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3. Results
summarizes the clinicopathologic characteristics of
the study cohort from which patient-reported data were
obtained. Median patient age in this cohort was 62
(interquartile range: 57- 67) yr, with a median reported
baseline IIEF-6 score of 28 (interquartile range: 21–30).
Each year increase in patient age resulted in a [10_TD$DIFF]0.27 (95%
CI: [16_TD$DIFF]0.18, [17_TD$DIFF]0.36, p < 0.0001) point reduction in baseline IIEF
scores ). Comorbidity reduced baseline scores, with a [18_TD
$DIFF] 0.81 (95% CI [19_TD$DIFF] 2.01, [20_TD$DIFF]0.38; p = [21_TD$DIFF]0.2), [22_TD$DIFF] 3.02 (95% CI [23_TD$DIFF] 4.40, [24_TD$DIFF]
1.65; p < 0.0001), and [25_TD$DIFF] 3.77 (95% CI [26_TD$DIFF] 5.58, [27_TD$DIFF] 1.96;
p < 0.0001) point change in IIEF for one, two, or three or
more comorbidities. However, there was no evidence that
erectile function declined faster with increasing age in
patients with comorbidities (p = [28_TD$DIFF]0.16 for the interaction
term). As such, comorbidities were excluded from the
model estimating postoperative recovery.
The degree of erectile function recovery after RP also
decreases ([11_TD$DIFF] 0.16 [12_TD$DIFF]IIF points/yr, 95% CI [13_TD$DIFF] 0.27, [14_TD$DIFF] 0.05, p = [15_TD$DIFF]
0.006). For example, a typical 55-yr-old patient would lose
7.5 points from pre-RP to 12-mo post-RP; a 60-yr-old
patient who would lose 8.4 points .
illustrates the predicted erectile function scores
over time for a 55-yr-old patient with a baseline IIEF-6 score
of 26 with immediate versus surgery delayed by 5 yr, a
timepoint at which about a third of men initially managed
on active surveillance have been treated The average 10-
yr IIEF score was higher on delayed surgery (2.1 points, 95%
CI: 0.4, 3.9). Indeed, even if we assume a very short delay to
surgery of only 3 yr, we continue to see a significant
improvement compared with immediate treatment
(1.5 points, 95% CI: 0.2, 3.0).
We repeated these analyses for men aged 60 yr and 65 yr
looking over 10-yr and 15-yr timeframes with similar
results ). For example, a man diagnosed with
prostate cancer at 65 yr old would have an average of
3.3 more points on the IIEF-6 over a 10-yr period if RP were
delayed for 5 yr (95% CI: 1.8, 4.6). In each scenario, delayed
RP was estimated to lead to an increase inmean IIEF-6 score,
although differences between groups were not statistically
significant in all cases.
As erectile function was superior on active surveillance
even if a man was subject to surgery after a relatively short
duration, incorporation of longer delays to surgery, or no
surgery at all, would have no effect on our conclusion that
erectile function is superior on delayed surgery. According-
ly, these planned analyses were not conducted.
4. Discussion
Using a robust database of baseline and postoperative
patient reported outcomes for men with low- and
intermediate-risk prostate cancer, we found that the
predicted average long-term erectile function is higher
for men who undergo delayed compared with immediate
RP at a younger age. Our findings disconfirm the hypothesis
that early surgery compared with active surveillance
improves sexual function by utilizing a window of
opportunity for postoperative recovery. Indeed, the results
suggest that a man should opt for active surveillance even if
he knew that surgery would be required within a few years.
Our data can be compared with other reports in the
literature. First, there is clear evidence for our finding that
recovery is age-related. Brajtbord et al report erectile
recovery after RP in two age groups, 60 yr and >60 yr.
Older men were more likely to have a “clinically significant”
Table 1 – Clinicopathologic characteristics of cohort (n = 1103; data
are given as median and quartiles or frequency and percentage)
Age (yr) 62 (57, 67)
Preoperative IIEF-6 28 (21, 30)
Preoperative PSA (ng/ml) 4.9 (3.6, 6.5)
Biopsy cores (N = [5_TD$DIFF]1095) 12 (6, 13)
Positive biopsy cores (N = [6_TD$DIFF]1099) 3 (1, 5)
Biopsy Gleason grade group
1 566 (51%)
2 537 (49%)
RP Gleason [7_TD$DIFF]grade group
1 264 (22%)
2 681 (62%)
3 153 (14%)
4 13 (1.2%)
5 12 (1.1%)
T Stage
pT2c 810 (73%)
pT3a 259 (23%)
pT3b 34 (3.1%)
Positive surgical margins 151 (14%)
Unknown 1 (<0.1%)
Comorbidities
0 372 (34%)
1 390 (35%)
2 234 (21%)
3+ 107 (10%)
Type of surgery
Laproscopic 288 (26%)
Open 294 (27%)
Robotically-assisted laproscopic 521 (47%)
IIEF-6 = International Index of Erectile Function-6; PSA = prostate-speci fic
antigen.
[(Fig._1)TD$FIG]
Fig. 1 – Effects of age on erectile function and recovery of erectile
function after radical prostatectomy. Black line[3_TD$DIFF]: International Index of
Erectile Function-6 (IIEF-6) measured erectile function by age. Grey line[4_TD$DIFF]:
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.
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