Over the years, I have spoken with many patients about the idea of doctors being 100% open with regard to their treatment results. I came across a large-scaled Swedish study on prostatectomy side effects, and it’s as transparent as it gets.
The fact that the study came out of Sweden might say something about how frank it is. Sweden is a nation that prides itself on openness. One of the government’s official websites says that openness and transparency are vital parts of Swedish democracy, noting that the press and the general public have access to government records. “Scrutiny is seen as valuable for a democracy, and transparency reduces the risk of power being abused.” [i] These principles are upheld in their constitution. I found myself asking, what if these same principles universally applied to medicine? What if physicians were expected to keep accurate data on their treatment results, and patients had open access to it? (Statistics only—the identities of all patients would continue to be protected as required by HIPAA law.) In any case, the spirit of openness and transparency that is so treasured by the Swedes is exemplified in this new study.
The research article is titled “Urinary Incontinence and Erectile Dysfunction after Robotic versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial.”[ii] The fact that it is prospective and controlled, coupled with the number of patients and medical centers that participated, makes it a very respectable study. (I’m proud to say that the same authoritative journal in which it’s published, European Urology, is carrying our new article on focal laser ablation.)
Fourteen Swedish medical centers were involved, and 2431 patients were evaluated 12 months after radical prostatectomy. The patients had either laparoscopic robotic radical prostatectomy (RALP) or open retropubic radical prostatectomy (RRP), which has long been the gold standard. The method of recording results tracked patients at baseline and again at 12 months after treatment, using clinical record forms and validated patient questionnaires. “The primary end point was urinary incontinence (change of pad less than once in 24h vs one time or more per 24h) at 12 mo. Secondary end points were erectile dysfunction at 12 mo and positive surgical margins.” Here is a summary of their results:
|12 months post RALP||12 months post RRP|
|Incontinence||366 men (21.3%)||144 (20.2%)|
|Erectile dysfunction||1200 men (70.4%)||531 (74.7%)|
|Positive surgical margins||21.8%||20.9%|
The authors concluded that the robotic surgery was only “modestly beneficial in preserving erectile function” compared with open prostatectomy, with no significant differences in rates of incontinence and positive surgical margins.
The reality of > 70% ED rates at a year after surgery is an honestly acknowledged problem by experts. A 2015 paper out of Rush University Medical College, Department of Urology contains this observation: “Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique.”[iii] This admission tells me that there’s more transparency about the “modest” benefits of robotic prostatectomy than we might be aware of.
I see a “disconnect” between the difference between transparent data as reported in scientific literature and the often-wishful beliefs of patients that nerve-sparing robotic prostatectomy has high rates of preserving potency. Wiser minds than mine can explain how this disconnect occurs, and I’m not suggesting that there is a deliberate deception going on by the medical profession. I believe as patients eager for honest answers become more familiar with how to use services like the National Institute of Health’s huge database of research abstracts (http://www.ncbi.nlm.nih.gov/pubmed/), they will discover that the transparency is there for the taking.
[ii] Haglind E, Carlsson S, Stranne J et al. Urinary incontinence and erectile dysfunction after robotic versus open radical prostatectomy: A prospective, controlled, nonrandomised trial. Eur Urol. 2015 Mar 11. pii: S0302-2838(15)00194-3.