Improved Recovery of Erectile Function in Younger Men after Radical Prostatectomy: Does it Justify Immediate Surgery in Low-risk Patients?

Abstract

Background: Although active surveillance is increasingly used for the management of low-risk prostate cancer, many eligible patients are still nonetheless subject to curative treatment. One argument for considering surgery rather than active surveillance is that the probability of postoperative recovery of erectile function is age dependent, that is, patients who delay surgery may lose the window of opportunity to recover erectile function after surgery.

Objective: To model erectile function over a 10-yr period for immediate surgery versus active surveillance.

Design, setting, and participants: Data from 1103 men who underwent radical prostatectomy at a tertiary referral center were used.

Outcome measurements and statistical analysis: Patients completed the International Index of Erectile Function (IIEF-6) pre- and postoperatively as a routine part of clinical care. Preoperative IIEF-6 scores were plotted against age to assess the natural rate of functional decline due to aging. Reported erectile scores in the 2-yr period following surgery were used to assess post-surgical recovery.

Results and limitations: Each year increase in patient age resulted in a 0.27 reduction in IIEF scores. In addition to IIEF reducing with increased age, the amount of erectile function that is recovered from presurgery to 12-mo postsurgery also decreases (-0.16 IIF points/yr, 95% confidence interval -0.27, -0.05, p=0.006). However, delayed radical prostatectomy increased the mean IIEF-6 score over a 10-yr period compared with immediate surgery (p=0.001), even under the assumption that all men placed on active surveillance are treated within 5 yr.

Conclusions: Small differences in erectile function recovery in younger men are offset by a longer period of time living with decreased postoperative function. Better erectile recovery in younger men should not be a factor used to recommend immediate surgery in patients suitable for active surveillance, even if crossover to surgery is predicted within a short period of time.

Patient summary: Younger men have better recovery of erectile function after surgery for prostate cancer. This has led to the suggestion that delaying surgery for low-risk disease may lead patients to miss a window of opportunity to recover erectile function postoperatively. We conducted a modeling study and found that predicted erectile recovery was far superior on delayed treatment because slightly better recovery in younger men is offset by a longer period of time living with poorer postoperative function in those choosing immediate surgery.

Keywords: Active surveillance; Erectile dysfunction; Patient-reported outcomes; Prostate neoplasm; Radical prostatectomy.

Fig. 1

Effects of age on erectile function and recovery of erectile function after radical prostatectomy. Black line International Index of Erectile Function-6 (IIEF-6) measured erectile function by age. Grey line is loss in IIEF-6 measured erectile function from pre- to 12-mo postradical prostatectomy by age. Dashed lines are 95% confidence intervals. Older patients have lower baseline IIEF scores and experience larger losses in erectile function compared to younger patients after surgery.

Fig. 2

Erectile function scores over time for a 55-yr-old patient with a baseline International Index of Erectile Function-6 (IIEF-6) score of 26 with immediate (dashed line) versus surgery delayed by 5 yr (solid line).