LAUSR

When performing a Google search for “robotic prostate surgery” the top results belong to clinics reporting 80–90% potency rates or even describing side effects to the surgery as “...practically eliminated”. Similar results are presented in several peer reviewed case series [1]. However, the rosy picture corresponds poorly with the experience gained from managing sexual problems in this particular patient group and the excellent outcomes have not been reproduced in strictly monitored randomized controlled trials (RCTs) [2]. In their recent paper in the International Journal of Impotence Research, Lovegrove and co-authors elegantly highlight this issue by pointing out systematic discrepancies in the available literature on sexual function following treatment for localized prostate cancer [3]. Most importantly, the authors highlight how the use of different questionnaires and arbitrary thresholds in patient reported outcome measures (PROM) result in a wide variety of definitions of potency. In addition to obscuring the true rate of erectile dysfunction following prostate cancer treatments, the discrepancies in reporting make comparisons of functional outcomes between different treatment modalities difficult. Further, it obstructs the evaluation of functional outcomes with new surgical methods and alternative treatment modalities such as high-intensity focused ultrasound and focal cryoablation. Admittedly, our own group have contributed to the confusion when defining adequate erections as an abbreviated International Index of Erectile Function (IIEF-5) score of at least 17 with or without Phosphodiesterase-5 Inhibitors (PDE5-Is) several years ago [4]. Meanwhile, a subsequent analysis of our patients showed a very different picture. Here we assessed the return of baseline erections by two different methods [5]. First, we looked at return to baseline IIEF-5 scores and found that about 20% of patients managed this. This corresponds to studies from other major institutions and may well be a reflection of the actual situation [6, 7]. It is a far stretch from the >80% successful erections reported in some studies. It is worth noting that the IIEF questionnaire is not validated in prostate cancer patients and was not developed to measure decrease in erectile function. Rather, it was developed to measure improvements with PDE5-Inhibitors in unselected men with ED [8]. For this reason, we added a simple question asking the men if their erections were as good as before the surgery. Only 7% of the overall population answered affirmatively and the number rose to 16% for men who had undergone bilateral nerve sparing surgery. In line with the issues highlighted by Lovegrove and co-authors, the study was difficult to publish due to skepticism from several reviewers. The most common comment was that the patients were simply wrong about their perceived decline in function. Interestingly, a similar belief was responsible for halting the first RCT on PDE5-Is for penile rehabilitation. Thus, the 2008 trial by Padma-Nathan et al. was terminated prematurely because an interim analysis showed that only about 25% of treated patients had good spontaneous erections 10 months after surgery according to the study criteria, which was interpreted as a lack of effect [9]. The psychology behind the optimistic PROMs in the published literature is not difficult to grasp. We all want to display that we belong to the surgical elite and we want patients to choose our centers for care. This seems to have caused an inflation in positive reporting. Once started this is difficult to reverse since only the most confident surgeons dare to display numbers which seem inferior. The problem is exacerbated by the fact that most readers of scientific literature do not go into detail with the methodology and by * Mikkel Fode [email protected]