Erectile function post-radical prostatectomy: the past 20 years

It would not be unreasonable to think, some 30+ years after Dr. Pat Walsh started to do nerve-sparing radical prostatectomies at Johns Hopkins, that there might have been a gradual — if small — improvement in the quality of erectile and sexual function post-surgery on average over time. So a group of Austrian and Swiss researchers set out to see if they could demonstrate this.

We need to be clear that their interest was exclusively in whether there had been improvements based solely on surgical technique — regardless of the use of other “aids” — and most especially other aids like new drugs and similar forms of assistance. So what they did was the looked for all the data they could find from the control arms of trials designed to test whether things like new drugs (and most commonly new drugs like sidenafil/Viagra, tadalafil/Cialis, etc.). In other words, they were interested in the erectile/sexual function of the men in these trials who were given the placebo in the trials.

Schauer et al. were able to identify a total of 11 randomized, controlled trials of penile rehabilitation therapy following radical prostatectomy. These trials were all published between 1997 and 2014. They included a total of 2,009 patients, and 685 of those patients (about a third) were treated with a placebo of some type — or they were just observed without additional treatment — in the control arms of the 11 trials.

Assessment of erectile function in the trials was  carried out through use of either the Sexual Encounter Profile (SEP) (in eight of the trials) and/or the International Index of Erectile Function (IIEF) (also in eight of the 11 trials). Here is what Schauer and his colleagues report:

  • The rates of positive response to SEP3 (i.e., erectile function sufficient for successful intercourse) in the control arms of the eight trials using this evaluation ranged from 20 percent in 1997 through 10 percent in 2003, 19 percent in 2004, 25 percent in 2008, 21 percent in 2010, 67 percent in 2011, 10 percent in 2013, to 22 percent in 2014.
  • The rates of positive responses to the IIEF-EF in the control arms of the eight trials using this evaluation ranged from 9.2 in 2003 through 13.3 in 2004, 8.8 in 2008, 25 and ≥ 22.0 in 2008, 17.4 in 2010, 58 and ≥ 26.0 in 2011, 9.3 in 2013, to 11.6  in 2014.

The authors conclude that their analysis suggests that (a) the rate of undisturbed erectile function is in the range 20 to 25 percent in most studies and that (b) these rates have not substantially improved or changed over the past 17 years.

In other words, any improvements in the quality of surgery over the past 17 years, on their own, have really been having a very limited impact on the quality of erectile/sexual function for radical prostatectomy patients over most of the past 20 years.

2 Responses

  1. I wonder if the study supports my impression that the so-called nerve-sparing surgery has not helped men who received that procedure to maintain erectile function as much as its advocates had initially claimed.

  2. Dear Dr. Hanline:

    It has long been my suspicion that nerve-sparing surgery can work well for a select group of patients who have completely organ-confined prostate cancer with no cancer close to the prostate capsule and who have a highly skilled and experienced surgeon who has a very high level of anatomical awareness of exactly what he (or she) is doing. It would also help if they were younger than average and had a high level of erectile function prior to their surgery.

    Once one starts to look at patients with any characteristics beyond that group, my suspicion (like yours) is that the success rate of nerve-sparing surgery drops rapidly.

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