September 2009

At the end of an editorial on erectile function recovery and robot-assisted prostate cancer surgery, Dr. John Mulhall quotes Oscar Wilde: "the truth is rarely pure and never simple." Indeed, for many years, the reported incidence of long-term erectile dysfunction (ED) after prostate surgery has been so wide ranging (between 14 % and 90 %) that it has interfered with effective patient counselling and men's ability to make informed treatment decisions, according to Mulhall.

Dr. Mulhall, who spoke at the September 2009 PCCN national conference, wants to change this situation. In a recent issue of the Journal of Sexual Medicine, the internationally recognized, peer-reviewed journal of which he is associate editor, he calls on researchers to provide more robust data and better analytical studies on the actual incidence of erectile dysfunction after radical prostatectomy (RP). And he helps answer the call himself. His article "Erectile Function Recovery Rate After Radical Prostatectomy: A Meta-Analysis" models one process of applying statistical methods to analyze high-quality data on erectile function recovery after prostate cancer surgery. (Read an abstract of this article.)

Mulhall and his colleagues searched for articles published between 1985 and 2007 that reported on erectile function recovery after radical prostatectomy. To be identified as appropriate for inclusion in their analysis, the studies had to have 50 or more men who had received only prostate surgery as a treatment, who had no erectile dysfunction prior to this treatment, and whose erectile function was followed for at least a year after surgery.

Only 22 of the 212 studies identified (about 10 %) met the strict inclusion criteria outlined by the researchers. In the end, the meta-analysis included the erectile function recovery data of 4,983 men, whose mean age was 61 (the range was 55 to 67).

Mulhall reports that the erectile function recovery rate of subjects was 58 %; in layperson's terms, after statistical error is factored in, between 56 and 67 per cent of the men included in the analysis recovered their ability to achieve erections. Bilateral nerve-sparing surgery was associated with better outcomes than unilateral nerve-sparing surgery. And men under 60 reported a higher rate of erectile function recovery than did men older than 60.

These findings are consistent with what is currently known about the factors that affect the recovery of erectile function after radical prostatectomy. Mulhall outlines those factors in his book Saving Your Sex Life: A Guide for Men with Prostate Cancer:

Factors Predicting Erectile Function Recovery after Radical Prostatectomy

• Patient age at time of surgery (younger better)
• Patient erectile function before surgery (harder better)
• Amount of nerve tissue preserved (more spared better)
• Blood flow into and out of penis after surgery (better blood flow better)
• Erection tissue health
• Surgeon results (specific to him or her)
• Surgeon volume (how often the surgeon does a radical prostatectomy)
• Number and severity of co-morbidities (diabetes, high blood pressure, high cholesterol, etc.)

As to whether one surgical approach is superior to another when it comes to preserving erectile function, Mulhall concedes that the verdict is still out. Currently, men may have the option of choosing open, laparoscopic, or robot-assisted laparoscopic prostatectomy. (See the PCCN article "Open, Laparoscopic, or Robotic Surgery for Prostate Cancer" for more information.)

Although Mulhall's meta-analysis did show a higher rate of erectile function recovery with robot-assisted laparoscopic prostatectomy (RALP), he warns that this finding should be interpreted cautiously. Only 343 patients involved in two studies underwent RALP, and neither study compared erectile function recovery results with those obtained after other forms of prostate cancer surgery. Also, most review articles conclude that the literature comparing the erectile function outcomes of different surgical approaches is scarce and insufficient to demonstrate any clear advantage of a certain approach. (See, for example, "Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis of Comparative Studies," European Urology, May 2009, 55(5): 1037-1063.)

As PCCN has advised in the past, all things being equal in terms of prognosis, it is often the surgeon's experience and skill that determine success rather than the surgical technique employed. Dr. Mulhall supports this idea. He cites the research of Herrell and Smith, who found that RALP results comparable with those achieved after the more traditional open radical prostatectomy were only reached after a surgeon had performed 150 or more RALP procedures. Also, surgeons needed to perform more than 250 robot-assisted laparoscopic surgeries to feel the same level of confidence and comfort with this procedure as with an open radical prostatectomy. (See an abstract of Herrell and Smith's research paper.)

There is obviously a learning curve for mastering any surgical technique.

Dr. Mulhall addresses the issue of surgical skill head on in his book. He notes that men contemplating prostate cancer treatments are often given statistics about surgical outcomes that are collected from so-called "centres of excellence." These statistics may not be replicated by surgeons in general practice. His advice: "Ask about the surgeon's personal figures. If he or she is reluctant to give these to you, my suggestion is that you should seek another opinion."

PCCN applauds Dr. Mulhall's patient-centred, down-to-earth approach to the sexual effects of prostate disease and its treatment. Any man interested in this topic would do well to read his book Saving Your Sex Life. (See a PCCN review of this book.) You will be sure to get the straight goods. As Dr. Mulhall himself puts it,

I am a great believer in realistic expectations for a patient and that patients should be allowed to make informed decisions about the right option for them. Without having an honest, fair, and balanced discussion regarding the side effects of radiation or surgery, the patient is at a disadvantage in his effort to make a truly informed decision.