medwireNews: Recovery of sexual function varies widely following radical prostatectomy at both the patient and surgeon level, but is not associated with surgeon case volume, US researchers report.
Nnenaya Agochukwu-Mmonu (New York University) and co-investigators found that 24% of 1426 men (median age 64 years, 84% White) with prostate cancer included in the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry had recovered sexual function 2 years after surgery. Recovery was defined as a patient regaining at least 90% of their baseline Expanded Prostate Cancer Index Composite (EPIC)-26 sexual function score.
On multivariable analysis, each 5-year increase in age was associated with a 23% lower likelihood of sexual function recovery and each 10-point increase in baseline EPIC-26 sexual domain score was associated with an 18% lower likelihood.
In addition, individuals with a BMI of 35 kg/m2 or higher were a significant 45% less likely to recover sexual function than those with a BMI below 25 kg/m2 while the likelihood was a significant 51% lower in men with Gleason grade of 5 relative to those with a Gleason grade of 1.
The researchers report in JAMA Surgery that, at baseline, the mean EPIC-26 sexual function scores in their cohort significantly differed at 48, 62, and 63 points in men undergoing no nerve sparing, unilateral nerve sparing, and bilateral nerve sparing procedures, respectively.
At 2 years postsurgery the corresponding scores continued to show a significant difference between the groups, at 23, 30, and 39 points.
However, surgeon-level analyses, conducted among men who underwent bilateral nerve-sparing surgery and had a baseline EPIC-26 sexual domain score of 73 or higher, revealed that post-surgery scores varied significantly.
At 2 years, mean EPIC-26 sexual function scores ranged from 27 to 64 points in 408 patients treated by 12 surgeons.
In this group, the proportions achieving sexual recovery at 2 years ranged from 3% to 44%, which the investigators say shows that “collaborative quality improvement may be needed to effect change in sexual function outcomes.”
However, Agochukwu-Mmonu and team found no correlation between sexual function recovery and surgeon case volume.
In an accompanying commentary, Jeffery Vehawn and Brock O’Neil, both from the University of Utah in Salt Lake City, USA, say that this finding “contradicts results of other larger studies examining the relationship between surgical volume and […] sexual function.”
They suggest: “It is possible that the inclusion criterion requiring surgeons to have operated on at least 10 men with good baseline sexual function over a 5-year period obscured this previously observed phenomenon.”
Vehawn and O’Neil also point out that 22% of men included in the study had Gleason grade 1 disease and 74% were clinical stage T1. They say that “patients such as these who are managed with active surveillance are likely to experience better sexual function outcomes compared to those managed with radical prostatectomy.”
Therefore, although surgical improvements are important for recovery of sexual function, “focusing on encouraging active surveillance in patients with low-risk cancer could have equal or greater improvements.”
The commentators conclude: “Reporting and understanding surgeon-level variation in outcomes represents a big step in collaborative surgical improvement. Whether such an approach can be efficiently leveraged to meaningful improvement in outcomes remains to be seen.”
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JAMA Surg 2021; doi:10.1001/jamasurg.2021.6215
JAMA Surg 2021; doi:10.1001/jamasurg.2021.6257