Expectation management and sexual/erectile outcomes after radical prostatectomy


A newly published paper in BJU International has helped to make clear that many surgical patients have unrealistic expectations about their recovery of erectile and sexual function after radical prostatectomy. There are many possible reasons for such unrealistic expectations, but The “New” Prostate Cancer InfoLink would consider that the onus is on the surgeon and his or her support team to make quite sure that patients really do have a accurate appreciation of their risks prior to giving consent for surgery.

In this new paper by Deveci et al., the authors surveyed 336 consecutive patients, all treated by nine surgeons, who presented for evaluation at a sexual medicine clinic within 3 months of their radical prostatectomy (open and robot-assisted) and asked the patients questions about the sexual function information that they had received pre-surgery.

Here is a summary of the findings:

  • The average (mean ± SD) age of the patients surveyed was 64 ± 11 years.
  • Of the 336 patients surveyed
    • 216 had received open surgery (ORP).
    • 120 had received a robot-assisted radical prostatecomy (RALP).
  • There was no evidence of  significant differences in patient age or comorbidity profiles between the two groups.
  • Only 38 percent of patients could accurately recall their nerve-sparing status.
  • The average (mean ± SD) time from surgery to postoperative assessment was 3 ± 2 months.
  • Compared to patients treated by ORP, patients treated by RALP expected
    • Shorter times to recovery of erectile function (6 vs. 12 months, p = 0.02)
    • Higher likelihood of recovery full baseline erectile function (75 vs. 50 percent, p = 0.01)
  • 30 percent of patients treated by ORP and 40 percent of patients treated by RALP were not aware that they were rendered anejaculatory by their surgery.
  • Few patients in either group were aware that
    • The nature of orgasm could change following the surgery
    • They could have pain on orgasm
    • They could leak urine at the moment of climax (“climacturia”)
  • None of the RALP patients and only 10 percent of the ORP patients recalled being informed of the potential for loss of penile length.
  • None of the patients at all were aware of the association between radical prostatectomy and risk for Peyronie’s disease.

The authors conclude that:

Patients who have undergone [radical prostatectomy] have largely unrealistic expectations with regard to their postoperative sexual function.

Now it should immediately be recognized that these 336 patients had all come for evaluation at a sexual medicine clinic, and so they are a self-selecting group pf patients. It would be unreasonable, necessarily, to assume that they are representative of all patients who have a radical prostatectomy. However, what this paper does very clearly show is that there is a high probability that (assuming that they have actually provided this information) even some of the very best surgeons are not successfully ensuring that their patients understand and really comprehend the risks associated with radical prostatectomy.

In a commentary about this study on the MedPage Today web site, Dr. Charles Ryan, a medical oncologist, speaking on behalf of the American Society of Clinical Oncology (ASCO) is quoted as follows:

It suggests that clinicians involved in recommending such therapies should be aware of this ‘expectation gap’ during the time that they counsel patients about upcoming treatments. Risks to sexual function may be a topic that patients and clinicians are both reluctant to bring up and so these data may be used as an effective conversation starter.

He continued by saying that, although the study involved data from a small group of surgeons at a single (but very highly regarded) center,

it can be instructive to all of us helping to guide patients through the maze of treatment options and their potential hazards.

We all tend to assume that people hear and absorb what we tell them. We are commonly less assiduous in ensuring that people really did hear and absorb what we thought we had told them. There are multiple ways to gain that assurance, for example, this can be done by:

  • Getting the patient to repeat back to you what you have told him, point by point.
  • Providing a short, written summary of the key risk factors associated with a particular type of surgery.
  • Having a trained nurse go over the risks and benefits of the surgery with the patient (and his spouse/partner) after the initial discussion with the surgeon

Patients recently diagnosed with prostate cancer (and any other form of cancer) are commonly in a state of shock. They often do not absorb information with a high level of accuracy. On top of that, discussing sexual and erectile function is a sensitive issue for all concerned. It has to be approached with care and caution … but it does need to be seriously discussed if the patient is to fully understand the risks he is taking.

One Response

  1. I would be curious how the well nine surgeons predicted their individual results prior to surgery. Or were they given/requested their individual results?

    Human tendency would be for the sum total of the predictions given to each individual to exceed the overall expectation of each surgeon.

    Even if the overall risks are understood, how many individual patients are given some measure of assurance that they will be on the favorable end of the spectrum rather than the worst end?

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