The question behind the question
The question usually comes late in the visit. We have covered the cancer, the operation, the catheter, and the time away from work. Then there is a pause, and he asks about erections. Sometimes his partner asks for him. Sometimes he waits until his partner has stepped out of the room.
The men in this essay are composites of many conversations, with the details changed. Their worry is the same. They want to be cured, and they want to be themselves afterward. I take both wishes seriously, and I try to say clearly when they pull against each other.
The nerves that control erections run in thin bundles along the sides of the prostate, lying close against its surface. During a robotic prostatectomy, I can try to release the prostate from those bundles and leave them in place. That is what surgeons mean by nerve sparing. The magnification and fine instruments of the robot help. The anatomy is still the anatomy, and the cancer still decides how close I can safely work.
What the guideline says
The American Urological Association guideline says that in men choosing radical prostatectomy, nerve sparing should be performed when it is oncologically appropriate. It also explains why. Preserving the neurovascular bundles has consistently been associated with a lower likelihood of erectile dysfunction after surgery. It has variously been associated with better urinary control. And it has not been found to significantly increase positive surgical margins or biochemical recurrence.
The guideline is candid about its limits. There are no randomized trials comparing nerve sparing with non nerve sparing surgery. The decision, it says, is multifactorial. It may draw on the PSA, the rectal exam, the biopsy findings including the grade, the amount of cancer and where it sits, the MRI, the man's erectile function before surgery, and how much he prioritizes sexual function.
Two more points from that section shape how I talk with patients. The panel says MRI should not be used on its own to decide about nerve sparing, because its ability to predict spread just outside the prostate, particularly microscopic spread, is limited. And it says nerve sparing need not be an all or none decision. Partial preservation, and preservation on one side only, are both legitimate choices.
Planning each side
I plan each side separately. If the cancer sits on the left near the edge of the gland, I may stay wider on the left to give the cancer a margin, and stay close to the prostate on the right where the biopsies were clean. I tell the man this before surgery, and I often draw it for him. I also tell him the plan may change in the operating room if what I see does not match what the scans suggested.
The order of priorities is explicit. Cancer control comes first. If preserving a nerve would mean leaving cancer behind, I will take the nerve, and I will have told him in advance that I might. Most men, asked plainly, agree with that order. A few want to weigh it differently, and we keep talking until we understand each other.
Some men have little erectile function before surgery. For them, the nerves matter less to the outcome they care about, and that changes the calculation. Others tell me sexual function is near the top of their list. I want to know which man I am operating on before I make a single cut.
Honest expectations
This is where I try hardest to be careful. Nerve sparing preserves the possibility of recovery. The recovery itself is slow. Even when the nerves are left in place, they are handled and stretched during the operation, and they often take many months to wake up. Some men recover well. Some recover partly. Some do not recover without help. I cannot tell any one man in advance which of those he will be.
Where he starts matters. A man who had firm, reliable erections before surgery has more to recover toward. Age, diabetes, heart disease, smoking, and some medications all play a part. I would rather he hear this from me before the operation than discover it alone afterward.
I also talk about continence, because men worry about it just as much. Leakage after the catheter comes out is common, and for most men it improves over the following weeks and months. The pelvic floor exercises we teach before surgery help. For the smaller group whose leakage lasts, there are effective treatments, and I tell men that before surgery too, so that nobody feels stranded.
Recovery and patience
Recovery of erections is something we work on together after surgery. We talk about medications, devices, and other options, and we start early. I ask men to measure progress in months and to judge it at a year or more. Progress at six weeks tells us very little.
I also talk with their partners when they want me to. Intimacy after prostate surgery is a shared project, and it goes better when both people know what to expect. Many couples find that the expectation of a slow return is easier to live with than a promise that turned out to be wrong.
The phrase I return to most often is honest expectations. I do not promise outcomes. I describe what I plan to do on each side, why I plan it, what usually happens afterward, and what we will do if recovery is slow. That is the version of this conversation I would want if I were the one about to be wheeled into the operating room.
Reviewed by the author ·
This is one surgeon's perspective, written for general education. It is not advice for any individual. Decisions about your care belong in a conversation with your own doctors.