Germany; 5 Asklepios Klinik Weissenfels, Weissenfels, Germany; 6 Zeisigwaldkliniken Bethanien Chemnitz, Germany and 7 Knappschaftskrankenhaus Dortmund, Germany. Correspondence: N Koehler, Universitaetsklinikum Leipzig, Abteilung fuer Medizinische Psychologie und Medizinische Soziologie, Philipp-Rosenthal-Str. 55, 04103 Leipzig, Germany. E-mail: norbert.koehler@medizin.uni-leipzig.de International Journal of Impotence Research (2012) 24, 155 -- 160 & 2012 Macmillan Publishers Limited All rights reserved 0955-9930/12 www.nature.com/ijir