Preoperative and postoperative factors causing the erectile dysfunction after bladder neck and nerve sparing robot-assisted laparoscopic radical prostatectomy

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According to the treatment options, complications may also be seen and the most common complications are urinary incontinence and erectile dysfunction. In our study, preoperative and postoperative factors affecting erectile functions after bladder neck and nerve-sparing robot assisted laparoscopic radical prostatectomy. Between October 2016 and October 2023, a total of 500 patients had bladder neck and nerve sparing robotic radical prostatectomy. Preoperative and postoperative factors related with the erectile functions have been evaluated in detail. Before operations; age, comorbidity status (cigarette smoking, hypertension, diabetes mellitus, additional illnesses), total PSA, free PSA, free/total PSA ratio, RDE findings, Prostate MRI findings, PSA density using the MRI, CFPB results, staging results were also noted. After operations; pathology results, control PSA results, need for additional treatments, continuing control PSA results after the additional treatments were noted. The age, lymphovascular invasion at CFPB, perineural invasion and surgical margin positiveness at postoperative pathology were detected to be important possible factors for the cause of postoperative ED. There was also significant correlation between the surgical margin positiveness and perineural invasion at the postoperative pathology reports (p = 0.001) showing the neural invasion of the tumor.Postoperative ED is an important factor that must be considered in both preoperative and postoperative period. Factors associated with postoperative ED must be evaluated in detail in order to avoid ED and also postoperative ED must be treated with effective treatment modalities that have been described in the literature. Health sciences/Risk factors Health sciences/Diseases/Urogenital diseases erectile dysfunction prostate cancer radical prostatectomy Figures Figure 1 Introduction Prostate cancer (PCa) is a prevalent disease with good prognosis and approximately 100% disease-specific survival rate is observed for the patients with localized cancer that treated with radical prostatectomy.[ 1 ] PCa is the most commonly diagnosed cancer in elderly population and may be the most common non-cutaneous cancer among men.[ 2 ] Retropubic radical prostatectomy is the gold standart treatment for locally invasive PCa.[ 3 ] PCa is diagnosed for most of the cancer cases among male population and is treated with various treatment modalities such as watchfull waiting, active surveillance, radical prostatectomy, radiotherapy, hormone therapy, chemotherapy and other treatment options.[ 4 ] According to the treatment options, complications may also be seen and the most common complications are urinary incontinence and erectile dysfunction.[ 4 ] Studies have shown significantly increased risk of erectile dysfunction 12 months postoperatively.[ 5 ] Robotic versus open radical prostatectomy operations have been compared in terms of urinary incontinence and erectile dysfunction and studies pointed not statistically improvement for urinary leakage with robotic technique but a small improvement for erectile function with robot-assisted operation.[ 6 ] Robot-assisted laparoscopic prostatectomy (RALP) is the most common technique but the evidence that this technique causes less erectile dysfunction is still unclear.[ 3 ] Adjuvant radiotherapy administrations have also detrimental effects on recovery of erectile functions after bilateral nerve-sparing radical prostatectomy.[ 7 ] Studies showed a significant decrease in penile size after nerve-sparing radical retropubic prostatectomy.[ 8 ] Treatment with phosphodieasterase type-5 inhibitors(PDE5-Is) after radical prostatectomy is commonly used for preventing erectile dysfunction after radical prostatectomy.[ 2 ] Up to 10% of the patients had significant erection with sildenafil after non-nerve sparing radical prostatectomy according to the studies.[ 9 ] There are several techniques that have been described in order to get best postoperative potency outcomes but there is no consensus or standart technique.[ 10 ] Antegrade and retrograde nerve sparing approaches have been reported in the literature.[ 10 ] The important point is to preserve much periprostatic fascia(PPF) and atraumatic neurovascular bundle(NVB) dissection.[ 10 ] International Index of Erectile Function-5 (IIEF-5) is one of the most common questionnaire for evaluating erectile functions after radical prostatectomy.[ 4 ] Studies suggested that nerve-sparing radical prostatectomy should be planned independently of preoperative potency status if oncologically or technically suitable.[ 11 ] Also fascia preservation scores, patient’s age, preoperative IIEF scores, Charlson Comorbidity Index scores(CCIS) and the use of surgical clips were found to be predictors for postoperative erectile functions.[ 12 ] There are several factors that are affecting erectile functions and cause erectile dysfunction after radical prostatectomy. In our study, preoperative and postoperative factors affecting erectile function after bladder neck and nerve-sparing robot assisted laparoscopic radical prostatectomy have been evaluated. Materials and Methods This study was approved by the Ethical Committee of University of Health Sciences Gulhane Research and Training Hospital with the number of 2023 − 288. Institution’s review Board of Human Subject Guidelines were followed. Between October 2016 and October 2023, a total of 500 patients had bladder neck and nerve sparing robotic radical prostatectomy. Between these patients 175 of them reported having normal erectile function before the operations. These patients were followed carefully after the operations. Patients having normal erectile function peroperatively and having erectile dysfunction postoperatively were evaluated to reveal the possible causes of erection deficiency. Routinely, annual prostate cancer scanning is advised to the male population. Patients with total PSA(Prostate Specific Antigen) ≥ 2.5ng/ml were defined as having elevated PSA, and a second test was applied for the verification at the same diagnostic laboratory. During this scanning program, patients with verified elevated total PSA, and/or abnormal palpation of prostate on rectal digital examination (RDE) having more than 10-years life expectancy were directed firstly to the Multiparametric Magnetic Resonance of prostate (Prostate MRI) and then to the cognitive fusion prostate biopsy (CFPB). Prostate MRI was applied using Siemens 3T MRI machine. Prostate MRI findings were evaluated using the PIRADS Version 2.1 score declared in 2023 by the European Society of Urogenital Radiology and American College of Radiology. [ 13 – 15 ]However, for central gland lesions, we used the same PIRADS scoring system determined for transitional zone. An expert in CFPB for 10 years performed the standard transrectal ultrasound (TRUS)-guided prostate biopsy (TRUSPB) using a dual-plane ultrasound device and transrectal probe (Logic C5). A minimum of a 12-core TRUSPB was applied using an 18-gauge trucut biopsy needle gun. The same expert applied CFPB by examining the Multiparametric Prostate MRI findings nearby the TRUS device while applying the TRUSPB. Minimum 12 cores sextant biopsy and additional cognitive targeted biopsies were taken. However, if the PIRADS score was 1, 2, or 3, CFPB couldn’t be applied in a good fashion and the targeted biopsy was taken focusing on the blurred area. We didn’t ignore biopsy for PIRADS 1, 2, or 3 patients. The major exclusion criteria for CFPB were the patients with less than 10-years life expectancy, despite the elevated PSA and/or abnormal RDE. After the pathologic evaluation, patients having prostate cancer (PCa) were classified according to D’Amico risk classification. [ 16 ]Patients classified over the low risk had a staging protocol using Ga 68 -PSMA-ligand PET/CT scintigraphy, Thoracoabdominopelvic Computed Tomography, and/or bone scintigraphy. Low risk patients didn’t have a staging protocol as suggested in the EAU 2024 guidelines.[ 16 ] Localized patients suitable for the radical prostatectomy were directed to bladder neck and nerve sparing robotic radical prostatectomy. Before the operations, International Index of Erectile Functions-5 (IIEF-5) form was fulfilled to determine the preoperative erection status. After the operations, one year follow up results of same IIEF-5 parameters were noted. Patients having erection function score ≥ 26 were defined as having normal erectile function. Patients having erection function score ≤ 25 were defined as having erectile dysfunction. Before operations; age, comorbidity status (cigarette smoking, hypertension, diabetes mellitus, additional illnesses), total PSA, free PSA, free/total PSA ratio, RDE findings, Prostate MRI findings, PSA density using the MRI, CFPB results, staging results were also noted. After operations; pathology results, control PSA results, need for additional treatments, continuing control PSA results after the additional treatments were noted. Total PSA ≥ 0.2ng/ml was defined as biochemically recurrence. Comparing these factors for patients having normal erectile function preoperatively and erectile dysfunction postoperatively, we tried to find the possible risk factors for postoperative erectile dysfunction. Statistical Analysis Statistical analysis was performed using Statistical Package for Social Sciences 26.0 software (SPSS 26.0 for Windows) (Chicago, USA) by an expert biomedical statistician. The Shapiro-Wilk, Kolmogorov-Smirnov, Kurtosis, and Skewness tests were used to assess the normality of the variables. Descriptive statistics of nominal samples were expressed with numbers and percentiles. Descriptive statistics of scale samples were expressed in median, mean ± standard deviation (minimum-maximum), because most of our parameters were not normally distributed. Chi-Square Test was used to compare the independent nominal parameters. Enter Logistic Regression Analyze was used to detect the important parameters for postoperative ED. ROC curve analyze was used to detect the sensitivity and specificity of patient age for ED. A cut-off age was detected equaled to %90 sensitivity and %90 specificity for having normal erectile function after operations. P < 0.05 was accepted as statistically significant. Results A total of 175 patients with normal erectile function had bladder neck and nerve sparing robotic radical prostatectomy due to the localized prostate cancer. Patients’ mean age was 68.96 ± 6.59 (43–75). The 81 patients were smoker, 71 patients had hypertension, 42 had diabetes mellitus, 31 had coronary artery disease, 10 had chronic obstructive pulmonary disease. The median and mean PSA value was 7.75 and 13.07 ± 26.06 (2.3–310) ng/ml. The median and mean free PSA value was 1.03 and 1.51 ± 1.97 (0.32-20) ng/ml. The median and mean free/total PSA ratio was 11% and 13%±9% (0–80%). There were only 6 (3%) patients with RDE pathology. Two (1%) had a nodule at prostate, 4 (2%) had the thickness of the full prostate. The Prostate MRI revealed 3 (3%) PIRADS 1, 30 (17%) PIRADS 2, 31 (18%) PIRADS 3, 71 (40%) PIRADS 4, and 40 (22%) PIRADS 5 lesions. Mean prostate volume was 67 ± 42 (24–123) ml. The median and mean PSAD was 0.20 and 0.29 ± 0.32 (0.04–2.36). The pathologic results of CFPB revealed 95 (55%) patients with gleason 3 + 3, 30 (17%) with 3 + 4, 19 (11%) with 4 + 3, 18(10%) with 4 + 4, 8(4%) with 4 + 5, 5 (3%) with 5 + 3. The median and mean tumor percentage compared to the all sampled prostatic tissue was calculated to be 10% and 16.7%±19.18% (1–90%). There were 31 perineural invasion, 9 high grade (Prostatic Intraepithelial Neoplasia (PIN), 1 intraductal carsinoma, no extraprostatic involvement, no seminal vesicula invasion, no lymphovascular invasion at the results of CFPB. 49 patients (28%) having PSA < 10ng/ml and gleason 3 + 3 prostate cancer classified as low risk according to to D’Amico risk classification and they were not directed to the staging imaging protocol. The remaining 126 patients (72%) were classified over low risk and had the staging protocol using either Ga 68 -PSMA-ligand PET/CT scintigraphy, thoracoabdominopelvic computed tomography, and/or bone scintigraphy. The 40 (22%) of the 126 patients had Ga 68 -PSMA-ligand PET/CT scintigraphy. There were 6 (3%) pathologic iliac lymph node involvement, and 1 (0.5%) focal bone metastasis at the iliac bone. The 86(49%) of 126 patients had thoracoabdominopelvic computed tomography, and/or bone scintigraphy. There were 1 (0.5%) pathologic iliac lymph node involvement and 1 (0.5%) focal bone metastasis. The pathologic results revealed 44 (55%) Gleason 3 + 3, 51 (17%) Gleason 3 + 4, 28 (11%) Gleason 4 + 3, 10(10%) Gleason 4 + 4, 3 Gleason 3 + 5, 4 Gleason 4 + 5, and 1 Gleason 5 + 4. There were 107 perineural invasions, 27 high grade PIN, 1 intraductal carcinoma, 47 surgical margin positivenesses, 15 seminal vesicula invasions, 15 lymphovascular invasions, 2 bladder neck involvements at the postoperative pathology. The median and mean tumor percentage compared to all prostatic tissue was calculated to be 10% and 16.26%±17.88% (1–90%). Comparing the preoperative CFPB and postoperative pathologic results, we detected an increased rate of Gleason score in the patients with preoperative Gleason 3 + 3 score, they mostly increased to Gleason 4 + 3 (p = 0.044). The patients having Gleason score over 3 + 3 didn’t have a significant increase after the operations (p = 0.571). Over all, the general total Gleason score change was not statistically different after operations (p = 0.117). The difference was also not significant for preoperative and postoperative other pathologic parameters mentioned above (p = 399). After the operations, there were 7,4,2,3,3,2,2,3,7,7 and 4 patients having biochemically recurrence at 3,6,9,12,15,18,21,24,36,48 and 60th month follow up periods, respectively. Other 131(74%) patients were recurrence free after the operations. These 44 (26%) patients with recurrences were directed to radiotherapy and castration hormonal therapy as secondary treatment modality after the detection of biochemical recurrence. After the secondary treatment modalities, all PSA values decreased to a nadir state. The postoperative ED were reported in 113 (64%) of patients in the 12th month follow up. The remaining 62 (36%) patients did not report ED. We analyzed/compared all the parameters mentioned in the material and methods section between patients having ED and normal erectile function. The age, lymphovascular invasion at CFPB, perineural invasion and surgical margin positiveness at postoperative pathology were detected to be important possible factors for the cause of postoperative ED (Table 1 ). Table 1 Possible factors which may cause erectile dysfunction after bladder neck and nerve sparing robotic radical prostatectomy. Factors P* value Odds ratio Age 0.014 0.993 Cigarette smoking 0.380 0.701 Hypertension 0.963 1.083 Diabetes Mellitus 0.538 1.289 Any other chronic illnesses 0.359 1.042 Total PSA 0.183 0.959 Free PSA 0.201 0.706 Free/Total PSA 0.718 2.620 Prostate MRI PIRADS score 0.186 0.741 PSAD 0.058 0.500 Preoperative total gleason score 0.709 0.905 Preoperative tumor percentage at prostate biopsy 0.372 0.989 Lymphovascular invasion at preoperative biopsy 0.001 0.537 Perineural invasion at preoperative biopsy 0.601 0.788 High grade PIN at preoperative biopsy 0.370 0.516 Any lesion at preoperative staging techniques 0.741 1.333 Postoperative total gleason score 0.149 0.692 Tumor percentage at postoperative pathology 0.306 0.988 Perineural invasion at postoperative pathology 0.012 2.888 Surgical margin positiveness at postoperative pathology 0.022 2.784 Lymphovascular invasion at postoperative pathology 0.363 1.857 High grade PIN at postoperative pathology 0.849 1.094 Seminal vesicle invasion at postoperative pathology 0.363 1.857 Bladder neck involvement at postoperative pathology 0.610 0.483 Having postoperative 3th PSA recurrence 0.244 3.547 Having postoperative 6th PSA recurrence 0.660 1.680 Having postoperative 9th PSA recurrence 0.413 0.306 Having postoperative 12th PSA recurrence 0.964 0.945 * Enter Logistic Regression After these results, we tried to find the best patient age for having normal erectile function after the operations. The age 58 was detected to be a cut off with %90 sensitivity and %90 specificity for having a normal erectile function. The patients < 58 years would not have ED with %90 sensitivity and %90 specificity. There was also significant correlation between the surgical margin positiveness and perineural invasion at the postoperative pathology reports (p = 0.001) showing the neural invasion of the tumor. Comparing the positive surgical margin locations for erectile dysfunction, there was no difference among lateral, posterior, anterior or apical locations (p = 0.837). This showed the complexity of neural fibers surrounding the prostate. The age was also analyzed for the prediction of surgical margin positiveness or perineural invasion, but it was not detected to be a predictive factor for surgical margin positiveness (p = 0.694). There was also no difference in biochemically recurrence rate between patients with normal erectile function and ED (p = 0.742) (Fig. 1 ). Discussion Postoperative erectile dysfunction is one of the most unwanted condition by patients after radical prostatectomy and they are highly concerned about the possibility of having ED.[ 17 ] Higher Gleason Scores were found to have possible effects on preoperative erectile functions.[ 17 ] Penile rehabilitation is necessary for all patients but younger patients have better results and quick recovery.[ 17 ] In our study, patient’s age was found to be statistically significant variable for postoperative erectile dysfunction. Preoperative ED has been shown to be associated with lower overall survival and survival from causes other than prostate cancer after radical prostatectomy.[ 18 ] Men with ED should be evaluated for cardiovascular risk factors and there must be preventive strategies for cardiovascular events.[ 18 ] Additional diseases such as hypertension, diabetes mellitus also other chronic diseases were not found to be statistically significant. Preoperative factors were also evaluated for the association with postoperative erectile dysfunction. Total PSA levels, Free PSA levels, Free/Total Ratio, Prostate MRI PIRADS scores, PSA density, preoperative total gleason score, preoperative tumor percentage at prostate biopsy, perineural invasion at preoperative biopsy and presence of high grade PIN at preoperative biopsy were not found to be statistically significant factors for postoperative ED. Only lymphovascular invasion at preoperative biopsy were found to be statistically significant for postoperative ED. Postoperative factors would be also associated with postoperative ED. These factors have been evaluated in detail in our study. Postoperative total gleason score, lymphovascular invasion at postoperative pathology, presence of high grade PIN, seminal vesicle invasion and bladder neck involvement at postoperative pathology and having postoperative PSA recurrence were not found to be statistically significant for postoperative ED. Preineural invasion and surgical margin positiveness at postoperative pathology were found to be statistically significant factors for postoperative ED. Several treatment modalities have been advised for postoperative ED and penile rehabilitation. Studies indicate PDE5-Is as the primary treatment option for post bilateral nerve-sparing radical prostatectomy ED.[ 1 ] Beneficial outcomes have been shown with the use of PDE5-Is comparing to placebo but the effect is often ends after the use of PDE5-Is.[ 3 ] In a study, subgroup analysis revealed less side effects with the use of daily PDE5-Is than on demand use of PDE5-Is.[ 19 ] Once daily use of Udenafil 75mg has been shown as an effective option for improving erectile function after bilateral nerve sparing robot-assisted laparoscopic prostatectomy(BNS-RALP).[ 20 ] Avanafil 200mg on demand has been shown to be the best treatment among PDE5-Is for the treatment of ED after nerve-sparing radical prostatectomy(NSRP).[ 2 ] However patients with venogenic ED were shown to have limited response when comparing to the patients with arteriogenic ED, Tadalafil 5mg daily intake was well-tolerated and signifigantly improved erectile functions.[ 21 ] Studies showed the efficacy of regular regimen of PDE5-Is for short term treatments and both regular and on-demand regimens for long term treatments.[ 22 ] Also Vacuum erection device, intracavernous injection and medicated urethral system for erections have also been pointed as promising treatment options.[ 3 ] Stem cell therapy is a promising and effective option for various diseases.[ 23 ] Autologous Adipose-Derived Regenerative Cells(ADRC) have been shown as safe and effective treatment options for erectile dysfunction after radical prostatectomy.[ 23 ] Low-intensity shockwave therapy (Li-ESWT) was shown as a safe treatment option that improves erectile functions and the therapy increased IIEF-5 and EHS scores after radical prostatectomy.[ 24 ] Studies have shown the positive effects of pelvic floor muscle training on quality of life after radical prostatectomy with positive outcomes for continence and penile rehabilitation.[ 25 ] Also preoperative physiotherapeutic interventions using biofeedback protocol was shown to be effective in decreasing the rate of urinary incontinence and erectile dysfunction after radical prostatectomy.[ 26 ] Prostate cancer is common cancer type among male population and surgical treatment modalities would affect postoperative quality of life with the effects on postoperative erectile functions. Postoperative ED is an important factor that must be considered in both preoperative and postoperative period. Factors associated with postoperative ED must be evaluated in detail in order to avoid ED and also postoperative ED must be treated with effective treatment modalities that have been described in the literature. Additional studies including more patients and more factors must be conducted in the following period for defining the needs and the realities for preoperative prevention and postoperative treatment of ED. Limitations The number of patients that have been included in our study is the main limitation. Follow-up periods, preoperative and postoperative additional factors must be considered in detail. Declarations Acknowledgements: Special thanks to the biochemistry laboratory team of Gulhane Research and Training Hospital for their essential assistance. Author Contributions: SS, TE designing and writing the manuscript, MSB collecting and extracting data, HGİ and SB supervising manuscript writing. Funding: No financial assistance was received in support of the study. Ethical Approval: This study was approved by the Ethical Committee of University of Health Sciences Gulhane Research and Training Hospital with the number of 2023-288. Institution’s review Board of Human Subject Guidelines were followed. Competing Interests: There are no competing financial interests. Data Availability Statement: The data of infertile male patients has been generated and analysed with using the hospital records and patient statements. Additional data are available from the corresponding author on reasonable request. References Wang X, Wang X, Liu T, He Q, Wang Y, Zhang X. Systematic review and meta-analysis of the use of phosphodiesterase type 5 inhibitors for treatment of erectile dysfunction following bilateral nerve-sparing radical prostatectomy. PLoS One. 2014;9(3):e91327. doi: 10.1371/journal.pone.0091327 . Yang J, Jian ZY, Wang J. Phosphodiesterase type-5 inhibitors for erectile dysfunction following nerve-sparing radical prostatectomy: A network meta-analysis. Medicine (Baltimore). 2021;100(8):e23778. doi: 10.1097/MD.0000000000023778 . Whelan P, Ekbal S, Nehra A. Erectile dysfunction in robotic radical prostatectomy: Outcomes and management. Indian J Urol. 2014;30(4):434–42. doi: 10.4103/0970-1591.142078 . Jurys T, Burzynski B, Potyka A, Paradysz A. Post-Radical Prostatectomy Erectile Dysfunction Assessed Using the IIEF-5 Questionnaire - A Systematic Literature Review. Int J Sex Health. 2022;34(1):55–64. doi: 10.1080/19317611.2021.1936333 . Geiger-Gritsch S, Oberaigner W, Muhlberger N, Siebert U, Ladurner M, Klocker H, et al. Patient-reported urinary incontinence and erectile dysfunction following radical prostatectomy: results from the European Prostate Centre Innsbruck. Urol Int. 2015;94(4):419–27. doi: 10.1159/000369475 . Haglind E, Carlsson S, Stranne J, Wallerstedt A, Wilderang U, Thorsteinsdottir T, et al. Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial. Eur Urol. 2015;68(2):216–25. doi: 10.1016/j.eururo.2015.02.029 . Gandaglia G, Lista G, Fossati N, Suardi N, Gallina A, Moschini M, et al. Non-surgically related causes of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Prostate Cancer Prostatic Dis. 2016;19(2):185–90. doi: 10.1038/pcan.2016.1 . Fraiman MC, Lepor H, McCullough AR. Changes in Penile Morphometrics in Men with Erectile Dysfunction after Nerve-Sparing Radical Retropubic Prostatectomy. Mol Urol. 1999;3(2):109–15. Gontero P, Fontana F, Zitella A, Montorsi F, Frea B. A prospective evaluation of efficacy and compliance with a multistep treatment approach for erectile dysfunction in patients after non-nerve sparing radical prostatectomy. BJU Int. 2005;95(3):359–65. doi: 10.1111/j.1464-410X.2005.05300.x . Basourakos SP, Kowalczyk K, Moschovas MC, Dudley V, Hung AJ, Shoag JE, et al. Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation. J Endourol. 2021;35(11):1601–9. doi: 10.1089/end.2021.0081 . Khoder WY, Waidelich R, Seitz M, Becker AJ, Buchner A, Trittschler S, et al. Do we need the nerve sparing radical prostatectomy techniques (intrafascial vs. interfascial) in men with erectile dysfunction? Results of a single-centre study. World J Urol. 2015;33(3):301–7. doi: 10.1007/s00345-014-1302-9 . KleinJan GH, Sikorska K, Korne CM, Brouwer OR, Buckle T, Tillier C, et al. A prediction model relating the extent of intraoperative fascia preservation to erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy. J Robot Surg. 2019;13(3):455–62. doi: 10.1007/s11701-018-0867-5 . Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012;22(4):746–57. doi: 10.1007/s00330-011-2377-y . Hamoen EHJ, de Rooij M, Witjes JA, Barentsz JO, Rovers MM. Use of the Prostate Imaging Reporting and Data System (PI-RADS) for Prostate Cancer Detection with Multiparametric Magnetic Resonance Imaging: A Diagnostic Meta-analysis. Eur Urol. 2015;67(6):1112–21. doi: 10.1016/j.eururo.2014.10.033 . Ponsiglione A, Brembilla G, Cuocolo R, Gutierrez P, Moreira AS, Pecoraro M, et al. ESR Essentials: using the right scoring system in prostate MRI-practice recommendations by ESUR. Eur Radiol. 2024;34(11):7481–91. doi: 10.1007/s00330-024-10792-7 . Cornford P, van den Bergh RCN, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2024;86(2):148–63. doi: 10.1016/j.eururo.2024.03.027 . Pikramenos K, Zachou M, Papadopoulos D, Papatsoris A, Varkarakis I, Mitsogiannis I. Post Radical Prostatectomy Erectile Dysfunction. A Single Centre Experience. Cureus. 2023;15(2):e34601. doi: 10.7759/cureus.34601 . Han M, Trock BJ, Partin AW, Humphreys EB, Bivalacqua TJ, Guzzo TJ, et al. The impact of preoperative erectile dysfunction on survival after radical prostatectomy. BJU Int. 2010;106(11):1612–7. doi: 10.1111/j.1464-410X.2010.09472.x . Goh HJ, Sung JM, Lee KH, Jo JK, Kim KN. Efficacy of phosphodiesterase type 5 inhibitors in patients with erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis. Transl Androl Urol. 2022;11(2):124–38. doi: 10.21037/tau-21-881 . Chung JH, Kwon TG, Kwak C, Sung GT, Kim SD, Cho JS, et al. Efficacy and Safety of Udenafil Once Daily in Patients with Erectile Dysfunction after Bilateral Nerve-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blind, Placebo-Controlled Study. World J Mens Health. 2023;41(3):612–22. doi: 10.5534/wjmh.220057 . Kim S, Sung GT. Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up. Sex Med. 2018;6(2):108–14. doi: 10.1016/j.esxm.2017.12.005 . Tian D, Wang XY, Zong HT, Zhang Y. Efficacy and safety of short- and long-term, regular and on-demand regimens of phosphodiesterase type 5 inhibitors in treating erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis. Clin Interv Aging. 2017;12:405–12. doi: 10.2147/CIA.S122273 . Haahr MK, Jensen CH, Toyserkani NM, Andersen DC, Damkier P, Sorensen JA, et al. Safety and Potential Effect of a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial. EBioMedicine. 2016;5:204–10. doi: 10.1016/j.ebiom.2016.01.024 . Ladegaard PBJ, Mortensen J, Skov-Jeppesen SM, Lund L. Erectile Dysfunction A Prospective Randomized Placebo-Controlled Study Evaluating the Effect of Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT) in Men With Erectile Dysfunction Following Radical Prostatectomy. Sex Med. 2021;9(3):100338. doi: 10.1016/j.esxm.2021.100338 . Milios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. Sex Med. 2020;8(3):414–21. doi: 10.1016/j.esxm.2020.03.005 . Perez FSB, Rosa NC, da Rocha AF, Peixoto LRT, Miosso CJ. Effects of Biofeedback in Preventing Urinary Incontinence and Erectile Dysfunction after Radical Prostatectomy. Front Oncol. 2018;8:20. doi: 10.3389/fonc.2018.00020 . Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5705798","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":397346784,"identity":"bcd41028-c3b3-455c-83ac-6df8f0428017","order_by":0,"name":"Selcuk Sarikaya","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-6426-1398","institution":"Gulhane Research and Training Hospital","correspondingAuthor":true,"prefix":"","firstName":"Selcuk","middleName":"","lastName":"Sarikaya","suffix":""},{"id":397346785,"identity":"8e931f4d-58ea-4089-9eb4-4394002cc636","order_by":1,"name":"Turgay Ebiloglu","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Turgay","middleName":"","lastName":"Ebiloglu","suffix":""},{"id":397346786,"identity":"9bf27a9b-5c23-4cac-813b-d1d8e2d07cec","order_by":2,"name":"Mehmet Buyantemur","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Buyantemur","suffix":""},{"id":397346787,"identity":"12af4a29-5a78-40a4-85bf-545c618af282","order_by":3,"name":"Halil Inal","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Halil","middleName":"","lastName":"Inal","suffix":""},{"id":397346788,"identity":"be325825-8d9d-4c4b-a7ed-317b29582744","order_by":4,"name":"Selahattin Bedir","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Selahattin","middleName":"","lastName":"Bedir","suffix":""}],"badges":[],"createdAt":"2024-12-24 11:15:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5705798/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5705798/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73051583,"identity":"82c34eb0-f9cd-48fe-982d-3eac3f33aed1","added_by":"auto","created_at":"2025-01-06 09:30:18","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56843,"visible":true,"origin":"","legend":"\u003cp\u003eThe relation between the PSA recurrence and Erectile Dysfunction status.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5705798/v1/20d3eedc021979019879bf45.jpeg"},{"id":76306321,"identity":"0a0a2405-a103-48b3-a585-7a04e4c223b2","added_by":"auto","created_at":"2025-02-14 14:45:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":687817,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5705798/v1/74e03df5-f6b3-4757-b642-5ce58b384a84.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Preoperative and postoperative factors causing the erectile dysfunction after bladder neck and nerve sparing robot-assisted laparoscopic radical prostatectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProstate cancer (PCa) is a prevalent disease with good prognosis and approximately 100% disease-specific survival rate is observed for the patients with localized cancer that treated with radical prostatectomy.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] PCa is the most commonly diagnosed cancer in elderly population and may be the most common non-cutaneous cancer among men.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Retropubic radical prostatectomy is the gold standart treatment for locally invasive PCa.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] PCa is diagnosed for most of the cancer cases among male population and is treated with various treatment modalities such as watchfull waiting, active surveillance, radical prostatectomy, radiotherapy, hormone therapy, chemotherapy and other treatment options.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] According to the treatment options, complications may also be seen and the most common complications are urinary incontinence and erectile dysfunction.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Studies have shown significantly increased risk of erectile dysfunction 12 months postoperatively.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Robotic versus open radical prostatectomy operations have been compared in terms of urinary incontinence and erectile dysfunction and studies pointed not statistically improvement for urinary leakage with robotic technique but a small improvement for erectile function with robot-assisted operation.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Robot-assisted laparoscopic prostatectomy (RALP) is the most common technique but the evidence that this technique causes less erectile dysfunction is still unclear.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Adjuvant radiotherapy administrations have also detrimental effects on recovery of erectile functions after bilateral nerve-sparing radical prostatectomy.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Studies showed a significant decrease in penile size after nerve-sparing radical retropubic prostatectomy.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Treatment with phosphodieasterase type-5 inhibitors(PDE5-Is) after radical prostatectomy is commonly used for preventing erectile dysfunction after radical prostatectomy.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Up to 10% of the patients had significant erection with sildenafil after non-nerve sparing radical prostatectomy according to the studies.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] There are several techniques that have been described in order to get best postoperative potency outcomes but there is no consensus or standart technique.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Antegrade and retrograde nerve sparing approaches have been reported in the literature.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The important point is to preserve much periprostatic fascia(PPF) and atraumatic neurovascular bundle(NVB) dissection.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] International Index of Erectile Function-5 (IIEF-5) is one of the most common questionnaire for evaluating erectile functions after radical prostatectomy.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Studies suggested that nerve-sparing radical prostatectomy should be planned independently of preoperative potency status if oncologically or technically suitable.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Also fascia preservation scores, patient\u0026rsquo;s age, preoperative IIEF scores, Charlson Comorbidity Index scores(CCIS) and the use of surgical clips were found to be predictors for postoperative erectile functions.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] There are several factors that are affecting erectile functions and cause erectile dysfunction after radical prostatectomy. In our study, preoperative and postoperative factors affecting erectile function after bladder neck and nerve-sparing robot assisted laparoscopic radical prostatectomy have been evaluated.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This study was approved by the Ethical Committee of University of Health Sciences Gulhane Research and Training Hospital with the number of 2023\u0026thinsp;\u0026minus;\u0026thinsp;288. Institution\u0026rsquo;s review Board of Human Subject Guidelines were followed.\u003c/p\u003e \u003cp\u003eBetween October 2016 and October 2023, a total of 500 patients had bladder neck and nerve sparing robotic radical prostatectomy. Between these patients 175 of them reported having normal erectile function before the operations. These patients were followed carefully after the operations. Patients having normal erectile function peroperatively and having erectile dysfunction postoperatively were evaluated to reveal the possible causes of erection deficiency.\u003c/p\u003e \u003cp\u003eRoutinely, annual prostate cancer scanning is advised to the male population. Patients with total PSA(Prostate Specific Antigen)\u0026thinsp;\u0026ge;\u0026thinsp;2.5ng/ml were defined as having elevated PSA, and a second test was applied for the verification at the same diagnostic laboratory.\u003c/p\u003e \u003cp\u003eDuring this scanning program, patients with verified elevated total PSA, and/or abnormal palpation of prostate on rectal digital examination (RDE) having more than 10-years life expectancy were directed firstly to the Multiparametric Magnetic Resonance of prostate (Prostate MRI) and then to the cognitive fusion prostate biopsy (CFPB).\u003c/p\u003e \u003cp\u003eProstate MRI was applied using Siemens 3T MRI machine. Prostate MRI findings were evaluated using the PIRADS Version 2.1 score declared in 2023 by the European Society of Urogenital Radiology and American College of Radiology. [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]However, for central gland lesions, we used the same PIRADS scoring system determined for transitional zone.\u003c/p\u003e \u003cp\u003eAn expert in CFPB for 10 years performed the standard transrectal ultrasound (TRUS)-guided prostate biopsy (TRUSPB) using a dual-plane ultrasound device and transrectal probe (Logic C5). A minimum of a 12-core TRUSPB was applied using an 18-gauge trucut biopsy needle gun. The same expert applied CFPB by examining the Multiparametric Prostate MRI findings nearby the TRUS device while applying the TRUSPB. Minimum 12 cores sextant biopsy and additional cognitive targeted biopsies were taken. However, if the PIRADS score was 1, 2, or 3, CFPB couldn\u0026rsquo;t be applied in a good fashion and the targeted biopsy was taken focusing on the blurred area. We didn\u0026rsquo;t ignore biopsy for PIRADS 1, 2, or 3 patients.\u003c/p\u003e \u003cp\u003eThe major exclusion criteria for CFPB were the patients with less than 10-years life expectancy, despite the elevated PSA and/or abnormal RDE.\u003c/p\u003e \u003cp\u003eAfter the pathologic evaluation, patients having prostate cancer (PCa) were classified according to D\u0026rsquo;Amico risk classification. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]Patients classified over the low risk had a staging protocol using Ga\u003csup\u003e68\u003c/sup\u003e-PSMA-ligand PET/CT scintigraphy, Thoracoabdominopelvic Computed Tomography, and/or bone scintigraphy. Low risk patients didn\u0026rsquo;t have a staging protocol as suggested in the EAU 2024 guidelines.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Localized patients suitable for the radical prostatectomy were directed to bladder neck and nerve sparing robotic radical prostatectomy.\u003c/p\u003e \u003cp\u003eBefore the operations, International Index of Erectile Functions-5 (IIEF-5) form was fulfilled to determine the preoperative erection status. After the operations, one year follow up results of same IIEF-5 parameters were noted. Patients having erection function score\u0026thinsp;\u0026ge;\u0026thinsp;26 were defined as having normal erectile function. Patients having erection function score\u0026thinsp;\u0026le;\u0026thinsp;25 were defined as having erectile dysfunction.\u003c/p\u003e \u003cp\u003eBefore operations; age, comorbidity status (cigarette smoking, hypertension, diabetes mellitus, additional illnesses), total PSA, free PSA, free/total PSA ratio, RDE findings, Prostate MRI findings, PSA density using the MRI, CFPB results, staging results were also noted.\u003c/p\u003e \u003cp\u003eAfter operations; pathology results, control PSA results, need for additional treatments, continuing control PSA results after the additional treatments were noted. Total PSA\u0026thinsp;\u0026ge;\u0026thinsp;0.2ng/ml was defined as biochemically recurrence.\u003c/p\u003e \u003cp\u003eComparing these factors for patients having normal erectile function preoperatively and erectile dysfunction postoperatively, we tried to find the possible risk factors for postoperative erectile dysfunction.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using Statistical Package for Social Sciences 26.0 software (SPSS 26.0 for Windows) (Chicago, USA) by an expert biomedical statistician. The Shapiro-Wilk, Kolmogorov-Smirnov, Kurtosis, and Skewness tests were used to assess the normality of the variables. Descriptive statistics of nominal samples were expressed with numbers and percentiles. Descriptive statistics of scale samples were expressed in median, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (minimum-maximum), because most of our parameters were not normally distributed. Chi-Square Test was used to compare the independent nominal parameters. Enter Logistic Regression Analyze was used to detect the important parameters for postoperative ED. ROC curve analyze was used to detect the sensitivity and specificity of patient age for ED. A cut-off age was detected equaled to %90 sensitivity and %90 specificity for having normal erectile function after operations. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was accepted as statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 175 patients with normal erectile function had bladder neck and nerve sparing robotic radical prostatectomy due to the localized prostate cancer. Patients\u0026rsquo; mean age was 68.96\u0026thinsp;\u0026plusmn;\u0026thinsp;6.59 (43\u0026ndash;75). The 81 patients were smoker, 71 patients had hypertension, 42 had diabetes mellitus, 31 had coronary artery disease, 10 had chronic obstructive pulmonary disease. The median and mean PSA value was 7.75 and 13.07\u0026thinsp;\u0026plusmn;\u0026thinsp;26.06 (2.3\u0026ndash;310) ng/ml. The median and mean free PSA value was 1.03 and 1.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97 (0.32-20) ng/ml. The median and mean free/total PSA ratio was 11% and 13%\u0026plusmn;9% (0\u0026ndash;80%).\u003c/p\u003e \u003cp\u003eThere were only 6 (3%) patients with RDE pathology. Two (1%) had a nodule at prostate, 4 (2%) had the thickness of the full prostate. The Prostate MRI revealed 3 (3%) PIRADS 1, 30 (17%) PIRADS 2, 31 (18%) PIRADS 3, 71 (40%) PIRADS 4, and 40 (22%) PIRADS 5 lesions. Mean prostate volume was 67\u0026thinsp;\u0026plusmn;\u0026thinsp;42 (24\u0026ndash;123) ml. The median and mean PSAD was 0.20 and 0.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32 (0.04\u0026ndash;2.36).\u003c/p\u003e \u003cp\u003eThe pathologic results of CFPB revealed 95 (55%) patients with gleason 3\u0026thinsp;+\u0026thinsp;3, 30 (17%) with 3\u0026thinsp;+\u0026thinsp;4, 19 (11%) with 4\u0026thinsp;+\u0026thinsp;3, 18(10%) with 4\u0026thinsp;+\u0026thinsp;4, 8(4%) with 4\u0026thinsp;+\u0026thinsp;5, 5 (3%) with 5\u0026thinsp;+\u0026thinsp;3. The median and mean tumor percentage compared to the all sampled prostatic tissue was calculated to be 10% and 16.7%\u0026plusmn;19.18% (1\u0026ndash;90%). There were 31 perineural invasion, 9 high grade (Prostatic Intraepithelial Neoplasia (PIN), 1 intraductal carsinoma, no extraprostatic involvement, no seminal vesicula invasion, no lymphovascular invasion at the results of CFPB.\u003c/p\u003e \u003cp\u003e49 patients (28%) having PSA\u0026thinsp;\u0026lt;\u0026thinsp;10ng/ml and gleason 3\u0026thinsp;+\u0026thinsp;3 prostate cancer classified as low risk according to to D\u0026rsquo;Amico risk classification and they were not directed to the staging imaging protocol.\u003c/p\u003e \u003cp\u003eThe remaining 126 patients (72%) were classified over low risk and had the staging protocol using either Ga\u003csup\u003e68\u003c/sup\u003e-PSMA-ligand PET/CT scintigraphy, thoracoabdominopelvic computed tomography, and/or bone scintigraphy.\u003c/p\u003e \u003cp\u003eThe 40 (22%) of the 126 patients had Ga\u003csup\u003e68\u003c/sup\u003e-PSMA-ligand PET/CT scintigraphy. There were 6 (3%) pathologic iliac lymph node involvement, and 1 (0.5%) focal bone metastasis at the iliac bone.\u003c/p\u003e \u003cp\u003eThe 86(49%) of 126 patients had thoracoabdominopelvic computed tomography, and/or bone scintigraphy. There were 1 (0.5%) pathologic iliac lymph node involvement and 1 (0.5%) focal bone metastasis.\u003c/p\u003e \u003cp\u003eThe pathologic results revealed 44 (55%) Gleason 3\u0026thinsp;+\u0026thinsp;3, 51 (17%) Gleason 3\u0026thinsp;+\u0026thinsp;4, 28 (11%) Gleason 4\u0026thinsp;+\u0026thinsp;3, 10(10%) Gleason 4\u0026thinsp;+\u0026thinsp;4, 3 Gleason 3\u0026thinsp;+\u0026thinsp;5, 4 Gleason 4\u0026thinsp;+\u0026thinsp;5, and 1 Gleason 5\u0026thinsp;+\u0026thinsp;4.\u003c/p\u003e \u003cp\u003eThere were 107 perineural invasions, 27 high grade PIN, 1 intraductal carcinoma, 47 surgical margin positivenesses, 15 seminal vesicula invasions, 15 lymphovascular invasions, 2 bladder neck involvements at the postoperative pathology.\u003c/p\u003e \u003cp\u003eThe median and mean tumor percentage compared to all prostatic tissue was calculated to be 10% and 16.26%\u0026plusmn;17.88% (1\u0026ndash;90%).\u003c/p\u003e \u003cp\u003eComparing the preoperative CFPB and postoperative pathologic results, we detected an increased rate of Gleason score in the patients with preoperative Gleason 3\u0026thinsp;+\u0026thinsp;3 score, they mostly increased to Gleason 4\u0026thinsp;+\u0026thinsp;3 (p\u0026thinsp;=\u0026thinsp;0.044). The patients having Gleason score over 3\u0026thinsp;+\u0026thinsp;3 didn\u0026rsquo;t have a significant increase after the operations (p\u0026thinsp;=\u0026thinsp;0.571). Over all, the general total Gleason score change was not statistically different after operations (p\u0026thinsp;=\u0026thinsp;0.117). The difference was also not significant for preoperative and postoperative other pathologic parameters mentioned above (p\u0026thinsp;=\u0026thinsp;399).\u003c/p\u003e \u003cp\u003eAfter the operations, there were 7,4,2,3,3,2,2,3,7,7 and 4 patients having biochemically recurrence at 3,6,9,12,15,18,21,24,36,48 and 60th month follow up periods, respectively. Other 131(74%) patients were recurrence free after the operations. These 44 (26%) patients with recurrences were directed to radiotherapy and castration hormonal therapy as secondary treatment modality after the detection of biochemical recurrence. After the secondary treatment modalities, all PSA values decreased to a nadir state.\u003c/p\u003e \u003cp\u003eThe postoperative ED were reported in 113 (64%) of patients in the 12th month follow up. The remaining 62 (36%) patients did not report ED.\u003c/p\u003e \u003cp\u003eWe analyzed/compared all the parameters mentioned in the material and methods section between patients having ED and normal erectile function. The age, lymphovascular invasion at CFPB, perineural invasion and surgical margin positiveness at postoperative pathology were detected to be important possible factors for the cause of postoperative ED (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePossible factors which may cause erectile dysfunction after bladder neck and nerve sparing robotic radical prostatectomy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP* value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0.014\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0.993\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCigarette smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.289\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny other chronic illnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree/Total PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.620\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate MRI PIRADS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative total gleason score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.709\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative tumor percentage at prostate biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymphovascular invasion at preoperative biopsy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.537\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineural invasion at preoperative biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh grade PIN at preoperative biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny lesion at preoperative staging techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.333\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative total gleason score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor percentage at postoperative pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerineural invasion at postoperative pathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.888\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical margin positiveness at postoperative pathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.784\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphovascular invasion at postoperative pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh grade PIN at postoperative pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.849\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeminal vesicle invasion at postoperative pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder neck involvement at postoperative pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.483\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaving postoperative 3th PSA recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaving postoperative 6th PSA recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaving postoperative 9th PSA recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaving postoperative 12th PSA recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.964\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Enter Logistic Regression\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter these results, we tried to find the best patient age for having normal erectile function after the operations. The age 58 was detected to be a cut off with %90 sensitivity and %90 specificity for having a normal erectile function. The patients\u0026thinsp;\u0026lt;\u0026thinsp;58 years would not have ED with %90 sensitivity and %90 specificity.\u003c/p\u003e \u003cp\u003eThere was also significant correlation between the surgical margin positiveness and perineural invasion at the postoperative pathology reports (p\u0026thinsp;=\u0026thinsp;0.001) showing the neural invasion of the tumor. Comparing the positive surgical margin locations for erectile dysfunction, there was no difference among lateral, posterior, anterior or apical locations (p\u0026thinsp;=\u0026thinsp;0.837). This showed the complexity of neural fibers surrounding the prostate.\u003c/p\u003e \u003cp\u003eThe age was also analyzed for the prediction of surgical margin positiveness or perineural invasion, but it was not detected to be a predictive factor for surgical margin positiveness (p\u0026thinsp;=\u0026thinsp;0.694).\u003c/p\u003e \u003cp\u003eThere was also no difference in biochemically recurrence rate between patients with normal erectile function and ED (p\u0026thinsp;=\u0026thinsp;0.742) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePostoperative erectile dysfunction is one of the most unwanted condition by patients after radical prostatectomy and they are highly concerned about the possibility of having ED.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Higher Gleason Scores were found to have possible effects on preoperative erectile functions.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Penile rehabilitation is necessary for all patients but younger patients have better results and quick recovery.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In our study, patient\u0026rsquo;s age was found to be statistically significant variable for postoperative erectile dysfunction.\u003c/p\u003e \u003cp\u003ePreoperative ED has been shown to be associated with lower overall survival and survival from causes other than prostate cancer after radical prostatectomy.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Men with ED should be evaluated for cardiovascular risk factors and there must be preventive strategies for cardiovascular events.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAdditional diseases such as hypertension, diabetes mellitus also other chronic diseases were not found to be statistically significant. Preoperative factors were also evaluated for the association with postoperative erectile dysfunction. Total PSA levels, Free PSA levels, Free/Total Ratio, Prostate MRI PIRADS scores, PSA density, preoperative total gleason score, preoperative tumor percentage at prostate biopsy, perineural invasion at preoperative biopsy and presence of high grade PIN at preoperative biopsy were not found to be statistically significant factors for postoperative ED. Only lymphovascular invasion at preoperative biopsy were found to be statistically significant for postoperative ED.\u003c/p\u003e \u003cp\u003ePostoperative factors would be also associated with postoperative ED. These factors have been evaluated in detail in our study. Postoperative total gleason score, lymphovascular invasion at postoperative pathology, presence of high grade PIN, seminal vesicle invasion and bladder neck involvement at postoperative pathology and having postoperative PSA recurrence were not found to be statistically significant for postoperative ED. Preineural invasion and surgical margin positiveness at postoperative pathology were found to be statistically significant factors for postoperative ED.\u003c/p\u003e \u003cp\u003eSeveral treatment modalities have been advised for postoperative ED and penile rehabilitation. Studies indicate PDE5-Is as the primary treatment option for post bilateral nerve-sparing radical prostatectomy ED.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Beneficial outcomes have been shown with the use of PDE5-Is comparing to placebo but the effect is often ends after the use of PDE5-Is.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] In a study, subgroup analysis revealed less side effects with the use of daily PDE5-Is than on demand use of PDE5-Is.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Once daily use of Udenafil 75mg has been shown as an effective option for improving erectile function after bilateral nerve sparing robot-assisted laparoscopic prostatectomy(BNS-RALP).[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Avanafil 200mg on demand has been shown to be the best treatment among PDE5-Is for the treatment of ED after nerve-sparing radical prostatectomy(NSRP).[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] However patients with venogenic ED were shown to have limited response when comparing to the patients with arteriogenic ED, Tadalafil 5mg daily intake was well-tolerated and signifigantly improved erectile functions.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Studies showed the efficacy of regular regimen of PDE5-Is for short term treatments and both regular and on-demand regimens for long term treatments.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Also Vacuum erection device, intracavernous injection and medicated urethral system for erections have also been pointed as promising treatment options.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Stem cell therapy is a promising and effective option for various diseases.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Autologous Adipose-Derived Regenerative Cells(ADRC) have been shown as safe and effective treatment options for erectile dysfunction after radical prostatectomy.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Low-intensity shockwave therapy (Li-ESWT) was shown as a safe treatment option that improves erectile functions and the therapy increased IIEF-5 and EHS scores after radical prostatectomy.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Studies have shown the positive effects of pelvic floor muscle training on quality of life after radical prostatectomy with positive outcomes for continence and penile rehabilitation.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Also preoperative physiotherapeutic interventions using biofeedback protocol was shown to be effective in decreasing the rate of urinary incontinence and erectile dysfunction after radical prostatectomy.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Prostate cancer is common cancer type among male population and surgical treatment modalities would affect postoperative quality of life with the effects on postoperative erectile functions. Postoperative ED is an important factor that must be considered in both preoperative and postoperative period. Factors associated with postoperative ED must be evaluated in detail in order to avoid ED and also postoperative ED must be treated with effective treatment modalities that have been described in the literature. Additional studies including more patients and more factors must be conducted in the following period for defining the needs and the realities for preoperative prevention and postoperative treatment of ED.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe number of patients that have been included in our study is the main limitation. Follow-up periods, preoperative and postoperative additional factors must be considered in detail.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eSpecial thanks to the biochemistry laboratory team of Gulhane Research and Training Hospital for their essential assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions: SS, TE designing and writing the manuscript, MSB collecting and extracting data, HGİ and SB supervising manuscript writing.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e No financial assistance was received in support of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethical Committee of University of Health Sciences Gulhane Research and Training Hospital with the number of 2023-288. Institution\u0026rsquo;s review Board of Human Subject Guidelines were followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u0026nbsp;Interests:\u003c/strong\u003e There are no competing financial interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThe data of infertile male patients has been generated and analysed with using the hospital records and patient statements. Additional data are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang X, Wang X, Liu T, He Q, Wang Y, Zhang X. Systematic review and meta-analysis of the use of phosphodiesterase type 5 inhibitors for treatment of erectile dysfunction following bilateral nerve-sparing radical prostatectomy. PLoS One. 2014;9(3):e91327. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0091327\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0091327\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang J, Jian ZY, Wang J. Phosphodiesterase type-5 inhibitors for erectile dysfunction following nerve-sparing radical prostatectomy: A network meta-analysis. Medicine (Baltimore). 2021;100(8):e23778. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MD.0000000000023778\u003c/span\u003e\u003cspan address=\"10.1097/MD.0000000000023778\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhelan P, Ekbal S, Nehra A. Erectile dysfunction in robotic radical prostatectomy: Outcomes and management. Indian J Urol. 2014;30(4):434\u0026ndash;42. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/0970-1591.142078\u003c/span\u003e\u003cspan address=\"10.4103/0970-1591.142078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJurys T, Burzynski B, Potyka A, Paradysz A. Post-Radical Prostatectomy Erectile Dysfunction Assessed Using the IIEF-5 Questionnaire - A Systematic Literature Review. Int J Sex Health. 2022;34(1):55\u0026ndash;64. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/19317611.2021.1936333\u003c/span\u003e\u003cspan address=\"10.1080/19317611.2021.1936333\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeiger-Gritsch S, Oberaigner W, Muhlberger N, Siebert U, Ladurner M, Klocker H, et al. Patient-reported urinary incontinence and erectile dysfunction following radical prostatectomy: results from the European Prostate Centre Innsbruck. Urol Int. 2015;94(4):419\u0026ndash;27. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000369475\u003c/span\u003e\u003cspan address=\"10.1159/000369475\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaglind E, Carlsson S, Stranne J, Wallerstedt A, Wilderang U, Thorsteinsdottir T, et al. Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial. Eur Urol. 2015;68(2):216\u0026ndash;25. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2015.02.029\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2015.02.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGandaglia G, Lista G, Fossati N, Suardi N, Gallina A, Moschini M, et al. Non-surgically related causes of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Prostate Cancer Prostatic Dis. 2016;19(2):185\u0026ndash;90. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/pcan.2016.1\u003c/span\u003e\u003cspan address=\"10.1038/pcan.2016.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFraiman MC, Lepor H, McCullough AR. Changes in Penile Morphometrics in Men with Erectile Dysfunction after Nerve-Sparing Radical Retropubic Prostatectomy. Mol Urol. 1999;3(2):109\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGontero P, Fontana F, Zitella A, Montorsi F, Frea B. A prospective evaluation of efficacy and compliance with a multistep treatment approach for erectile dysfunction in patients after non-nerve sparing radical prostatectomy. BJU Int. 2005;95(3):359\u0026ndash;65. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1464-410X.2005.05300.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2005.05300.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasourakos SP, Kowalczyk K, Moschovas MC, Dudley V, Hung AJ, Shoag JE, et al. Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation. J Endourol. 2021;35(11):1601\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/end.2021.0081\u003c/span\u003e\u003cspan address=\"10.1089/end.2021.0081\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhoder WY, Waidelich R, Seitz M, Becker AJ, Buchner A, Trittschler S, et al. Do we need the nerve sparing radical prostatectomy techniques (intrafascial vs. interfascial) in men with erectile dysfunction? Results of a single-centre study. World J Urol. 2015;33(3):301\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00345-014-1302-9\u003c/span\u003e\u003cspan address=\"10.1007/s00345-014-1302-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKleinJan GH, Sikorska K, Korne CM, Brouwer OR, Buckle T, Tillier C, et al. A prediction model relating the extent of intraoperative fascia preservation to erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy. J Robot Surg. 2019;13(3):455\u0026ndash;62. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-018-0867-5\u003c/span\u003e\u003cspan address=\"10.1007/s11701-018-0867-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012;22(4):746\u0026ndash;57. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00330-011-2377-y\u003c/span\u003e\u003cspan address=\"10.1007/s00330-011-2377-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamoen EHJ, de Rooij M, Witjes JA, Barentsz JO, Rovers MM. Use of the Prostate Imaging Reporting and Data System (PI-RADS) for Prostate Cancer Detection with Multiparametric Magnetic Resonance Imaging: A Diagnostic Meta-analysis. Eur Urol. 2015;67(6):1112\u0026ndash;21. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2014.10.033\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2014.10.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePonsiglione A, Brembilla G, Cuocolo R, Gutierrez P, Moreira AS, Pecoraro M, et al. ESR Essentials: using the right scoring system in prostate MRI-practice recommendations by ESUR. Eur Radiol. 2024;34(11):7481\u0026ndash;91. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00330-024-10792-7\u003c/span\u003e\u003cspan address=\"10.1007/s00330-024-10792-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornford P, van den Bergh RCN, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2024;86(2):148\u0026ndash;63. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2024.03.027\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2024.03.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePikramenos K, Zachou M, Papadopoulos D, Papatsoris A, Varkarakis I, Mitsogiannis I. Post Radical Prostatectomy Erectile Dysfunction. A Single Centre Experience. Cureus. 2023;15(2):e34601. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.34601\u003c/span\u003e\u003cspan address=\"10.7759/cureus.34601\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan M, Trock BJ, Partin AW, Humphreys EB, Bivalacqua TJ, Guzzo TJ, et al. The impact of preoperative erectile dysfunction on survival after radical prostatectomy. BJU Int. 2010;106(11):1612\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1464-410X.2010.09472.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2010.09472.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoh HJ, Sung JM, Lee KH, Jo JK, Kim KN. Efficacy of phosphodiesterase type 5 inhibitors in patients with erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis. Transl Androl Urol. 2022;11(2):124\u0026ndash;38. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/tau-21-881\u003c/span\u003e\u003cspan address=\"10.21037/tau-21-881\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung JH, Kwon TG, Kwak C, Sung GT, Kim SD, Cho JS, et al. Efficacy and Safety of Udenafil Once Daily in Patients with Erectile Dysfunction after Bilateral Nerve-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blind, Placebo-Controlled Study. World J Mens Health. 2023;41(3):612\u0026ndash;22. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5534/wjmh.220057\u003c/span\u003e\u003cspan address=\"10.5534/wjmh.220057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim S, Sung GT. Efficacy and Safety of Tadalafil 5 mg Once Daily for the Treatment of Erectile Dysfunction After Robot-Assisted Laparoscopic Radical Prostatectomy: A 2-Year Follow-Up. Sex Med. 2018;6(2):108\u0026ndash;14. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.esxm.2017.12.005\u003c/span\u003e\u003cspan address=\"10.1016/j.esxm.2017.12.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian D, Wang XY, Zong HT, Zhang Y. Efficacy and safety of short- and long-term, regular and on-demand regimens of phosphodiesterase type 5 inhibitors in treating erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis. Clin Interv Aging. 2017;12:405\u0026ndash;12. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/CIA.S122273\u003c/span\u003e\u003cspan address=\"10.2147/CIA.S122273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaahr MK, Jensen CH, Toyserkani NM, Andersen DC, Damkier P, Sorensen JA, et al. Safety and Potential Effect of a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial. EBioMedicine. 2016;5:204\u0026ndash;10. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ebiom.2016.01.024\u003c/span\u003e\u003cspan address=\"10.1016/j.ebiom.2016.01.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLadegaard PBJ, Mortensen J, Skov-Jeppesen SM, Lund L. Erectile Dysfunction A Prospective Randomized Placebo-Controlled Study Evaluating the Effect of Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT) in Men With Erectile Dysfunction Following Radical Prostatectomy. Sex Med. 2021;9(3):100338. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.esxm.2021.100338\u003c/span\u003e\u003cspan address=\"10.1016/j.esxm.2021.100338\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. Sex Med. 2020;8(3):414\u0026ndash;21. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.esxm.2020.03.005\u003c/span\u003e\u003cspan address=\"10.1016/j.esxm.2020.03.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerez FSB, Rosa NC, da Rocha AF, Peixoto LRT, Miosso CJ. Effects of Biofeedback in Preventing Urinary Incontinence and Erectile Dysfunction after Radical Prostatectomy. Front Oncol. 2018;8:20. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fonc.2018.00020\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2018.00020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"erectile dysfunction, prostate cancer, radical prostatectomy","lastPublishedDoi":"10.21203/rs.3.rs-5705798/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5705798/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eProstate cancer (PCa) is a prevalent disease with good prognosis and approximately 100% disease-specific survival rate is observed for the patients with localized cancer that treated with radical prostatectomy. According to the treatment options, complications may also be seen and the most common complications are urinary incontinence and erectile dysfunction. In our study, preoperative and postoperative factors affecting erectile functions after bladder neck and nerve-sparing robot assisted laparoscopic radical prostatectomy. Between October 2016 and October 2023, a total of 500 patients had bladder neck and nerve sparing robotic radical prostatectomy. Preoperative and postoperative factors related with the erectile functions have been evaluated in detail. Before operations; age, comorbidity status (cigarette smoking, hypertension, diabetes mellitus, additional illnesses), total PSA, free PSA, free/total PSA ratio, RDE findings, Prostate MRI findings, PSA density using the MRI, CFPB results, staging results were also noted. After operations; pathology results, control PSA results, need for additional treatments, continuing control PSA results after the additional treatments were noted. The age, lymphovascular invasion at CFPB, perineural invasion and surgical margin positiveness at postoperative pathology were detected to be important possible factors for the cause of postoperative ED. There was also significant correlation between the surgical margin positiveness and perineural invasion at the postoperative pathology reports (p\u0026thinsp;=\u0026thinsp;0.001) showing the neural invasion of the tumor.Postoperative ED is an important factor that must be considered in both preoperative and postoperative period. Factors associated with postoperative ED must be evaluated in detail in order to avoid ED and also postoperative ED must be treated with effective treatment modalities that have been described in the literature.\u003c/p\u003e","manuscriptTitle":"Preoperative and postoperative factors causing the erectile dysfunction after bladder neck and nerve sparing robot-assisted laparoscopic radical prostatectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-06 09:22:13","doi":"10.21203/rs.3.rs-5705798/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f59b9a6a-c1c5-4cbe-80d5-c59a24841e39","owner":[],"postedDate":"January 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":42333000,"name":"Health sciences/Risk factors"},{"id":42333001,"name":"Health sciences/Diseases/Urogenital diseases"}],"tags":[],"updatedAt":"2025-02-14T14:37:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-06 09:22:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5705798","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5705798","identity":"rs-5705798","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}