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Impotence more common after prostatectomy than previously thought

Scott Gottlieb New York

Impotence occurs far more frequently after radical prostatectomy than previous studies have shown, according to the first nationally representative study to evaluate long term outcomes after prostate surgery.

The new, broad based population study found far more patients admitting that they had problems after the operation than earlier estimates, which have been as low as 20%.

In the current study, researchers followed 1291 men aged 39-79 who were randomly sampled from six National Cancer Institute cancer registries across the United States. They found that 60% were impotent 18 months after the surgery, 8% experienced total urinary incontinence, and 40% had occasional genitourinary problems (JAMA 2000;283:354-60).

Men surveyed in the study had all undergone radical prostatectomies for localised prostate cancer between 1994 and 1995. Previous studies have usually involved a single surgeon or institution, or have involved limited patient populations.

The new study is considered to be more comprehensive and offers more accurate information about what to expect after a radical prostatectomy.

Treatment of prostate cancer is among the most controversial areas in oncology, with five options available: radiation therapy, radical prostatectomy, brachytherapy (seeding the tumour with tiny radioactive pellets), "watchful waiting" in elderly patients, and hormone therapy.

Men who undergo surgery have generally been younger and healthier than those who opt for radiation therapy. All therapies are believed to have similar five year survival rates if therapy is begun early in the course of the disease, but no large scale, randomised trials exist to settle the debate.

The study's lead author, Dr Janet Stanford, and colleagues intentionally reviewed a higher proportion of cases among black men, Hispanic men, and men aged under 65 because research in these groups has previously been limited.

Dr Stanford, a full member and public health researcher at the Fred Hutchinson Cancer Research Center in Seattle, said that the new data ought to be more accurate and should help men to better balance the risks and benefits of radical prostatectomy.

"When we designed the study, it was clear that there were no comprehensive data on outcomes [after radical prostatectomy]," Dr Stanford said. "We wanted to look at all men with prostate cancer confined to the prostate with the goal of filling this gap in information," she said.

Even though 42% of the study's participants considered sexual function after radical prostatectomy to be a "moderate to big" problem, three quarters said that they were pleased with the surgery, with 72% of the men saying that they would choose radical prostatectomy again.

Other important findings concern how well men fared after undergoing a nerve sparing radical prostatectomy, a procedure that has been widely touted as having the capability of leaving potent men still potent after the surgery. In the study, impotence rates in men receiving this technique were still high, although not as high as with the "non-nerve sparing" procedure.

Of the men who received the non-nerve sparing procedure, 66% said that they were impotent after the surgery, compared to 56% of the men who had a bilateral nerve sparing procedure. Of the men undergoing a unilateral nerve sparing procedure, 59% said that they became impotent.

The study also showed marked differences in the rates of impotence reported by men of different races. Thirty eight per cent of black men reported that they were still potent at least 18 months after surgery, compared with 26% of Hispanic men, and just 21% of white men.
 
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