Clinical investigation: prostate
Meta-analysis of rates of erectile function after treatment of localized prostate carcinoma

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Abstract

Purpose: The results of a 1997 meta-analysis of the rates of erectile function after external beam radiotherapy (EBRT) and radical prostatectomy have been widely used in patient and professional education materials and as a reference against which new findings are compared. With a number of recent publications, it is now possible to update this analysis and compare brachytherapy with or without EBRT with EBRT alone, standard and nerve-sparing radical prostatectomy, and cryotherapy.

Methods: A comprehensive literature review and subsequent meta-analysis of the rates of erectile dysfunction associated with the treatments of localized prostate carcinoma was conducted. A simple logistic regression analysis was used to combine the data from the 54 articles that met the selection criteria.

Results: The predicted probability of maintaining erectile function after brachytherapy was 0.76, after brachytherapy plus EBRT 0.60, after EBRT 0.55, after nerve-sparing radical prostatectomy 0.34, after standard radical prostatectomy 0.25, and after cryotherapy 0.13. When only studies reporting ≥2 years follow-up were considered, the only significant change was a decline in the probability for nerve-sparing radical prostatectomy. No brachytherapy studies had a follow-up of ≥2 years. When the probabilities were adjusted for age, the spread between the RT methods and surgical approaches was greater.

Conclusion: The differences in the probability of maintaining erectile function after different treatments of localized prostate cancer are significant.

Introduction

In 1997, a meta-analysis was published of the rates of erectile dysfunction after radical prostatectomy and external beam radiotherapy (EBRT) (1). The results of this study have been used in patient 2, 3, 4 and professional 5, 6, 7, 8 educational materials and have provided a standard against which new treatments and findings are compared 9, 10, 11.

The reasons to update this meta-analysis are several. First, brachytherapy and cryotherapy could not be included in the 1997 meta-analysis because the number of published articles on these treatments was insufficient. With more published studies available, it is now possible to include brachytherapy and cryotherapy. Second, the 1997 study included articles in which the treating physician conducted the assessment of erectile function. The treating physician assessment of treatment complications has been shown to be biased 12, 13. With this finding, it is important to update the meta-analyses and exclude articles that may be biased in this way. Third, quality-of-life issues and, particularly, erectile function remain an important consideration for patients who have to choose between several possible prostate cancer treatments (14). The two traditional treatments, EBRT and radical prostatectomy, are considered to be equivalent in terms of survival benefits (15). The two newer treatments of brachytherapy and cryotherapy are also thought to offer survival benefits comparable to the traditional treatments 16, 17, 18, 19, 20, 21. In addition, watchful waiting still presents a reasonable choice for some patients (22). Given that none of these options are considered medically superior, healthcare professionals and patients often turn to the published data of the complication rates for each treatment to guide their decision. Hence, accurate estimates of the complication rates are needed. Finally, there are still no published randomized clinical trials comparing the available prostate cancer treatments with regard to their complication rates. Current knowledge is largely based on case series from single institutions reporting on single treatment methods. Consequently, a meta-analysis that combines the available case series continues to be the best method for obtaining estimates of the complication rates for each treatment. The results from meta-analyses are more robust than those obtained by referring to a single study or the box scores of significant results and avoid the subjectivity of a narrative review (23).

Section snippets

Data sources and study selection

A comprehensive literature search was conducted in December 2001 using the databases Medline and Cancerlit. Articles published in English, French, Dutch, or German were reviewed. The studies were selected using the following inclusion criteria: (1) articles published from 1970 onward; (2) studies reporting results of EBRT, radical prostatectomy, brachytherapy, and cryotherapy (combined use with neoadjuvant hormonal therapy was permitted); (3) studies reporting data on primary, discrete data

Description of studies

In total, 1475 articles were reviewed. Of these, 44 were excluded because they relied exclusively on the treating physician’s assessment of erectile function. Only 54 study reports met all the inclusion criteria and were selected for this meta-analysis (references for the articles are available from the corresponding author). A breakdown of the number of studies for each treatment method is given in Table 1. Among the studies reporting on radical prostatectomy, we distinguished between studies

Discussion

The potential loss of erectile function is a major consideration for prostate cancer patients when assessing their treatment options. For some men, it may influence whether to undergo treatment at all 30, 31, 32. This meta-analysis provides estimates on the relative probability of maintaining erectile function after EBRT, brachytherapy plus EBRT, brachytherapy, standard radical prostatectomy, nerve-sparing radical prostatectomy, and cryotherapy. The findings showed statistically significant

Conclusion

The findings indicate that men who are concerned about retaining their erectile function have reason to choose one treatment over another. Brachytherapy had the highest probability approximately 1 year after treatment and thus appears to offer the best chance of retaining erectile function after treatment for localized prostate cancer, at least in the short term. Patients need to be cautioned that further declines may occur with time. It should be noted that any advantage of brachytherapy over

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    Supported by a grant from Indigo Medical, Johnson and Johnson.

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