Normal Erection After Prostatectomy Is 'Rare'

Do Urologists Overestimate Return of Function?

Nick Mulcahy

April 14, 2015

After a radical prostatectomy, it is highly uncommon for a man to have erections like the ones he normally had before surgery, according to a study presented at the European Association of Urology 30th Annual Congress in Madrid.

The researchers reached that conclusion because only 14 patients in the 210-men study (6.7%; 95 %confidence interval [CI], 4.4% - 10.1%) reported that their erections were the same before and after surgery.

"What this work shows is that having an erection as good as before surgery is a rare event," lead researcher Mikkel Fode, MD, PhD, from the Herlev Hospital in Copenhagen, Denmark, said in a meeting press statement.

There is "controversy" about the incidence of erectile dysfunction after surgery for prostate cancer, the researchers write in their abstract.

The controversy stems, in part, from the fact that the "most commonly used" questionnaire in this setting, the International Index of Erectile Function (IIEF), has not been validated in prostate cancer patients and is vague, the team notes.

To clarify this issue, Dr Fode and colleagues added their own question to the IIEF-5, which is an abbreviated version of the longer questionnaire: "Is your erectile function as good as before the surgery (yes/no)."

They mailed their version of the IIEF-5 to 210 men treated at the Herlev Hospital who completed the questionnaire an average of about 23 months after surgery.

Even without the extra question, IIEF-5 scores indicated that the men (mean age, 65 years) were struggling.

 
Having an erection as good as before surgery is a rare event.
 

For men who completed the IIEF-5 questionnaire before surgery, the mean score was 21.7 (95% CI, 20.6 - 22.9). After treatment, the mean score dropped to 9.9, with a lower score indicating more dysfunction (95% CI, 8.6 - 11.3).

The researchers also collected information on the use of erectile aids.

Of the 189 men who did not use aids before radical prostatectomy, 83 started to do so after surgery. Specifically, 58 patients began using phosphodiesterase type 5 inhibitors, 17 began using injection therapy, five began using urethral suppository alprostadil (MUSE), one began using a vacuum erection device, and two received a penile implant.

Notably, the 49 patients (23.3%; 95% CI 18.9% - 28.5%) who did not use erectile aids showed no decline in IIEF-5 score.

But an unchanged IIEF-5 score does not necessarily mean that all is completely well, erection-wise, suggest Dr Fode and colleagues. That's because, as noted above, only 14 of the 210 men reported, in answer to the extra question, that their erections were unaffected by surgery.

"The IIEF-5 questionnaire may not adequately reflect patients' experience," the researchers conclude.

The study results are not entirely surprising, said an expert not involved with the study.

"Prostate cancer treatment, whether surgery or radiation, definitely hits below the belt," said Alexander Kutikov, MD, an attending surgeon in urologic oncology at the Fox Chase Cancer Center in Philadelphia.

"There is no doubt that even for men who have 'functional' potency following prostate cancer treatment, erectile function is rarely the same," he told Medscape Medical News in an email.

"Reported potency rates vary widely and differ between datasets, institutions, and surgeons. Results reported by these authors certainly dovetail with previous data," he noted.

"Morbidity following prostate cancer treatment...is real, should be discussed with patients in detail, and should not be sugar-coated," advised Dr Kutikov.

Urologists Are Asking the "Wrong Question"

 
Erectile function is rarely the same.
 

Return to normal sexual functioning might be regularly "overestimated" by clinicians, the researchers suggest in meeting press materials.

Dr Fode explained why: "Fundamentally, we may have been asking patients the wrong question."

The traditional IIEF-5 tool focuses on performance over a 6-month period, and asks questions about a man's "confidence" in his erection, "satisfaction" with intercourse, and ability to "complete" intercourse. There are no specific questions about the impact of treatment on erections.

"The occurrence of sexual dysfunction after prostate cancer surgery is well known, but our method of evaluating it is new," said Dr Fode. "We think that this work gives a more realistic idea of the real problems most men have after prostate surgery."

Dr Kutikov said that some variables help predict who will suffer the most. "We know very well that erectile function following prostatectomy often suffers, and very much depends on the degree of nerve sparing, patient age at surgery, and level of potency prior to surgery," he explained.

In fact, bilateral nerve sparing (P = .003) and the absence of cardiovascular disease (P = .04) were significant predictors of a subjective return to baseline erectile function, the researchers found.

However, age, time since surgery, D'Amico classification, and other comorbidities were not significant predictors.

More work is needed to validate the usefulness of the question from the Danish researchers, Dr Kutikov said.

"These data are interesting; however, to crystallize their significance a control dataset is needed. For instance, what do data from a cohort of men who had to answer this question following say, bowel resection surgery, look like?" he asked.

Dr Kutikov noted that there is an assessment tool that attempts to quantify the chances of erectile function recovery after surgery (JAMA. 2011;306:1205-1214).

The researchers and Dr Kutikov have disclosed no relevant financial relationships.

European Association of Urology (EAU) 30th Annual Congress: Abstract 1629. Presented March 22, 2015.

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