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Purpose: Modifications to surgical technique, particularly the widespread adoption of robotic surgery, have been proposed to improve functional recovery after prostate cancer surgery. However, rigorous comparison of men in historical vs contemporary practice to evaluate the cumulative effect of these changes on urinary and sexual function after radical prostatectomy is lacking., Materials and Methods: We compared prospectively collected patient-reported urinary and sexual function from historical (PROSTQA [Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment study], n=235) and contemporary (MUSIC-PRO [Michigan Urological Surgery Improvement Collaborative Patient Reported Outcome] registry, n=1,215) cohorts at the University of Michigan to understand whether modern techniques have resulted in functional improvements for men undergoing prostate cancer surgery., Results: We found significant differences in baseline function, with better urinary (median [IQR]; 100 [93.8-100] vs 93.8 [85.5-100], P < .001) and sexual scores (median [IQR]; 83.3 [66.7-100] vs 74.4 [44.2-87.5], P < .001) prior to treatment in PROSTQA compared to MUSIC-PRO patients, respectively. There was no statistically significant difference in the pattern of urinary incontinence recovery after surgery from 6-24 months between groups ( P = .14). However, men in the contemporary MUSIC-PRO group did have significantly better recovery of sexual function compared to men in the historical PROSTQA group ( P < .0001). Further, we found that contemporary practice consists of men with more unfavorable demographic and clinical characteristics compared to historical practice., Conclusions: Our results demonstrate that the widespread alterations in prostate cancer surgery over the past 2 decades have yielded improvements in sexual, but not urinary, function recovery.

Background: We evaluated the use of secondary treatments in men with grade group (GG) 1 PC following a period of active surveillance (AS) compared with men undergoing immediate radical prostatectomy (RP) to evaluate what is potentially lost in terms of cancer control, if a patient trials AS and transitions to treatment., Methods: We reviewed the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men with GG1 PC undergoing RP from April 2012 to July 2018. Men were classified into groups based on time from diagnosis to RP: immediate (surgery within 1 year of diagnosis) and delayed RP (surgery >1 year after initiation of AS). Time to secondary treatment was estimated using Kaplan-Meier curves and compared using the log-rank test. A multivariable Cox proportional hazards model was fit to assess the association between timing of RP and use of secondary treatments. A chi-squared test was used to assess the association between delayed RP and adverse pathology., Results: We identified 1878 men that underwent an RP during the study period, of which 1489 (79%) underwent immediate RP and 389 (21%) underwent delayed RP. The incidence of adverse pathology was higher in men with delayed versus immediate RP (49% vs. 36%, p < 0.0001, respectively). However, we noted only a small absolute difference in the estimated 24-month secondary treatment-free probability between men with delayed versus immediate RP (93% and 96%, respectively). On multivariable analysis, delayed RP was associated with increased use of secondary treatments (hazard ratio = 1.94, 95% confidence interval = 1.23-3.06, p = 0.004)., Conclusions: The use of secondary treatment after RP in men with GG1 PC undergoing immediate or delayed prostatectomy was rare. These data suggest that the burden of treatment is near equivalent in patients who progress to treatment on AS compared with those who underwent immediate RP., (© 2021 Wiley Periodicals LLC.)

Importance: Of patient-reported outcomes for individuals undergoing radical prostatectomy, sexual function outcomes are among the most reported and the most detrimental to quality of life. Understanding variations at the patient and surgeon level may inform collaborative quality improvement., Objective: To describe patient- and surgeon-level sexual function outcomes for patients undergoing radical prostatectomy in the Michigan Urological Surgery Improvement Collaborative (MUSIC) and to examine the correlation between surgeon case volume and sexual function outcomes., Design, Setting, and Participants: This is a prospective cohort study using the MUSIC registry and patient-reported sexual function outcome data. Patient- and surgeon-level variation in sexual function outcomes were examined among patients undergoing radical prostatectomy from May 2014 to August 2019. Sexual function outcome data were collected using validated questionnaires, which were completed before surgery and at 3, 6, 12, and 24 months' follow-up following surgery. All participants were male. Race and ethnicity data were self-reported and were included to examine potential variation in outcomes by race and/or ethnicity. Data were analyzed from January 2021 to March 2021., Main Outcomes and Measures: There were 4 outcomes in this study, including the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) sexual function scores at 3, 6, 12, and 24 months' follow-up; patient-level sexual function recovery at 12- and 24-month follow-up; surgeon-level variation in sexual function outcomes at 12- and 24-month follow-up; and correlation between surgeon case volume and sexual function outcomes., Results: A total of 1426 male patients met inclusion criteria for this study. The median (IQR) age was 64 (58-68) years. A total of 115 participants (8%) were Black, 1197 (84%) were White, 25 (2%) were of another race or ethnicity (consolidated owing to low numbers), and 89 (6%) were of unknown race or ethnicity. Among patients undergoing bilateral nerve-sparing radical prostatectomy, mean (SD) EPIC-26 sexual function scores at 12- and 24-month follow-up (12 months, 39 [28]; 24 months, 63 [29]) did not return to baseline levels. There was wide variation in EPIC-26 sexual function scores at both 12-month follow-up (range, 23-69; P < .001) and 24-month follow-up (range, 27-64; P < .001). Similar variations were found in EPIC-26 sexual function scores and recovery of sexual function by surgeon. Recovery rates ranged from 0% to 40% of patients at 12-month follow-up (18 surgeons; P < .001) and 3% to 44% of patients at 24-month follow-up (12 surgeons; P < .001). Surgeon case volume and sexual function outcomes were not significantly correlated. On multivariable analysis, the following variables were associated with better recovery at 24-month follow-up: younger age (P < .001), lower baseline EPIC-26 sexual function score (P < .001), lower Gleason score (P = .05), and nonobesity (P = .03)., Conclusions and Relevance: In this study, there was significant patient- and surgeon-level variation in sexual function recovery over 2 years following radical prostatectomy. Variation in surgeon-level sexual function outcomes presents an opportunity and model for surgical collaborative quality improvement.

Importance: Understanding variation in patient-reported outcomes following radical prostatectomy may inform efforts to reduce morbidity after this procedure., Objective: To describe patient-reported urinary outcomes following radical prostatectomy in the diverse practice settings of a statewide quality improvement program and to explore whether surgeon-specific variations in observed outcomes persist after accounting for patient-level factors., Design, Setting, and Participants: This prospective population-based cohort study included 4582 men in the Michigan Urological Surgery Improvement Collaborative who underwent radical prostatectomy as primary management of localized prostate cancer between April 2014 and July 2018 and who agreed to complete validated questionnaires prior to surgery and at 3, 6, and 12 months after surgery. Data were analyzed from 2019 to June 2019., Exposures: Radical prostatectomy., Main Outcomes and Measures: Patient- and surgeon-level analyses of patient-reported urinary function 3 months after radical prostatectomy. Outcomes were measured using validated questionnaires with results standardized using previously published methods. Urinary function survey scores are reported on a scale from 0 to 100 with good function established as a score of 74 or higher., Results: For the 4582 men undergoing radical prostatectomy within the Michigan Urological Surgery Improvement Collaborative who agreed to complete surveys, mean (SD) age was 63.3 (7.1) years. Survey response rates varied: 3791 of 4582 (83%) responded at baseline, 3282 of 4137 (79%) at 3 months, 2975 of 3770 (79%) at 6 months, and 2213 of 2882 (77%) at 12 months. Mean (SD) urinary function scores were 88.5 (14.3) at baseline, 53.6 (27.5) at 3 months, 68.0 (25.1) at 6 months, and 73.7 (23.0) at 12 months. Regression analysis demonstrated that older age, lower baseline urinary function score, body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher, clinical stage T2 or higher, and lack of bilateral nerve-sparing surgery were associated with a lower probability of reporting good urinary function 3 months after surgery. When evaluating patients with good baseline function, the rate at which individual surgeons' patients reported good urinary function 3 months after surgery varied broadly (0% to 54.5%; P < .001). Patients receiving surgery from top-performing surgeons were more likely to report good 3-month function. This finding persisted after accounting for patient risk factors., Conclusions and Relevance: In this study, patient- and surgeon-level urinary outcomes following prostatectomy varied substantially. Documenting surgeon-specific variations after accounting for patient factors may facilitate identification of surgical factors associated with superior outcomes.

Introduction: The International Index of Erectile Function (IIEF) is the predominant patient-reported outcomes instrument for assessing male sexual function. There are obvious problems with the use of the IIEF in the assessment of an individual patient, such as for men who use injections and men who do not engage in intercourse., Aim: The aim of the current study is to redesign the erectile function domain of the IIEF (IIEF6) to more accurately assess the individual patient., Methods: In an observational study of men undergoing treatment for prostate cancer at a tertiary care institution, including 24,732 questionnaires completed by 6,780 individuals, IIEF6 scores were compared for patients using and not using erectile aids. Men not engaging in sexual intercourse were asked to describe the reason., Main Outcome Measure: The main outcome we were seeking was the IIEF6 scores., Results: Mean scores before erectile aids items were added was 17.7 compared with predicted scores of 18.3 vs 16.7 if patients reported their function with vs without the use of aids. No intercourse was reported for 35% of surveys. Reasons given were lack of ability or confidence in 53%, lack of willing and available partner in 28%, "other" in 17% (including respondent's or partner's health issues, low libido, preference for nonpenetrative sex or for sex with men). Doubling the sum of the 3 nonintercourse IIEF6 questions had excellent properties (difference of 0.06, limits of agreement -3.10 to 3.22)., Clinical Implications: Erectile function instruments must include items about erectile aids. Men who report that they have not attempted intercourse should not be assumed to have erectile dysfunction, but should be asked the reason why. For men who report lack of opportunity or preference for intercourse, the score of the 3 nonintercourse IIEF6 questions should be doubled., Strengths & Limitations: This is a large study of patients in a real-world setting. Although the study only includes radical prostatectomy patients, and although the study cohort is not fully representative of the US prostate cancer population as a whole, these issues would not affect the key findings., Conclusion: The IIEF6 can be redesigned to better assess the individual patient. Vickers AJ, Tin AL, Singh K, et al. Updating the International Index of Erectile Function: Evaluation of a Large Clinical Data Set. J Sex Med 2020;17:126-132., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Patient-reported outcomes after radical prostatectomy have focused on erectile function. To date, no studies have validated the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction single item measures in patients with prostate cancer, nor have studies examined how these measures relate to erectile function. In addition, data are lacking with regard to the clinical responsiveness of these measures to treatment. We sought to validate and examine the clinical utility of these measures in men after radical prostatectomy., Patients and Methods: We identified men who underwent a robotic radical prostatectomy from May 2014 to January 2016 in the Michigan Urological Surgery Improvement Collaborative. A single item from the PROMIS Global Satisfaction With Sex Life subdomain and a single item from the PROMIS Interest in Sexual Activity subdomain were administered. Erectile function was also assessed. Differences between baseline and 24-month T-scores for both PROMIS interest and satisfaction were examined. Multilevel models were constructed to examine change over time., Results: A total of 1,604 patients were included in the analysis. Convergent and discriminant validity of the PROMIS measures was supported. The mean PROMIS interest T-score decreased significantly from baseline to 3 months ( P = .001) and significantly increased from 3 months to 24 months in this cohort, with 24-month scores exceeding baseline scores ( P < .001). The mean PROMIS satisfaction T-score declined from baseline to 3 months and increased from 3 months to 24 months ( P < .002)., Conclusion: PROMIS Global Satisfaction With Sex Life and Interest in Sexual Activity single-item measures are fundamental measures in prostate cancer survivorship. Patients are interested in sex despite functional losses and can salvage satisfaction, thereby giving insight into attainable patient-centered survivorship goals for sexual recovery after radical prostatectomy.

Purpose: Seminal vesicle sparing may reduce the risk of neurovascular bundle injury and improve functional outcomes after prostatectomy. While several observational studies have shown better functional outcomes following seminal vesicle sparing approaches, evidence from randomized trials is lacking. We performed a randomized controlled trial comparing functional and cancer control outcomes between nerve sparing prostatectomy augmented with seminal vesicle sparing and standard nerve sparing prostatectomy., Materials and Methods: A total of 140 men with early stage prostate cancer were enrolled in a randomized phase II trial comparing nerve sparing prostatectomy augmented with seminal vesicle sparing to standard nerve sparing prostatectomy. Patient reported sexual and urinary functional scores were assessed prior to surgery, and 6 and 12 months postoperatively. Surgical margin status and prostate specific antigen recurrence were evaluated as secondary outcomes., Results: There were no differences in sexual or urinary function scores after surgery between the study groups. The median urinary incontinence domain score was 92 in the nerve sparing group and 87.5 in the nerve plus seminal vesicle sparing group at 12 months (p = 0.77). Median sexual function domain scores were 73.7 in the nerve sparing group and 77.1 in the nerve sparing plus seminal vesicle sparing group at 12 months (p = 0.29). Margin status and 12-month biochemical recurrence were similar in the groups., Conclusions: Recovery of continence and sexual function was similar between the groups in this randomized controlled trial. Seminal vesicle sparing did not negatively affect margin status or 12-month biochemical (prostate specific antigen) recurrence. These results suggest limited usefulness of seminal vesicle sparing prostatectomy., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: A priority of MUSIC (Michigan Urological Surgery Improvement Collaborative) is to improve patient outcomes after radical prostatectomy. As part of these efforts we developed a novel system that uses unambiguous events to define an uncomplicated 30-day postoperative recovery and compares these outcomes across diverse urology practices., Materials and Methods: MUSIC used a consensus approach to develop an uncomplicated recovery pathway comprising a set of precise perioperative events that are reliably measured and collectively reflect resource utilization, technical complications and coordination of care. Events that occurred outside the uncomplicated recovery pathway were considered deviations, including rectal injury, high blood loss, extended length of stay, prolonged drain or catheter placement, catheter replacement, hospital readmission or mortality. For men undergoing radical prostatectomy trained abstractors prospectively recorded clinical and perioperative data in an electronic registry. When a deviation from the NOTES (Notable Outcomes and Trackable Events after Surgery) pathway occurred, precipitating events were described by abstractors and we analyzed the events., Results: From April 2014 through July 2015 a total of 2,245 radical prostatectomies were performed by 100 surgeons in a total of 37 diverse participating MUSIC practices. In the 29 practices in which 10 or more radical prostatectomies were performed during the interval analyzed the risk adjusted deviation rate ranged from 0.0% to 46.1% (p <0.0001). Anastomotic and gastrointestinal events were contributing factors in 50.2% of deviated cases., Conclusions: The novel NOTES system provides comparative data on unambiguous and actionable short-term outcomes after radical prostatectomy. The observed variation in outcomes across practices suggests opportunities for quality improvement initiatives. Decreasing anastomotic and gastrointestinal events represents a high impact opportunity for initial quality improvement efforts., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the acceptance and knowledge attained in a preoperative psychoeducational group seminar for patients and partners. Education before radical prostatectomy (RP) helps patients set appropriate expectations for functional recovery. We hypothesized that the seminar would be acceptable and would facilitate learning., Materials and Methods: Men scheduled for RP from March 1, 2012, to July 31, 2013, were eligible, and partners were invited. The 2.5-hour interactive seminar included multidisciplinary presentations about surgery-related urinary and sexual outcomes, rehabilitation, and couples' work toward recovering sexual intimacy. A satisfaction and knowledge survey was administered immediately afterward. We analyzed demographic and satisfaction data with descriptive statistics and evaluated congruence of patients' and partners' knowledge responses using nonparametric statistics., Results: Of 618 patients scheduled, 426 patients and 342 partners attended; 323 couples provided complete data. Over 90% of participants found the seminar informative and 74% found a group setting comfortable; 84% found travel to the seminar burdensome. Most patients and partners (84% and 90%, respectively) expected some urinary incontinence and understood rehabilitation strategies to regain bladder control; 84% of patients and 78% of partners expected postsurgery sexual activity to be different and 73% of patients and 65% of partners expected surgery to make erections worse. Couples were incongruent regarding frequency of incontinence, likelihood of erectile dysfunction, and sex being different after surgery: patients were more realistic., Conclusion: A preoperative psychoeducational group seminar on the recovery from RP side effects promotes realistic expectations and is acceptable to patients and partners. Incongruent couples may need further instruction after surgery. Web-based methodology could improve access and should be studied in future research., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: We expanded the clinical usefulness of EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) by evaluating its responsiveness to health related quality of life changes, defining the minimally important differences for an individual patient change in each domain and applying it to a sexual outcome prediction model., Materials and Methods: In 1,201 subjects from a previously described multicenter longitudinal cohort we modeled the EPIC-CP domain scores of each treatment group before treatment, and at short-term and long-term followup. We considered a posttreatment domain score change from pretreatment of 0.5 SD or greater clinically significant and p ≤ 0.01 statistically significant. We determined the domain minimally important differences using the pooled 0.5 SD of the 2, 6, 12 and 24-month posttreatment changes from pretreatment values. We then recalibrated an EPIC-CP based nomogram model predicting 2-year post-prostatectomy functional erection from that developed using EPIC-26., Results: For each health related quality of life domain EPIC-CP was sensitive to similar posttreatment health related quality of life changes with time, as was observed using EPIC-26. The EPIC-CP minimally important differences in changes in the urinary incontinence, urinary irritation/obstruction, bowel, sexual and vitality/hormonal domains were 1.0, 1.3, 1.2, 1.6 and 1.0, respectively. The EPIC-CP based sexual prediction model performed well (AUC 0.76). It showed robust agreement with its EPIC-26 based counterpart with 10% or less predicted probability differences between models in 95% of individuals and a mean ± SD difference of 0.0 ± 0.05 across all individuals., Conclusions: EPIC-CP is responsive to health related quality of life changes during convalescence and it can be used to predict 2-year post-prostatectomy sexual outcomes. It can facilitate shared medical decision making and patient centered care., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Importance: The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain., Objective: To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer., Design, Setting, and Patients: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010., Main Outcomes and Measures: The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both., Results: In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001)., Conclusion and Relevance: Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.

Objective: To examine the feasibility of using automated interactive voice response calls to assess prostate cancer survivor quality of life (QOL). In light of an increasing focus on patient-centered outcomes, innovative and efficient approaches to monitor QOL among prostate cancer survivors are increasingly valuable., Methods: Forty prostate cancer survivors less than 1 year post-treatment were enrolled at a university-based cancer center clinic from July through August 2011. We adapted the Expanded Prostate Cancer Index Composite (EPIC) survey, a prostate cancer-specific QOL instrument, for use via personal telephone with interactive voice response. We compared written vs interactive voice response EPIC scores across urinary, sexual, bowel, and vitality domains., Results: The median age of respondents was 63 years (range, 41-76 years) and the majority had undergone surgery (97.5%). The entire interactive voice response call was completed by 35 participants (87.5%). Over half of all interactive voice response calls were answered after 2 attempts with a median length of 11.3 minutes. On average, interactive voice response EPIC scores were slightly lower than written scores (-2.1 bowel, P = .05; -4.6 urinary incontinence, P < .01). Test-retest reliability was very high for urinary incontinence (r = .97) and sexual function domains (r = .96). Although mean scores were similar for other domains, their distributions had significant ceiling effects limiting our reliability measure interpretation., Conclusion: Automated interactive voice response calls are a feasible strategy for assessing prostate cancer survivor QOL. Interactive voice response could provide a low cost, sustainable, and systematic approach to measuring patient-centered outcomes, conducting comparative effectiveness research, and monitoring the quality of prostate cancer care., (Published by Elsevier Inc.)

Objectives: This study compared oncologic and health-related quality-of-life outcomes among patients undergoing intraperitoneal or extraperitoneal robotic prostatectomy., Methods: Of 215 patients undergoing robotic prostatectomy, the approach was intraperitoneal in 48 and extraperitoneal in 167. Cancer control was evaluated using margin status. Recovery after surgery and functional health was assessed using the convalescence and recovery evaluation and expanded prostate cancer index composite questionnaires, respectively., Results: Positive surgical margin rates were similar between approaches (14% extraperitoneal, 10% intraperitoneal; P = .63). Functional outcomes were slightly improved for those with the extraperitoneal approach (i.e., higher urinary irritation/obstruction scores at 3 months). The extraperitoneal group demonstrated higher activity (91.8 vs 83.3, P = .03) and cognitive scores (94.9 vs. 91.7, P = .04) at 6 weeks as well as higher gastrointestinal scores at 2 weeks (94.2 vs. 90.8, P = .05)., Conclusions: These data support efforts to broaden the adoption of the extraperitoneal approach for robotic prostatectomy.

Context: Sexual function is the health-related quality of life (HRQOL) domain most commonly impaired after prostate cancer treatment; however, validated tools to enable personalized prediction of erectile dysfunction after prostate cancer treatment are lacking., Objective: To predict long-term erectile function following prostate cancer treatment based on individual patient and treatment characteristics., Design: Pretreatment patient characteristics, sexual HRQOL, and treatment details measured in a longitudinal academic multicenter cohort (Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment; enrolled from 2003 through 2006), were used to develop models predicting erectile function 2 years after treatment. A community-based cohort (community-based Cancer of the Prostate Strategic Urologic Research Endeavor [CaPSURE]; enrolled 1995 through 2007) externally validated model performance. Patients in US academic and community-based practices whose HRQOL was measured pretreatment (N = 1201) underwent follow-up after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer. Sexual outcomes among men completing 2 years' follow-up (n = 1027) were used to develop models predicting erectile function that were externally validated among 1913 patients in a community-based cohort., Main Outcome Measures: Patient-reported functional erections suitable for intercourse 2 years following prostate cancer treatment., Results: Two years after prostate cancer treatment, 368 (37% [95% CI, 34%-40%]) of all patients and 335 (48% [95% CI, 45%-52%]) of those with functional erections prior to treatment reported functional erections; 531 (53% [95% CI, 50%-56%]) of patients without penile prostheses reported use of medications or other devices for erectile dysfunction. Pretreatment sexual HRQOL score, age, serum prostate-specific antigen level, race/ethnicity, body mass index, and intended treatment details were associated with functional erections 2 years after treatment. Multivariable logistic regression models predicting erectile function estimated 2-year function probabilities from as low as 10% or less to as high as 70% or greater depending on the individual's pretreatment patient characteristics and treatment details. The models performed well in predicting erections in external validation among CaPSURE cohort patients (areas under the receiver operating characteristic curve, 0.77 [95% CI, 0.74-0.80] for prostatectomy; 0.87 [95% CI, 0.80-0.94] for external radiotherapy; and 0.90 [95% CI, 0.85-0.95] for brachytherapy)., Conclusion: Stratification by pretreatment patient characteristics and treatment details enables prediction of erectile function 2 years after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer.

Objectives: Preservation of periprostatic neurovascular tissue at the time of radical prostatectomy has been correlated with subsequent erectile function and urinary continence. We evaluated whether the amount of neurovascular tissue identified on prostatectomy specimens correlated with surgeon's intention of nerve-sparing and/or predicted quality of life outcomes., Materials and Methods: Radical prostatectomy specimens from 60 patients were evaluated by 2 pathologists for residual neurovascular bundle tissue. Reviewable pathology was available for 17, 19, and 19 patients with bilateral, unilateral, and non-nerve-sparing radical prostatectomy, respectively. The patients completed the Expanded Prostate Cancer Index Composite, a validated quality of life questionnaire. Differences between neurovascular tissue thickness, surgeon's intent at nerve-sparing, and quality of life among patients in each group were analyzed using standard statistical software., Results: Neurovascular tissue thickness identified on radical prostatectomy specimens did not correlate with surgeon's intent at performing a nerve-sparing procedure, nor was it found to be predictive of postoperative quality of life. Surgeon's intent at neurovascular preservation, however, was associated with improved sexual and urinary function scores at 1 year (both P < 0.05)., Conclusions: Surgeon intent, regardless of the amount of neurovascular tissue identified on radical prostatectomy specimen, is predictive of postoperative sexual-related and urinary quality of life. This suggests that factors other than the amount of neurovascular tissue spared contribute to postoperative sexual and urinary function., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Purpose: The commencement of quality-improvement initiatives such as Pay for Performance and the Physician Consortium for Performance Improvement has underscored calls to evaluate the quality of cancer care on a patient level for nationally representative samples., Methods: We sampled early-stage prostate cancer cases diagnosed in 2000 through 2001 from the American College of Surgeons National Cancer Data Base and explicitly reviewed medical records from 2,775 men (weighted total = 55,160 cases) treated with radical prostatectomy or external-beam radiation therapy. We determined compliance with 29 quality-of-care disease-specific structure and process indicators developed by RAND, stratified by race, geographic region, and hospital type., Results: Overall compliance exceeded 70% for structural and pretherapy disease assessment indicators but was lower for documentation of pretreatment functioning (46.4% to 78.4%), surgical pathology (37.1% to 86.3%), radiation technique (62.6% to 88.3%), and follow-up (55%). Geographic variations were observed as higher compliance in the South Atlantic division than the New England division for having at least one board-certified urologist (odds ratio [OR], 9.2; 95% CI, 1.9 to 45.0), at least one board-certified radiation oncologist (OR, 3.3; 95% CI, 1.2 to 9.0), use of Gleason grading (OR, 4.1; 95% CI, 1.2 to 13.8), and administering total radiation dose >or= 70 Gy (OR, 3.1; 95% CI, 1.6 to 6.1). Teaching/research hospitals and Comprehensive Cancer Centers had higher compliance than Community Cancer Centers, whereas racial differences were not observed for any indicator., Conclusion: The significant and unwarranted variations observed for these quality indicators by census division and hospital type illustrate the inconsistencies in prostate cancer care and represent potential targets for quality improvement. The lack of racial disparities suggests equity in care once a patient initiates treatment.

Objectives: The length of stay (LOS) after surgical procedures often varies regionally and reflects local idiosyncratic practice patterns. We sought to elicit the influence of local pressures (in the form of the technologic imperative exerted by laparoscopy) on discharge physician practice style as measured by LOS., Methods: Patients undergoing prostatectomy, nephrectomy, and hysterectomy in 2003 were identified from the Nationwide Inpatient Sample using the International Classification of Diseases, Ninth Revision, codes. Within each procedure, the laparoscopy volume was measured and sorted into tertiles. Patients remaining in the hospital longer than the 90th percentile after each surgery were excluded to minimize the influence of imperative indications on LOS. For each procedure, generalized linear models were used to measure the relationship between the hospital laparoscopy volume and log-transformed LOS outcomes among patients undergoing conventional surgery., Results: In 2003, 2%, 19%, and 16% of patients underwent laparoscopic prostatectomy, nephrectomy, and hysterectomy, respectively. A hospital's laparoscopy and conventional volumes were moderately to highly correlated for hysterectomy (r = 0.65) and nephrectomy (r = 0.58) and less so for prostatectomy (r = 0.24). Among patients undergoing conventional prostatectomy and nephrectomy, those treated at high-volume laparoscopy hospitals had 0.41 and 0.30 fewer hospital days, respectively, compared with those treated at hospitals at which only conventional surgery was performed (both P <0.05). This effect was partially explained by a hospital's open procedure volume (both P = 0.07). Similar relationships were not evident for hysterectomy., Conclusions: These data highlight that patients treated by conventional methods at high-volume laparoscopy centers have shorter hospital stays and suggest that physician practices might susceptible to external influences such as the technologic imperative.

Objectives: We evaluated the impact of the specialized medical and ancillary services available at low vs. high volume prostatectomy centers on prolonged length of stay (LOS) outcomes after radical prostatectomy., Methods: Using the Nationwide Inpatient Sample, we identified patients who underwent prostatectomy (n = 9,266) for prostate cancer in 2003 using ICD-9 codes. Hospital characteristics were ascertained using the American Hospital Association file. Differences in health services availability according to hospital prostatectomy volume were estimated using logistic regression. Logistic models were fitted to measure the effect of available health services on a prolonged LOS (>90 percentile for sample was 5 days)., Results: Among patients undergoing radical prostatectomy in 2003, 19.0% and 5.4% of patients had a prolonged LOS at low and high volume hospitals, respectively (unadjusted OR 4.2, 95% CI 2.5-6.9). After adjusting for differences in patients and availability of select health services, those treated at low volume centers were 3.3 times more likely to have a prolonged hospitalization compared with those treated at high volume hospitals (95% CI 1.9-5.6). Adjusting for hospital differences attenuated the volume effect by 14.8%., Conclusions: There are substantial differences in the health care environment according to radical prostatectomy volume. Generally, high volume hospitals offer a much wider array of health care services specific to both post-prostatectomy and general medical care.

Objectives: To prospectively compare the relevant in-hospital and postdischarge short-term health outcomes in a contemporary group of patients undergoing either robotic or conventional radical prostatectomy., Methods: A total of 117 robotic and 89 conventional radical prostatectomy patients participated in a prospective study evaluating short-term postoperative recovery. A validated short-term health outcomes questionnaire was self-administered at 2 and 6 weeks postoperatively. All patients were given the same preoperative and postoperative instructions., Results: The significant differences in short-term health outcome measures between the two groups were that robotic patients had less mean narcotic use during the first 24 hours of admission (32 versus 52 mg morphine sulfate equivalents, P = 0.001) and a shorter mean length of hospital stay (1.2 versus 1.3 days, P = 0.048). No difference was found between the robotic and conventional radical prostatectomy groups regarding the median time to normal activity, 100% activity, and time to driving (9 and 8, 21 and 28, and 13 and 14 days, respectively). No difference was found in the postdischarge pain levels at 2 and 6 weeks, as reflected in the equivalent time of narcotic use between the two groups (10.6 and 9 days for the robotic and conventional radical prostatectomy groups, respectively)., Conclusions: The results of this prospective study have shown that both robotic and conventional radical prostatectomy provide comparable short-term postdischarge recovery, including time to normal and full activity, driving, and postdischarge narcotic use.

Objectives: To study the evolution of surgical margins in robotic prostatectomy (DVP), to ascertain the surgical volume necessary to provide quality cancer care., Methods: Clinicopathologic data on consecutive DVP patients were abstracted from our institutional database. The primary outcome evaluated was the presence of any positive surgical margin. Surgeon DVP volume was the unit of exposure. A logistic model was fit to measure the association of volume and margin status, adjusting for patient differences., Results: Between November 2001 and August 2005, 193 consecutive patients underwent DVP. Disease and patient characteristics were similar across the levels of surgeon volume. Overall, surgical margins did not dramatically decline over time (first 15 cases, 26% versus cases 81 and beyond, 22%; P = 0.82). However, extensive margins were largely eliminated (first 15 cases, 12% versus cases 81 and beyond, 2%; P = 0.05). After adjusting for preoperative patient differences, the odds of any positive margin among those treated by a surgeon in the highest-volume group was 0.99 (95% confidence interval 0.36 to 2.72) compared with those treated during a surgeon's first 15 cases., Conclusions: Although extensive surgical margins decline with increasing volume, overall positive margin rates after DVP respond slowly. It seems that cumulative surgeon volume beyond that which can be obtained in the typical urology practice may be needed to obtain ideal margin rates with this new technology.

Background: The authors assessed adherence with the College of American Pathologists (CAP) radical prostatectomy (RP) practice protocol in a national sample of men who underwent RP for early-stage prostate cancer., Methods: Using the National Cancer Data Base, the authors identified a nationally representative sample of 1240 men (unweighted) who underwent RP. For each patient, local cancer registrars performed an explicit medical record review to assess patient-level compliance with surgical pathology report documentation of 7 morphologic criteria (ie, quality indicators). Applying the CAP prognostic factor classification framework, composite measures and all-or-none measures of quality indicator compliance were calculated for the following analytic categories: 1) a strict subset of CAP category I prognostic factors (3 indicators), 2) a broad subset of CAP category I factors (6 indicators), and 3) the full set of 7 indicators., Results: Among a weighted sample of 24,420 patients who underwent RP, compliance with documentation of the CAP category I factors varied from 54% (95% confidence interval [95% CI], 50-58%) for pathologic tumor, lymph node, metastases classification (according to the American Joint Committee on Cancer staging system) to 97% (95% CI, 96-99%) for Gleason score. In composite, RP pathology reports contained 83% (95% CI, 81-84%), 85% (95% CI, 84-87%), and 79% (95% CI, 78-80%) of the recommended data elements measured by the strict CAP category I subset, the broad CAP category I subset, and the full set of 7 indicators, respectively. In contrast to the generally higher composite scores, only 52% (95% CI, 48-56%) and 41% (95% CI, 37-45%) of men who underwent RP had complete documentation in their pathology reports for the strict and broad CAP category I subsets, respectively., Conclusions: RP surgical pathology reports contained most of the recommended data elements; however, the frequent absence of pathologic stage provides an opportunity for quality improvement., (Copyright 2007 American Cancer Society.)

Objectives: Establishing realistic health-related quality-of-life (HRQOL) expectations before the choice of cancer treatment is made is an important goal of patient counseling. We prospectively studied the pretreatment expectations of prostate cancer-specific HRQOL with an adapted Expanded Prostate Cancer Index Composite instrument., Methods: Baseline pretreatment Expanded Prostate Cancer Index Composite scores, pretreatment expectation scores, and 1-year posttreatment scores were prospectively collected for 50 patients undergoing radical prostatectomy or external beam radiotherapy. The pretreatment expectations and observed HRQOL scores at 1 year after treatment were compared for the urinary incontinence, urinary irritation, bowel, sexual, and hormonal domains., Results: The expectation scores did not differ from the HRQOL scores at 1 year for urinary irritation, bowel function, and the hormonal domain. However, the sexual domain expectations were 22.5% greater than observed sexual domain scores 1 year after treatment (P <0.0001, 99% confidence interval 11 to 34) for both surgery and radiotherapy subjects. Anxiety, depression, education level, and income did not correlate with the expectations for HRQOL outcomes. A modest correlation was found between optimism and greater expectations for the sexual domain (Pearson correlation coefficient 0.38, P <0.001)., Conclusions: Measuring HRQOL expectations before treatment may elucidate discrepancies between patient expectations and observed outcomes. This pilot study found that patients' expectations regarding urinary and bowel outcomes more closely reflected their eventual observed outcome than did their expectations regarding sexual outcome.

Purpose: We sought to elucidate long-term changes in health-related quality-of-life (HRQOL) outcomes by prospectively re-evaluating a well-characterized cohort of prostate cancer (PC) survivors 4 to 8 years after primary treatment., Patients and Methods: Patients who had been evaluated previously at a median of 2.6 years after radical prostatectomy (RP), external radiation (three-dimensional conformal radiation therapy [3-D CRT]), or brachytherapy (BT) were recontacted at a median of 6.2 years after treatment. The clinical relevance of long-term HRQOL impairment among survivors was established by comparison with controls of similar age. Factors associated with HRQOL changes during this interval were evaluated., Results: Of the 964 eligible men, 709 (73.5%) completed measurable questionnaires. In four domains (urinary irritative-obstructive, urinary incontinence, bowel, and sexual), significant HRQOL differences were detected for at least one of the therapy groups, compared with controls (all P < .05). During the 4-year interval, significant improvement was observed for the urinary irritative-obstructive (P < .0001) and bowel (P < .0001) domains among BT patients, whereas urinary incontinence HRQOL worsened for both the BT (P = .0017) and 3-D CRT (P = .0008) treatment groups. Overall sexual HRQOL deteriorated for the 3-D CRT cohort (P = .0017), as well as for controls (P = .0136). Among RP patients, significant HRQOL changes were not observed., Conclusion: During a 4-year interval from earlier to longer-term phases of PC treatment survivorship, sexual, urinary, and bowel dysfunction remain significant concerns among early-stage PC treatment survivors, compared with control men. Although postprostatectomy HRQOL remains relatively stable during this interval, disease-specific HRQOL continues to evolve among men treated with BT and 3-D CRT.

Background: African-American men have a greater incidence of and mortality from prostate carcinoma compared with white men, and they are less likely to receive definitive therapy (radical prostatectomy or external beam radiation therapy). During the 1990s, the use of brachytherapy increased; however, its influence on racial and ethnic prostate carcinoma treatment trends remains unclear. The objective of this study was to describe treatment trends over the period 1992-1999 for localized/regional prostate carcinoma among white, Hispanic, and African-American men., Methods: Using the Surveillance, Epidemiology, and End Results (SEER) registry data from 1992 through 1999, logistic regression models were used to determine whether the odds of receiving a specific treatment modality differed by racial and ethnic group and whether the differences changed over time when the models were adjusted for age, marital status, tumor grade, and SEER site (geography)., Results: The authors identified 142,340 men, including white men (81.6%), Hispanic men (6.4%), and African-American men (12.0%). Racial and ethnic differences in the rates of use of androgen-deprivation therapy/expectant management were noted; however, these differences appeared to lessen over time (P < 0.001). The rate of utilization of radical prostatectomy increased for Hispanic men, remained flat for African-American men, and decreased for white men. The utilization of brachytherapy and combination therapy increased for all three groups; however, the greatest increase in utilization was among white men., Conclusions: Further research will be required to determine the patient-level and provider-level variables that influence racial and ethnic treatment differences in localized/regional prostate cancer., ((c) 2004 American Cancer Society)

Objectives: To identify the preoperative patient, treatment, and surgeon factors associated with the administration of homologous blood transfusion during or after radical retropubic prostatectomy (RRP) to be able to better inform patients regarding the probability of transfusion. Homologous blood transfusion is sometimes required during or after RRP, but predictive models for estimating transfusion probability using patient and surgical characteristics are lacking., Methods: Data were prospectively collected regarding patient characteristics, cancer severity, surgeon experience, anesthetic used, operative blood loss, and transfusion among 1123 consecutive RRP cases. Multivariate regression analysis identified baseline factors associated with a homologous transfusion requirement and generated a model for predicting the likelihood of perioperative homologous transfusion., Results: Homologous transfusion was administered in 3.8% of subjects; the mean estimated blood loss was 953 mL. Multivariable regression analysis identified prostate size (P <0.0001, odds ratio [OR] 1.74), use of general anesthesia (P = 0.01, OR 2.22), use of neoadjuvant hormonal therapy (P = 0.006, OR 3.35), and surgeon expertise (P <0.0001, OR 8.63) as independent risk factors associated with a need for perioperative homologous transfusion. The most influential factor, surgical expertise, clustered among surgeons who performed more than 15 RRPs annually, because these surgeons had lower transfusion rates and lower estimated blood loss more consistently than did surgeons who performed fewer RRPs annually., Conclusions: Larger prostate size, use of general anesthesia, use of neoadjuvant hormonal therapy, and annual surgeon case volume were independently associated with an increased probability that an individual patient would receive homologous transfusion during or after RRP. A nomogram indicating the probability of homologous transfusion based on these factors provides a benchmark of expected homologous transfusion rates according to individual patient and treatment parameters.

Prostate specific antigen (PSA) screening has heralded stage migration in prostate cancer toward cancers that may be readily eliminated by primary intervention. We sought to identify contemporary, preprostatectomy measures of cancer severity useful and significant for predicting postprostatectomy, recurrence-free survival. The association of baseline variables clinical variables (age, clinical stage, serum PSA, and race) and prostate biopsy parameters (Gleason score, presence of perineural invasion, number of biopsy cores with cancer, and the greatest percentage of a biopsy core occupied by cancer--GPC) with recurrence-free survival was evaluated by multivariate Cox proportional hazards regression among consecutive patients that underwent radical prostatectomy as primary therapy between 1994 and 2002. Tables were generated depicting expected 5-year recurrence-free survival after prostatectomy. From 1414 patients, 183 developed biochemical recurrence, 8 died from prostate cancer, and 31 died of all causes. Multivariable Cox regression found that clinical stage, PSA, Gleason score, and the greatest percentage of a biopsy core involved by cancer (GPC), were each significant determinants of post-prostatectomy, PSA recurrence-free survival (P < 0.05 for each). Gleason score and GPC were also significantly associated with clinical recurrence-free survival and cancer death, whereas other biopsy parameters and PSA were not. The amount of cancer in a biopsy core is a significant predictor of recurrence-free survival after prostatectomy, and is a simple clinical measure that complements baseline PSA, and Gleason score in predicting outcome. Tabulated 5-year PSA-free survival outcomes, stratified by these preoperative parameters, provide a basis for preoperative counseling of patients regarding postprostatectomy cancer control expectations.

Purpose: We combined the strengths of previous patient reported studies (that is use of a validated instrument) with the assets of previous single surgeon, physician reported series (that is prospective collection of operative data) by performing a multiple surgeon study to identify demographic and operative determinants of post-prostatectomy sexual health related quality of life outcomes., Materials and Methods: Sexual outcome was measured after prostatectomy in 671 prostate cancer cases with a followup of 4 to 52 months treated by any of 7 urologists at a high volume medical center and 112 age matched controls by cross-sectional health related quality of life assessment using the Expanded Prostate Cancer Index Composite validated questionnaire. Multivariable ANCOVA was done to identify the baseline determinants affecting post-prostatectomy sexual health outcomes among 17 clinical and demographic factors., Results: Factors independently associated with better sexual health outcome in patients included younger age (p <0.0001), nerve sparing technique (p <0.0001), time since prostatectomy (p = 0.0001), smaller prostate size (p = 0.003), higher education level (p = 0.02), and higher household income (p = 0.02). Orgasm was achieved at a higher rate than erection. In controls only age (p = 0.0004) and having a partner (p = 0.04) were significantly associated with sexual health., Conclusions: Larger prostate size adversely affected sexual health outcome after radical prostatectomy independent of all other measured factors. Patient sexual outcome did not differ significantly among surgeons who performed a broad range of such procedures yearly, suggesting that surgical expertise cannot be measured simply by the number of such operations that a surgeon performs. Stratifying patient reported sexual function by the principal determinants of age, nerve sparing and prostate size provides a basis for counseling patients.

Purpose: Health-related quality-of-life (HRQOL) concerns are pivotal in choosing prostate cancer therapy. However, concurrent HRQOL comparison between brachytherapy, external radiation, radical prostatectomy, and controls is hitherto lacking. HRQOL effects of hormonal adjuvants and of cancer control after therapy also lack prior characterization., Patients and Methods: A cross-sectional survey was administered to patients who underwent brachytherapy, external-beam radiation, or radical prostatectomy during 4 years at an academic medical center and to age-matched controls. HRQOL among controls was compared with therapy groups. Comparison between therapy groups was performed using regression models to control covariates. HRQOL effects of cancer progression were evaluated., Results: One thousand fourteen subjects participated. Compared with controls, each therapy group reported bothersome sexual dysfunction; radical prostatectomy was associated with adverse urinary HRQOL; external-beam radiation was associated with adverse bowel HRQOL; and brachytherapy was associated with adverse urinary, bowel, and sexual HRQOL (P < or =.0002 for each). Hormonal adjuvant symptoms were associated with significant impairment (P <.002). More than 1 year after therapy, several HRQOL outcomes were less favorable among subjects after brachytherapy than after external radiation or radical prostatectomy. Progression-free subjects reported better sexual and hormonal HRQOL than subjects with increasing prostate-specific antigen (P <.0001)., Conclusion: Long-term HRQOL after prostate brachytherapy showed no benefit relative to radical prostatectomy or external-beam radiation and may be less favorable in some domains. Hormonal adjuvants can be associated with significant impairment. Progression-free survival is associated with HRQOL benefits. These findings facilitate patient counseling regarding HRQOL expectations and highlight the need for prospective studies sensitive to urinary irritative and hormonal concerns in addition to incontinence, sexual, and bowel HRQOL domains.

PurposeHarms of prostate cancer treatment on urinary health related quality of life have been thoroughly studied. In this study we evaluated not only the harms but also the potential benefits of prostate cancer treatment in relieving the pretreatment urinary symptom burden.Materials and methodsIn American (1,021) and Spanish (539) multicenter prospective cohorts of men with localized prostate cancer we evaluated the effects of radical prostatectomy, external radiotherapy or brachytherapy in relieving pretreatment urinary symptoms and in inducing urinary symptoms de novo, measured by changes in urinary medication use and patient reported urinary bother.ResultsUrinary symptom burden improved in 23% and worsened in 28% of subjects after prostate cancer treatment in the American cohort. Urinary medication use rates before treatment and 2 years after treatment were 15% and 6% with radical prostatectomy, 22% and 26% with external radiotherapy, and 19% and 46% with brachytherapy, respectively. Pretreatment urinary medication use (OR 1.4, 95% CI 1.0-2.0, p = 0.04) and pretreatment moderate lower urinary tract symptoms (OR 2.8, 95% CI 2.2-3.6) predicted prostate cancer treatment associated relief of baseline urinary symptom burden. Subjects with pretreatment lower urinary tract symptoms who underwent radical prostatectomy experienced the greatest relief of pretreatment symptoms (OR 4.3, 95% CI 3.0-6.1), despite the development of deleterious de novo urinary incontinence in some men. The magnitude of pretreatment urinary symptom burden and beneficial effect of cancer treatment on those symptoms were verified in the Spanish cohort.ConclusionsMen with pretreatment lower urinary tract symptoms may experience benefit rather than harm in overall urinary outcome from primary prostate cancer treatment. Practitioners should consider the full spectrum of urinary symptom burden evident before prostate cancer treatment in treatment decisions.

PurposeWe expanded the clinical usefulness of EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) by evaluating its responsiveness to health related quality of life changes, defining the minimally important differences for an individual patient change in each domain and applying it to a sexual outcome prediction model.Materials and methodsIn 1,201 subjects from a previously described multicenter longitudinal cohort we modeled the EPIC-CP domain scores of each treatment group before treatment, and at short-term and long-term followup. We considered a posttreatment domain score change from pretreatment of 0.5 SD or greater clinically significant and p ≤ 0.01 statistically significant. We determined the domain minimally important differences using the pooled 0.5 SD of the 2, 6, 12 and 24-month posttreatment changes from pretreatment values. We then recalibrated an EPIC-CP based nomogram model predicting 2-year post-prostatectomy functional erection from that developed using EPIC-26.ResultsFor each health related quality of life domain EPIC-CP was sensitive to similar posttreatment health related quality of life changes with time, as was observed using EPIC-26. The EPIC-CP minimally important differences in changes in the urinary incontinence, urinary irritation/obstruction, bowel, sexual and vitality/hormonal domains were 1.0, 1.3, 1.2, 1.6 and 1.0, respectively. The EPIC-CP based sexual prediction model performed well (AUC 0.76). It showed robust agreement with its EPIC-26 based counterpart with 10% or less predicted probability differences between models in 95% of individuals and a mean ± SD difference of 0.0 ± 0.05 across all individuals.ConclusionsEPIC-CP is responsive to health related quality of life changes during convalescence and it can be used to predict 2-year post-prostatectomy sexual outcomes. It can facilitate shared medical decision making and patient centered care.

BACKGROUND: Despite significant sexual dysfunction and distress after localized prostate cancer treatment, patients typically receive only physiologic erectile dysfunction management. The authors performed a randomized controlled trial of an online intervention supporting couples' posttreatment recovery of sexual intimacy. METHODS: Patients treated with surgery, radiation, or combined radiation and androgen deprivation therapy who had partners were recruited and randomized to an online intervention or a control group. The intervention, tailored to treatment type and sexual orientation, comprised 6 modules addressing expectations for sexual and emotional sequelae of treatment, rehabilitation, and guidance toward sexual intimacy recovery. Couples, recruited from 6 sites nationally, completed validated measures at the baseline and 3 and 6 months after treatment. Primary outcome group differences were assessed with t tests for individual outcomes. RESULTS: Among 142 randomized couples, 105 patients (mostly surgery) and 87 partners completed the 6‐month survey; this reflected challenges with recruitment and attrition. There were no differences between the intervention and control arms in Patient‐Reported Outcomes Measurement Information System Global Satisfaction With Sex Life scores 6 months after treatment (the primary outcome). Three months after treatment, intervention patients and partners reported more engagement in penetrative and nonpenetrative sexual activities than controls. More than 73% of the intervention participants reported high or moderate satisfaction with module content; more than 85% would recommend the intervention to other couples. CONCLUSIONS: Online psychosexual support for couples can help couples to connect and experience sexual pleasure early after treatment despite patients' sexual dysfunction. Participants' high endorsement of the intervention reflects the importance of sexual health support to couples after prostate cancer treatment. LAY SUMMARY: This study tested a web‐based program supporting couples' sexual recovery of sexual intimacy after prostate cancer treatment.One hundred forty‐two couples were recruited and randomly assigned to the program (n = 60) or to a control group (n = 82).The program did not result in improvements in participants' satisfaction with their sex life 6 months after treatment, but couples in the intervention group engaged in sexual activity sooner after treatment than couples in the control group.Couples evaluated the program positively and would recommend it to others facing prostate cancer treatment. Couples coping with prostate cancer participated in a randomized controlled trial of a sexual recovery support program. Although participants assigned to the intervention were not more satisfied with their sex life 6 months after treatment, they re‐engaged in sexual activity earlier than a control group and found the program beneficial. [ABSTRACT FROM AUTHOR]

Abstract Background Nearly 1.5 million clinicians in the United States will be affected by Centers for Medicare and Medicaid Services' (CMS) new payment program, the Merit-based Incentive Program (MIPS), where clinicians will be penalized or rewarded based on the health care expenditures of their patients. We therefore examined expenditures for major cancer surgery to understand physician-specific variation in episode payments. Methods We used Surveillance, Epidemiology and End Results–Medicare data to identify patients aged 66–99 y who underwent a prostatectomy, nephrectomy, lung, or colorectal resection for cancer from 2008 to 2012. We calculated 90-d episode payments, attributed each episode to a physician, and evaluated physician-level payment variation. Next, we determined which component (index admission, readmission, physician services, postacute care, hospice) drove differences in payments. Finally, we evaluated payments by geographic region, number of comorbidities, and cancer stage. Results We identified 39,109 patients who underwent surgery by 1 of 7182 providers. There was wide variation in payments for each procedure (prostatectomy: $7046–$40,687; nephrectomy: $8855–$82,489; lung resection: $11,167–$223,467; colorectal resection: $9711–$199,480). The largest component difference in episode payments varied by condition: physician payments for prostatectomy (29%), postacute care for nephrectomy (38%) and colorectal resections (38%), and index hospital admission for lung resections (43%) but were fairly stable across region, comorbidity number, and cancer stage. Conclusions For patients undergoing major cancer surgery, 90-d episode payments vary widely across surgeons. The components driving such variation differ by condition but remain stable across region, number of comorbidities, and cancer stage. These data suggest that programs to reduce specific component payments may have advantages over those targeting individual physicians for decreasing health care expenditures. [ABSTRACT FROM AUTHOR]

Prostate cancer affects couples' sexual intimacy, but men rarely use recommended proerectile aids. This mixed-methods study aimed to identify couples' preprostatectomy barriers to sexual recovery. Interviews about anticipated sexual recovery were paired with surveys: the Dyadic Assessment Scale, the Protective Buffering Scale, the Expanded Prostate Cancer Index Composite, the Sexual Experience Questionnaire (men), and the Female Sexual Function Index. Potential barriers were derived using Grounded Theory. Quantitative data triangulated qualitative findings. Heterosexual couples (N = 28) participated. Men's average age was 62 years and their partners' average age was 58 years. Preexisting and diagnosis-related barriers included aging-related sexual dysfunction, inadequate sexual problem-solving skills, stressors, worry, avoidance of planning for sexual recovery, and dislike of artificially assisted sex. Participants endorsed moderate/high marital satisfaction (DAS: for men, M = 110.0, SD = 11.4; for partners, M = 114.1, SD = 12.1) and communication (PBS: for men, M = 24.5.2, SD = 6.1; for partners, M = 25.1, SD ± 6.2). Men reported mild erectile dysfunction and incontinence (EPIC sexual function M = 76.6, SD = 21.5, urinary incontinence M = 88.4, SD = 18.2). Men's couple sexual satisfaction was lowest (Sexual Experience Questionnaire: M = 60.1, SD = 26.9). Mean total Female Sexual Function Index was low (M = 21.6, SD = 7.8). Heterosexual couples face prostatectomy-related sexual side-effects having experienced developmental sexual losses. Couples use avoidant strategies to defend against worry about cancer and anticipated prostatectomy-related sexual changes. These potential barriers are modifiable if couples can learn to cope with sexual losses and accept sexual rehabilitation strategies. [ABSTRACT FROM AUTHOR]

Background: We sought to identify determinants of health-related quality of life after primary treatment of prostate cancer and to measure the effects of such determinants on satisfaction with the outcome of treatment in patients and their spouses or partners. Methods: We prospectively measured outcomes reported by 1201 patients and 625 spouses or partners at multiple centers before and after radical prostatectomy, brachytherapy, or external-beam radiotherapy. We evaluated factors that were associated with changes in quality of life within study groups and determined the effects on satisfaction with the treatment outcome. Results: Adjuvant hormone therapy was associated with worse outcomes across multiple quality-of-life domains among patients receiving brachytherapy or radiotherapy. Patients in the brachytherapy group reported having long-lasting urinary irritation, bowel and sexual symptoms, and transient problems with vitality or hormonal function. Adverse effects of prostatectomy on sexual function were mitigated by nerve-sparing procedures. After prostatectomy, urinary incontinence was observed, but urinary irritation and obstruction improved, particularly in patients with large prostates. No treatment-related deaths occurred; serious adverse events were rare. Treatment-related symptoms were exacerbated by obesity, a large prostate size, a high prostate-specific antigen score, and older age. Black patients reported lower satisfaction with the degree of overall treatment outcomes. Changes in quality of life were significantly associated with the degree of outcome satisfaction among patients and their spouses or partners. Conclusions: Each prostate-cancer treatment was associated with a distinct pattern of change in quality-of-life domains related to urinary, sexual, bowel, and hormonal function. These changes influenced satisfaction with treatment outcomes among patients and their spouses or partners. N Engl J Med 2008;358:1250-61. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether completing a decision aid, Personal Patient Profile - Prostate (P3P), prior to prostatectomy, affects self-reported bother from post-prostatectomy urinary incontinence and erectile dysfunction.Materials and Methods: This retrospective analysis included data from men with newly diagnosed clinically localized, very low to intermediate risk prostate cancer who elected for prostatectomy within the Michigan Urological Surgery Improvement Collaborative between 2018-2021. Multivariable logistic regression models were used to estimate the association between P3P use and bother from post prostatectomy erectile dysfunction and urinary incontinence as measured by the Expanded Prostate Cancer Index Composite (EPIC-26).Results: Among the 3987 patients included, 7% used P3P (n = 266). Men who used P3P reported significantly less bother from erectile dysfunction at 6 months vs non-users (aOR 0.42 [95% CI 0.27-0.66]). At 12 months, the effect of P3P on bother from erectile dysfunction was not statistically significant (aOR 0.62 [95% CI 0.37-1.03]). Men who used P3P did not have a statistically significant difference in bother from urinary incontinence (3-month: aOR 0.56 [95% CI 0.30-1.06]; 6-month; aOR 0.79 [95% CI 0.31-1.97]).Conclusion: Within the stated limitations of this study, we find that use of a decision aid for localized prostate cancer was associated with decreased odds of men being bothered from sexual dysfunction but not urinary incontinence at 6 months post prostatectomy. [ABSTRACT FROM AUTHOR]

Objectives: Widespread implementation of health-related quality-of-life (HRQOL) measurement in prostate cancer practice and research requires concise instruments. With 50 questions, the full-length Expanded Prostate Cancer Index Composite (EPIC) is cumbersome to administer outside of studies focusing exclusively on HRQOL. To facilitate HRQOL measurement in a broad range of prostate cancer research and practice settings, we developed and validated an abbreviated version of the EPIC. Methods: The 50 questions that constitute the full-length EPIC-50 were evaluated to identify the items suitable for elimination while retaining the ability to measure the 5 prostate cancer-specific HRQOL domains of the EPIC-50. The resulting abbreviated version (EPIC-26) was validated using question responses from 252 subjects who had undergone brachytherapy, external beam radiotherapy, or prostatectomy for prostate cancer. The EPIC-26 internal consistency was measured by Cronbach''s α coefficient and reliability using test–retest correlation. Results: Using the high item–scale correlations, clinically relevant content, and preservation of domain psychometrics, 26 items were retained in the EPIC-26 from the 50 questions in the full-length EPIC-50. A high correlation was observed between the EPIC-50 and EPIC-26 versions for the urinary incontinence, urinary irritation/obstruction, bowel, sexual, and vitality/hormonal domain scores (all r ≥0.96). The correlations between the different domains were low, confirming that EPIC-26 retained the ability to discern the 5 distinct HRQOL domains. The internal consistency and test–retest reliability for EPIC-26 (Cronbach''s α ≥0.70 and r ≥0.69, respectively for all 5 HRQOL domains) supported its validity. Conclusions: EPIC-26 is a brief, valid, and reliable subjective measure of health quality among patients with prostate cancer and is suitable for measuring the HRQOL among patients undergoing treatment of early-stage prostate cancer. [Copyright &y& Elsevier]