Two strikingly different reports by well-respected groups were published in prestigious medical journals in January 2000. The first appeared in the journal Urology; it was authored by Patrick Walsh, MD, and his colleagues from Johns Hopkins Medical School. Walsh is considered by many to be one of the best prostate surgeons in the world. His article titled "Patient Reported Urinary Incontinence and Sexual Function After Anatomic Radical Prostatectomy" is very optimistic. They studied 64 men for 18 months after prostate surgery with repeated questionnaires; 93 percent reported no significant urinary problems and 86 percent said they were able to have erections and intercourse and that they had either no or only minor sexual problems.

The authors noted that other studies were not nearly so encouraging and concluded "patient reported rates of continence and potency after radical prostatectomy performed by an experienced surgeon are high. Patients and their referring physicians should seek out centers with high volume experienced surgeons who can document their results through validated outcome studies".

The second report, in the Journal of the American Medical Association, titled "Urinary and Sexual Function After Radical Prostatectomy for Clinically Localized Prostate Cancer" was from the renowned Fred Hutchinson Cancer Research Center in Seattle, Washington. It is far less optimistic. They followed 1,291 men, ages 39 to 79 years, for up to two years. Eighteen months after prostatectomy, 8.4 percent reported frequent urinary incontinence, 40 percent reported occasional urinary leaking (incontinence), and 60 percent were impotent. The frequency of impotence ranged from 66 percent for men whose surgery did not spare nerves in the prostate area, to 56 percent for those whose surgery was of the same nerve sparing type used by Dr. Walsh at Johns Hopkins. Forty-two percent of the men in the Seattle study said their sexual performance (or rather non-performance) was a moderate to large problem. Men over age 60 at the time of surgery were more likely to experience both sexual impotence and urinary incontinence.

These distressing findings were not related to the severity or extent of the cancer at the time of operation. The investigators note that because this was a multi-center study involving six geographic regions in the United States, it was more likely to accurately reflect the post-prostate surgery problems around the United States than studies involving single institutions.

The authors conclude "our study suggests that radical prostatectomy is associated with significant erectile dysfunction and some decline in urinary function".

Commentary: How can one resolve the striking difference between the two studies? The Johns Hopkins study says just pick a good surgeon who does nerve-sparing prostate surgery and all will be well. But even at Johns Hopkins, one of fourteen men had long-term urinary problems and one of seven experienced major sexual performance problems. The Hopkins study involved only 64 men and their current results looked better than past results from the same group, so the small number of men studied may have resulted in overly optimistic conclusions. There can be no question about the extraordinary ability of Dr. Walsh as a prostate surgeon, but the notion that all men have to do is seek out "experienced" surgeons at a hospital that does a lot of operations is much too glib. One argument is that the Johns Hopkins group pioneered the nerve-sparing surgery, and that accounts for their better outcomes and fewer complications. But, the investigators reporting in the Journal of the American Medical Association found that nerve-sparing surgery is also associated with a very high impotence rate. Furthermore, both reports refer to an even more discouraging study in 1997 which noted high rates of incontinence and almost 80 percent impotence after prostate surgery. That report was from the renowned Dana Farber Cancer Institute of Harvard Medical School, clearly a group of "experienced" surgeons doing nerve-sparing surgery in a "high volume" institution.

The bottom line is that, at present, in the United States, men undergoing prostate cancer surgery can expect a significant likelihood that they will experience long-term post-operative complications, including impotence and less often urinary incontinence problems.

Rating: No rating required. Men should be aware that, at present, there is no definitive proof that any treatment for prostate cancer, including surgery, either saves lives or prolongs good quality life.

Major multi-center studies are now being carried out that should provide the answers. But for now, those undergoing prostate surgery for cancer do so with the uncertain knowledge about benefit and the certain knowledge that, for a substantial number, even in marvelous institutions with superb surgeons, quality of life may be diminished because of long-term impotence or urinary incontinence.

Walsh, P.C., et al. Patient Reported Urinary Continence and Sexual Function After Radical Prostatectomy. Urology. Volume 55. Pg 58-61. 2000.

Stanford, J.L., et al. Urinary and Sexual Function after Radical Prostatectomy for Localized Prostate Cancer. Journal of the American Medical Association. Vol 283, pgs 354-360. 2000.