In highly selected cases, men who have good baseline erectile function can recover potency following nerve-sparing radical cystectomy (RC), according to the findings of a single-center, prospective nonrandomized trial presented at the 2022 American Urological Association annual meeting in New Orleans, Louisiana.
“Most men undergoing RC have poor erectile function at baseline and experience further decline after surgery without recovery. However, in a select group of men with good erectile function at baseline, the use of nerve-sparing surgery allowed many to recover erectile function after surgery, and this recovery continued out to 2 years,” said study investigator Benjamin Beech, MD, a urologic oncology fellow at Memorial Sloan Kettering Cancer Center, New York, New York.
RC can have significant adverse effects on quality of life (QoL). Both sexual impairment and sexual dysfunction are significant problems for men and women post-RC. Sexual dysfunction may be due to a combination of organic and surgery-related iatrogenic factors. There is a paucity of data on long-term outcomes and the impact of preoperative erectile function.
Dr Beech and colleagues examined the natural history of erectile function before and after RC and examined QoL in 210 men who were seen between 2008 and 2014. All the men completed the International Index of Erectile Function (IIEF) at their presurgical visit and at 3, 6, 12, 18, and 24 months post-RC.
Orthotopic neobladder was performed in 115 men (55%) and ileal conduit in 95 (45%). Bilateral or unilateral nerve-sparing surgery was performed in 50% of the men with neobladder and 11% of men with ileal conduit. In this cohort, ileal conduit patients were significantly older (73 vs 63 years) and had a significantly higher rate of severe ED (65% vs 44%) prior to RC. They also were significantly less likely to have no ED (17% vs 30%) prior to RC.
The researchers found that 84% of men reported having severe ED at 12 months and 79% at 24 months post-RC. However, among 35 men with no preoperative ED and neobladder diversion, 16.7% reported no ED at 3 months (67% had bilateral nerve sparing and 22% underwent partial nerve sparing). The largest recovery occurred from 12-24 months, with rates of no ED improving from 14% to 35%.
Among men who were potent preoperatively and underwent nerve-sparing surgery, around one-third of those with orthotopic neobladder and one-fifth of those with ileal conduit reported no ED at 24 months.
“We believe these findings are clinically relevant and can help with preoperative counselling for men facing radical cystectomy and can also inform the decisions of surgeons around nerve sparing surgery,” Dr Beech said.
The strengths of the current study include the prospective collection of patient-reported outcome measures conducted repeatedly over the short to medium-term post-operative period. Limitations included a focus on EF specifically, which does not account for other components of overall sexual function, such as desire, orgasmic function, and satisfaction.
Eric Klein, MD, chair of the Glickman Urological & Kidney Institute at Cleveland Clinic in Ohio, where he is professor of surgery in the Lerner College of Medicine, said it is important to have serial monitoring and long-term follow-up in this patient population. “There is older literature supporting this concept, both with respect to not compromising cancer control and return of erectile function,” Dr Klein said. “Nerve sparing is the right thing to do in appropriately selected patients.”
“Nerve sparing is a major aspect of radical prostatectomy, but within pelvic uro-oncology it has received less attention as a part of the technique for radical cystectomy,” said Zachary Dovey, MD, assistant professor, general urology, robotics and uro-oncology at Mount Sinai Queens and Icahn School of Medicine at Mount Sinai, New York, New York. “This study confirms the important finding that, when oncologically safe, nerve sparing is feasible and can maintain EF in the postoperative period.”
Neobladder for appropriately selected patients, especially using the robotic approach, is increasingly performed in high-volume pelvic uro-oncology centers as the chosen modality of urinary diversion for the surgical treatment of muscle-invasive bladder cancer, Dr Dovey said. The study by Dr Beech’s group is clinically relevant because of its prospective nature with repeated surveillance.
Beech B, Clements M, Atkinson T, et al. Characterizing male erectile function after radical cystectomy. Presented at: AUA2022, May 13-16, 2022, New Orleans, Louisiana. Abstract PD10-04.