Younger men with good function before surgery are likely to maintain their level of sexual function and continence following prostatectomy, research published in European Urology has shown.

Two studies followed more than 1,700 consecutive radical prostatectomy patients of a single ‘high-volume’ surgeon. Patients were followed up at 3, 6, 12, 24, 96 and 120 months using a series of validated questionnaires.

At one year, 90% of patients responded to the survey, but this had decreased significantly towards the end of the study, with only 43% of patients followed up to ten years.

The continence rate decreased significantly from baseline to 3 months post procedure (99% versus 72.6%, P < 0.001). In the first two years after surgery, continence rates continued to improve reaching 95.5% at two years. Although not statistically significant, continence rates worsened between two and eight years’ follow-up (95.5% to 93.1%, P = 0.059) and between eight and ten years (93.1% to 91.1%, P = 0.229). Continence rates at ten years compared with two years showed a marginal, but significant, decrease (P = 0.024).

The best long-term outcomes were seen, not surprisingly, in men who were aged under 60 at the time of their surgery.

The sexual function study reports changes to both overall sexual function (incorporating erectile function, ability to ejaculate, quality of erection and ability to function sexually) and erectile function alone.

A standardised postoperative clinical pathway was used for all potent men at the time of surgery – 50 mg of sildenafil daily or 10 mg tadalafil on alternate days, with penile injection therapy recommended at 3 months if partial erectile function had not returned.

More than three quarters of patients had bilateral nerve-sparing surgery and 15% unilateral, reflecting the early stage in their disease of many of these patients.

After an expected initial decline post surgery, both sexual function and erectile function improved steadily throughout the first two years. Following this, both parameters were relatively stable up to ten years – again younger men, and those with better pre-operative function were more likely to maintain sexual and erectile function in the long term.

The study shows, however, that many men had an improvement in sexual function beyond two years post prostatectomy.

Baseline characteristics of the patients are important. Mean age was 59, and almost 50% of the patients had low-grade disease i.e. Gleason 6 or less. These factors will inevitably mean post-operative potency and sexual function should be better in this population than in a typical UK case load, consisting of many older men with higher grade and higher volume disease.

When faced with the option of radical prostatectomy, one of the key issues is the impact on long-term quality of life, particularly with regard to continence and erectile dysfunction. While the introduction of new surgical techniques such as the nerve-sparing prostatectomy has undoubtedly improved these outcomes, there has been considerable uncertainty around long-term outcomes for these two parameters, with the majority of studies to date following patients only in the short to medium term, usually up to two years post surgery.

This was a real-life study in the sense that all patients were included, but requires caution in interpretation given the experience and expertise of the surgeon involved who carried out significantly higher numbers of operations per year than most urologists in the UK.

These results are encouraging for the patient who faces the prospect of radical prostatectomy. Long-term continence and potency are realistic expectations for younger men with good pre-operative function and if function is good within the first two years after surgery they can expect this to be maintained in the long term.

Older men, and those with erectile difficulties before surgery need to be counselled appropriately in terms of worse outcomes – this will again reinforce the importance of serious consideration of an active surveillance pathway for these men if they have low-risk disease.

Dr Jonathan Rees