Is nerve-sparing prostatectomy’s sexual benefit overstated?

James A. Talcott, M.D. Director, Center for Outcomes Research, Massachusetts General Hospital Cancer Center; Assistant Professor of Medicine, Harvard Medical School       YES Our prospective data show that nerve-sparing prostatectomy, particularly when performed unilaterally, results in less-improved sexual function than previously reported.   We asked 49 men enrolled in a cohort study of early prostate-cancer treatment about sexual and urinary function before surgery and again at three and 12 months postop. At 12 months, most men reported inadequate erections, including 15 of 19 who had bilateral nerve-sparing surgery.   Our results are consistent with three retrospective surveys-a sample of Medicare beneficiaries, men treated at a California HMO, and a large series of Stanford patients.   Three factors could explain why our results differ from surgeons’. The most important is that not all patients report treatment-related problems accurately and completely. Perhaps that’s because patients are reluctant to disappoint their urologists, or because their doctors hope the sexual function will improve. We asked blunt, clear questions about potency and erections.   Second, impotent patients rarely get nerve-sparing surgery. So if all the patients who were impotent before treatment end up in the non-nerve-sparing group, and those who were potent wind up in the nerve-sparing group, that will affect the numbers.   Also, patients who received nerve-sparing surgery, particularly when it was bilateral, tended to have smaller tumors, lower PSAs, and infrequent high-grade tumors-evidence that the nerve-sparing patients, particularly if bilateral, were highly selected.   The surgeons in our study do the procedure with reasonable frequency. The results didn’t change when we analyzed them with or without the most experienced surgeons.

Patrick C. Walsh, M.D. Professor and Director of Urology, Johns Hopkins       NO First, Dr. Talcott and colleagues had only 18 evaluable patients who were potent before surgery and in whom they claimed both nerves were spared. So they are using limited data to discredit something that has been done successfully for thousands at centers of excellence.   Second, the surgeons who did the operations had little experience with this complicated procedure, averaging less than one per year in the study. So their results are what one might expect. A proper conclusion would have been that with inexperienced surgeons this operation doesn’t work well. That is true. People shouldn’t have surgery by amateurs.   Next, they call the operation nerve-sparing radical prostatectomy. But, in fact, they don’t know whether the nerves were spared. The only way they assessed it was to look at operative reports, which is not sufficient. Also, half the patients were so incontinent at one year that they wore pads. Yet others reported improvement in urinary control with nerve-sparing surgery. This is further evidence that the nerves were never spared in many of the patients in Dr. Talcott’s study.   The group’s premise is that patients lie to their doctors about complications, but it’s not proven. We have done an independent survey of more than 100 of my patients to assess sexual function. The concordance rate between what the patient told the surveyor and my records was 90%.   We urologists examine our patients, and we take down their pants. If half were wearing pads, they couldn’t keep that a secret from us.   A patient doesn’t suffer impotence quietly or say he’s potent if he isn’t. There are too many ways to treat impotence these days