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Use of a Validated Quality of Life Questionnaire to Assess Sexual Function Following Laparoscopic Radical Prostatectomy

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Use of a Validated Quality of Life Questionnaire to Assess Sexual Function Following Laparoscopic Radical Prostatectomy International Journal of Impotence Research (2006) 18, 69–76 & 2006 Nature Publishing Group All rights reserved 0955-9930/06 $30.00 www.nature.com/ijir ORIGINAL ARTICLE Use of a validated quality of life questionnaire to assess sexual function following laparoscopic radical prostatectomy A Wagner, R Link, C Pavlovich, W Sullivan and L Su James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA Wide variations exist in the methods for evaluating potency following radical prostatectomy. We describe our technique of laparoscopic radical prostatectomy (LRP), present our methods for assessing the return of potency following LRP, and discuss the relevant literature. Sexual function was assessed pre- and postoperatively using the Expanded Prostate Cancer Index Composite questionnaire (EPIC). Sexual function subscale scores (SFSS) were reported as a percentage of preoperative baseline sexual function. The EPIC was also used for single-question assessment of successful intercourse. We also reviewed the literature on prospective health-related quality of life results following LRP and open radical retropubic prostatectomy. Only patients reporting preoperative intercourse were analyzed. Of these, 72 and 35% undergoing bilateral and unilateral nerve sparing (NS) reported postoperative intercourse at 12 months (P ¼ 0.01). Mean SFSS at 12 months was 61 and 57% of baseline after bilateral and unilateral NS, respectively (P ¼ 0.71). Following NS procedures, 74% of patients p58 years of age and 41% of patients 458 years of age reported successful intercourse at 12 months (P ¼ 0.015). Mean SFSS was 64 and 52% of baseline function (P ¼ 0.249) at 12 months for patients p58 and 458 years of age, respectively. In patients o58 years of age who underwent bilateral NS surgery, 82% reported intercourse at 12 months. In conclusion, return of sexual function following NS LRP in our experience is comparable to reports from centers of excellence in open prostatectomy. Standardizing data collection using validated quality of life instruments can provide both surgeon and patient with a realistic forecast of relative return to normal sexual function following prostatectomy. International Journal of Impotence Research (2006) 18, 69–76. doi:10.1038/sj.ijir.3901376; published online 11 August 2005 Keywords: prostatectomy; quality of life; laparoscopy Introduction geons have also refined surgical technique to allow for decreased blood loss and better visualization of Inherent in determining the relative success of any the external striated sphincter and urethra, thus treatment modality for localized prostate cancer is achieving continence rates of 490%.3,4 In contrast the assessment of three main outcome measures: to the success observed with oncologic and con- cancer cure, preservation of urinary continence, and tinence end points, the preservation of postopera- return of sexual function. Since the mid-1900s tive sexual function has been far less consistent. surgical treatment of prostate cancer has been Wide variations exist in reported potency rates considered the standard by which other therapies following RRP.4–8 Single surgeon case series de- have been compared. High-volume radical retro- scribe potency rates from 76 to 86% in those men pubic prostatectomy (RRP) centers report excellent undergoing bilateral nerve sparing (NS) proce- oncologic success as measured by 10-year biochem- dures.4,8 Others have reported potency rates after ical-free survivals of 68–85%.1,2 Experienced sur- NS surgery as low as 21%, suggesting that case series are not representative of more global prosta- tectomy outcomes.5,9,10 The reason for this wide variation is multifactorial. To begin with, erections, Correspondence: Dr A Wagner, James Buchanan Brady Urological Institute, Johns Hopkins University, 4940 East- unlike continence, are dependent not only upon ern Avenue, Baltimore, MD 21224, USA. physiologic factors such as cavernous nerve func- E-mail: [email protected] tion, but also upon various psychological, behavior- Received 31 May 2005; revised 23 June 2005; accepted 29 al, and social factors. Therefore, inherent difficulties June 2005; published online 11 August 2005 exist when critically evaluating a single variable (i.e. Use of a validated quality of life questionnaire A Wagner et al 70 neurovascular bundle (NVB) preservation during cautery is avoided during seminal vesicle dissec- prostatectomy) without the ability to control the tion. The posterior dissection of the prostate gland is remaining variables. Second, comparing studies accomplished by dissecting between Denonvillier’s from different institutions or national databases is fascia and the rectum. Access is then gained to the confounded by differences in patient selection, anterior prostate by dividing the urachus and experience/skill of the surgeons, surgical technique, entering the prevesical space of Retzius. The dorsal and the often-subjective assessment of NVB pre- venous complex is ligated using intracorporeal servation. Lastly, differing terminology is used to suturing with 2–0 polyglactin suture. define successful postoperative sexual function The endopelvic fascia along the lateral aspect of (e.g. spontaneous erections vs successful inter- the prostate is sharply incised, thus exposing the course) and differing methods of data collection periprostatic fascial planes. The NVBs run along the (e.g. physician inquiry vs patient-reported validated posterolateral surface of the prostate and lie within survey) have been used in different studies. Taken an outer levator fascia and inner prostatic fascia together, these vagaries make it difficult for both (Figure 1). In efforts to preserve the NVBs, bilateral surgeons and patients to realistically predict return NVB ‘grooves’ are created on the anterolateral aspect of normal sexual function following prostatectomy. of the prostate. To avoid iatrogenic entry into the Laparoscopic radical prostatectomy (LRP) has its prostate gland, the levator fascia is superficially basis in the anatomic RRP but enjoys the benefits of grasped and lifted off of the prostate, allowing a improved cosmesis, reduced blood loss, and shorter small incision to be made through this layer and postoperative convalescence typical of laparoscopic exposing the underlying prostatic fascia. The pro- surgery.11 Although it will require at least 10-year static fascia appears smooth, glistening and white, follow-up to fully evaluate the oncologic success of visibly different than the prostate parenchyma, LRP, the functional results of LRP from experienced which appears tan in color and more granular in centers appear comparable to most RRP series.12,13 texture. On occasion, large prostatic veins (i.e. Recently, there has been increased emphasis venous branches of the deep dorsal venous com- on patient-reported health-related quality of life plex) are encountered between the periprostatic (HRQOL) outcomes following treatment for prostate fascial layers. In this instance, when possible, cancer.5,10,12,14–17 Investigators have also developed dissection should be carried out deep to these veins validated instruments that were purposely designed as they travel between the levator and prostatic to address the prostate-specific domains of urinary, fascia. Once the prostatic fascia is identified, the bowel, and sexual function.18 Pre- and postoperative precise plane between the levator and prostatic assessment of HRQOL using these questionnaires fascia is then gently and bluntly developed using a allows each patient to serve as his own internal fine-tipped right-angled clamp along the anterolat- control, and is an ideal method of determining long- eral surface of the prostate starting at the base and term functional outcome in each specified domain. working towards the apex with the levator fascia In this manuscript, the authors will detail a method incised along the way. Electrocautery is minimized of pre- and postoperative assessment of sexual during this dissection so as to avoid thermal injury function that can be used to provide patients with to the cavernous nerves.21 Dissection also continues a greater understanding of the likelihood, timing, and relative return to baseline sexual function following LRP. Methods Operative technique We have previously described our technique of LRP,19 which is accomplished using a modification of the Montsouris technique.20 Our modifications have to do primarily with NVB preservation and are detailed here. Briefly, the patient is placed in the Trendelenburg position on the operating table. After CO2 gas insufflation of the peritoneal cavity, four to five laparoscopic trocars are placed in an inverted U-shaped configuration below the umbilicus. Retro- vesical dissection of the vas deferentia and seminal Figure 1 Periprostatic fascial planes with reference to the location of the neurovascular bundles. The dashed line indicates vesicles is first performed. As the cavernous nerves the course of interfascial dissection to optimize preservation of to the penis travel within the NVB and course the neurovascular bundle (Copyright 2005, Johns Hopkins within millimeters of the seminal vesicles, electro- University). International Journal of Impotence Research Use of a validated quality of life questionnaire A Wagner et al 71 deeper in a posterolateral direction and the NVBs on a per patient basis to 100%. Sexual function are meticulously released bilaterally from the pros- subscale scores (SFSS) at 3, 6, and 12 months tate resulting in two
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