Major pelvic urological surgery comprises radical prostatectomy and radical cystectomy in the male patient and radical cystectomy in the female. Postsurgical sexual dysfunction (SD) has been reported with a high prevalence in both sexes and is becoming increasingly important in the patient's view as a result of improved cancer prognosis, refinements in surgical technique, and increased awareness of quality of life aspects that involve sexual satisfaction. The pathophysiology of the problem is essentially related to the disruption of the nerves during the procedure, although a vascular impairment may also be implicated. Nerve-sparing surgery enables the recovery and/or maintenance of sexual functioning in a significant proportion of patients and it is now also adopted for women. Validated questionnaires to assess preoperative baseline sexual function and postoperative outcomes have become available and their use in clinical practice should be promoted. A number of erectile aids are available to treat postsurgical male erectile dysfunction successfully. As far as female SD is concerned, a number of potential treatment options is currently under investigation.