European Urology

Michl UH, Friedrich MG, Graefen M, Haese A, Heinzer H, Huland H
J Urol 2006;176:227–31.
Expert's summary:
In their elegant paper, Michl and coworkers highlight possible predictive factors for postoperative sexual function (SF) conservation in patients undergoing either unilateral (U) or bilateral (B) nerve-sparing radical prostatectomy (NSRP) for a locally confined prostate cancer. Assessments of erectile function (EF) preoperatively and at least at 12 mo postoperatively were obtained objectively using the International Index of Erectile Function (IIEF), the most widely used, multidimensional self-report instrument for the evaluation of male SF. Among a convenience sample of patients who underwent NSRP and with complete data collection, having applied the strict diagnostic criteria of Cappelleri et al. [1], the authors reported a baseline preoperative normal EF in 55% of the men. The postoperative functional outcome evaluation showed a median decrease in IIEF-EF domain score of 7 points, with a significantly greater negative impact in patients after UNSRP as compared with those after BNSRP. Overall, baseline potency, as objectively defined by the index, and extent of nerve sparing (UNSRP vs. BNSRP) was significantly associated with better postoperative EF, whereas age was not.
Expert's comments:
Conservation/recovery of EF still remains one of the key points in assessing the functional outcome in patients undergoing RP. The importance of this aspect is increasingly highlighted because the diagnosis of prostate cancer is becoming more frequent in younger patients. The scientific scenario, therefore, has included studies relating to potency conservation, recovery, and treatment after RP, with an impressive number of 589 papers published on this topic in indexed journals during the last 2.5 yr, as demonstrated by a PubMed search on 2 September 2006. The manuscript by Michl et al. provides data with an interesting link to different aspects in both the urologic and the sexual medicine fields.

“Preoperative patient’ self-reported potency: fact or fiction?” In their cohort of candidates for NS procedures, these authors reported a dramatic prevalence of 45% of EF impairment before the surgery. This result confirms our previous experience [2] that in men who preoperatively verbally self-reported full sexual potency and strong motivation to maintain postoperative EF there is large prevalence of patients suffering of severe erectile dysfunction (ED), who very often did not actually attempt any sexual intercourse during the period prior to RP. In my personal perspective, this item is of paramount importance because (1) the latter data show that an objective (i.e., questionnaire/index-based) assessment of preoperative SF is compulsory prior to any surgical approach to subsequently objectively define the postoperative functional outcome, but still it is mostly neglected [2], [3], and [4]; (2) the investigation of the treatment effectiveness in both promoting an earlier potency recovery and curing the postoperative ED may not be scientifically considered as evidence-based when a baseline assessment of the patient's SF profile is lacking, but still it is mostly neglected [5]; and (3) the fascinating perspective of developing international, prospective studies in terms of both oncology and sexual medicine outcome research may need to “speak” a common language, probably represented by reliable validated indexes.