Age Difference Between Patient and Partner is a Predictive Factor of Potency Rate Following Radical Prostatectomy

Modeling recovery curves with application to prostatectomy

In many clinical settings, a patient outcome takes the form of a scalar time series with a recovery curve shape, which is characterized by a sharp drop due to a disruptive event (e.g., surgery) and subsequent monotonic smooth rise towards an asymptotic level not exceeding the pre-event value. We propose a Bayesian model that predicts recovery curves based on information available before the disruptive event. A recovery curve of interest is the quantified sexual function of prostate cancer patients after prostatectomy surgery. We illustrate the utility of our model as a pre-treatment medical decision aid, producing personalized predictions that are both interpretable and accurate. We uncover covariate relationships that agree with and supplement that in existing medical literature.

Predictors of Patient and Partner Satisfaction Following Radical Prostatectomy

INTRODUCTION

The diagnosis and treatment of prostate cancer adversely affects the physical and emotional well-being of patients and partners and has been associated with sexual dysfunction in patients and their intimate partners.

AIM

To identify predictors of sexual satisfaction in prostate cancer survivors and their partners based on a review of the current literature.

METHODS

We performed a comprehensive review of the PubMed database from January 2000 to May 2017 focused on the (i) prevalence of patient and partner sexual dysfunction related to radical prostatectomy, (ii) differences in patient and partner perspectives of sexual function and dysfunction, and (iii) predictors of patient and partner sexual satisfaction after radical prostatectomy.

MAIN OUTCOME MEASURES

Patient- and partner-reported sexual satisfaction.

RESULTS

There is a paucity of published data examining sexual satisfaction in prostate cancer survivors and their partners. Patients and partners can have different expectations of sexual outcomes after radical prostatectomy and different attitudes toward the relative importance of recovery of sexual function after surgery. Available data suggest that patients' and partners' mental and physical health and the quality of communication between them are important contributors to their sexual satisfaction. Patient-perceived partner support also is associated with better patient-reported erectile function and greater relationship satisfaction.

CONCLUSION

Mental health, physical health, quality of interpersonal communication, and patient-perceived partner support appear to be the most important predictors of sexual satisfaction for patients and partners in the post-prostatectomy period. There is a definite need for further research on this topic to develop interventions to improve sexual function and quality of life for prostate cancer survivors and their intimate partners. Guercio C, Mehta A. Predictors of Patient and Partner Satisfaction Following Radical Prostatectomy. Sex Med Rev 2018;6:295-301.

[Sexuality of couples 5 years after radical prostatectomy. Sexuality of patients and their partners 1 year postoperatively in sexually active couples]

BACKGROUND

Erectile dysfunction after radical prostatectomy (RPx) does affect the sexual life of patients and their partners. In our study, we evaluated sexual life over the long-term of 60 months following nerve-sparing (ns) RPx in couples who successfully performed sexual intercourse (SI) 12 months after surgery.

PATIENTS AND METHOD

A total of 36 patients and their female partners who had SI prior to and 12 months after nsRPx were included in this study. Sixty months following nsRPx, couples were asked about frequency of SI, satisfaction of sexual life, usage of medical aid for erections, and sexual function [patients: IIEF-5 (International Index of Erectile Function), partners: FSFI (Female Sexual Function Index)].

RESULTS

Thirty couples (83.3%) were available for follow-up. A total of 70% of couples performed SI 60 months after nsRPx. In contrast to couples who did not have SI 60 months after nsRPx, couples who successfully had SI were more satisfied, had SI more often, had higher IIEF-5 scores, and higher frequency of bilateral ns surgery. In 80% of those patients, no medical aid except PDE-5 inhibitors were used. The partners of those patients were more satisfied with their sexual life, compared to the patients themselves. Couples, in whom the patient had IIEF-5 scores ≥19 were more satisfied, had SI more often, and the partners had higher FSFI scores, compared to couples with patients' IIEF-5 scores <19.

CONCLUSION

Couples who had successfully performed SI within 12 months following nsRPx continue to have satisfying SI in the long-term. Those couples are more satisfied with their sexual life and have SI more often prior to and 12 months after nsRPx.

Current status of penile rehabilitation after radical prostatectomy

Although disease-free survival remains the primary goal of prostate cancer treatment, erectile dysfunction (ED) remains a common complication that affects the quality of life. Even though several preventive and therapeutic strategies are available for ED after radical prostatectomy (RP), no specific recommendations have been made on the optimal rehabilitation or treatment strategy. Several treatment options are available, including phosphodiesterase-5 inhibitors, vacuum erection devices, intracavernosal or intraurethral prostaglandin injections, and penile prostheses. Urologists must consider more effective ways to establish optimal treatments for ED after RP. ED is an important issue among patients with prostate cancer, and many patients hope for early ED recovery after surgery. This review highlights the currently available treatment options for ED after RP and discusses the limitations of each.

Erectile Function Following Prostate Cancer Treatment: Factors Predicting Recovery

Prostate cancer represents the most common nonskin malignancy encountered in men, and the excellent long-term survival achieved in the majority of patients has allowed more attention to be given to the side effects associated with its treatment. Erectile function is one of the main concerns of patients when considering treatment options for prostate cancer. Not surprisingly, post-treatment sexual function is closely related to outcome satisfaction and has long-lasting effects on quality of life. Radical prostatectomy is currently the most commonly employed therapy for prostate cancer. Conflicting rates of erectile dysfunction have been reported after surgery, owing not only to different surgical techniques but also because of dissimilar patient populations and definitions. Providing accurate information to individual patients in regards to their chances of recuperating the ability to have intercourse after treatment is important not only because it allows patients to make informed decisions but also because it has the potential to reduce treatment dissatisfaction. This article mainly focuses on discussing predictors of erectile function after radical prostatectomy. Patient factors, surgical aspects, including comparisons between open, laparoscopic, and robotic approaches, and postoperative management issues that impact sexual outcomes are evaluated. Prediction models combining multiple factors are described. The definition and chronology of erectile function recovery and impact of sexual function on quality of life after surgery are also discussed. Teloken PE and Mulhall JP. Erectile function following prostate cancer treatment: Factors predicting recovery. Sex Med Rev 2013;1:91-103.

Dissociation between patients and their partners in expectations for sexual life after radical prostatectomy

OBJECTIVE

To analyze expectations for sexual life after radical prostatectomy in patients and their partners, and its influence on sexual motivation and bothers in the postoperative period.

METHODS

A total of 162 patients who underwent retropubic radical prostatectomy and their partners were evaluated. The patients' sexual function, sexual bother and expectations for postoperative sexual life were assessed prospectively at baseline, and at 1, 3, 6 and 12 months after radical prostatectomy. The partner was asked questions about postoperative sexual life before the operation. Sexual function and sexual bother were evaluated by the University of California Los Angeles Prostate Cancer Index. Expectations for postoperative sexual life were studied using three ad hoc questions.

RESULTS

The rate of having sexual intercourse and adequate penile rigidity for vaginal penetration at baseline was 29.0% and 21.6%, respectively. A significantly higher rate of patients considered "sexual life is important" (patient 35.2%, partner 13.0%), hoped for "preservation of erectile function" (patient 66.0%, partner 33.3%) and accepted "use of phosphodiesterase type 5 inhibitor" (patient 65.4%, partner 43.2%) compared with their partners (P < 0.001). Patients who had partners with a negative sexual attitude lost sexual motivation 1 year after operation. However, patients with cooperative partners maintained sexual motivation, although they felt greater sexual bother 1 year after radical prostatectomy.

CONCLUSIONS

There was a significant dissociation in perspectives of postoperative sexual life between patients undergoing radical prostatectomy and their partners. Partners' low expectations are associated with patients' low sexual bother and motivation. Partners' cooperative attitude might contribute to maintaining patients' sexual desire and motivation.

Prevention and management of postprostatectomy sexual dysfunctions. Part 1: choosing the right patient at the right time for the right surgery

CONTEXT

Sexual dysfunction is common in patients following radical prostatectomy (RP) for prostate cancer (PCa).

OBJECTIVE

To review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics and intra- and postoperative factors that may influence EF recovery.

EVIDENCE ACQUISITION

A literature search was performed using Google and PubMed database for English-language original and review articles either published or e-published up to November 2011.

EVIDENCE SYNTHESIS

The literature demonstrates great inconsistency in what constitutes normal EF before surgery and what a man may consider a normal erection after RP. The use of validated psychometric instruments with recognised cut-offs for normalcy and severity during the pre- and postoperative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative erectile dysfunction (ED), the concept of spontaneous or pharmacologically assisted erections, and the difference between "back to baseline" EF and "erections adequate enough to have successful intercourse" clearly emerge as key issues in the eventual understanding of the prevention of ED and promotion of satisfactory EF recovery post-RP. Patient factors (including age, baseline EF, and status of comorbid conditions), cancer selection (unilateral vs bilateral nerve sparing), type of surgery (ie, intra- vs inter- vs extrafascial surgeries), surgical techniques (ie, open, laparoscopic, and robot-assisted RP), and surgeon factors (ie, surgical volume and surgical skill) represent the key significant contributors to EF recovery.

CONCLUSIONS

The complexity of the issues discussed throughout this review culminates in the simple concept that optimal outcomes are achieved by the careful choice of the correct patient for the correct type of surgery.

Choosing the best candidates for penile rehabilitation after bilateral nerve-sparing radical prostatectomy

INTRODUCTION

Controversy exists regarding the ideal candidates for penile rehabilitation after bilateral nerve-sparing radical prostatectomy (BNSRP).

AIM

To test the effect of penile rehabilitation according to preoperative patient characteristics.

METHODS

We included 435 consecutive patients treated with BNSRP between 2004 and 2008. Preoperative age, International Index of Erectile Function (IIEF) and Charlson Comorbidity Index (CCI) were used to subdivide patients into three groups according to foreseen risk of erectile dysfunction (ED) after surgery: low (age ≤65, IIEF-erectile function (EF) ≥26, CCI ≤1; N = 184), intermediate (age 66-69 or IIEF-EF 11-25, CCI ≤1; N = 115), and high (age ≥70 or IIEF-EF ≤10 or CCI ≥2; N = 136). The Kaplan-Meier method was used to test the difference in EF recovery rates among patients left untreated after surgery (N = 193), those receiving on-demand phosphodiesterase type 5 inhibitors (PDE5-I; N = 147), and those treated with chronic use of PDE5-I (taken every day or every other day for 3-6 months; N = 95). The same analyses were repeated within each risk category.

MAIN OUTCOME MEASURE

Erectile function (EF) was evaluated using the International Index of Erectile Function (IIEF). Recovery of EF after BNSRP was defined as an IIEF-EF domain score ≥22.

RESULTS

No difference in terms of EF recovery was found between patients receiving on-demand vs. daily PDE5-I (P = 0.09) in the overall population. Similarly, comparable efficacy of the two treatment schedules (on-demand vs. chronic) was demonstrated in patients with low and high risk of ED (all P ≥ 0.8). Conversely, daily therapy with PDE5-I showed significantly higher efficacy for the EF recovery rate compared with the on-demand PDE5-I administration schedule in patients with intermediate risk of ED (3-year EF recovery: 74% vs. 52%, respectively; P = 0.02).

CONCLUSION

The ideal candidates for penile rehabilitation after surgery are patients at intermediate risk of ED.

Emerging concepts in erectile preservation following radical prostatectomy: a guide for clinicians

Radical prostatectomy (RP) is a commonly performed procedure for the management of prostate cancer. While documented oncologic outcome for early stage disease is excellent, functional impairments such as incontinence and erectile dysfunction (ED) are common after the procedure. Recent evidence has implicated cavernous nerve damage and subsequent corporal oxygen deprivation, as well as corporal inflammation, in the pathogenesis of post-RP ED. Targeted therapies such as oral phosphodiesterase-5 inhibitors, mechanical vacuum erection devices, local alprostadil delivery and testosterone replacement (for hypogonal patients) have demonstrated some efficacy in the management of post-RP ED. This review aggregates much of the recent data in support of these therapies and critically reviews them. The article then presents tools to assess patients and partner sexual function to aid in identifying and monitoring post-RP ED. Finally, the article describes a protocol in use at Baylor College of Medicine as a guide toward the development of a protocol for erectile preservation (EP). The purpose of this work is to educate clinicians on emerging concepts in EP and provide an implementable protocol for use in practice.

Racial differences in sexuality profiles among American, Japanese, and Japanese American men with localized prostate cancer

INTRODUCTION

Although there were marked racial differences in the clinical outcomes among Japanese men (JP), Caucasian men (CA), and Japanese American (JA) men with localized prostate cancer, the effect of race/ethnicity on sexual profiles remains unclear.

AIM

To determine differences of sexual profiles in JP, CA, and JA with localized prostate cancer.

METHODS

A total of 412 JP, 352 CA, and 54 JA with clinically localized prostate cancer were enrolled in separate studies of health-related quality of life outcomes. We developed a collaborative study in each database.

MAIN OUTCOME MEASURE

Sexual function and bother were estimated before treatment with validated English and Japanese versions of the University of California in Los Angeles Prostate Cancer Index (UCLA PCI).

RESULTS

The CA reported the highest sexual function score of all. Even after controlling for age, prostate specific antigen, clinical T stage, Gleason score and comorbidity, the JP were more likely than the CA to report poor sexual desire, poor erection ability, poor overall ability to function sexually, and poor ability to attain orgasm. With regard to sexual bother, however, no differences were reported between CA and JP. The JA reported sexual function closely approximate that of the JP, and they were less likely than the CA to report erection ability and intercourse. The JA were more likely to feel distress from their sexual function than the CA. When the JA were divided into two groups according to the ethnicity of their partners, UCLA PCI sexual function scores were equivalent between JA-partnered men and men partnered with other races. On the other hand, JA-partnered men were significantly less likely to report sexual bother scores than men partnered with other races.

CONCLUSION

We found significant interethnic variations among CA, JP, and JA with prostate cancer in terms of their sexual profiles. Ethnicity and/or country appear to modify some of these variables.

Sexual quality of life for localized prostate cancer: a cross-cultural study between Japanese and American men

Introduction

Race and ethnicity are important factors in health-related quality of life (QOL) because of racial differences in preferences for, and trust in, health systems. Such factors are likely to affect QOL and patient satisfaction with care.

Results

Using a self-reported questionnaire, Japanese men with prostate cancer reported lower sexual function scores at baseline. In detail, Japanese men were more likely than American men to report poor sexual desire, poor erection ability, poor overall ability to function sexually, poor ability to attain orgasm, poor quality of erections, infrequency of erections, infrequency of morning erections, and intercourse in the previous 4 weeks. However, Japanese men were less likely than American men to be concerned about their sexual function. Two years after surgery, American patients were more likely than Japanese patients to regain their baseline sexual function. The use of phosphodiesterase-5 (PDE-5) inhibitors has been widely publicized as the solution to erectile dysfunction after prostate cancer treatment. Although PDE-5 inhibitors have been available in Japan since 1999, it is striking that Japanese men with localized prostate cancer are much less likely (only 10%) to use PDE-5 inhibitors than American men.

Conclusion

Japanese patients with localized prostate cancer report worse sexual function but are less concerned about their reduced function. In the absence of a biological explanation for such differences, however, we suspect that cultural differences may explain the differences between QOL survey results from Japanese or American men with prostate cancer.

The female factor: predicting compliance with a post-prostatectomy erectile preservation program

INTRODUCTION

Early post-radical prostatectomy (RP) erectile preservation (EP) therapy may be critical to preserve erections after surgery.

AIM

To assess if pre-RP female sexual function predicts of partner compliance with an EP protocol.

MAIN OUTCOME MEASURES

Compliance, defined as use of localized penile EP therapy (intracavernosal injections [ICIs], vacuum erection device [VED], or alprostadil) at 3 and 6 months after RP.

METHODS

Records of patients enrolled in our EP program from April 2007 to June 2008 were reviewed. Before surgery, patients completed the Sexual Health Inventory for Men (SHIM) and their female partners completed the Female Sexual Function Index (FSFI) questionnaire. Prior to surgery, patients were advised to take sildenafil 25 mg every nightly and use a 250-µg alprostadil suppository three times/week. At 1 month, additional daily use of a VED was encouraged. All patients unable to achieve erections sufficient for penetration were encouraged to initiate ICI of Trimix (phentolamine, papaverine, and PGE1) twice weekly after 3 months following surgery. Data were analyzed using binary logistic regression analysis holding all input variables constant.

RESULTS

Twenty-nine patients had preoperative SHIM>7 and pre-RP partner FSFI data available. After a 4-week follow-up, compliance with alprostadil suppository declined and both ICI and VED usage increased. At 6 months, six (25.0%) patients had return of natural erectile function and 22 (91.7%) were achieving assisted erections. Higher preoperative partner FSFI scores were associated with greater compliance to the localized penile therapy component of our EP protocol (risk ratio 3.8, P=0.05).

CONCLUSIONS

Preoperative female sexual function correlated with greater partner compliance with the localized component of our EP protocol. Consideration of a female partner's preoperative sexual function in predicting patient erectile function recovery after RP is warranted. Future studies are necessary to determine the clinical significance of this factor.

Predicting erectile function recovery after bilateral nerve sparing radical prostatectomy: a proposal of a novel preoperative risk stratification

INTRODUCTION

No multivariable model is currently available for the prediction of erectile function (EF) recovery after bilateral nerve sparing radical prostatectomy (BNSRP).

AIM

The aim of this study was to develop a novel preoperative risk stratification aimed at assessing the probability of EF recovery after BNSRP.

MAIN OUTCOME MEASURE

The International Index of Erectile Function (IIEF) was used to evaluate EF after BNSRP.

METHODS

This study included 435 patients treated with retropubic BNSRP between 2004 and 2008 at a single Institution. Preoperative data, including age, IIEF, Charlson comorbidity index (CCI), and body mass index (BMI) were available for all patients. Moreover, all patients were assessed postoperatively every 3 months and were asked to complete the IIEF during each visit. Cox regression models tested the association between preoperative predictors (age at surgery, preoperative IIEF-EF domain score, CCI, BMI) and EF recovery. Independent predictors of EF recovery were then used to stratify patients into three groups according to the risk of erectile dysfunction (ED) after surgery: low (age <or= 65 years, IIEF-EF >or= 26, CCI <or= 1; n = 184), intermediate (age 66-69 years or IIEF-EF 11-25,CCI <or= 1; n = 115), and high (age >or= 70 years or IIEF-EF <or= 10 or CCI >or= 2; n = 136). Kaplan-Meier curves assessed the time to EF recovery (defined as IIEF-EF score >or= 22). Predictive accuracy of our proposed classification was quantified using the AUC method.

RESULTS

Of 435 patients, 242 (55.6%) received phosphodiesterase type 5 inhibitors (PDE5-I) either on demand or every day for a period of 3-6 months. Overall, EF recovery rate was 58% at 3-year follow-up. Patients treated with PDE5-I had significantly higher 3-year EF recovery rate as compared with patients left untreated after surgery (73 vs. 37%; P < 0.001). Except for BMI (P = 0.7), all preoperative covariates showed a significant association with EF recovery (all P <or= 0.04). The 3-year EF recovery rate significantly differed between the three groups, being 85, 59, and 37% in patients with low, intermediate, and high risk of postoperative ED, respectively (P < 0.001). Multivariable Cox regression analysis confirmed a highly significant association between the risk classification and EF recovery (P < 0.001). The proposed patient stratification tool showed a 69.1% accuracy. Similar results were achieved when patients were stratified according to the use of ED treatment after surgery (all P < 0.001).

CONCLUSIONS

We report the first preoperative risk stratification tool aimed at assessing the probability of EF recovery after BNSRP. It is based on routinely available baseline data such as patient age, preoperative erectile function, and comorbidity profile.

Erectile function recovery rate after radical prostatectomy: a meta-analysis

INTRODUCTION

Erectile function recovery (EFR) rates after radical prostatectomy (RP) vary greatly based on a number of factors, such as erectile dysfunction (ED) definition, data acquisition means, time-point postsurgery, and population studied.

AIM

To conduct a meta-analysis of carefully selected reports from the available literature to define the EFR rate post-RP.

MAIN OUTCOME MEASURES

EFR rate after RP.

METHODS

An EMBASE and MEDLINE search was conducted for the time range 1985-2007. Articles were assessed blindly by strict inclusion criteria: report of EFR data post-RP, study population >or=50 patients, >or=1 year follow-up, nerve-sparing status declared, no presurgery ED, and no other prostate cancer therapy. Meta-analysis was conducted to determine the EFR rate and relative risks (RR) for dichotomous subgroups.

RESULTS

A total of 212 relevant studies were identified; only 22 (10%) met the inclusion criteria and were analyzed (9,965 RPs, EFR data: 4,983 subjects). Mean study population size: 226.5, standard deviation = 384.1 (range: 17-1,834). Overall EFR rate was 58%. Single center series publications (k = 19) reported a higher EFR rate compared with multicenter series publications (k = 3): 60% vs. 33%, RR = 1.82, P = 0.001. Studies reporting >or=18-month follow-up (k = 10) reported higher EFR rate vs. studies with <18-month follow-up (k = 12), 60% vs. 56%, RR = 1.07, P = 0.02. Open RP (k = 16) and laparoscopic RP (k = 4) had similar EFR (57% vs. 58%), while robot-assisted RP resulted in a higher EFR rate (k = 2), 73% compared with these other approaches, P = 0.001. Patients <60 years old had a higher EFR rate vs. patients >or=60 years, 77% vs. 61%, RR = 1.26, P = 0.001.

CONCLUSIONS

These data indicate that most of the published literature does not meet strict criteria for reporting post-RP EFR. Single and multiple surgeon series have comparable EFR rates, but single center studies have a higher EFR. Younger men have higher EFR and no significant difference in EFR between ORP and LRP is evident.

[Characteristics of prostate cancer in men less than 50-year-old]

OBJECTIVE

To report the characteristics of prostate cancer (PCa) in men less than 50-year-old and the results of different treatments of PCa in this population.

METHOD

A bibliographic research was performed using Pubmed database. The keywords that we used were: prostate cancer, age, young, radical prostatectomy, brachytherapy, radiotherapy, active surveillance. The studies which included a significant number of patients were selected. A total of 38 articles were used as bibliographic references.

RESULTS

PCa in young men does not seem to have different characteristics than in older men. Nevertheless, young men seem to have a lower risk of severe urinary and sexual sequelae, particularly following radical prostatectomy.

CONCLUSIONS

There is no recommendation regarding management of PCa in men less than 50-year-old. In case of localized cancer, two options may be considered. First option consists in decreasing the urinary and sexual complications of radical prostatectomy. A minimally-invasive treatment, such as brachytherapy or even active surveillance, may reach this objective. Second option consists in being more aggressive. To propose a radical prostatectomy offers to the patient the possibility of salvage radiation therapy in case of locally-advanced tumor or local recurrence.

Prostate weight and early potency in robot-assisted radical prostatectomy

OBJECTIVES

Using an athermal technique for nerve preservation we noted that approximately 40% are potent compared with approximately 60% who are not at 3 months after robot-assisted laparoscopic prostatectomy (RLP). In an attempt to understand this difference, we examine factors potentially influencing potency at 3 months.

METHODS

Of 300 consecutive RLPs, we identified 139 men who met preoperative inclusion criteria: age <or= 65 years with International Index of Erectile Function (IIEF-5) scores of 22-25. All men were instructed to take 5'-phosphodiesterase inhibitors postoperatively. All data were collected and entered prospectively into an electronic database. Sexual outcomes were obtained via self-administered validated questionnaires. We defined potency by affirmative answers to the following questions: Were erections adequate for penetration, and were they satisfactory?

RESULTS

At 3 months, 53 subjects (38%) were potent. Univariate and multivariate analysis demonstrated no effect for IIEF-5 score, body mass index, nerves spared, estimated blood loss, hypertension, diabetes, use of cholesterol-lowering agents, and lifestyle issues. Prostate weight (43.3 vs 51.4 g, P = .038) and age (55 vs 57, P = .03) were significant in univariate analysis. In multivariate analysis only prostate weight was predictive of potency (P = .04). To ascertain a possible relation between traction nerve injury and prostate weight, analysis between prostate weight groups and potency demonstrated an inverse relationship.

CONCLUSIONS

Low prostate weight was the only factor found to correlate with early return of potency. Our data also suggest that increasing prostate weight increases the risk of delay in potency recovery.

The sexual impact of cancer and cancer treatments in men

This article presents an overview of the literature on the impact cancer and associated therapies have on male sexuality, interventions to maintain or improve sexual function after cancer, and identification of gaps in health care providers' knowledge of this topic. Normal sexual activity depends on a complex inter-relationship among multiple systems, including psychologic, biochemical, neurologic, and physiologic. Furthermore, there are multiple factors associated with the diagnosis and treatment of cancer that have an impact on male sexuality, including the complex psychologic and symptom burden of the disease and treatments. There are an increasing number of pharmacologic and nonpharmacologic interventions to treat erectile function; however, success rates are variable and long-term compliance is generally low. Little study has been devoted to interventions that may improve compliance, such as counseling, or that focus on aspects of male sexuality other than erectile dysfunction.