RALP not associated with better continence, sexual function after prostate cancer surgery

The “New” Prostate Cancer InfoLink has long been pointing out the lack of any evidence that men who are treated with robot-assisted laparoscopic prostatectomy (RALP) will have better outcomes with respect to continence and sexual function than men who elect to have the older, “open” form of radical prostatectomy.

A recently published study by Barry et al. has now confirmed the accuracy of our opinion on this matter, noting that “Medicare-age men should not expect fewer adverse effects following robotic prostatectomy” than have historically been observed in men having open surgery.

We should be clear up front that there are short-term benefits associated with RALP as compared to open surgery. These include: a reduction in risk for blood loss and for resultant blood transfusion during surgery; less post-operative pain; and a shorter postoperative recovery time.  However, many men are under the mistaken illusion that RALP is also associated with a higher probability of complete continence and better sexual function than open surgery.

Barry and his colleagues set out very specifically to compare the risks of problems with continence and sexual function following the two different types of radical prostatectomy among Medicare-age men. They did this by using a random sample of Medicare claims submitted between August 1 and December 31, 2008. All patient participants had hospital and physician claims for radical prostatectomy, diagnostic codes for prostate cancer, and reported being treated with either RALP or open surgery. They were asked to complete a mail survey that included self-ratings of problems with continence and sexual function at an average  (median) of 14 months after their surgery.

Here are the survey results:

  • 685/797 eligible patients (85.9 percent) returned completed surveys.
  • Of these 685 eligible patients
    • 406 men (59.3 percent) reported having had a RALP.
    • 220 men (32.1 percent) reported having had open surgery.
  • 189/607 men (31.1 percent) reported having a moderate or big problem with continence.
  • 522/593 men (88.0 percent) reported having a moderate or big problem with sexual function.
  • Model-based analyses, with appropriate adjustments for patient age and educational level, predicted that 
    • RALP was actually associated with a non-significant trend toward greater problems with continence (odds ratio [OR] = 1.41).
    • RALP was not associated with greater problems with sexual function (OR = 0.87).

In other words, even though RALP is now much more common than open radical prostatectomy as a surgical treatment for men with clinically localized prostate cancer, there are in fact no data to suggest that post-surgical continence or sexual function are any better after RALP than they are after open surgery.

Now, carefully selected surgeons may indeed be able to demonstrate that their personal outcomes (in terms of continence and sexual function) are in fact “better than the average” using either open surgical procedures or RALP. As The “New” Prostate Cancer InfoLink regularly observes, the skill levels of individual surgeons are much more likely to be a key factor in such outcomes than the technology used to carry out the surgery. Some physicians may be able to achieve such results through the use of robot-assisted techniques; others may prefer to use open surgery. What one can not expect, however, is that having one’s surgery carried out with robot assistance necessarily improves the probability of high continence and good sexual function post-surgery.

14 Responses

  1. I had the standard RP back in 2003, and several of my friends had RALP. We all have the same issues. Recovery may be faster with RALP because it is less invasive, and there may be less nerve damage with RALP, but that is very subjective, it depends upon the skill of the surgeon. We all have problems with “leakage” when doing anything strenuous, coughing, etc., especially if our bladders are more than half full. We no longer have the added “valve” of the prostate gland surrounding the urethra. Maybe they will invent an implantable device that will stay closed until we activate it and stop all leakage.

  2. This post, for me, just demonstrates again that prostate cancer is a big business that markets over-treatment. We as patients must ensure that treatment decisions are patient centered. This means giving the patient and his family clear and accurate information about all treatment options, and having the patient and family share in the decision making as to what treatment. Finally, there should be collaboration throughout the entire healthcare system to meet patients’ needs from their perspective.

  3. These data, from surgeries carried out in 2008, is striking to me for a different reason. When almost a third of patients report moderate or big problems with continence and 88% with sexual function, it points out the potential over-treatment with RP in general (traditional open or laparoscopic). For low-risk, localized prostate cancer (the most common type), radiation therapy is demonstrated to be equally effective as curative treatment with much lower rates of side effects and complications. Radiation therapy comes with almost no continence problems and statistically fewer sexual issues, because they don’t remove your prostate but rather treat it in place. Modern radiation therapy — IMRT and PBRT — also limits the damage to surrounding tissue that earlier forms of radiation therapy didn’t spare.

    My simple advice to men with prostate cancer: Stop being unduly mesmerized by the so-called “gold standard” (i.e., radical prostatectomy) and give fair consideration to radiation therapy, especially if minimal side effects appeal to you.

  4. I would like to see a breakdown of this cohort based upon physician experience. I am certain that physicians that recently trended over to robotic procedures have less desirable results than those who have used the device for many years.

    Besides, I bet we’ll see less of these procedures as more urologists trend into the lucrative radiation oncology business.

  5. 88% … Boy howdy, does this industry need to quit lying to men about their potential to recover sexual function!

  6. Dear Nerf:

    Re your comment above, perhaps the real question is how many of these men ever really needed any form of invasive treatment at all and could have been managed very satifactorily with active surveillance (with absolutely no risk for problems with continence or sexual dysfunction at all, assuming that the managing physician doesn’t get obsessed with ideas like annual biopsies).

    Of course we can’t ever know the answer to that question from this study.

  7. At 5 years post-treatment, aren’t the percentage of sexual side effects actually higher on the radiation side? That’s sort of the big lie of the “hope” of radiation. Everything may initially keep working, but at 5 years post-treatment an even higher percentage of men are impotent than at 5 years post-surgery. Men deserve the whole ugly truth of it.

  8. Dear Tracy:

    I have never seen any compelling data about the comparative potency levels of men treated with surgery or radiation therapy at 5 or 10 years post-treatment.

    There does tend to be a drop-off in sexual functionality over time in men who have radiation therapy for prostate cancer, and it does tend to be significant in that it is higher than the age-related loss of sexual functionality. Whether men treated with radiation therapy would actually have a greater, a lesser, or a similar level of sexual functionality compared to men who had surgery after 5 or 10 years of follow-up is much harder to determine. To date, the studies on this topic that I have seen have invariably had to deal with the fact that the men electing radiation therapy as their first-line treatment were either older than or had more advanced diseasae than the comparison cohort of men beintg treated with radical prostatectomy. Such differences tend to limit the value of the study data.

  9. The damage that radiation does to healthy tissue has absolutely nothing to do with the aggressiveness of disease, right? Just like the nerve damage caused by surgery is not directly related to aggressiveness of disease.

    So, a man with a minute spec of diagnosable Gleason 6 prostate cancer may end up untreatably impotent after either surgery or radiation, while a man treated for Gleason 8 may be “fine, just fine,” as a nurse I know likes to say. I guess my point is, the risks of permanent damage and threat to longevity from disease and treatment have to be understood separately when determining a course of action — and for many, many men the most likely realized risk from being diagnosed with prostate cancer is permanent damage due to treatment, not risk of damage or death due to the disease itself. And some of those who proffer various forms of treatment are some of the time less than forthcoming with authentic and accurate information about the relative risk of life-altering damage due to disease vs. due to treatment.

  10. Tracy,

    I offer you two recent academic sources in answer to your question:

    1. Sexual function in prostate cancer patients receiving external beam radiation therapy (EBRT) decreases within the first 2 years after treatment but then stabilizes and does not continuously decline (International Journal of Radiation Oncology*Biology*Physics, Jan. 1, 2010). The study authors found that the strongest predictor of sexual function after treatment was sexual function before treatment and the only statistically significant decrease in function occurred in the first 2 years after treatment and then stabilized with no significant changes thereafter.

    2. Observational study of 1,027 men with localized prostate cancer who underwent prostatectomy, EBRT, or brachytherapy as primary treatment from 2003 to 2006 reported that, 2 years after treatment, among men with functional erections prior to treatment, erectile dysfunction was reported by 52%, 42%, and 37% of men, respectively, in the three groups (Journal of the American Medical Association, Sept. 21, 2011). Factors associated with functional erections 2 years after treatment included pretreatment sexual HRQOL score, age, PSA level, race/ethnicity, body-mass index, and treatment. Per Sitemaster above, the men electing radiation therapy as their first-line treatment were older than the men in the prostatectomy and brachytherapy groups, making the delta between RP and RT even more pronounced if you actually adjusted these percentages for age.

    Based on the foregoing, it’s hard to dispute that, overall, radiation therapy doesn’t produce at least the same or even better sexual outcomes as radical prostatectomy. Moreover, radiation therapy has made significant strides since 2003-06 (e.g., introduction and widespread use of IMRT and PBRT), meaning I imagine recent radiation therapy experience is likely more favorable in this area.

  11. For the record…

    February 16 marks my fifth year post-surgery and post-radiation. I am and have been fully continent since early in the first year. I also went on a stint of 2.5 years on hormone therapy during which I had no sexual functionality. When I stopped that therapy I was like a young man again and erectile dysfunction is in the past. My side effects were as advertised.

    I definitely had some things going for me in that I was young at RALP at 44, and I had completed adjuvant radiation therapy at age 45. I think my young age helped recover from therapy well. I also think that when I chose a surgeon, one I had to travel to use, I knew he was good. He had a huge number of completed da Vinci procedures and he was the chair of the prostate cancer program at his institution. The ugly truth may lie within a large number of doctors who are new to this technology and not as good as others who are not new to it. I still had a somewhat advanced stage of the disease with bilateral seminal vesicle invasion, but I have never had a climb in PSA since my surgery. But after 5 years that probably isn’t a bad report on my experience. …

  12. I am with Tracy, it’s all about over-treatment, not what method of treatment. For me it is all about patient-centered care, which means treating patients with dignity and respect; giving them all the information to make informed decisions about their disease; ensuring decisions about treatment are truly shared decisions between the patient and provider; and ensuring that there is collaboration with patients throughout the healthcare system.

  13. I’m a practicing urologist and some of the comments above are reasonably close to correct; others are way off.

    First, despite public opinion, I don’t know physicians who “do a procedure for financial gain”. I really don’t. What I can tell you is I’m fully versed in both robotic and open prostate cancer surgery.

    I’m just going to tell you my opinion on erectile dysfunction because it’s more straight forward. In my opinion, most men who are having prostate cancer surgery already have erectile dysfunction to a degree, whether they admit it to themselves or not. Second, most have andropause, i.e., low testosterone. Third, as a country we are reasonably unhealthy: high blood pressure, obesity, high cholesterol, etc. My point is … all of those patients are going to have a problem despite your surgeon. Too many strikes against the average American patient.

    That being said, doing surgery on young and very healthy patients … they usually regain their continence and erectile function despite having surgery.

    All that being said … yes robotic surgery does reduce pain; post-operative healing is faster and hospitalization is certainly reduced. Incontinence and ED … I do think patients do better overall with robotic surgery. However, the incidence of these two problems is relatively high … despite your surgeon. One thing you might see are numbers from big university centers being advertised as “better”. I personally believe this is because, if you read their studies closely, patients with problems prior to surgery aren’t included in the study data.

    To conclude … yes if we only did surgery on patients with no problem with ED prior to surgery, most would do well after surgery. There just aren’t many patients with prostate cancer that can honestly say they have the same quality of erection in their late fifties, for example, as they did at eighteen. Make sense?

  14. Dear Frank:

    Just out of curiosity, about what percentage of your community practice patients do you now tell that some form of active monitoring would be an entirely appropriate form of management in their case? And what proportion of those men still insist on having immediate active treatment of some type? (There is no judgment of anyone being implied here; I am genuinely curious, and I have seen no publications at all on this aspect of prostate cancer management.)

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