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comorbidity scores have a significantly lower chance of
achieving satisfactory EF recovery after RP, regardless of
their age at surgery. Other investigators further confirmed
these data, and several prognostic models include comor-
bidities as an independent factor in postoperative EF
recovery Therefore, a change in terms of comorbidity
status (eg, new onset or worsening of pre-existing condi-
tions) might occur in the timeframe from diagnosis to
treatment and could be responsible for a worse baseline
biological substrate that might eventually negatively
impact on the magnitude of EF recovery after surgery,
independent of patient age.
Second, all the patients included were treated with an NS
approach, so there is an assumption that delaying treatment
would not affect the chance of undergoing conservative
surgery. In this context, Filippou et al retrospectively
compared pathological outcomes for patients eligible for AS
who were treated with either immediate (n = 521) or
delayed (n = 157) RP. They reported a significantly higher
rate of disease upgrading, extraprostatic extension, and
positive surgical margins for the group of patients treated at
a median of 19 mo from diagnosis compared to the
immediate treatment group. Conversely, other authors
outlined that among patients properly selected for AS,
those undergoing surgery for reasons other than disease
progression have comparable pathologic outcomes to
patients treated with immediate surgery . However, a
risk of disease progression in approximately one-third of
patients on AS cannot be ruled out ; therefore, it should
be pointed out that in the case of cancer progression, the
need for more extensive resection of tissue would certainly
reduce the probability of EF recovery.
Third, the authors did not report clear data on adherence
to phosphodiesterase type 5 inhibitor therapy to enhance
postoperative recovery of EF. Data from the REACTT trial
comparing therapy with tadalafil to placebo after RP
showed that after a drug-free washout period, a significant
advantage for tadalafil was observed only for patients aged
<61 yr, suggesting that younger men could eventually gain
the greatest advantage from a proper rehabilitation protocol
after surgery. Moreover, Mulhall et al conducted a post
hoc analysis on the same trial to assess the probability of
returning back to the preoperative IIEF-6 score. They
showed that up to 22.3% of patients were “back to baseline ”
after treatment; among them, only one patient had a
preoperative IIEF-6 score <26, suggesting that men with a
higher preoperative EF score have a better chance of
achieving full EF recovery after RP. In light of these findings,
we cannot ignore the possibility that getting older and
dealing with a worse baseline EF would decrease the net
and real benefit of penile rehabilitation after RP.
Finally, as properly underlined by Lee and colleagues
we need to further stress that while we should not persuade
a young patient that his chance of EF recovery would
certainly be better with immediate surgery, this is certainly
not the main point of discussion when counseling a young
man with low-risk PCa. The treatment decision may be
harder for young patients given the greater impact of
therapy on their longer life expectancy and their greater
desire for cancer eradication. The ProtecT trial recently
provided level 1b evidence on the outcomes of active
monitoring versus radical treatment for patients with low-
risk disease of note, although cancer-specific and
overall mortality were comparable between the groups,
patients managed with active monitoring showed a
significantly higher incidence of clinical progression and
metastasis compared to the radical treatment groups,
underlining the importance of a comprehensive discussion
of the harms and benefits of treatment with young patients.
Further research is certainly needed to identify low-risk
patients who might benefit from early treatment from both
functional and oncological perspectives.
Conflicts of interest: The authors have nothing to disclose.
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