Quality of life following radical prostatectomy

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1 Critical Reviews in Oncology/Hematology 43 (2002) 141/151 Quality of life following radical prostatectomy Ruth Kirschner-Hermanns, Gerhard Jakse * Urological Clinic, University Clinic, Rheinisch-Westfälische Technische Hochschule, Pauwelsstrasse 30, Aachen, D-52057, Germany Accepted 25 January 2002 Contents 1. Introduction Urinary function Bowel function Sexual function Patients and their partners Comparative studies Summary Reviewer References Biography Abstract Radical prostatectomy is a procedure performed with increasing frequency in patients with localized prostate cancer. Although, the operative morbidity is considerably low, urinary incontinence and erectile dysfunction remain an important and persistent problem. Since several years the impact of radical prostatectomy on the quality of life (HRQOL) is investigated. However, there are only few prospective studies dealing with rather small groups of patients. These studies indicate that urinary and sexual function have major impact on HRQOL. Although, there is a steady improvement in urinary function and decrease in urinary bother only about 65% of the patients reach the baseline at the end of the first year. In spite of this almost 90% of patients reach baseline in all other HRQOL domains such as general health perception, physical and social function after a mean period of 5 months. The importance of sexual desire and erectile capacity decreases with age; being important in 75 and 84% of men at the 5th decenium and 48 and 59% at the 6th decenium. After standard radical prostatectomy almost all of the patients are impotent. Applying so-called nerve sparing techniques erectile function may be preserved in careful selected patients. It is the common theme that preservation of the neurovascular bundles equals a high rate, but still age depended postoperative potency; however difficulties in regaining urinary control may embarrass the patient to such an extent to withdraw from sexual activity. Furthermore, the change of sexual ability and quality may have impact on the partner who do not want to initiate sexual activity because of the possible failure. This may cause an increased level of emotional distance, which again is deleterious for sexual activities. Patients who are sexually active prior to surgery report major distress in case of postoperative erectile impotence, but even in case of maintained erectile capacity some patients are bothered by the sexual dysfunction. Sexual counselling and providing the optimal erectile aid is therefore very important. Psychlogical distress of spouses may be significantly greater than that of the patients; general cancer distress, treatment related worries, concerns on physical limitations and pain are the main reasons. However, it may well be that women are willing to * Corresponding author. Tel.: / ; fax: / address: gjakse@ukaachen.de (G. Jakse) /02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S ( 0 2 )

2 142 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/151 report their problems more often than their partners who may have a grin-and-bear-it attitude. In spite of this caveate, it is important to include the patient s spouse into the discussions on therapy and associated morbidity early on. Since radical prostatectomy for localized prostate cancer is only one of the possible treatment options, the patient has to be informed about the incidence and various types of morbidity which is associated with treatment and their possible impact on HRQOL. Appropriate and honest counselling will have significant influence on the well being of the patient after completing therapy. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Prostate cancer; Radical prostatectomy; Incontinence; Impotence; Quality of life 1. Introduction Complete removal of malignancy is the mainstay treating localized prostate cancer. Following the principles of Halsted radical prostatectomy implicated excision of the prostate and seminal vesicles as well as surrounding tissue to obtain negative surgical margins. The perioperative morbidity was considerable, patients were uniformly impotent and a significant percentage were severely incontinent. Since the early eighties the improved knowledge of pelvic functional and structural anatomy radical prostatectomy resulted in a technically safe operation with less morbidity. The appropriate selection of patients in terms of co-morbidity and small tumor burden lead to an almost zero operative mortality and better cancer control rate. Moreover, urinary incontinence (UI) seems to be a lesser problem as reported previously. Refinements in intraoperative technique allowed the preservation of cavernosal nerves responsible for erectile function in appropriately selected younger patients with low volume disease. Additional measures such as removing the indwelling catheter as early as possible, short hospitalization, pelvic floor training to gain continence within a reasonable time, provision of erectile aids are all meant to reduce morbidity and improve HRQOL. Competing means for local control of ct1 and ct2 prostate cancer such as external beam high dose radiotherapy, brachytherapy or iodine seed implantation can be offered. Each modality may have a different outcome in terms of long-term survival, cancer recurrence, severity of side effects and impact on HRQOL. Until now none of these treatment options were compared to each other in randomized trials. A clear statement regarding the superiority of one of these in respect of cancer control can not be made either. HRQOL questionnaires should not only assess effects on physical abilities, but also on psychological and social functions. The later will be influenced by expectations, perceptions, beliefs and personal experience as well as socioeconomic status and culture. In addition to HRQOL instruments for the general evaluation of cancer patients such as EORTC-QLQ-C30, FACT or SF36 instruments should deal with the typical symptoms and adverse effects of the type of cancer under investigation [1,2]. Different outcome in case the treating physician or an uninvolved person is performing the evaluation is well documented [3]. The accuracy of recall of the baseline QOL is poorly correlated to the actual data of the baseline interview [4]. Most of the HRQOL reports concerning prostate cancer deal with crosssectional retrospective data after treatment providing the patients HRQOL at a given time [5]. Moreover, these reports concentrate mainly on physical function and bother. Time of evaluation differs in most studies significantly within a given collective, but also differs to various reports published. The impact of additional cancer treatment such as androgen deprivation, or radiotherapy on HRQOL may be significant and further invalidates the meaning of cross-sectional data. Furthermore, sociodemographic variables such as education, martial status, ethnicy and are rarely taken into account. In contrast, longitudinal data collection facilitates the assessment of changes with time and moreover it enables to determine the likelihood of the return of HRQOL to pretreatment level. Influence of secondary treatment can easily be seen. Until now there is limited information published about individual changes of HRQOL following radical prostatectomy. Furthermore, it is important to note that different questionnaires were and are used to assess the severity of side effects and HRQOL indicating that a simple comparison of data is not possible. Moreover, prostate cancer specific instruments are rarely used. Finally, it is evident that large observational studies may identify specific domains of HRQOL, which need further evaluation. Comparing HRQOL of different therapies is certainly possible only in randomized trials; however, it is also very clear that some randomized trials will never be performed, therefore, future studies have to have a consistency in databases. Although, we know about these drawbacks of our present HRQOL data the information we already have at hand should be used in counseling patients in the pretreatment situation rather than reflecting on anecdotal professional experience. 2. Urinary function UI following radical prostatectomy occurs in 5/74% depending on the definition of UI, method of evalua-

3 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/ tion, questionnaire vs chart review, center of excellence vs survey and independancy of the investigator. The impact of UI on HRQOL was not assessed until recently. Herr evaluated 50 patients 1 /5 years following radical prostatectomy [6]. All of the patients experienced some degree of incontinence (at least three pads daily) but were free of cancer. The patients were investigated by means of a self de-signed questionnaire considering the degree of incontinence and it is global impact upon activities of daily living and satisfaction regarding the results of the operation. Most of the patients (63%) were moderately to severely upset about their incontinence and some (24%) reported limitations in their physical activity compared to the preoperative situation. Interestingly, 53% of patients who have had their surgery 5 years previously would not undergo radical prostatectomy again because of the severity of incontinence. This percentage was much lower (17%) in patients who were evaluated 1 /3 years postoperatively. This finding suggests that with longer follow-up persistent incontinence may dampen earlier enthusiasm of having a successful operation. Braslis et al. evaluated 51 patients who have had a radical prostatectomy at least 12 months before [7]. Sixty one percentage of patients stated that they had no problem with incontinence, but 39% regarded incontinence as a problem. Six (12%) patients were significantly irritated. There was an inverse correlation between patient s incontinence and self-perceived physical and psychological well being. Increased confusion, depression and anger was also significantly associated with incontinence. The impact of the diagnosis cancer, the regular medical attendance, incontinence, erectile dysfunction and the fear of dying may all be associated with an increased hardship score. At our institution we evaluated 137 patients who have undergone radical prostatectomy 6 /121 months (mean: 33.7) previously in regard to UI and HRQOL by means of the ICS urinary symptoms questionnaire and the EORTC-QLQ-C30. No leakage (40.7%), occasional leakage (48.9%) or sometimes leakage (2.2%) with stress was reported by 91.8% patients and these patients are in general view considered as completely continent. But al ready these minor degrees of urinary leakage were a significant problem for 12.9% of these patients (Fig. 1). Moreover, the general perception of well being was negatively influenced not only by UI itself, but by the severity of the symptom (measured by the bother score) (Fig. 2). Considering the different aspects of HRQOL it became evident that incontinence had the greatest negative impact on the daily physical activity. Using the data base of the United States military health care system Kao et al. mailed a modified questionnaire which was initially designed by Fowler et al. to 1396 patients who had undergone radical prostatectomy at five military medical centers by multiple surgeons [8,9]. The analysis of 1013 questionnaires showed that incontinence was present in 65.6% (any urinary leakage which warranted protection) and had significant impact on quality of life (818 patients evaluated). Fowler et al. surveyed a random sample of Medicaire patients 2/4 years after surgery [9]. Thirty two percentage of the patients reported to wear pads or clamps to control dripping urine. However, only 23% reported dripping or leaking as a medium or big problem: Surprisingly, postsurgical patients scored high on indices of overall HRQOL similarly to patients who have had prostatectomy for benign disease. Whereas, the above mentioned reports were the results of cross-sectional studies Litwin et al. performed a longitudinal study on 90 patients who underwent radical prostatectomy and were followed by self-administered questionnaires at intervals of 3 months through 1 year [10]. They used the RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index. There was a steady improvement in urinary function and decrease in urinary bother, but only 61 and 69% of patients reached the baseline, respectively. In spite of this 90% or more of the patients have reached the baseline in all other domains such as Fig. 1. Urinary stress incontinence and bother score in patients after radical prostatectomy.

4 144 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/151 Fig. 2. Health related quality of life and UI. general health perception, physical and social function after a mean period of 5 months. Married and white patients were more likely to achieve a return to baseline QOL during the first year postoperatively. Interestingly enough, the higher the education level the lower the likelihood to return to baseline. There study provides relevant data based on reliable and validated instruments and follow-up over 1 year. Similarly we evaluated 67 patients prior, 6 months and 12 months after radical prostatectomy by means of the ICS urinary symptoms questionnaire and the EORTC-QLQ-C30. Four percentage of patients used two or more pads and 67% were completely dry with stress. There was no significant improvement between months 6 and 12. Although, these results have to be confirmed by other investigators, we already can use these informations to reassure our patients that after a mean time of 6 months more than 90% of patients will gain almost complete urinary continence and experience in most aspects the same quality of life as prior to surgery. In a recent progress

5 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/ report Litwin et al. stated that urinary function remained stable during the second year after surgery and age, ethnicity and co-morbidity did not impact on urinary function or bother, but being married had an advantage [11]. Stanford et al. performed a longitudinal study with follow-up questionnaires at 6, 12 and 24 months [12]. At 24 months only 31.9% of patients gained total urinary control and 40.2% reported on occasional leakage. There was an improvement of urinary control until month 12. Men aged 75/79 having a significantly higher incidence of UI than younger men. However, it is important to note, that the baseline information was taken in this survey retrospectively and only 78% of patients were fully continent prior to therapy. It has to be stressed that the recall of urinary or sexual function is poor [4]. The after authors demonstrated that patients do not recall their pretreatment HRQOL correctly if asked 6 months to 3 years after and this uncertainty remains stable from months 6 /36. Even minor degrees of UI have a major impact on HRQOL. Therefore, it is recommended to assess urinary dysfunction by questionnaire and respond to problems by appropriate counselling and treatment if necessary. 3. Bowel function Fecal incontinence is defined as the loss of anal sphincter control leading to unwanted release of feces or gas and the inability to control the colon content until a release is possible in a social acceptable point of time and place [13]. Fecal incontinence has significant impact on self-confidence, personal image and social life [14]. Incontinence to solid stool and anal incontinence may occur in up to 4% in an elderly population 60/70 years of age. Age being the most important risk factor [14,15]. However, in the normal population with a median age 42.5 years fecal incontinence including soiling may already occur in as much as 5% with the predominance of the male gender [16]. Fecal continence is the result of a complex mechanism, which includes the anal sphincter, rectum and stool volume and consistency. Innervation and anatomy of the anal canal may be altered by radical prostatectomy. Recently, Bishoff et al. reported in a retrospective survey, that fecal incontinence is significantly associated with radical prostatectomy [17]. Moreover, patients who underwent perineal prostatectomy have had a significant (P/0.002) higher rate of less than monthly fecal incontinence (16%) than patients after retropubic prostatectomy (8%). Furthermore, the patients after perineal prostatectomy were more likely to wear pads for stool leakage, experienced more accidents, had a larger amount of stool leakage and had less formed stool compared to retropubic prostatectomy. Litwin et al. demonstrated in a prospective study that bowel function is disturbed in the early phase after radical prostatectomy and that full recovery may last 12 months or more [10]. Bacon et al. showed that bowel function remains disturbed in a significant number of patients during a follow-up of up to 5 years [18]. Schapiro et al. evaluated 42 patients before and 3 and 12 months after radical prostatectomy [19]. There was no significant effect on bowel function after 12 months. Helgason et al. evaluated 314 men without prostate cancer and 342 with cancer, the incidence of faecal leakage was 4 and 8%, respectively, [20]. Twenty two patients were interviewed after radical retropubic prostatectomy. The rate of fecal leakage and bowel urgency was 9 and 10% and this was not different to patients undergoing endocrine treatment. Only 1% of patients were severely distressed by these symptoms. Potosky et al. followed 961 patients after radical prostatectomy for at least 2 years 3.3% of patients were bothered by frequent bowel movement, pain or urgency, although pain (9.2%), urgency (14.5%) and soiling (14.2%) was reported significantly more often [21]. In applying the Kelley questionnaire considering the bowel function in more detail we were able to show in a prospective study that bowel dysfunction was present already preoperatively in 3/49% of patients, with obstipation as the leading symptom. Stool smearing as a sign of fecal incontinence was reported preoperatively by 13% of patients. Twelve months postoperatively sensitivity and discrimination was diminished in 4 and 18% of patients, respectively, (Table 1). Stool smearing was reported 1/ month, 1/week and 3/week in 14, 5 and 2%. The after symptoms were newly reported in 11, 2 and 0%. There was no correlation between the occurrence of UI and bowel symptoms. It has to be stressed that the questionnaires used in the above indicated publications should be considered only as an instrument for a crude information identifying those patients who have a postoperative alteration of bowel habits and continence. The identified individuals have to have at least a careful medical history and physical examination. In this way true incontinence can be usually differentiated from pseudo-incontinence due to prolapsing hemorrhoids or simple poor hygiene. If diagnosis is in doubt rectomanometry, EMG and packaged enema will provide further information. However, it is obvious that bowel dysfunction may occur after radical prostatectomy and has an impact on HRQOL. Therefore, careful pre- and postoperative counselling is necessary. 4. Sexual function The term sexual function includes not only penile capacity for tumescence and erection but also aspects such as frequency of sexual activity, sexual desire, ability

6 146 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/151 Table 1 Bowel symptoms before and 12 months after radical prostatectomy 6 Monate 12 Monate Newly developed All Newly developed All Frequency 3 /5/day 4.3% (2) 6.5% (3) 5.5% (3) 7.3% (4) More often Consistency Soft 6.5% (3) 10.9% (5) 5.5% (3) 10.9% (6) Loose Sensibility Impaired 2.2% (1) 4.3% (2) 1.8% (1) 3.6% (2) Missing Discrimination Impaired 10.9% (5) 15.2% (7) 12.7% (7) 18.2% (10) Missing 0 2.2% (1) 0 1.8% (1) Urgency Seconds 2.2% (1) 2.2% (1) 3.6% (2) 3.6% (2) No control Smearing 1 /2/month 6.5% (3) 8.7% (4) 10.9% (6) 14.5% (8) 1/week 2.2% (1) 8.7% (4) 1.8% (1) 5.5% (3) 3/week 0 2.2% (1) 01.8% (1) Täglich Pad use Night Rarely Always 2.2% (1) 2.2% (1) 3.6% (2) 3.6% (2) Obstipation Sometimes 6.5% (3) 45.7% (2) 19.1% (5) 43.6% (24) Always 2.2% (1) 2.2% (1) 1.8% (1) 1.8% (1) Incomplete emptying Sometimes 17.4% (8) 41.3% (19) 16.4% (9) 36.4% (20) Always to achieve orgasm and others. Men at the age of 50/80 years of age report a decrease in sexual desires, erection capacity and orgasm pleasure between 50 and 70% [20]. Four to nine percentage of men are severely distressed by the decrease of these sexual functions. The importance of sexual desire and erectile capacity decreases with age; being important in 75 and 84% of men at the 5th decenium and 48 and 59% at the 6th decenium (Table 2). In this context it is also important to note that the willingness to sacrifice potency for even an uncertainty of longer life expectancy is around 45% in Swedish men and 80% in men from USA [20,21]. Although, waning sexual function is largely due to side effects of treatment, factors associated with physiological impotence include diabetes mellitus, myocardial infarction and different medication [22]. After standard radical prostatectomy almost all of the patients are impotent. Applying so-called nerve sparing procedures erectile function may be preserved in a considerable number of patients. However, the recovery Table 2 Feelings about waning sexual function Impaired function Feeling unfortunate Little/no relevance 50/59 years 60/69 years 50/59 years 60/69 years 50/59 years 60/69 years Sexual desire (%) Erection (%) Orgasm (%) Modified from Ref. [22].

7 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/ of erectile function after nerve sparing surgery is most of the times gradual and unrealistic expectations may influence postoperative recovery. Erectile function depends not only on an intact neural pathway, but also on an adequate arterial supply and cavernous muscle function, not taking into account psychogenic and comorbidity factors. Therefore, the present questionnaires can provide only crude information on sexual function and should be supported by information on well-known variables such as diabetes, hypertension, smoking, etc. Compared to publications on incontinence and HRQOL even less robust information can be extracted from the present literature. Braslis et al. and Litwin et al. (based on a prospective study) reported that sexual function was diminished significantly after prostatectomy, but only a minority or an unknown percentage of patients had undergone a nerve-sparing procedure [7,10]. Only 30% of patients surveyed by Litwin et al. reached the baseline in sexual function after a follow-up of at least 12 months [10]. The QOL scores for sexual function were significantly diminished. 72.7% of patients in Stanford et al. survey were potent before surgery [12]. Eighteen months after only 27.6% reported erections firm enough for intercourse. Potency varied according to whether a nervesparing procedure was attempted: impotence was reported by 65.6% of patients undergoing non-nervesparing procedures and 56% with bilateral nerve-sparing procedures. Disturbance of sexual function was a moderate-to-big problem in 41.9% of patients, this bother was significantly associated with age ( B/65 years or older). Postoperative sexual function was strongly predicted by baseline sexual function, the time from surgery and age. However, these data have to be considered with caution because of the unusual high percentage of potency in patients undergoing non-nervesparing surgery. It is the general belief that patients undergoing standard radical prostatectomy are usually impotent. Pedersen et al. evaluated 131 patients following radical prostatectomy using a HRQOL questionnaire developed at York University and modified by the authors [23]. The patients were asked to weight their feelings on a 100 mm long visual analogue scale. Thirty five patients completed the questionnaire before surgery and 39 patients at 18 months. The median distress value for voiding was low (4 mm, range, 0/35). Whereas the distress associated with erectile dysfunction was major or severe in half of the patients. Fossa et al. used the EORTC-QLQ-C33 and the PAIS questionnaire for the cross-sectional evaluation of 96 patients in whom a nerve-sparing procedure has been performed when ever possible [24]. The impotence rate raised from 18% preoperatively to 78% after prostatectomy. Sexual pleasure, interest and overall sexuality was impaired in 71% of patients. The sexual function score was lower compared to an observation group, but there was no significant correlation of impaired sexual life to global quality of life. In a recent retrospective study performed by Gralnek et al. 145 patients who underwent radical prostatectomy were evaluated by means of RAND-36 and UCLA prostate cancer index. In 46 of them a nerve-sparing procedure was performed [25]. In 22 (39%) the erectile function was preserved. The sexual function score and bother score was significantly better in the men with preserved function than in those in whom the procedure had failed (Table 3). However, the mean sexual bother score was still 34% below normal even in patients with preserved erectile function. Importantly in patients with failed nerve-sparing procedure who used erectile aids the sexual function was significantly lower compared to the group of patients who had spontaneous erections sufficient for intercourse. Nevertheless, the sexual bother score was similar in both groups. Perez et al. who performed also a retrospective study on patients who had undergone standard and nerve-sparing radical prostatectomy, indicated that patients who failed nerve sparing procedure or in whom a non-nerve-sparing procedure was performed, but used some erectile aid had the same outcome [26]. However, patients with so-called successful nerve sparing surgery had a significantly lower frequency of sexual activity, less satisfaction with sex life and worse erectile functioning and orgasmic capability than the erectile-aid group. Walsh et al. reported an excellent 86% potency rate after 12/18 months in patients in whom one experienced surgeon (PCW) performed a nerve-sparing prostatectomy, mostly bilaterally (89%) [27]. However, it is important to note that in this prospective study about 65% of patients (50/67 years of age) were bothered by a decrease of sexual function. Table 3 Potency, sexual function and bother score (100normal) after nerve sparing prostatectomy Nerve sparing surgery No of patients Sexual function score Sexual bother score Successful Unsuccessful Erectile aids No erectile aids Modified from Ref. [25].

8 148 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/151 The data presented above are difficult to compare since different questionnaires were used and the assessment was done at different points of time. It is certainly so that prospective studies considering sexuality with two questions only, as performed by Talcott et al. and a short follow-up (12 months) are less informative than a retrospective analysis with a more detailed questionnaire as used by Perez et al. [26,28]. Furthermore, it is not very helpful to present large groups of patients of whom very little is known in regard to the type of surgery, etc. [12,29]. Time of follow-up ( /2 years), sexual counselling and use of erectile aids are important variables which have to be provided in such investigations. Because erectile nerves are usually damaged by direct trauma daring surgery early postoperative erectile function within 6 months occurs only in few patients [30]. Hong et al. evaluated 198 patients with a validated questionnaire (EDITS) and demonstrated that the maximum satisfaction rate was observed after 18 /24 months [31]. If oral medication such as sildenafil or early intracavernous injection of vasoactive drugs will speed up healing of the intraoperative nerval damage, improve the potency rate and reduce sexual function bother remains to be seen [32]. The effect of sexual counseling on erectile function and sexual satisfaction is unknown. To make the situation even more complex the data from Sweden which demonstrate a gradual decrease of sexual function may have a negative influence on the long-term data on nerve-sparing prostatectomy [33]. Considering the natural history, Formenti et al. provided data indicating that 43% of patients who underwent nervesparing prostatectomy and were potent at 1 year became impotent at 3 or more years of follow-up [34]. None of the patients who had undergone unilateral nerve-sparing surgery maintained potency at 3 years or later. Therefore, the variations in rates of erectile dysfunction among series are not only the result of the quality of surgery, the methods of assessment, patients selection, patients age, but most importantly of the natural history of sexual function. It is the common theme that preservation of the neurovascular bundles equals a high rate but still age depended postoperative potency; however, difficulties in regaining urinary control may embarrass the patient to such an extent to withdraw from sexual activity. In addition surgery per se may cause sexual dysfunction without causing damage to neurotransmission or vascular supply [35]. Moreover, diagnosis and treatment of prostate cancer leads to a significant emotional stress with anger, fear, depression and loss of self-esteem. Furthermore, the change of sexual ability and quality may have impact on the partner who do not want to initiate sexual activity because of the possible failure. This may cause an increased level of emotional distance, which again is deleterious for sexual activities. The above indicated complex situation can only roughly be assessed by self-report questionnaires [36]. These quality of life instruments can be ideally used as screening instruments to identify patients who have problems and will be useful in comparing different forms of treatment. Problems and disabilities in sexual function have to be seen as a complex situation including the sexual partner. Therefore, interviews with the couple will provide more insight in other dimensions such as sexual interest, sexual arousal, etc. 5. Patients and their partners Traditionally we as urologists concentrate our followup on tumor control and physical disabilities. However, it is quite common that patients are accompanied by their spouses at first consultation and during follow-up visits. Although, we have the general feeling that the threat of the disease and the therapy induced morbidity has a psychosocial impact on both patients and partners, we usually do not ask and do not do anything to solve their problems. However, it is important to note that psychological distress of spouses may be significantly greater than that of patients [37]. Reasons for this finding may be severalfold. General cancer distress, treatment related worries, concerns on physical limitations and pain are the main reasons [38]. Whereas, sexual concerns or urinary function disorders are more of a problem for the patient than the partner. However, it may well be that women are willing to report their problems more often than their partners who may have a grin-and-bear-it attitude. In a recent publication Mathias et al. showed that sexual function is reliably reported by the spouses [39]. Although, there were only minor differences in reporting the frequency of erection, identical firmness of erection and satisfaction, the authors indicate that there is not enough overlap to suggest redundancy. Based on this findings it is important to include the patients spouse not only into the discussion on therapy but also on the assessment of HRQOL and associated morbidity. It is important to realize that married patients may have a significant survival advantage over widowed, separated or single ones, therefore the after need additional social support. 6. Comparative studies There are several cross-sectional studies using established and validated HRQOL instruments to compare the effects of radical prostatectomy to radiotherapy. Lim et al. evaluated 135 patients who had either undergone prostatectomy (89) or external beam radiotherapy (46) [40]. The mean score for incontinence and sexual function was significantly worse for the prosta-

9 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/ tectomy group, whereas bowel problems were worse in the radiotherapy group. Interestingly the perception of incontinence as a big problem was more often noted in the radiotherapy group. Similar results were reported by Shrader-Bogen et al. for a larger group of patients and using different instruments such as FACT-G and PCTO-Q [41]. However, the overall FACT-G summary score as well as the functional well being (subscale) were not affected after age adjustment. Recently, HRQOL data on long-term follow up (up to 5 years) after prostatectomy, radiotherapy and watch full waiting were presented by Bacon et al. indicating that external radiotherapy had significantly worse outcome for most HRQOL domains, but patients reported less urinary and sexual symptoms [18]. The authors explained their findings by the immediate effects caused by prostatectomy, which may gradually improve, whereas radiotherapy is leading to increasing adverse effects over time. In contrast to the above indicated studies Fossa et al. did not show any differences comparing radiotherapy with prostatectomy using EORTC-QLQ-C33, I-PSS (urinary symptoms) and PAIS (sexual function) [24]. However, radiotherapy patients displayed the highest mean scores for global quality of life. The severity of urinary tract symptoms and amount of fatigue were the only independent factors, which had influence on quality of life. Recently, Brandeis et al. compared prostatectomy patients to brachytherapy patients and healthy control [42]. They used the same instruments as Litwin et al. [10]. Only physical function scored better for the prostatectomy group regarding the general HRQOL domains. As in previous studies urinary function was in favour of brachytherapy, whereas bowel function scores were decreased in the brachytherapy group. Sexual function and bother were equivalent in the prostatectomy and brachytherapy group and worse than in controls. Litwin et al. performed a longitudinal study comparing radical prostatectomy (n/415) to radiation (n / 149) [11]. Urinary function was worse in patients immediately after radical prostatectomy compared to the radiotherapy group but improved during the first year. Both groups were similar during the second year. Surprisingly, urinary bother was more significant in the radiotherapy group than in the prostatectomy group. This finding was also supported by the fact that anticholinergics were used more often by patients who underwent radiotherapy. The later tend to have more frequency and urgency than stress incontinence, but ultimately the patient adopts to the symptoms and they are no longer terribly bothersome. Potosky et al. compared patients after radical prostatectomy to patients after radiation in a semi -longitudinal study (recall of base line HRQOL) [21]. Twenty eight percent of patients had to wear pads to stay dry after radical prostatectomy, whereas this was reported by only 3.5% after radiation. Accordingly, there were 11.2 and 2.3% of patients bothered by dripping or leaking urine. Whereas the decline in urinary function was the greatest for radical prostatectomy patients during the first year, a small but significantly greater improvement compared to radiotherapy patients occurred during the second year. The improvement in urinary function during the second year is in contrast to the findings of Litwin et al. and our own experience [11]. Probably this is due to the high rate of incontinent patients, which was observed in this study. Potosky et al. reported a significant higher percentage of impotent patients after prostatectomy (76%) than radiotherapy (45%), all of the patients were initially potent [21]. Moreover, prostatectomy patients were more likely to report having no sexual activity at 2 years after diagnosis. However, the difference of sexual function bother was age dependent. Patients younger than 60 years of age were bothered significantly more after radical prostatectomy (59.4%) than after radiotherapy (25.3%), but there was no difference at the older age group (60/ /), The longitudinal data also indicate that sexual function improves in younger patients undergoing prostatectomy during the second year, whereas radiotherapy patients report a further decline. At the present time the comparative studies present a sound basis for patient counselling. However, we have to bear in mind that these studies have some draw backs, such as no randomization or questionnaires not designed to evaluate symptoms specific for the treatment. Furthermore, sexual function for prostatectomy patients is usually assessed without the knowledge of the type of surgery i.e. nerve sparing or non-nerve-sparing technique. The same is true for radiotherapy in terms of dosage, etc. Finally, patients receiving external beam radiotherapy are usually older and of less physical health including urinary and sexual function [43]. 7. Summary Radical surgery means complete eradication of cancerous tissue. In case tumor is left behind local recurrence as well as metastases can only be prevented in a minor percentage of patients by adjuvant measures. Whereas in the first years patients focus on survival, after impairment of QOL becomes an essential issue in those remaining without tumor recurrence. Incontinence, bowel and sexual dysfunction are the main adverse effects, which have significant impact on HRQOL. Since radical prostatectomy for localized prostate cancer is only one of the possible treatment options, the patient has to be informed about the incidence of various types of morbidity which are

10 150 R. Kirschner-Hermanns, G. Jakse / Critical Reviews in Oncology/Hematology 43 (2002) 141/151 associated with the treatment and their possible impact on HRQOL. Appropriate and honest counseling will have significant influence on the well being of the patient after completing therapy. It is important to stress the fact that not only the patients but also their spouses should be included from the beginning, because there is a significant distress on spouses caused by the diagnosis of cancer, the possible physical impairment of their partners during therapy and the mental limitations of their partners. Centers of excellence may have better results than reported in surveys, therefore technical skills, selection of patients, counseling and appropriate support are important to improve outcome for the general population. Moreover, every center should evaluate the own patients instead of referring to reports in the current literature. 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