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Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence.

Find out more here: https://training.cochrane.org/grade-approach was poor, mainly because of a lack predefined outcomes Outcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise).

In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. and inconsistency in reporting standards (varying definitions of potency, different follow-up durations, multiple modes of assessment including both physician and patient-reported outcomes etc). All men in these studies had some form of nerve-sparing performed during their surgery so this review was not able to assess the effect of nerve-sparing on subsequent recovery of erections as there was no control group to compare to.

Previous studies have convincingly demonstrated the critical nature of nerve-sparing (Patel et al., 2011).

The decision to undertake nerve-sparing is made in advance by the surgeon and depends on the extent of cancer. Robotic surgery has allowed more precise and meticulous surgical dissection of the surrounding layers of the prostate. Indeed, 80% of UK prostatectomies are now completed with a da Vinci robot, the remainder split evenly between laparoscopic and open surgery.

The outer layers of the prostate are a bit like an onion with several layers.

The layer containing the nerves is like the brown skin on the onion and the surgeon can choose to cut inside this layer to leave the brown skin (or nerve layer) in place.

The outer layers of the prostate are a bit like an onion with several layers.

The layer containing the nerves is like the brown skin on the onion and the surgeon can choose to cut inside this layer to leave the brown skin (or nerve layer) in place.

However, when there is a lot of cancer there is a real possibility of leaving some cancer cells behind if this close approach is taken, and so the surgeon instead chooses intentionally to take this outer layer with the prostate – the brown skin stays on the onion. So, while it may increase the risk A way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. of prostate tissue being left behind (which incidentally, is one of the reasons why the PSA may remain high post-operatively), sparing the nerves is a critical step for preservation of erectile function, and men who undergo an intentional non-nerve-sparing procedure should always be warned of the inevitability of erectile dysfunction after surgery.

Of course, for those men who have already have erectile dysfunction before surgery, no amount of nerve sparing will return natural erections. A box of four 100mg tablets (Viagra, Pfizer) will cost the NHS or you (by private prescription) ?23.50 per box. However, since December 2017 in the US, and amazingly since June 2013 in the UK, it has been legal for other drug manufacturers to make generic sildenafil and so, with a private prescription you can now pick up a box of 4 x 100mg sildenafil citrate tables for as little as 79p, a thirty-fold price reduction. The NHS is slowly waking up to this but still official NHS guidance only permits one packet of four tables per month for those who meet strict erectile dysfunction criteria.

We hope this will change soon, sildenafil citrate online pharmacy given that 11 boxes could be purchased for the ?8.80 standard NHS prescription charge!

Furthermore, Cialis also came off patent in December 2018 in the US and we can therefore expect generic tadalafil , which currently costs ?54.99 for a box of 28 x 2.5mg – cialis is generally taken daily due to its longer half-life – to come down to similar prices. Increasing availability of these previously expensive drugs is a tremendous help for men who have undergone radical prostate surgery. Despite the uncertainty regarding penile rehabilitation, there is no doubt that real-time erections often improve while on Viagra (or Cialis or Levitra etc) and so straightforward access to these drugs is essential for a speedy return to a functioning sex life after cancer, for those who want it.

Join in the conversation on Twitter with @CochraneUK or leave a comment on the blog.

Alastair Lamb and Altan Omer have nothing to disclose. Omer MD FEBU is a Pelvic Uro-Oncology and Robotic Surgery Fellow at the Churchill Hospital, Oxford.

Mr Alastair D Lamb, MA(Oxon), MBChB, PhD(Cantab), FRCS(Urol) is a Cancer Research UK Clinician Scientist, Senior Fellow in Robotic Surgery and Honorary Consultant Urologist at the Nuffield Department of Surgery, University of Oxford and Oxford University Hospitals NHS Foundation Trust, UK. My clinical focus is to deliver excellent and timely prostate cancer care to men referred to our team from the Oxford regional area, focussing on state-of-the-art diagnostics with multiparametric MRI and targeted transperineal biopsies, followed by robotic-radical prostatectomy (RARP) or indeed active surveillance where appropriate.

I have a particular interest in pushing the boundaries of minimal access surgery (MIS), for example to performing cytoreductive radical prostectomy in locally advanced or metastatic disease and RARP in fit, older men where such approaches are deemed safe and evidence-based. My research goal is to provide a robust molecular platform for accurate decision-making in early stage prostate cancer. Erections after prostatectomy surgery: does Viagra still work? I had prostate surgery it have been about six weeks no action with my love making .so I tired tadalafil 20 mg did not for me.so I tried 40 mg nothing .

For me it will be two years in May for my prostate surgery removal so I tired the penis pump viagra and no action in the bedroom and my age 52.

I’ve tried All the injections but the erection is only 70%,I’ve also tried viagra 100mg abit better but again only 80%.Is it dangerous to take a double dosage.

Mr Lamb, I am now 68 and had nerve sparing laparoscopic prostatectomy in 2006 and have managed reasonable erections on sildenafil although not every time and the frequency of success has reduced markedly over the last few months. I had no ED issues before my RP and am a slim, fit, non smoker with lowish blood pressure and not on any medication.

Is it just my age or as my wife suggests it may be partly in my mind and if so do you think therapy might help. My husband is 75, and had prostate surgery, due to cancer, in March 2018. He works out of town most of the time, so we have not had a good chance to try the remedies for ED. He also had open heart surgery several years ago, and his heart doctor has been reluctant to prescribe Viagra, or some similar drug. Is there anything that you might suggest that might help him when he is not home? There is some response, even at this late date after prostate surgery, when he is home, but he needs something to try in the meantime. Is Viagra safe in low doses, to help stimulate him?

A suhagra online shopping viberator seems to help some enlargement and maybe some blood flow.

I had a radical prostatectomy on October 31st, (for Halloween I was dressed as a hospital patient with nurses, IV’s and real blood), Sorry,…maybe a bit too graphic ?? Question; it is now 4 weeks since I had this procedure, so,…. Is it too soon to start with any kind of ED meds to “wake up” the sleeping giant??? Hello Tom, blog author and urologist Alastair Lamb has posted a reply to another comment here (by Susan) which may be helpful to you, as he talks about the timing and purpose of taking ED drugs after prostatectomy.

Best wishes, Sarah Chapman [Editor] My husband (52, fit, healthy, normal sexual function before surgery) has just had a radical nerve preserving surgery and was told to start on viagra straight away.

We tried it 3 days after having the catheter, blood drain and stitches out (open surgery) and it failed. I feel it was too soon to try after having all these tubes removed but the surgeon had stressed the importance of getting things moving again straight away.

How long should we leave it before trying viagra again? I’m really glad that your husband has got through his surgery well.

As you say, it can seem quite early to start taking viagra so soon after a major operation. However, there is a bit of evidence emerging (not strong as yet) that starting viagra early, or even before surgery, can help.

The message is a little mixed as, from the Cochrane Review we commented on above, the concept of “penile rehabilitation” has essentially been debunked. However, it may be that starting the drug very early catches the vessel and nerve changes at just the right time. It should be emphasised that the purpose of taking viagra this early is not to give immediate erections, but rather to improve future erections in the weeks and months to follow.

Tadalafil is probably the best PDE5 inhibitor to take for this purpose because of it’s longer half-life, but it is still rather expensive and so, as outlined above, I tend to give my patients a quarter dose (25mg) of sildenafil (viagra) daily which, when prescribed “privately”, can be paid for over the pharmacy counter and is almost as cheap as paracetamol.

I have not been part of any survey and had my prostate removed one year ago using the Da Vinci robot.

I am still clear with no follow up radiation or hormone treatment.

After not getting on with muse or the cream variant of the same drug I took it upon myself to buy some Viagra over the counter as I had seen some evidence of activity. To cut a long story short the Viagra helped but I didn’t get a full erection.

I told my post surgical team and they are now trying me on Cialis. Most recently I have express scripts sildenafil tried the 20mg dose less frequently and results within a few hours seem further improved.

Mr Lamb, it’s very impressive that you’ve attended Mani Menon’s recent presentation at AUA19 on 5 May of the Menon Precision Prostatectomy technique, aimed at reducing ED. Plainly, one should not just MRI the area of the PZ to be left in situ, but also biopsy it too.

Yes, there is a risk that the sliver of PZ which is left in situ may generate CaP. But in any event, even if you did a full RARP, traditional or Retzius-sparing, my understanding is that the patient will still be taking some risk of biochemical reoccurrence in some circumstances, even if there are “clear” margins at the finish of the operation.