Owing to widespread and intensive prostate-specific antigen screening, the incidence rate of prostate cancer has steadily increased in East Asia (most significantly in Korea) over the last decade [1]. Nerve-sparing radical prostatectomy preserves erectile function in males treated for prostate cancer. Unfortunately, a nerve-sparing procedure is not always possible in all males, and even when a nerve-sparing approach is attempted, it is not always successful. Despite the surgical technique and approach used, various degrees of nerve damage tend to occur, even in nerve-sparing surgery, secondary to local trauma and the consequent ischemic effects [2]. A recent interesting study performed by Pak et al. [3] investigated 211 Korean males and evaluated the longitudinal changes in health-related quality of life and satisfaction after radical prostatectomy performed for the treatment of prostate cancer. Post radical prostatectomy sexual domain scores showed the greatest reduction among all domains. At 1 month, the mean sexual function score showed a significant reduction from the baseline score. Although gradual improvement in scores was observed at each subsequent time-point, the scores did not recover at the 12-month time-point. In this study, Korean males undergoing radical prostatectomy for prostate cancer reported a more pronounced decline in sexual function and dissatisfaction compared with other health-related quality of life outcomes.

Penile fibrosis and shortening prevent the spontaneous recovery of erectile function. Phosphodiesterase type 5 inhibitors are used as first-line treatment for post radical prostatectomy erectile dysfunction owing to their ease of administration, safety profile, and positive effect on erectile function. This therapy is followed by intracavernosal injections and the use of vacuum erection devices. Penile prosthesis implantation is considered third-line treatment in males with erectile dysfunction in whom medical treatment is ineffective or unacceptable. In such cases, the implantation of a prosthesis is the only possible treatment to recover the patient's penile erection and to restore the patient's sexual quality of life [45]

In our opinion, it is important to evaluate and confirm a patient's baseline erectile function before performing radical prostatectomy. Additionally, males scheduled to undergo radical prostatectomy should receive complete information regarding the development of post radical prostatectomy erectile dysfunction. Preoperative counseling regarding post radical prostatectomy erectile dysfunction will improve patients' quality of life and enable a rapid return to normal activities of daily living post surgery.

We want to thank you for taking an interest in our article and for addressing important comments. We agree entirely, pretreatment counseling regarding erectile dysfunction post-surgery should be given to males with localized prostate cancer. The pros and cons of each therapeutic option, including posttreatment sexual functional changes, should be discussed with patients prior to treatment.

We believe physicians should consider providing patients with more accurate information regarding postprostatectomy erectile dysfunction when counseling preoperatively. Firstly, an adequate assessment of individual baseline sexual function is necessary. Our study revealed a subgroup of preoperative potent patients (questionnaire-based assessment), whereby sexual function and bother increased f rom 6 months post-surgery and reached approximately 80% of baseline after 12 months, which was markedly higher than the overall population [1]. Secondly, preoperative evaluation to determine patient eligibility for nerve-sparing radical prostatectomy paramount. There are many validated predictive tools and recent advances in multiparametric magnetic resonance imaging (MRI) may be useful to select eligible patients for nerve-sparing radical prostatectomy [2,3]. Particularly, evidence has accumulated demonstrating MRI as a valuable modality to predict side-specific extracapsular extension.

Moreover, we believe that postoperative counseling for patients suffering from erectile dysfunction after radical prostatectomy is also important. There was variation in the recovery times of erectile function post radical prostatectomy [4]. Various treatment options are available for rehabilitating erectile function after radical prostatectomy, and psychosocial support may also be beneficial [5]. We commend you for discussing these vital points.