Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Comment
  • Published:

Standardized reporting for sexual function following prostate cancer treatment

International Journal of Impotence Research volume 32, pages 549–550 (2020)Cite this article

Subjects

When performing a Google search for “robotic prostate surgery” the top results belong to clinics reporting 80–90% potency rates or even describing side effects to the surgery as “…practically eliminated”. Similar results are presented in several peer reviewed case series [1]. However, the rosy picture corresponds poorly with the experience gained from managing sexual problems in this particular patient group and the excellent outcomes have not been reproduced in strictly monitored randomized controlled trials (RCTs) [2]. In their recent paper in the International Journal of Impotence Research, Lovegrove and co-authors elegantly highlight this issue by pointing out systematic discrepancies in the available literature on sexual function following treatment for localized prostate cancer [3]. Most importantly, the authors highlight how the use of different questionnaires and arbitrary thresholds in patient reported outcome measures (PROM) result in a wide variety of definitions of potency. In addition to obscuring the true rate of erectile dysfunction following prostate cancer treatments, the discrepancies in reporting make comparisons of functional outcomes between different treatment modalities difficult. Further, it obstructs the evaluation of functional outcomes with new surgical methods and alternative treatment modalities such as high-intensity focused ultrasound and focal cryoablation.

Admittedly, our own group have contributed to the confusion when defining adequate erections as an abbreviated International Index of Erectile Function (IIEF-5) score of at least 17 with or without Phosphodiesterase-5 Inhibitors (PDE5-Is) several years ago [4]. Meanwhile, a subsequent analysis of our patients showed a very different picture. Here we assessed the return of baseline erections by two different methods [5]. First, we looked at return to baseline IIEF-5 scores and found that about 20% of patients managed this. This corresponds to studies from other major institutions and may well be a reflection of the actual situation [6, 7]. It is a far stretch from the >80% successful erections reported in some studies. It is worth noting that the IIEF questionnaire is not validated in prostate cancer patients and was not developed to measure decrease in erectile function. Rather, it was developed to measure improvements with PDE5-Inhibitors in unselected men with ED [8]. For this reason, we added a simple question asking the men if their erections were as good as before the surgery. Only 7% of the overall population answered affirmatively and the number rose to 16% for men who had undergone bilateral nerve sparing surgery. In line with the issues highlighted by Lovegrove and co-authors, the study was difficult to publish due to skepticism from several reviewers. The most common comment was that the patients were simply wrong about their perceived decline in function. Interestingly, a similar belief was responsible for halting the first RCT on PDE5-Is for penile rehabilitation. Thus, the 2008 trial by Padma-Nathan et al. was terminated prematurely because an interim analysis showed that only about 25% of treated patients had good spontaneous erections 10 months after surgery according to the study criteria, which was interpreted as a lack of effect [9].

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Tal R, Alphs HH, Krebs P, Nelson CJ, Mulhall JP. Erectile function recovery rate after radical prostatectomy: a meta-analysis. J Sex Med. 2009;6:2538–46.

    Article  Google Scholar 

  2. Schauer I, Keller E, Muller 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;3:661–5.

    Article  CAS  Google Scholar 

  3. Lovegrove CE, Ficarra V, Montorsi F, N’Dow J, Salonia A, Minhas S. Sexual function outcomes following interventions for prostate cancer: are contemporary reports on functional outcomes misleading? Int J Impot Res. 2019. https://doi.org/10.1038/s41443-019-0220-1.

  4. Fode M, Sonksen J, Jakobsen H. Radical prostatectomy: initial experience with robot-assisted laparoscopic procedures at a large university hospital. Scand J Urol. 2014;48. https://doi.org/10.3109/21681805.2013.868514.

  5. Fode M, Frey A, Jakobsen H, Sønksen J. Erectile function after radical prostatectomy: do patients return to baseline? Scand J Urol. 2016;50. https://doi.org/10.3109/21681805.2015.1102964.

  6. Woo SH, Kang DIl, Ha Y-S, Salmasi AH, Kim JH, Lee D-H, et al. Comprehensive analysis of sexual function outcome in prostate cancer patients after robot-assisted radical prostatectomy. J Endourol. 2014;28:172–7.

    Article  Google Scholar 

  7. Nelson CJ, Scardino PT, Eastham JA, Mulhall JP. Back to baseline: erectile function recovery after radical prostatectomy from the patients’ perspective. J Sex Med. 2013;10:1636–43.

    Article  Google Scholar 

  8. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822–30.

    Article  CAS  Google Scholar 

  9. Padma-Nathan H, McCullough AR, Levine LA, Lipshultz LI, Siegel R, Montorsi F, et al. Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Int J Impot Res. 2008;20:479–86.

    Article  CAS  Google Scholar 

  10. Frey A, Pedersen C, Lindberg H, Bisbjerg R, Sønksen J, Fode M. Prevalence and predicting factors for commonly neglected sexual side effects to external-beam radiation therapy for prostate cancer. J Sex Med. 2017;14. https://doi.org/10.1016/j.jsxm.2017.01.015.

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Zealand University Hospital, Roskilde, Denmark

    Mikkel Fode

  2. Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark

    Mikkel Fode, Christian Fuglesang S. Jensen & Peter B. Østergren

  3. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Mikkel Fode

Authors
  1. Mikkel Fode
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christian Fuglesang S. Jensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Peter B. Østergren
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mikkel Fode.

Ethics declarations

Conflict of interest

MF is speaker and advisory board representative for Ferring Pharmaceuticals and Astellas Pharma. CFSJ has no conflicts to report. PBØ is speaker for Astellas Pharma, Ipsen and Ferring Pharmaceuticals.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fode, M., Jensen, C.F.S. & Østergren, P.B. Standardized reporting for sexual function following prostate cancer treatment. Int J Impot Res 32, 549–550 (2020). https://doi.org/10.1038/s41443-020-0251-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41443-020-0251-7

This article is cited by

Search

Advanced search

Quick links