Post-Op Expectations about Sexual Function - Article Reprint

Post-radical prostatectomy expectations
about sexual function unrealistic

By Mac Overmyer

Patient education about post-surgical outcomes is necessary

Chicago—A significant number of patients undergoing open or robotic radical prostatectomy have unrealistic expectations regarding postoperative sexual function, according to a study from Weill Cornell Medical College, New York.

The study, presented here at the AUA annual meeting, found that many patients were unaware that the prostatectomy would lead to an inability to ejaculate, and "almost none understood that there are documented orgasm changes or that radical prostatectomy may be associated with Peyronie's disease," the authors wrote.

"I think there are many patients who just have false expectations going into their prostate surgery," senior author John Mulhall, MD, who was an associate professor of urology at Weill Cornell at the time of the study, told Urology Times. "They think they are going to get back to the way they were before the operation. For a significant number of men, that is just not true. They are not going to ejaculate. There are patients who are going to have orgasmic dysfunction. There are penile length loss issues, and many appear to just not know that."

The researchers posed 11 questions to 336 patients, 216 of whom had undergone open radical prostatectomy and 120 who had undergone the robotic procedure. The procedures were performed by nine different referring urologists.

Only 10% of the open procedure patients and 12% of the robot-assisted laparoscopic prostatectomy (RALP) patients said they knew that their orgasms would be different after their respective procedures. While 70% of the open surgery patients and 60% of the RALP patients understood that they would not ejaculate (produce semen) following the operation, only 2% of the RALP patients seemed to know that the procedure carried the risk that pain might accompany orgasm or that orgasm might be accompanied by urine leakage.None of the RALP patients seemed to be aware of these possible sequelae, and neither group knew that Peyronie's disease was also a potential risk of the procedure.

"What we need to do is develop a structured discussion for patients prior to treatment. We need to document that the discussion has occurred, and the patients need to be given educational material that comprehensively addresses the different and often transient sexual side effects," said Dr. Mulhall, who is currently director of the male sexual and reproductive medicine program at Memorial Sloan-Kettering Cancer Center in New York.

The study also found curious differences in responses between those undergoing the open and robotic procedures. The average open procedure patient anticipated that he would return to full sexual function in 12 months. The average RALP patient thought he would return to full function in 6 months. Half (50%) of the open patients thought they would have full recovery compared to 75% of the RALP patients. Only 20% of the open patients were aware of the potential need for intercavernosal injections to achieve erections, while only 4% of the RALP patients were aware of it.

The study was designed to establish parameters for patients' understanding of prostatectomy outcomes. It was not designed to determine the origins of their knowledge or their ignorance.

Dr. Mulhall said a number of factors might have contributed to the data. The patients may not have been adequately informed. They may have acquired misinformation about treatment outcomes from Internet sites that promote success and downplay potential adverse outcomes. They may have focused their thinking on the cancer and its treatment, and neglected consideration of treatment outcomes.

"The message, however, is clear. Patients end up after surgery not understanding what might happen to them. We should be making a structured and concerted effort to ensure these patients know what to expect," Dr. Mulhall said.

Reprinted from:
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Post-radical-prostatectomy-expectations-about-sexu/ArticleStandard/Article/detail/614300?contextCategoryId=40184

In the News - Good Survivor Rates for Prostate Cancer

"A study of almost 13,000 American men who had a radical prostatectomy -- surgical removal of a cancerous prostate gland -- between 1987 and 2005 found that only 12% of them died of the cancer, according to the report in the July 27 issue of the Journal of Clinical Oncology."

Men Who Have Prostate Cancer Surgery Do Well

By Ed Edelson
HealthDay Reporter
Source: http://www.medicinenet.com


MONDAY, July 27 (HealthDay News) -- A major study has good news for men who have prostate cancer surgery but leaves unanswered the complicated question of whether a man should have that operation, another treatment or just watchful waiting.

The study of almost 13,000 American men who had a radical prostatectomy -- surgical removal of a cancerous prostate gland -- between 1987 and 2005 found that only 12% of them died of the cancer, according to the report in the July 27 issue of the Journal of Clinical Oncology.

"Patients with what we thought of as high-risk prostate cancer had a much lower risk of dying of their cancers than we ever thought," said Dr. Peter T. Scardino, chairman of the department of surgery at Memorial Sloan-Kettering Cancer Center, and a member of the research team. "Patients with more favorable prostate cancers did remarkably well, so well that you have to begin to question whether they should have been treated."

The choice of surgery, radiation therapy or watchful waiting must be made each year for more than 190,000 American men, most middle-aged or older, who are diagnosed with prostate cancer. Most choose some kind of treatment, said Dr. Andrew Stephenson, head of urological oncology at the Cleveland Clinic's Glickman Urological and Kidney Institute, and another member of the research team. From 40% to 50% choose surgery, about 10% choose watchful waiting, and the rest choose some form of radiation therapy, Stephenson said.

For men who have surgery, the new research has produced a tool that can allow them to predict their chance of survival for at least 15 years, Scardino said. Survival is measured by essentially three elements: the clinical stage of the cancer when it is detected, determined in great part by how large it is; the Gleason score, a measure of how much of its normal structure the prostate gland has lost; and blood levels of prostate-specific antigen, a protein produced by the gland.

The study found that the score had an accuracy of 82% in predicting 15-year survival, Scardino said. "If you could predict what would happen in the stock market in the next 15 years with 82% accuracy, you would be a genius," he said.

Overall, there was a greater chance that a man in the study would die of a cause other than prostate cancer. The rate of death from other causes was 38%, compared to 12% attributed to prostate cancer.

The new predictive method will be made public soon, after medical review, so that physicians and men can learn about their anticipated survival after surgery, Scardino said.

"Any person can look at it and put in the numbers," he said.

The new predictive tool is an improvement over the existing method, which relies essentially on readings of prostate-specific antigen levels, Stephenson said.

But no such predictive method exists for newly diagnosed men who must chose between treatment and watchful waiting, and so the study presents a predicament for those men and their physicians, he said.

"It questions the lethality of prostate cancer," Stephenson said. "Perhaps a similarly low risk might have been seen if the men did not have prostatectomy. We can't say whether a cancer poses enough of a threat to the patient so that therapy is needed."

Prostate cancer surgery is not free of problems, Stephenson said. Its major side effects are incontinence and loss of sexual function.

Many prostate cancers grow slowly -- so slowly that an old medical byword is that "more men die with their prostate cancer than of it." No existing method can single out the cancers that will be fatal if left untreated.

"We really need better tools for really identifying prostate cancers that pose a threat to longevity," Stephenson said. "Many have been proposed. All are being investigated, and hopefully in the future we will have better tools that accurately predict the risk of dying from prostate cancer."

Until those tools are available, the question is often "a balance between quantity and quality of life," he added. "That is a very complicated decision that must take many factors into consideration."

SOURCES: Peter T. Scardino, M.D., chairman, department of surgery, Memorial Sloan-Kettering Cancer Center, New York City; Andrew Stephenson, M.D., head, urological oncology, Cleveland Clinic Glickman Urological and Kidney Institute, Ohio; July 27, 2009, Journal of Clinical Oncology, online

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