By: Dan Sperling, M.D.

A March 24, 2015 report published online by Renal and Urology News opened with an attention-getting statement: “Achieving normal erectile function after radical prostatectomy (RP) is a rare event…”[i] This is disturbing news, especially men age 55 and younger who are diagnosed with prostate cancer (PCa), as most men in that demographic are still sexually active with spontaneous erections. The report summarized a paper presented by a Danish team at this year’s European Association of Urology Congress in Madrid who assessed the erectile function of 210 men before RP and again 23 months after. The IIEF-5 questionnaire (International Index of Erectile Function, a standardized self-report) was used to evaluate performance. Scores range from 0-30, with a score of 25-30 indicating no dysfunction; in the Danish study, the average pre-surgery score was 21.7, which dropped to 9.9 after RP. Sexual function in most cases improves during 6-18 months following surgery, but how many men actually return to baseline (pre-surgery) performance? The Danish team found that based on IIEF, 23.3% of their patients had the same level of performance 23 months after surgery. However, the team also asked a new pointblank question: Is your erectile function as good as before the surgery: yes or no? Only 6.7% responded yes. One of the investigators, Dr. Fode, noted, “Fundamentally, we may have been asking patients the wrong question, but of course we really need bigger trials to confirm this.”

Because such a blunt question has not been a part of similar post-surgery ED studies, it’s possible that IIEF questionnaires are not adequate to reflect patients’ actual experience. Still, there are numerous studies that confirm the reality of what patients must deal with in terms of potency after RP. Three examples are summarized here.

A Swiss-Austrian study

Schauer et al. (2015) reviewed eleven randomized, controlled studies on post-RP penile rehabilitation that utilized IIEF or another questionnaire called SEP-5 (Sexual Encounter Profile), involving a total of 2,009 patients.[ii] (The articles covered 17 years.) Their goal was to determine if improvements in RP technology as well as better diagnosis have improved post-treatment potency rates. Aggregate analysis was difficult due to biased patient inclusion, differences in surgical approach, and non-uniform outcome criteria, among other factors. However, they determined that rates of “undisturbed erectile function” after nerve-sparing RP ranged from 20-25% and there has been no substantial improvement or change during the past 17 years.

A German study

Mandel et al. (2015) explored the correlation between age and post-surgical potency recovery to learn how much effect aging has on regaining sexual function.[iii] They recognized that as life expectancy increases thanks to advances in medicine and health awareness, older patients in otherwise good condition (e.g. no cardiovascular disease) are likely to remain sexually active, a fact that will influence their choice of PCa treatment. This is a noteworthy study involving IIEF reports, since the sample size is 8,295 men who had prostatectomy between Jan. 2009 – July 2013. Potency was defined as a score of 18 or higher (compare this with a range of 19-24 indicating mild dysfunction), and the study cohort completed IIEF at 3 and 12 months following treatment. The one-year potency rates reported by patient age using the definition score of > 18 were:

< 65 years                      59.3%

? 65 and < 70                46.9%

? 70 and < 75                44.4%

? 75                                31.3%

While the reported statistics seem significantly higher than those in the Danish and Swiss-Austrian papers, the German team notes that, “Nerve sparing, pT category, patients’ body mass index, and use of PDE5 inhibitor or intracavernous injection therapy significantly influenced potency.” In other words, a large number of patients using oral medication or injections would otherwise have had significantly lower IIEF scores. The authors concluded that patients, especially older men, should be counseled about the increased risk of impotence due to age.
A European prostate center study

Geiger-Gritsch et al. (2015) administered the IIEF to 253 consecutive patients whose localized prostate cancer was treated by RP between 2008-9 at the European Prostate Centre Innsbruck.[iv] The baseline IIEF questionnaires were completed prior to surgery, and follow-up IIEF at 12 months after. In their study, the authors demonstrated an average drop from baseline rates of 39.6% (of various severity) to post-surgery ED rates of 80.1% at 12 months post-op. Put another way, roughly 20% of patients were able to perform sexually one year after RP.

To return to the Danish study, the above-cited article concluded:

After analysis, bilateral nerve-sparing surgery and the absence of cardiovascular disease were the only significant predictors of a return to pre-surgery erectile function. “As the average age of patients undergoing radical prostatectomy is decreasing, maintaining the ability to have an erection after an operation is increasingly important to men facing surgery…” commented Francesco Montorsi, MD, Editor Emeritus of European Urology. “We need to look more closely at nerve sparing techniques, and ensure that good post-operative care is available for each patient.”[v]

While some individual surgeons may justly claim higher rates of return to potency, especially if they are highly experienced in nerve-sparing robotic prostatectomy for qualified patients, the body of evidence in peer-reviewed publications suggests that the majority of men who undergo RP do not return to pre-treatment levels of sexual function without medication or other help.

[i] “Return to Full Potency Rare After Prostate Surgery.” Renal and Urology News, March 24, 2015. http://www.renalandurologynews.com/prostate-cancer/return-to-full-potency-rare-after-prostate-surgery/article/405192/

[ii] Schauer I, Keller E, Müller A, Madersbacher S. Have rates of erectile dysfunction improved within the past 17 years after radical prostatectomy? A systematic analysis of the control arms of prospective randomized trials on penile rehabilitation. Andrology. 2015 Jul;3(4):661-5. doi: 10.1111/andr.12060.

[iii] Mandel P, Graefen M, Michl U et al. The effect of age on functional outcomes after radical prostatectomy. Urol Oncol. 2015 May;33(5):203.e11-8. doi: 10.1016/j.urolonc.2015.01.015. Epub 2015 Mar 24.

[iv] Geiger-Gritsch S, Oberaigner W, Mühlberger N et al. Patient-reported urinary incontinence and erectile dysfunction following radical prostatectomy: results from the European prostate centre innsbruck. Urol Int. 2015;94(4):419-27. doi: 10.1159/000369475. Epub 2015 Jan 31.

[v]  “Return to Full Potency…” Ibid.