Modern Anatomy of the prostate with neuro vascular bundles necessary for an erection.

Is sex possible after radical prostatectomy?

The physiological mechanism that allows us to trigger and maintain an erection in humans is complicated.

It is a vascular phenomenon: the erection occurs when the corpus cavernosum in the penis fill with arterial blood with a high flow into the cavernous arteries and a subsequent decrease in venous outflow.

This vascular phenomenon is triggered by nerve control, through the erector nerves, and can occur in a certain hormone climate created by the presence in the body of the male hormone, testosterone, produced by the testes.

The vascularization and innervation of the erection is represented by particularly fine and complex anatomical structures which have been described by the work of Walsh in the 1970s and which are not yet fully known to date.

Somewhat schematically, arterial and venous vascular structures, as well as the nerves, are located, on the right as on the left, in a vasculo-nervous pedicle which comes from the sacred area and goes down by crossing back to front the side faces of the rectum to then follow the postero-lateral edges of the prostate, from base to apex.

At this level, these structures are in intimate contact with the prostatic capsule, a region to the particularly complex anatomy, especially the envelopes that surround the prostate between sheets of which these structures are located.

Modern Anatomy of the prostate with neuro vascular bundles necessary for an erection.

Modern Anatomy of the prostate with neuro vascular bundles necessary for an erection.

P: prostate

Rec.: rectum

LPF: Peri-prostatic fascia

LA: superioris muscle of anus

PF: pelvic fascia

BVN: Neuro vascular bundle

 

 

The surgeon doesn’t see these famous nerves of the erection during the operation, but he knows the benchmarks that allow him to locate their presumed anatomical situation, and all improvements and optimizations of surgical techniques are developed to preserve more completely the neurovascular bundles.

Thus, it is not the prostate itself which is the organ that triggers the erection, but because the vascular and nerve structures responsible for the phenomenon are so closely located near the prostate the Prostatectomy can have a sexual impact.

Note in passing that it is for the same reasons of very close anatomical relationship that irradiation techniques also result in a sexual impact, whether external or interstitial brachytherapy radiation, because neurovascular bundles receive the same large doses of radiation than the prostate to treat.

However, because the rays cause devascularization phenomena which deprive the tissue of blood supply, and evolve gradually after treatment, the installation of erectile dysfunction is often not immediate after irradiation but develops gradually within the following 2 years. While for those who have been operated on, impotence is usual in the postoperative and recovery period, it can last longer when 2 bundles – or one of them–could has been preserved.

This preservation is also not desirable in all cases. The goal of Prostatectomy is to cure cancer and if the cancer is too developed, as indicated by the result of the biopsy, a too fine dissection, at the contact of the prostatic capsule, is at risk of leaving cancerous tissue in place. In these cases it is best to dissect more remotely or even sacrifice the bundle entirely.

The surgeon must deal with the sexuality issue of the couple before the procedure and precisely assess the sex lives of the partners involved and the quality of erections of the husband, to assess whether it is licit to consider this nerve preservation.

It is not feasible in all cases where it has been considered, based on the local state of the tissue that can be sometimes highly inflammatory thereby greatly complicating the dissection; as well as difficulties that no preoperative examination can suspect.