Nomograms predict erectile function recovery

A set of evidence-based nomograms for predicting recovery of erectile function (EF) after radical prostatectomy (RP) is now available, and the developers hope that surgeons will use these tools to provide prostate cancer patients with a more accurate personalized estimate of their sexual function outcome.

The project was reported in a recently published paper (J SexMed 2019; 16:1796-1802).

“Rates of post-RP erectile dysfunction reported in the literature range from 10% to 90%. The large variability can be explained by differences in criteria used to define erectile dysfunction as well as in the populations studied and the methods of data acquisition. The discrepancy in reported outcomes also creates a dilemma for urologists who look to the literature for information to use in their patient counseling discussions,” lead author John P. Mulhall, MD, MSc, told Urology Times.  

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“With our instruments, which are the first published nomograms for predicting post-RP EF, surgeons should be able to give each patient a realistic expectation for his outcome,” added Dr. Mulhall, director of the Male Sexual and Reproductive Medicine Program, Memorial Sloan Kettering Cancer Center (MSKCC), New York.

The set is comprised of three nomograms incorporating standard preoperative and postoperative factors that predict both the probability of recovery of EF at 24 months after surgery (ie, an International Index of Erectile Function erectile function domain [IIEF EFD] score ≤10) with or without use of a phosphodiesterase-type-5 inhibitor (PDE5i) and of severe EF at 24 months (ie, IIEF EFD score ≥24). A preoperative nomogram includes the patient’s baseline IIEF EFD score, age, and comorbidity status. A second tool that is designed to be used in the first months after surgery takes into account nerve-sparing status, and the third nomogram, which is for use in the second year after surgery, adds in the patient’s 12-month post-op IIEF EFD score.

The nomograms were developed using a prospective quality-of-life database. Data were included from 272 patients operated on by one of three experienced surgeons who had completed the IIEF preoperatively and at least once after surgery.

Nerve-sparing status was assigned using the MSKCC nerve-sparing score that is assigned by the surgeon for each neurovascular bundle to assess the quality of intraoperative nerve-sparing. Comorbidities were extracted from the patient’s chart and included coronary artery disease, peripheral vascular disease, stroke, diabetes, hypertension, hyperlipidemia, hypercholesterolemia, obesity, and cigarette smoking status.

Dr. Mulhall discussed a few caveats and limitations for using the nomograms. He noted that the predictions of EF recovery are with or without use of a PDE5i because data collection early on did not determine if and when men who were on one of these medications discontinued treatment.

In addition, the nerve-sparing status input uses the MSKCC scoring system. Clinicians who don’t use that method can derive a score for their patients by knowing that the MSKCC system assigns a score of 1 for perfect nerve sparing, 2 for mild damage, 3 for moderate damage, and 4 for complete resection.

Next: Predictions represent best-case scenarioPredictions represent best-case scenario

Dr. Mulhall also said that because all of the data used to develop the nomograms are from patients operated on by very experienced surgeons, the predictions of recovery may be considered to represent a best-case scenario. With that in mind, he mentioned that the nomograms predict that even a patient with ideal factors is at risk for losing EF after RP.

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As an example, Dr. Mulhall observed that according to the early postoperative nomogram, a man who is 40 years of age with robust erectile function preoperatively, perfect nerve-sparing surgery, and no comorbidities can be expected to have a 4- to 6-point drop in the EFD score at 24 months after surgery.

“That is a clinically meaningful change,” Dr. Mulhall said.

Clinicians can now access the nomograms by referring to the published article. In the future, the nomograms will be posted on the MSKCC website.

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