International Journal of Urology (2023) doi: 10.1111/iju.

15264

Review Article

Evaluation of sexual function after robot-assisted radical

prostatectomy: A farewell to IIEF questionnaire
Koji Shiraishi
Department of Urology, Yamaguchi University School of Medicine, Yamaguchi, Japan

Abbreviations & Acronyms Abstract: Longevity with localized prostate cancer (PCa) has been achieved, and the
ED = erectile dysfunction contribution of robot-assisted radical prostatectomy (RARP) to cancer control is evident.
IIEF = International Index of The next step to investigate in the treatment of localized PCa is improvement of the
Erectile Function quality of life (QOL) after RARP. Erectile dysfunction has been considered a major
NSEs = neglected side surgical complication, and patient satisfaction after RARP has not improved despite the
effects development of nerve preservation and penile rehabilitation. To comprehensively
PCa = prostate cancer understand sexual dysfunction after RARP, we must investigate other complications with
QOL = quality of life regard to sexual health, including low sexual desire, disturbed orgasmic function (i.e.,
RARP = robot-assisted anejaculation, orgasm intensity, painful orgasm, and climacturia), shortening of penile
radical prostatectomy length, penile curvature (Peyronie’s disease) and unique psychological alterations after
RS-RARP = Retzius-sparing the diagnosis of PCa, which are neglected side effects after prostatectomy. In this
RARP context, routine evaluation of erectile function by the International Index of Erectile
TRT = testosterone Function only is not sufficient to understand patients’ difficulties. A questionnaire is just
replacement therapy one way of enabling patients to evaluate their pre- and postoperative concerns; listening
to patients face-to-face is warranted to detect symptoms. Understanding the relationship
Correspondence between symptoms and preserved nerve localization can ultimately provide an
Koji Shiraishi M.D., Ph.D., individualized nerve-sparing procedure and improve patient satisfaction after RARP. In
Department of Urology, combination with psychological counseling, including the partner and medical treatment,
Yamaguchi University School of such as testosterone replacement, it is time to reconsider ways to improve sexual
Medicine, 111 Minami-Kogushi, dysfunction after RARP.
Ube, Yamaguchi 755-8505,
Key words: prostate cancer, robot-assisted radical prostatectomy, sexual dysfunction.
Japan.
Email: shirak@yamaguchi-u.ac.jp

Received 21 May 2023; INTRODUCTION

accepted 9 July 2023.
Prostate cancer (PCa) is the most prevalent malignancy in men, and an increasing number of
PCa cases are diagnosed during localized stages in the era of prostate-specific antigen (PSA)
screening. The disease-specific 10-year survival rate of localized PCa has been shown to be
up to 100%1 if treated appropriately by radical prostatectomy using robot-assisted radical
prostatectomy (RARP) and radiation therapy through brachytherapy or external beam radio-
therapy. Despite its long-term survival benefit, postoperative complications are inevitable after
RARP, including erectile dysfunction (ED) and urinary incontinence. Urinary incontinence is
a universal concern for patients, while ED is associated with anxiety, depression, and low
self-esteem to different degrees, and the needs of partners are not equivalent among patients.2
Therefore, ED is an important and individualized postoperative concern for patients, partners,
and their relationships and is known to negatively impact quality of life (QOL).3 The overall
preservation rate of sufficient erectile function after RARP has been shown to be approxi-
mately 35%4 depending on the nerve-sparing technique, patient’s age, comorbidities, and pre-
operative sexual function. Capogrosso et al. failed to show sufficient satisfaction of erectile
function after RARP in recent decades despite novel operative techniques (e.g., hood tech-
nique, Retzius-sparing RARP [RS-RARP]) and the development of penile rehabilitation.5
Investigation of this topic is difficult because of the wide variety of patients’ goals for sex-
ual health, which may be largely dependent on racial differences. To comprehensively focus
on sexual dysfunction after RARP, it is necessary to understand other complications related to
sexual health, including low sexual desire, disturbed orgasmic function (i.e., anejaculation,

© 2023 The Japanese Urological Association. 1

SHIRAISHI
orgasm intensity, painful orgasm and climacturia), and short-
ening of penile length and penile curvature (Peyronie’s
disease).6 These complications, which are not life-threatening
and are often difficult to evaluate, are called neglected side
effects (NSEs) after prostatectomy.6 As a typical example,
almost half of all patients were unaware that they were ren-
dered anejaculatory after surgery.7 This is common sense for
urologists, but a majority of patients do not fully understand
what the prostate and seminal tracts are. These situations
sometimes cause RARP, a newer and innovative procedure,
to be associated with a high rate of dissatisfaction and
regret.8 This is true for Japanese patients, as patients with
high interest in sex are more likely to be bothered by sexual
dysfunction than those with low interest in sex.9,10
Currently, the International Index of Erectile Function
(IIEF) and its short form, the IIEF-5 and Expanded Prostate
Cancer Index Composite (EPIC), are the most widespread
questionnaires to evaluate and identify symptoms and con-
cerns after RARP. However, these questionnaires cannot ade-
quately evaluate NSEs. A majority of urologic oncologists
routinely give these questionnaires to patients or use them for
research purposes and do not take their patients’ sexual dys-
function seriously, and it is extremely rare to evaluate and
treat sexual dysfunction face to face. As a result, only one-
fifth of men who have been diagnosed with PCa, and pre-
sumably fewer cases in Japan, ever discuss issues related to
sexual dysfunction with their physicians.11 Recently, the
International Society of Sexual Medicine published a guide-
line regarding sexual health care for PCa patients,12 which
stated that there are large differences depending on national
origin and ethnicity. In other words, it is impossible to unify
sexual care with one guideline, and it is necessary to fit the
situation of each country. Since there is no comprehensive
review from Japan on sexual care after RARP, this review
discusses the current situation of evaluations of sexual dys-
function by presenting our experiences as well as future
directions for evaluating sexual dysfunction after RARP. In
this review, we minimize the discussion of ED after RARP
and mainly focus on NSEs to fit the actual situation in Japan.
QUESTIONNAIRES FOR SEXUAL
DYSFUNCTION OF RARP AND ITS
LIMITATIONS
For the evaluation of erectile function, the best objective
method is the measurement of nocturnal penile tumescence
using RigiScan®. Because of its complexity, it has been
replaced by questionnaire-based approach. According to a
recent systematic review, the number of health-related QOL
(HRQOL) and disease-specific questionnaires has increased
tremendously, with 298 questionnaires reported for PCa.13
Therefore, it is important for physicians to understand the
characteristics and roles of each questionnaire. The IIEF is
the first and most well-known questionnaire developed for
the evaluation of erectile function.14 By modifying this land-
mark questionnaire, several questionnaires have subsequently
been developed: the Sexual Health Inventory for Men
(SHIM) for men who do not need sexual intercourse,15 the
Erectile Function Domain (EFD) of the IIEF, the Patient-
2 © 2023 The Japanese Urological Association.
Reported Outcomes Measure Information System
(PROMIS),16 and the Erectile Dysfunction Inventory for
Treatment and Satisfaction (EDITS).17 Subsequent validation
efforts established 10 points to constitute a clinically impor-
tant difference in EDITS scores.18 The Erection Hardness
Score (EHS), which was developed in 2007, is simple and
includes four grades of penile hardness19; it correlates posi-
tively with the IIEF and helps to evaluate erectile function.
To combine information other than sexual function, such as
bowel and urinary function, the University of California Los
Angeles Prostate Cancer Index (UCLA-PCI) was developed,
which consists of 20 questions that address impairments in
urinary, bowel and sexual domains.20 The EPIC is a 50-
question questionnaire that updated the UCLA-PCI with 30
additional questions,21 but patients are often uncomfortable
answering all the questions. There is no “best” questionnaire
for PCa patients because no questionnaire can comprehen-
sively and individually evaluate QOL, including NSEs after
RARP, psychological concerns, and partners’ needs. The
questionnaires described below are used as second-line ques-
tionnaires to evaluate each patient individually. The Self-
Esteem and Relationship (SEAR) questionnaire,22 Sexual Dis-
tress Scale in Men with Prostate Cancer (SDS),23 Peyronie’s
Disease Questionnaire (PDQ),24 and Female Sexual Function
Index (FSFI)25 enable us to perform a multifaceted assess-
ment of sexual dysfunction and seek proper individualized
treatment options.
Although improvement in sexual function is associated
with increased sexual satisfaction, satisfaction is not simply
dependent on erections. HRQOL for PCa patients should not
be evaluated only from the standpoint of erectile function but
should also be evaluated by including other sexual function,
NSEs, and general health.26 One of the most commonly used
general HRQOL questionnaires is the 36-Item Short Form
Survey (SF-36), which contains 36 questions covering 8
health domains within the realms of physical and mental
health. In combination with the development of the Func-
tional Assessment of Cancer Therapy-General (FACT-G), the
FACT-Prostate (FACT-P) was developed in 1997, and the
FACT-P is the newest HRQOL questionnaire specific to pros-
tate cancer.27 The FACT-P consists of 27 general questions
from the FACT-G and 13 prostate cancer-specific questions,
including sexual, urinary, and bowel domains. Psychosocial
changes related to cancer treatment and changes in HRQOL
can all affect post-RARP questionnaire satisfaction. The
recovery, combination, and sequential use of the current
questionnaire can sometimes be useful. Currently, however, a
single questionnaire and some combinations still fail to com-
prehensively assess individual patients. To effectively evalu-
ate the QOL for PCa patients and develop a proper
questionnaire, we must understand the background of sexual
health in a specific country and region.
CURRENT SITUATION OF SEXUAL
MEDICINE FOR PROSTATE CANCER
PATIENTS IN JAPAN
The low frequency of sexual intercourse among Japanese
couples is a well-known fact, and there are limited impacts

on sexual dysfunction if expressed as a mean.28,29 On the
other hand, a number of patients need sexual care, and
strong, albeit limited, sexual concerns have been found in
men with high sexual activity.10 Unsatisfied patients in the
high-interest group demonstrated significantly deteriorated
sexual health at 6 and 12 months after surgery despite rela-
tively good recovery of sexual function.10 The goals of sex-
ual function differ for each patient. It is necessary to
understand, clarify and fully discuss the purposes and goals
of the preservation of sexual function prior to RARP, which
may ultimately play a role in reducing difficulties for each
patient (Figure 1a). The most difficult goal for the preserva-
tion of sexual function is to achieve the partner’s orgasm
through sexual intercourse, which impairs the satisfaction of
partners. Approximately 81%–93% of patients report that
RARP negatively affected their sex lives,30 with 20%–58%
of men reporting the cessation of sexual activity with their
partner; this situation occasionally leads to divorce. This is a
rare situation in Japan; most patients desire orgasm by mas-
turbation, with weak rather than strong erections during
(a)
Harder
FIGURE 1 Goals of sexual function after RARP
on classical (a) and neglected sexual function (b).
Classical sexual function is focused on erectile Easier
function and the levels of goal is different among
the patients.
points
25
20
15
10
5
FIGURE 2 Changes in erectile function evaluated
by IIEF-5 and IIEF-5 masturbation version after
0
RARP. Both questionnaires were used
simultaneously for 30 patients.
© 2023 The Japanese Urological Association.
Evaluation of sexual function after RARP
foreplay with partners and morning erections, which are rela-
tively achievable goals compared with sexual intercourse. In
other words, it would be erroneous to proceed with the evalu-
ation by restricting it to sexual intercourse and erectile func-
tion, which sometimes cause this type of upsetting situation.
After understanding the diversity of sexual functions, it is
possible to carefully evaluate the situation through face-to-
face interviews but not through questionnaires alone.
We investigated the recovery of sexual function up to
12 months after surgery in 30 patients who had experienced
both masturbation and sexual intercourse before surgery and
who had undergone nerve preservation at least unilaterally.
The IIEF-masturbation version, which we used, simply
replaces “sexual intercourse” with “masturbation.” It showed
significant improvement after 3 months and was more sensi-
tive than the IIEF-5 in evaluating patients’ sexual function
and the biological results of nerve sparing (Figure 2). In the
case of the IIEF-5, as shown in the Figure 2, the level of sex-
ual function is high, the psychogenic element is large, and
the partner factor is included, so the questionnaire has lower
(b)
Classical Often neglected
sexual function sexual function
Partner’s orgasm by sexual intercourse Orgasmic pain
Partner’s satisfaction by sexual intercourse
Climacturia
Orgasm by sexual intercourse
Penile shortening/
At least penetrate Peyronie’s disease
Orgasm by masturbation
Decreased libido/
Arousal disorder
Weak erection during foreplay with partner
Morning erection or occasional erection
IIEF-5
Masturbation version
IIEF-5
Pre-operative 3 months 6 months 9 months 12 months
3
SHIRAISHI
sensitivity. The IIEF-masturbation version is more appropriate
for Japanese men than the SHIM. These preliminary results
should be prospectively examined in large numbers of
patients.
ORGASMIC DYSFUNCTION
Men’s sexual cycle is considered to consist of four interactive
phases: desire, arousal (or excitement), orgasm, and
resolution.31 Erection is associated with the arousal phase and
continues until the resolution phase, whereas ejaculation cor-
responds to only the orgasm phase.31 Physiologically, ejacu-
lation consists of two distinct phases: the emission phase
(i.e., secretion of sperm with mixed components from the
prostate, seminal vesicles, and ampullary vas deferens into
the prostatic urethra) and the expulsion phase (i.e., forceful
propulsion accompanied by rhythmic contractions of perineal
striated muscles of the mixture from the prostatic urethra to
the urethral meatus). The bulbospongiosus muscle, one of the
major components of the perineal muscles, plays an important
role in intensive and rhythmic syringeal contraction.32 The
sympathetic, parasympathetic, and somatic nervous systems,
via the pelvic plexus, pudendal nerve, and hypogastric nerve
impulses act in a synergistic manner to initiate and complete
seminal emission by activating these smooth muscle contrac-
tions.33–36 The sympathetic system also commands bladder
neck contraction simultaneously.34 Ejaculation represents the
climax of the male sexual cycle and lasts only several
seconds.37 The orgasmic feeling associated with ejaculation is
concomitant with the expulsion phase, but the sensory path-
way is not fully understood. Importantly, ejaculation and
orgasm are neurophysiologically distinct and should not be
regarded as the same biological phenomenon.34 The dorsal
nerve of the penis, a sensory branch of the pudendal nerve,
carries impulses from sensory receptors harbored in the penis
to the sacral segments of the spinal cord. RARP, the removal
of the prostate and seminal vesicle prevents the emission (but
not expulsion) phase of ejaculation, resulting in a “dry”
orgasm.38 It is apparent that patients with “dry” orgasm can
still experience orgasm concomitantly with the expulsion
phase.38 ED is basically associated with the ejaculatory
response, although in some conditions, ejaculation can be
triggered in the absence of a full erection.39 Furthermore,
orgasm has been described as a distinct cerebral cortical
event that is experienced phenomenologically and
emotionally.35 In this scenario, erectile function and orgasmic
function should be evaluated separately, and their manage-
ment inevitably differs.
Orgasm is an important function of QOL in most men,
including elderly individuals. It contributes to marital satisfac-
tion, happiness, and stability, and maintaining orgasmic func-
tion is highly important to many men,40 especially Japanese
men who often masturbate. RARP removes the prostate and
surrounding bladder neck, seminal vesicles, and part of the
vas deferens, which may result in altered orgasmic sensation
or orgasmic threshold.6,41 Increased incidence of ED is a
well-known complication of RARP, but orgasmic dysfunction
has not received much attention and is regarded as an NSE.
The rate of anorgasmia after RARP has been reported to
4 © 2023 The Japanese Urological Association.
range from 14% to 37%.36,42,43 There are a number of reports
on the impairment of orgasmic function after RARP, and
mean changes in orgasm intensity have been reported to be
up to 78%.44 In a report from Japan, 259 questionnaires were
used for analysis. Among sexually active patients (n = 145),
33 (22.8%) reported anorgasmia and 83 (57.2%) reported
decreased orgasm intensity. Twenty-two (15.1%) patients
reported dysorgasmia; among these patients, pain was experi-
enced almost always or always in 13.6%, sometimes in
13.6%, and a few times in 72.8% of cases.43
The correlation between nerve-sparing status and orgasmic
function was confirmed by Tewari et al.36 However, orgasmic
function tends to be retained more often than erectile func-
tion, and satisfactory ability to achieve orgasm is possible
even in patients who lack sufficient erection.45–47 There is a
close relationship between the recoveries of erectile function
and orgasmic function. However, there is no distinct recovery
rate categorized by nerve-sparing status (i.e., unilateral and
bilateral preservation),47 suggesting that other neural path-
ways exist to regulate orgasmic function, such as pudendal
nerves; this possibility is supported by other researchers.45 To
differentiate this situation, Dubbelman et al.41 and Salonia
et al.42 used the orgasmic domain of the IIEF in 48 and 334
patients, respectively. They showed that when counseling
patients about orgasmic function after prostatectomy, it is
important to stress that the ability to reach orgasm might be
retained even if they experience ED. Taken together, these
observations indicate that neural regulation differs between
erectile and orgasmic function, and it is necessary to investi-
gate how nerve-sparing RARP should be performed to pre-
serve orgasmic function.
Painful orgasm is a bothersome complication that has a
significant impact on the QOL of patients after RARP.46,48
The cause of painful orgasm has been suggested to be post-
prostatectomy conversion of the physiological bladder neck
closure that occurs during orgasm into spasms of the vesi-
courethral anastomosis or pelvic floor dystonia.33 To support
this theory, seminal vesicle-sparing prostatectomies are signif-
icant predictors of painful orgasm because contraction and
secretion of the remaining seminal vesicles may also cause
pain.46,48 This dysfunctional contraction has been supported
by the improvement of painful orgasm with alpha-blocker
medications, possibly due to the inhibition of seminal vesicle
or bladder neck contractions,33,46 indicating that anorgasm
and painful orgasm should be evaluated and treated
separately.
SEXUAL INCONTINENCE
Sexual incontinence is also an NSE after RARP and includes
arousal incontinence (sometimes called foreplay incontinence)
and climacturia. Climacturia is defined as organism-associated
incontinence that occurs during sexual arousal, sexual inter-
course, and masturbation with a prevalence of 20%–93%49–51;
it is an issue for patients and their partners. Among 1177
patients at a men’s clinic, climacturia was reported by 39%
and 52% of patients with a history of radical prostatectomy
alone and radical prostatectomy and radiation, respectively. A
significant reduction in climacturia was noted for men who

were >1 year out from surgery compared with men who were
<1 year out.52 The mechanisms of climacturia after RARP
are not fully understood, although previous evidence has
shown that daytime urinary incontinence after RARP
increases the risk of climacturia.49,53 Sullivan et al. reported
that in a multivariable analysis, urethral width on MRI was
associated with climacturia.54 A decrease in functional ure-
thral length, bladder neck incompetence, and external sphinc-
teric deficiency are believed to be associated with this
condition. An important issue is that all of these men felt
concern related to this condition, and two-thirds of them
avoided sexual activity because of these symptoms,55 which
may trigger a decrease in QOL after RARP. Improvements in
climacturia and stress urinary incontinence have also been
described in a small series of men undergoing mini-Jupette
grafts after radical prostatectomy, with >90% of patients not-
ing significant or complete resolution of climacturia.56,57 This
finding indicates that climacturia and urinary incontinence
share, at least in part, a common pathophysiology.
As a nonsurgical treatment, emptying the bladder prior to
sexual intercourse should be advised, and pelvic floor rehabil-
itation has been reported to show significant success.58,59
Based on the pathophysiology of climacturia, tension loops60
and artificial urinary sphincters have been reported to be
effective.61 In a study of 46 men with climacturia following
radical prostatectomy, 100% had resolution of their climac-
turia after transobdurator sling placement62; however, these
surgical approaches are too invasive for climacturia alone. At
the same time, as the implantation of penile prostheses, graft-
ing a mesh to support the urethra is a reasonable option.56
Patients who need these treatments are extremely rare in
Japan, but we should understand these options because cli-
macturia is one of the major NSEs. Efforts to improve post-
operative urinary incontinence may contribute to decreasing
climacturia. Several modifications of RARP have been devel-
oped, but the incidence of climacturia among these tech-
niques has not been elucidated. Regarding our preliminary
experience with RS-RARP, 17 sexually active men following
RS-RARP did not experience sexual incontinence. This find-
ing should be confirmed with an increased number of patients
and comparisons with other surgical techniques.
PENILE SHORTENING AND PEYRONIE’S
DISEASE
In addition to functional complications after RARP, patients
often experience postoperative changes in penile anatomy,
such as penile shortening and shape (i.e., acquired penile cur-
vature), including Peyronie’s disease,63–67 which in turn can
influence self-esteem.65,67 Savoie et al. reported that approxi-
mately 50% of patients lost penile length, but 92% of patients
presented normal baseline erectile function.68 Several reports
in the literature have highlighted that up to 70% of
men have documented penile length loss of approximately
1–3 cm.63,64,68,69 A significant reduction in penile shaft length
has been variably reported in post-RP series, with data
showing a range of 15%–68% of patients complaining of
postoperative penile shortening.6,70,71 Evaluated objectively,
prospective assessments of postprostatectomy patients report
© 2023 The Japanese Urological Association.
Evaluation of sexual function after RARP
an incidence of penile length loss ranging from 68% to
71%.63,64 Capogrosso et al. compared the rate of penile mor-
phometric alterations after either RARP or open
prostatectomy.72 In multivariable analysis, robot-assisted sur-
gery was independently associated with a lower risk of post-
operative penile morphometric alterations (OR: 0.38; 95% CI:
0.16–0.93). Exact preservation of penile blood flow, nerve
sparing, and pelvic muscles by RARP may, at least in part,
contribute to these results. Reports regarding NSEs after
RARP are extremely rare but there is a publication on penile
shortening from Japan.73 This means that irrespective of the
need for sexual intercourse or masturbation, shortening and
deformity of the penis can be bothersome and affect patients’
self-esteem, even in sexually inactive patients. In the
REACCT trial,74 which investigated daily dosing of tadalafil
5 mg after radical prostatectomy, stretched penile length loss
was 6 mm in men treated with placebo for 9 months after rad-
ical prostatectomy, whereas patients taking daily tadalafil had
a mean length loss of 2 mm. The clinical significance of 4-
mm stretched penile length preservation is debatable.
Regarding de novo penile curvatures, a study from 2000
noted that 45 of 110 men with ED after prostatectomies had
measurable penile curvatures and/or waistband deformities.68
This corresponded to 11% of all patients undergoing prosta-
tectomies in the specified period. Subsequently, a much larger
study (N = 1011) reported de novo curvatures in 15.9% of
patients developing at a mean of 13.9 months after
prostatectomy.75 The incidence of Peyronie’s disease in the
Japanese general population has been reported to be 0.6%,
which is much lower than that in the US and Europe.76 How-
ever, there is no information on men after RARP. Penile cur-
vatures after prostatectomy have been related to the
development of fibrotic plaques occurring at the level of the
tunica albuginea. Ciancio et al. reported the occurrence of
either penile curvatures or deformities in 11% of operated
patients.68 Of clinical interest, palpable plaques were identi-
fied only in a proportion of patients reporting penile curva-
tures, leading the authors to classify the phenomenon as a
‘penile fibrotic change’ rather than formal Peyronie’s
disease,68 which may cause diagnostic difficulty to exclude
nonspecific fibrotic changes from Peyronie’s disease. In this
situation, treatment options for penile curvature and Peyro-
nie’s disease after RARP are similar irrespective of RARP.
Strategies for prevention include the use of PDE5 inhibitors,
vacuum devices and/or penile traction. Information on the
success rate of surgical approaches, such as tunica albuginea
plication or plaque excision and grafting are very limited.
PSYCHOLOGICAL CONCERNS
The evaluation of sexual function in men after RARP is com-
plex because of strong psychological impacts. It is known
that increasing PSA and a diagnosis of PCa per se might be
sufficient to disturb sexual function. Subsequent hospital
visits and treatments are an obvious cause of psychological
problems and can lead to issues such as a loss of masculine
identity, loss of self-esteem, and anxiety.77 As a result, it has
been shown that depression, feelings of anxiety, and relation-
ship closeness play important roles in overall sexual
5
SHIRAISHI
satisfaction.78 Furthermore, a cycle of frustration and avoid-
ance of sexual activity has been identified by Nelson et al. as
follows: (1) disappointment and shame related to ED, (2) fear
and anxiety of entering into a sexual situation, (3) avoidance
of sexual situations, (4) loss of valued life experience, and
(5) increased frustration, distress and depression.79 In addition
to RARP, we must pay attention to patients’ psychological
concerns. Although patients who reach their baseline erectile
function will not necessarily need to manage sexual
satisfaction,10,80 the erectile function score is not correlated
with overall satisfaction. In the literature, several factors in
addition to erectile function were found to be associated with
sexual satisfaction: sexual desire, intensity of orgasm, sexual
self-esteem, age, time since diagnosis, relationship variables,
and psychological variables such as depression and anxiety.80–84
There is a significant association between depressive
symptoms and erectile dysfunction, and depressive symptoms
may contribute to a delay in the improvement of sexual satis-
faction in patients with ED due to RARP.83,85 We must clar-
ify whether this depressive condition may be caused by ED
per se or the combination of the other sexual dysfunction
symptoms. It is also necessary to evaluate the cycle of
frustration78 patients face and break this vicious and frustrat-
ing cycle.
Despite the impact of PCa treatments on partners’ and cou-
ples’ sexual health, partners are often excluded from evalua-
tions of the sexual side effects of treatment, and most
resources do not incorporate partners’ priorities. As a result,
partner-specific unmet sexual health needs remain poorly
understood.86 Generally, female partners respond differently
to long-term sexual health challenges from PCa therapy.87
Female partners are more likely to recognize the importance
of communication and are more likely to perceive strain on
the relationship from sexual dysfunction. In other words, PCa
has been described as a couple’s disease,88 but a validated
measure to assess sexual relationships has yet to be devel-
oped. In Japan, this point remains underinvestigated, but
racial differences are believed to exist. The number of cou-
ples who need this kind of sexual care is uncertain, but this
issue needs to be clarified. We must prepare opportunities for
patients to discuss these issues with physicians or other
health care professionals with expertise in sexual medicine to
help patients express and understand the feelings elicited by
their situation.
GIVING BACK TO SURGICAL TECHNIQUE
AND HORMONAL MANAGEMENT
To maximize the preservation of the number and volume of
nerves, we have made efforts to improve procedures, such as
the peel technique, high anterior release, and athermal and
atraumatic dissection, although it is unclear how many nerve
fibers are viable and which nerve preservation techniques
contribute to orgasm, climacturia, or penile deformities as
well as erectile function. On the other hand, unilateral preser-
vation is sometimes sufficient for full erection, and very occa-
sionally, non-nerve-sparing cases present weak erection.
Precise nerve volume and localization are not fully under-
stood and differ for each patient.
6 © 2023 The Japanese Urological Association.
Triggering and maintaining orgasm is highly dependent on
the pudendal nerve, in which the nerve type and localization
are completely different from erectile function.89 These nerve
fibers merge to assemble the dorsal nerve of the penis. The
dorsal nerve converges with other perineal nerves to become
the internal pudendal nerve, which ascends to the dorsal roots
of the second to fourth sacral nerves. The ascending path-
ways in the spinal cord travel via the spinothalamic tract to
the thalamus and to the sensory cortex. The pudendal nerve
goes through Alcock’s canal and the apex of the prostate, dis-
tributes into the perineum and innervates the bulbocavernosus
and ischiocavernosus muscles. These muscles are believed
not only to provide temporary increases in intracavernosal
pressure and contribute to penile rigidity during erection but
also to play roles in the sensation of the penile surface. Pre-
cise distribution of pudendal nerve distal from Alcock’s canal
has not fully been investigated but we have to avoid thermal
and mechanical damage to paraurethral tissues and levator
ani around the urethra. If a patient needs orgasm by mastur-
bation rather than sexual intercourse, his purpose and goal
after RARP is not to preserve full erection but to preserve
orgasmic function; therefore, we need to concentrate on pre-
serving the nerve bundles around the apex and urethra rather
than the base of the prostate. Taking into account the
information regarding sexual dysfunction after colorectal
surgery,90 describing that complications from radical abdomi-
noperineal resection and lower anterior resection can result in
sexual dysfunction, specifically including erectile and ejacula-
tory dysfunction for male patients, and the pathophysiology
has not been fully investigated, we must accumulate clinical
symptoms and nerve-sparing status not only for prostate sur-
gery but also for other surgeries of pelvic organs.
In addition to classical anterior RARP, novel surgical tech-
niques such as Retzius-sparing RARP91 and hood RARP92
have been reported. Presumably, the number of locations of
preserved nerves will differ among the maneuvers, and we
must evaluate the sexual dysfunction of each maneuver to
identify differences in the recovery of sexual function. In
turn, this may open a window to understand the physiological
aspects of sexual function. This kind of investigation will
ultimately provide an individualized nerve-sparing procedure
for men who receive RARP and reduce patient regret after
surgery.
Controversies still exist on the testosterone replacement
therapy (TRT) for PCa patients.93 On the other hand, the
oncological safety of TRT in PCa survivors after definitive
local therapy has been shown.94,95 Several small studies have
been reported of men with treated or nonmetastatic prostate
cancer who received testosterone for symptomatic hypogo-
nadism. These studies have shown minimal or no increased
risk of prostate cancer progression in these settings.96–98 Two
small studies99,100 of 7 and 10 men have been published
reporting the use of TRT in men following radical prostatec-
tomy and with undetectable PSA. No PSA recurrence was
noted in any of the men, with the longest follow-up being
12 years. We often face this situation in patients after RARP
who underwent androgen deprivation prior to surgery. Men
who are symptomatic for T deficiency, particularly if they
appear stable with regard to PCa, may request treatment for

their hypogonadal symptoms. In addition to the development
of surgical techniques, we must manage patients after RARP
from the standpoint of hormonal aspects, which will be
expected to improve patient QOL.
CONCLUSIONS
We believe it might be helpful to ask patients about sexual
desire, how it occurs (i.e., sexual intercourse or masturbation)
and sexual satisfaction during sexual counseling rather than
counseling them only about erectile function. Questionnaires
are just one method of evaluating patients’ concerns pre- and
postoperatively. Furthermore, listening to patients face to face
is warranted to detect symptoms that patients do not offer
voluntarily. We should not rely on questionnaires only, but it
is not necessary to say a permanent farewell to IIEF. Instead,
we must focus on the importance of a variety of evaluations
regarding sexual function for each patient.
Despite advances in surgical techniques for PCa and post-
operative care, such as penile rehabilitation, a recent study
found that the probability of regaining functional erections
after prostatectomy has not improved over the last decade.5
This is a result of the failure to sufficiently investigate NSEs
after RARP. Furthermore, there is a limitation that surgical
improvement is not sufficient to completely manage sexual
dysfunction after RARP. In other words, psychological and
hormonal approaches, such as TRT and pre- and postopera-
tive sexual counseling with partners, may contribute to
improving sexual dysfunction after RARP. It is time to
change directions to improve sexual dysfunction after RARP.
AUTHOR CONTRIBUTIONS
Koji Shiraishi: conceptualization, writing (original draft,
review and editing) and format analysis.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
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