Regaining Erectile Function | Robotic Prostatectomy | Thomas Ahlering, M.D. (2023)

Recent Findings About Regaining Potency (erectile function) after Radical Prostatectomy

It is important to remember that regaining erectile function takes time after radical robotic prostatectomy. Most studies in the literature use endpoints of 18-36 months after prostate cancer surgery. Nerve tissue can be easily damaged during robotic prostatectomy, regardless of the skill of the surgeon, and takes a long time to regenerate. It is believed that early postoperative medical therapy can aid an earlier return to potency.

Dr. Ahlering, a physician with UC Irvine Medical in Orange County, CA. has pioneered the use of electrocautery-free preservation of the neurovascular bundles (potency nerves) which are essential for the return of potency after prostate surgery. A recent study by Dr. Patrick Walsh and associates at John Hopkins has shown that mono and bipolar cautery near the potency nerves severely impact the erectile function of dogs. Mono and bipolar cautery are routinely used by many institutions to limit the bleeding during surgery by heat-sealing or 'cauterizing' the bleeding vessels.

The nerves for potency are intertwined with a bundle of blood vessels, which must be controlled during prostate cancer surgery to prevent large blood losses. Thus to preserve the nerves of potency, a surgeon also must prevent the bleeding of these vessels also. Cautery is considered a standard method of sealing the blood vessels, allowing the nerve bundles to now be properly visualized.

The OC Hospital's, Dr. Ahlering theorized that cautery near the potency nerve bundles must damage the nerves in some way. Since early 2004, he began a new innovative technique to avoid bleeding without the use of damaging electrocautery, by using small steel clamps routinely used in surgery of the kidney. These clamps are considered non damaging, and are used for only a short duration of the surgery. He applied this method to prostate surgery and this is the 1st reported use of this technique in robotic prostatectomy, and it was recently published in the Journal Urology in May 2005.

Dr. Ahlering has also recently published the early results of this technique. This paper was published in the July/August 2005 issue of the Journal of Endourology. The study compared men who potency nerves were spared with bipolar electrocautery versus men who nerves were sparred without the use of electrocautery, and whose bleeding around the nerves was controlled by the novel technique of the 'Bulldog Clamp".

At 3 months, 41% of the pre potent men, aged 65 or less, who underwent the electrocautery free technique by the 'Bulldog Clamp", were able to achieve erections satisfactory for intercourse, versus only 8% of the men who had bipolar cautery. The men in the study underwent either bilateral (saving the potency nerves on both sides of the prostate) or unilateral nerve sparing (preserving only one of the nerves). The ability to achieve partial erections at this early period also significantly favored the electrocautery free technique: 88% had partial erections, while in the bipolar cautery group, only 32% had partial erections at 3 months.

(Video) Prostate Cancer Surgery: What to Look For by Dr. Thomas Ahlering - UCI Department of Urology

Long-term published data for potency after robotic prostatectomy is limited due to how new the procedure is. Very few surgeons world-wide have been using the da Vinci Robot for more than a few years. As such, the two year endpoint traditionally used for open robotic prostatectomy is not available.

For comparison we show the standard data on open prostatectomy potency (very little is published about potency in the first 6-12 months after prostatectomy):

Percentage of Men Obtaining Full Erections 2 Years after Open Prostatectomy

(From Campbell's Urology Textbook)
Nerves Spared
<60 yr
Both (Bilateral)
One (Unilateral)
None (Non)

As one can see, the chance of regaining potency diminishes with age and with the number of nerves damaged. Even though it is usually technically possible to spare the nerves, sometimes the nerves themselves are cancerous and must be removed since the primary goal of the surgeon is to remove the prostate cancer. If the cancer has not reached the nerves controlling erection, the da Vinci Robot has the visual capabilities and the precision necessary to spare these nerves in most cases, thus it is possible that using the robot may add to the chances of being potent after surgery. However, there is no way to guarantee this due to variability in patient anatomy and condition. It is important to realize that some men never regain the ability to maintain an erection after robotic prostatectomy.

It is still unclear how using the da Vinci robot for prostatectomy will affect potency effects. While, as mentioned above, it would appear that using the robot may increase chances of potency, and research into how all this may translate into earlier return or increased percentage of potency is still ongoing. It is known that using the robot reduces blood loss during robotic prostatectomy surgery, and length of hospital stay. Presumably this is indicative of a decrease in trauma and inflammation, which leads us to speculate that there may be a higher chance of potency(erectile function). Urinary continence at zero pads, bladder capacity, and urinary symptom scores (for men with moderate symptoms) at three months are all also improved over open surgery results. The robot certainly has its benefits.

As mentioned above, medical therapy may aid in return to erections, but this has not as of yet been fully substantiated. Usage of sildenafil (Viagra) and newer erectile medications (such as Cialis and Levitra) may potentially increase the potency percentages in the table above but this has not been proven. A recently presented study (Padma-Nathan, April 2003) found that daily doses of 50mg or 100mg sildenafil (Viagra) for 9 months increased full erections by 7 fold when compared with a group who did not receive any medication.

When Can I return to Sexual Activity?

(Video) Learn from Dr. Thomas Ahlering about the Impact of Low Free Testosterone on Prostate Cancer

Let the surgery heal for three to four weeks before attempting anything. After one month after the robotic prostatectomy, it is recommended that you resume sexual activity. Stimulation of the nerves is thought to be a first step on the journey back to potency. Remember that you can still experience the pleasures of orgasm and other sensual stimulations without full erections. The average time to recovery for erections adequate for intercourse (in those who do recover) is 6-12 months, but in some men it is even longer. You should also be performing kegel exercises regularly to help your return to potency.

I Don't Have Erections After Surgery, Am I Impotent for Life?

Think of your erections as a well conditioned athlete, who has been injured. This injury is going to take time to heal. You should try to remain patient, and remember that this will be an ongoing battle for many months and even years. Rehabilitation of potency is much like a sports injury. Proper conditioning and medical treatment may potentially speed up recovery, but it is not guaranteed.

If you see any fullness in your erections in the months after your robotic prostatectomy surgery, this is a positive sign that some of the nerves are working or re-growing. You are taking the first steps down the potency recovery path. Remember though, as shown in the previous table for open prostatectomy, 25-55% of men do not regain erections.

Medical Therapy For Erectile Function

Medical therapy requires a prescription from a doctor. Therapies include medications (Viagra, Cialis, Levitra), treatments (Muse), devices (Vacuum Pump) and small injections (Caverject.) All of these therapies have their respective costs and benefits.


Sildenafil (Viagra) has limited, not 100%, success in prostatectomy patients. Nonetheless, existing literature on its use after radical robotic prostatectomy suggests it may significantly aid potency. Certain heart medications and Viagra are potentially fatal. Viagra can also produce headaches, skin flushing, and other side effects.Always obtain permission from your physician before starting Viagra.

(Video) Life After Prostate Cancer: Recovery is a Journey

Viagra works best if taken 1/2 hour before sexual activity. It should also be taken on an empty stomach, and remember that alcohol suppresses its effectiveness.

If you take Viagra, and nothing happens, you may try it again. Viagra can be taken at anytime during the potency process, and will work better as the nerves heal. Thus it is possible, that it may begin to work later, even after not working noticeably initially. Viagra (R) is a product of Pfizer Inc., please visit their site for more information. Prescriptions and sample packs for Dr. Ahlering's patients can be obtained by contacting his assistant Lydia at (714) 456-6068.


Tadalafil (Cialis) conceivably works similar to Viagra as a "potency tickler" to encourage a faster return to erections. Just as with Viagra, potentially lethal combinations with certain other medications exist, so consult your physician before beginning Cialis. As advertized, Cialis can begin to work within 30 minutes, but notably, can work for up to 36 hours. Because it is longer lasting, it has been speculated that this may make it more effective as a "potency tickler." However, this has not yet been proven. Cialis is made by Lilly, you can learn more by visiting their site.


Vardenafil (Levitra) has been studied for use after radical robotic prostatectomy, similar to Viagra, and is believed to aid the return to potency due to the positive results of such studies. As with both Cialis and Viagra, serious side effects with certain medications are possible, so consult your physician before use.


A tiny wax suppository is used tostimulate the erection, and is inserted with a small plastic deviceinto the urethra. As many as 70% of men who fail to achieveerection with Viagra will be responsive to Muse therapy. Thereis, however, a potential irritating burning pain during the firstseveral erections, and it costs more per use than the above oralmedications. Muse videos demonstrating the process are free andcan be sent to you upon request. Muse is made by Vivus, visit their site for more information, or contact Dr. Ahlering's assistant Lydia.

(Video) Intuitive using Bang for MD to MD collaboration robotic prostatectomy

Vacuum Pump

The vacuum pump is a non-invasive method to obtain erections. This method has been around for quite some time now. The efficacy of the pump, however, is somewhat low.


Caverject, made by Pharmacia Corporation, effectively produces erections in approximately 80% of men, and may work in men for whom Viagra did not work. One slightly unpleasant drawback is that Caverject must be directly injected into the penis correctly via a small syringe and needle by the patient, or the patient's partner, at home. However, studies have shown men using Caverject after radical robotic prostatectomy have an earlier return to potency.

What You Never Lose: The Good News about Sexual Function

Regaining Erectile Function | Robotic Prostatectomy | Thomas Ahlering, M.D. (1)

(Video) #23349 Nerve Sparing Radical Prostatectomy in High-Risk Prostate Cancer Patients is feasible wit...

While regaining erectile functiom is not possible for all men, it is important to remember that erection is just one part of a satisfying sex life. The other parts remain intact despite prostate cancer surgery. Sexual feelings, sexual fulfillment, climax and the sensation of orgasm are still available without erection.

What Do We Know About Potency After a Robitic Prostatectomy

The return of potency is dependent on several factors:

  • Previous sexual function before surgery. Unfortunately, robotic prostatectomy will at best return you to your level of sexual function pre-surgery. It will not improve upon what you already had before surgery.
  • Age. Theyounger you are, the better your chances. Men under 65 have abetter chance of regaining potency, or erectile function than those over 65.
  • How many nerves are spared.As discussed previously, ideally both nerves can be spared and thiswill give you the highest chance of regain erections. However,even men with no nerve sparing can regain erectile function.

Ejaculation (the release of fluid during orgasm) will no longer occur in any patient. This is because the seminal vesicles (which store fluid for ejaculation,) and the vas deferens (the tubes that carry sperm to the prostate), are removed and cut during the surgery. This means that you will no longer be able to father children (at least by any standard means.)


Will I get my erection back after prostate surgery? ›

Most men who have normal sexual function and receive treatment for early prostate cancer regain erectile function and can have satisfying sex lives after robotic prostatectomy. However, it is a gradual process and may take up to a year.

What is the best pill to take for erectile dysfunction after prostatectomy? ›

The most common ED medication that's prescribed after prostate cancer treatment is a phosphodiesterase type 5 (PDE5) inhibitor. PDE5 inhibitors are oral medications that include sildenafil (Viagra), tadalafil(Cialis), and vardenafil (Levitra).

What is the latest treatment for erectile dysfunction after radical prostatectomy? ›

Penile prosthesis implantation represents the third line treatment for the post-radical prostatectomy erectile dysfunction.

Does Sildenafil work after prostate removal? ›

Viagra is an effective treatment for impotency in men who have their prostate removed. For men whose nerves have been spared, the drug improves the ability to have an erection by nearly 60%, but the effectiveness drops to 20% in those with no nerves spared.

What percentage of men have ED after prostate removal? ›

Results At 18 or more months following radical prostatectomy, 8.4% of men were incontinent and 59.9% were impotent.

How do I overcome erectile dysfunction after prostate surgery? ›

ED treatment

Medications or devices can help ED recovery after surgery. Popular ED medications, such as sildenafil (Viagra) and tadalafil (Cialis) can be effective. About 75 percent of men who undergo nerve sparing radical prostatectomy can achieve successful erections with these drugs.

What age does a man stop getting a hard on? ›

The answer to the question, “what age does a man stop getting hard?” is simple: it doesn't exist. Some men in their 90s can still get erections without any trouble, while many men in their 20s struggle with erectile dysfunction.

Can you get an erection without a prostate? ›

When you have a radical prostatectomy, you have surgery to remove your prostate gland. These nerves, blood vessels, and muscles may be weakened when you have surgery for your prostate cancer. For a period of time after surgery, many men are not able to get an erection. This time is different for each man.

How long does Ed last after prostate surgery? ›

The average time to recovery for erections adequate for intercourse (in those who do recover) is 6-12 months, but in some men it is even longer. You should also be performing kegel exercises regularly to help your return to potency.

How often should I take Viagra after prostatectomy? ›

To get the most of Viagra after prostatectomy, studies have shown that it is most effective when Viagra is taken on a regular and scheduled basis (daily or twice a week ) instead of based on need. It's recommended to be taken on an empty stomach and not to be mixed with alcoholic drinks or heart pills.

Does Cialis Work after prostate surgery? ›

Daily treatment with the PDE-5 inhibitor tadalafil (Cialis) led to a significant decrease in loss of penile length among men who had undergone bilateral nerve-sparing radical prostatectomy.

What food or drink is good for erectile dysfunction? ›

Here are some foods that can help you stay erect and support a medically sound erectile dysfunction treatment.
  • Watermelon. Watermelon contains citrulline, another precursor to nitric acid. ...
  • Spinach and Other Leafy Greens. ...
  • Coffee. ...
  • Dark Chocolate. ...
  • Salmon. ...
  • Pistachios. ...
  • Almonds, Walnuts, and Other Nuts. ...
  • Oranges and Blueberries.
21 Jul 2021

What is the best food to fight erectile dysfunction? ›

Foods to Help Erectile Dysfunction
  • Dark Chocolate. 5/12. ...
  • Nuts. 6/12. ...
  • Juice. 7/12. ...
  • Garlic. 8/12. ...
  • Fish. 9/12. ...
  • Greens. 10/12. Kale is also a nitric-oxide booster. ...
  • Peppers. 11/12. You might spice up your love life by adding some chili peppers to your diet. ...
  • Olive Oil. 12/12. Olive oil may help your body make more testosterone.
17 Jan 2022

Can you take testosterone after prostate removal? ›

Results: Available literature provides evidence for the safe application of TTh in patients previously treated for prostate cancer with either radical prostatectomy or radiotherapy. Furthermore, there exists evidence that severely hypogonadal levels of testosterone may lead to worse oncological outcomes.

How do you get hard after 70? ›

Lifestyle changes
  1. quitting smoking.
  2. limiting or avoiding alcohol or substance use.
  3. maintaining a moderate weight.
  4. exercising more often than not.
  5. following a healthy diet that supports cardiovascular health, such as the Mediterranean diet.
13 Jan 2021

What is the fastest way to cure ED? ›

For fastest results, it's best to consult a doctor to get appropriate treatment recommendations, which may include:
  1. Lifestyle changes. Maintaining a healthy weight. ...
  2. Counseling. ...
  3. Medications. ...
  4. Vacuum constriction devices. ...
  5. Surgery. ...
  6. Alternative therapy.
13 Jul 2021

How long do you wait for Round 2? ›

Women need only wait a few seconds before the second round, with many even achieving multiple orgasms in one session. In comparison, the male refractory period varies post ejaculation, with some men ready after a few minutes and some men needing several hours to days.

Can a prostate grow back? ›

It is known that the prostate starts to grow again after surgery and about one in ten men need a repeat procedure within ten years of having TURP. Researchers are hoping to secure funding for a follow-up trial to compare how quickly the prostate grows back in men who had either TURP or ThuVARP procedures.

What is life like without a prostate? ›

The two prominent quality-of-life issues associated with living without a prostate are the loss of urinary control and the loss of erectile function. When you read or hear that success rates in these two areas are in the 90% range, it's highly probable you're reading hype.

What happens to a man after his prostate is removed? ›

The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and erectile dysfunction (impotence; problems getting or keeping erections). These side effects can also occur with other forms of prostate cancer treatment.

How long does it take for PSA levels to go down after prostatectomy? ›

The PSA test measures the level of prostate-specific antigen in your blood. The lab will report your results in nanograms of PSA per milliliter (ng/mL) of blood. Only the prostate gland releases PSA, so your numbers should drop to almost zero within 4 weeks after your surgery.

Can a man with no prostate get a woman pregnant? ›

Surgery to remove your prostate gland means that you no longer ejaculate any semen (dry orgasms). So you will not be able to have children by natural sexual intercourse.

How long does ED last after prostate surgery? ›

The average time to recovery for erections adequate for intercourse (in those who do recover) is 6-12 months, but in some men it is even longer. You should also be performing kegel exercises regularly to help your return to potency.

How long after prostate surgery can you use Viagra? ›

How soon after prostatectomy can I take Viagra? Men should consult with their doctors and get a prescription for Viagra after surgery. However, most men are safe to resort to Viagra as soon as four weeks after their prostatectomy. This is when their catheters are being removed.

Can you get an erection without a prostate? ›

Erectile dysfunction following radical prostatectomy for clinically localized prostate cancer is a known potential complication of the surgery. With the advent of the nerve-sparing radical prostatectomy technique, many men can expect to recover erectile function in the current era.

Does Cialis Work after prostatectomy? ›

Daily treatment with the PDE-5 inhibitor tadalafil (Cialis) led to a significant decrease in loss of penile length among men who had undergone bilateral nerve-sparing radical prostatectomy.


2. Hormonal Therapy for Prostate Cancer: Is There a Best Castration Strategy?
(UBC Urology Rounds)
3. 515. "Robotic Assist. Laparoscopic Radical Prostatectomy" by Arnold I. Chin, M.D., April 27, 2017.
(Prostate Forum of Orange County)
4. Weill Cornell Robotic Prostatectomy: Nerve Sparing Prostate Cancer Surgery (5/6)
5. The Evolution of Surgical Treatment For Prostate Cancer: From Hugh Hampton Young to da Vinci
(UBC Urology Rounds)
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