Editorial Comment to Health‐related quality of life after radical retropubic prostatectomy and permanent prostate brachytherapy: A 3‐year follow‐up study

The authors prospectively collected data on 204 patients treated with either prostatectomy or brachytherapy.1 Patients were allowed to select their own treatment. At baseline, 1, 3, 6, 12 and 36 months, symptoms and quality of life were evaluated using the Short Form-8, International Prostate Symptom Score, and 50-item Expanded Prostate Cancer Index Composite (SF-8, IPSS and 50-item EPIC). The authors state in their introduction that “generally, postoperative incontinence is the main problem after radical retropubic prostatectomy whereas urinary irritative and obstructive symptoms and bowel symptoms are problems after permanent prostate brachytherapy and external beam radiation therapy”. In contrast, they found that although urinary incontinence was significantly worse at 3 years after radical prostatectomy compared with brachytherapy, scores for urinary irritation, obstruction and bowel symptoms were similar in the two groups. Furthermore, there was an advantage in sexual function at 3 years in the brachytherapy patients. These results are identical to the findings of Crook et al. on 190 men with favorable risk prostate cancer who were considered appropriate for either radical prostatectomy or brachytherapy and were educated about their choices in an ethics-approved multidisciplinary session that was part of the phase 3 American College of Surgeons Oncology Group trial entitled SPIRIT (Surgical Prostatectomy vs Interstitial Radiation Therapy”, which was designed to randomize men between the two treatment modalities).2 Although the majority of men selected their own treatment, 34 were randomized and the entire group was followed prospectively for quality of life outcome at 5 years using the same instruments for evaluation as Hashine et al. in this report. Incontinence and sexual function were significantly better in the brachytherapy population, whereas urinary irritation, obstructive urinary symptoms and bowel function showed no difference between the surgical and brachytherapy groups. A single center randomized study from Italy reported on 200 men after 5 years.3 No details were provided on the informed consent process and the men were approximately 5 years older than the men in the study by Crook et al. Although corrective surgery was used for men with severe incontinence after prostatectomy, no difference in urinary or sexual functional outcomes were noted at 5 years. This might be partly explained by the older age of the patients and the fact that the practice of prescribing PDE5 postintervention was not specified. Schiff et al.4 have shown that early use of PDE5 after brachytherapy leads to improved erectile function. Unfortunately, a large-scale multicenter randomized trial to investigate quality of life after prostatectomy and brachytherapy is unlikely. Certainly, the concerted effort in the USA by the American College of Surgeons Oncology Group failed quite definitively, closing after randomization of just 55 of the intended 1900 men in the 4 years that it was open. Reports such as those by Hashine et al. and Crook et al. are consistently showing better continence and sexual function for men undergoing brachytherapy compared with those undergoing surgery. After the acute recovery period is over, men undergoing brachytherapy enjoy superior quality of life. Men for whom these end-points are important should be made aware of these differences when making decisions about their management. None declared.

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