The Journal of Urology
Volume 179, Issue 5, Supplement , Pages S45-S46, May 2008

Commentary on Urinary and Sexual Outcomes after Radical Prostatectomy

Department of Urology, University of California, Los Angeles, Los Angeles, California

Article Outline

 

In August 1987 when Penson was embarking on his first year of medical school at Boston University (and almost 20 years before he would be awarded the American Urological Association’s prestigious Gold Cystoscope for his work in urological outcomes research), the inimitable Dr. Harry Herr perspicaciously noted that “the goal of any treatment strategy for cancer is to improve not only patient survival but also quality of that survival.”1 With an affirming nod to the then neoteric nerve sparing approach to pelvic surgery, Herr underscored the importance of valid and objective methods to assess quality of life outcomes. Since then, the urological literature has experienced enormous expansion and abiding maturation of research into patient reported outcomes following prostate cancer treatment.2

Building on the cross-sectional work of Fowler et al in Medicare patients,3 the fastidiously conducted CaPSURE® registry,4, 5 the development of validated instruments6, 7 and the early prospective single institution series by Talcott et al,8, 9 Potosky et al undertook the Prostate Cancer Outcomes Study (PCOS). Drawing subjects from SEER (Surveillance, Epidemiology and End Results) registries across the United States, PCOS was the first nationally representative, population based, longitudinal cohort examining prostate cancer outcomes from the patient perspective. Undertaken with great prescience by the National Cancer Institute, PCOS sought to collect “comprehensive and generalizable information about the effects of prostate cancer therapy.”10

Initial PCOS results revealed that 2 years after radical prostatectomy more than 90% of men were continent and about half were by some definition potent.11 This represented a dramatic improvement over the era before Walsh and Donker reported their now classic description of the cavernous erectile nerves posterolateral to the prostate,12 a journey recounted 25 years later in Walsh’s lyrically serendipitous cadence of scientific discovery.13

Subsequent PCOS results revealed that 5 years after treatment men who had undergone surgery reported stable urinary function, while those who had undergone radiation experienced progressive urinary impairment. Just as striking was the finding that 3 to 5 years after treatment patients treated with radiation had a much sharper decrease in sexual function than those treated surgically,14 thus providing empirical evidence for the widely held observation that time homogenizes sexual outcomes after surgery or radiation. This decline in sexual function may be due to the effects of aging, cumulative radiation injury and/or postoperative nerve recovery.

The preceding article by Penson et al in this issue of The Journal is an update to the 5-year PCOS data, which features several important observations for men undergoing radical prostatectomy. First, significant urinary leakage, uncommon though not trivial, remains fairly constant between 11% at 2 years and 14% at 5 years postoperatively. Associated urinary distress is commensurate with leakage, occurring in only 13% of surgical cases. Second, Penson et al reiterate our understanding of how vastly different sexual outcomes are between urologists in general and those at referral centers with higher volume subspecialty practices.15 Third, sildenafil appeared to aid in the postoperative return of erections for those PCOS participants who were potent at baseline and who underwent the bilateral nerve sparing procedure, as nearly two-thirds of them reported erections firm enough for intercourse. Fourth, for the majority of men functional outcomes remained fairly stable between 2 and 5 years after surgery.

A finding of paramount importance, inconspicuously placed in table 3 of the article, is that although only 28% of respondents overall reported erections firm enough for intercourse, almost twice as many (54%) stated they were sexually active at least once a month. This result clarifies that the nature of sexual function in prostate cancer survivors includes activities beyond coitus alone, an observation that has clinical relevance for men whose sexual partner is unable or unwilling to have intercourse or does not have a vagina.

One constraint of the PCOS methodology, acknowledged by its investigators, was that participants were not actually surveyed at baseline but rather were asked to recall pretreatment levels of sexual and urinary function as long as 6 months after diagnosis. Evidence varies as to the accuracy of such recall16, 17 and so it remains unclear whether men are able to use the true baseline impairments in sexual or urinary function to make informed treatment decisions rationally.18 The other principal structural limitation of PCOS was that data could not be collected on the technical aspects of nerve sparing for men undergoing prostatectomy. Nonetheless, Penson et al working with the PCOS cohort have provided a uniquely comprehensive view of population based, patient reported outcomes for men treated for early stage prostate cancer.

Penson is now hard at work expanding on these findings. He was recently funded by the National Cancer Institute to undertake a 10-year followup study of even longer term outcomes for this study population. Despite its limitations, PCOS continues to provide valuable insights into prostate cancer survivorship. In the words of Tony award-winning lyricist, Edward Kleban, this report from Penson et al on the 5-year experience after radical prostatectomy represents, for an outcomes study, the “quintessence of making the grade.”

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References 

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PII: S0022-5347(08)00550-8

doi:10.1016/j.juro.2008.03.008

The Journal of Urology
Volume 179, Issue 5, Supplement , Pages S45-S46, May 2008

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