PATIENT-REPORTED IMPOTENCE AND INCONTINENCE AFTER NERVE-SPARING RADICAL PROSTATECTOMY

Background: The age-adjusted rate of radical prostatectomy, the most c ommon treatment of early (nonmetastatic) prostate cancer, increased al most sixfold between 1984 and 1990. This increase was due in part to r eported improvements in postoperative sexual potency after the use of newly developed ''nerve-sparing'' procedures. However, published estim ates from physicians of impotence following various types of radical p rostatectomy may be low, since not all patients may report treatment-r elated complications accurately and completely to their doctors. In co ntrast, direct surveys of patients indicate much higher rates of posto perative sexual and urinary dysfunction. One problem with most physici an and patient surveys is that they have been performed retrospectivel y, and pretreatment impotence and incontinence prevalent in older men cannot be assessed accurately in retrospective studies. Purpose: This study was initiated in a cohort of men before they underwent radical p rostatectomy to assess treatment-related effects on impotence and inco ntinence. Methods: The study population consisted of 94 men enrolled i n a cohort study of treatment for early prostate cancer. The patients completed questionnaires about sexual and urinary functions before sur gery and at 3 and 12 months after surgery and had adequate information to assess the type of surgical technique used (non-nerve-sparing, uni lateral nerve-sparing, or bilateral nerve-sparing). Because items asse ssing sexual function were inadvertently omitted from the questionnair e in the initial months of the study, information on sexual function f or all time periods was available for only 49 men. Results: Compared w ith men who had not been treated with a nerve-sparing procedure, men w ho underwent nerve-sparing radical prostatectomy, particularly of the bilateral type, were younger and had better prognostic features, indic ating less advanced cancers. Before surgery, nine (75%) of 12 men not treated with a nerve-sparing procedure reported erections that were us ually inadequate for sexual intercourse compared with six (33%) of 18 men and one (5%) of 19 men who underwent unilateral and bilateral nerv e-sparing prostatectomies, respectively. At 12 months after surgery, m ost men reported inadequate erections, including 15 (79%) of the 19 me n who had bilateral nerve-sparing surgery; unilateral nerve preservati on provided no apparent benefit. In general, nerve-sparing surgery was associated with more use of absorbent pads at 3 and 12 months followi ng treatment, and this approach was associated with substantial urinar y incontinence at 3 months but not at 12 months following surgery. Con clusions: Nerve-sparing prostatectomy, particularly when performed uni laterally, improves postoperative sexual function to a lesser extent t han previously reported. Because men with preoperative impotence and m ore advanced cancers receive nerve-sparing surgery less often, some of the previously reported benefit of nerve preservation may be the resu lt of patient selection and not of the technique per se.