Neuromodulatory Drugs in a Radical Pelvic Surgery Patient

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Since the introduction of the nerve sparing prostatectomy by Dr. Patrick Walsh in 1983 it has been recognized in multiple analyses that cavernous nerve preservation is quantitatively related to the recovery of erectile function. It is well appreciated that both spontaneous and PDE5 inhibitor response is heavily predicated upon the nerve sparing status with bilateral nerve sparing patients faring better than unilateral nerve sparing patients. Besides cavernous nerve status, other factors identified by Rabbani in the Memorial Sloan Kettering analysis of predictors of erectile function recovery include preoperative erectile function and patient age. A number of authorities have suggested that postoperative alterations in erectile hemodynamics is important and there is evidence to suggest that accessory pudendal artery injury with postoperative arteriogenic arterial insufficiency may have a negative long term impact on erectile function. Likewise, structural damage leading to venous leak is a poor prognostic indicator. There is little data on the role of vascular comorbidities, however, most authorities believe that the presence and severity of vascular comorbities is likely to have a negative impact upon long term erectile function recovery. The term “never-sparing” essentially means that the surgeon, using his/her experience and expertise defines if the nerves are anatomically (macroscopically) intact. This may have less than perfect correlation with the function of the cavernous nerves on either side. While intra-operative nerve stimulation may help in this regard there are concerns about false positive and false