Editorial Comment on: Recoverability of Erectile Function in Post–Radical Cystectomy Patients: Subjective and Objective Evaluations

Abstract

Radical cystectomy and urinary diversion—preferably by an orthotopic ileal neobladder reconstruction—is the mainstay of treatment for muscle-invasive and recurrent, high-grade superficial bladder cancer, providing 10-yr diseasespecific survival rates of more than 80% and satisfactory functional results [1,2]. In the past decade, several modifications have been exploited to further improve functional results along with quality of life for cystectomy patients. Radical cystectomy may be modified by a more or less meticulous preservation of the neurovascular bundles on one or both sides in selected patients without affecting the local recurrence rate [3] or by even more modified nerve-preserving techniques that also spare the seminal vesicles and deferential ampullae while the prostate is still removed completely [4]. Nerve-sparing (NS) but still radical cystectomy can maintain spontaneous erectile function and a sufficient autonomous innervation of the proximal urethra to even further increase urinary continence rates. In this article [5], the authors present the functional results of 21 consecutive potency preserving cystectomies compared to 24 patients that underwent a non–nerve-sparing surgery (NNS) during the same time period in a nonrandomized study. Postoperative erectile function was assessed on a subjective and objective basis using the International Index of Erectile Function (IIEF) as well as penile Doppler ultrasound (PDU) to assess penile blood flow. Despite the fact that this was not a randomized study, the results are convincing in regard to the superior erectile function following nerve-sparing cystectomy, with 78.8% of patients maintaining erectile function with (21%) or without (57.8%) phosphodiesterase type 5 (PDE5) inhibitors. Only 4 of 21 patients did ultimately need prostaglandin E1 (PGE1) injections despite nerve sparing and are regarded as failures of the potency-sparing procedure. In contrast, no patient in the NNS group had spontaneous erections. Interestingly, PDU revealed that the peak systolic velocity (PSV) as a surrogate for the penile artery inflow was insignificantly reduced in both groups postoperatively. However, the end diastolic velocity (EDV) as a surrogate for the veno-occlusive capacity after pelvic surgery was significantly reduced in both groups early after surgery but recovered gradually in NS patients after 12 mo compared to the NNS group. These results do further suggest that a preserved autonomous regulation of penile vascular crosstalk is obviously the key to success for functional pelvic surgery. The authors did not address the issue of patient selection for nerve-sparing surgery in their paper. Decisions were made at the discretion of the surgeons. One should keep in mind that decision making toward a more or less radical cystectomy and limited or extended pelvic node dissection is primarily based upon proper oncologic criteria such as superficial high-grade disease or muscleinvasive tumors opposite to the site where nerve sparing is attempted. Thus, a properly performed nerve-sparing radical cystectomy along with an orthotopic neobladder urinary reconstruction does, in carefully selected patients, match the important principles of cancer surgery and function-preserving surgery.