Sunao Shoji

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A Review of Quality of Life Following  
Treatments for Localized Prostate Cancer 
Sunao Shoji 
Department of Urology, Tokai University Hachioji Hospital 
Japan 
1. Introduction 
Recently, a number of alternative, less invasive treatments have been developed for patients 
with localized prostate cancer, who are not indicated for surgery, or who do not want to 
experience the potential side effects of surgery. Laparoscopic radical prostatectomy, robotic 
assisted laparoscopic radical prostatectomy (RALP), 3-dimensional conformal radiotherapy 
(3D-CRT), brachytherapy, intensity-modulated external beam radiotherapy (IMRT), high-
intensity focused ultrasound (HIFU) and cryoablation of the prostate have all been applied 
to treat this group of patients. 
QOL measurements for prostate cancer therapy have become an essential component of 
clinical trial evaluations, and should be integrated into comprehensive cancer care. 
Health-related QOL (HRQOL) concerns, urinary function, and potency rate after 
treatment are important to patients when selecting treatment options for clinically 
localized prostate cancer, and they also play a critical role in evaluating outcome 
following intervention. 
Many studies have been carried out with the aim of improving QOL, urinary function, and 
potency rate after treatment for localized prostate cancer with many modalities. Clinicians 
have an obligation to assess the impacts these treatments have on QOL, and use this 
knowledge in an overall evaluation of efficacy. 
2. QOL changes after treatment for localized prostate cancer 
There are few changes in general HRQOL after a retropubic radical prostatectomy (RRP) or 
interstitial brachytherapy.1-3 However, disease-specific QOL, especially bowel function and 
urinary irritative symptoms, is worse in the interstitial brachytherapygroup, and urinary 
incontinence and sexual function are worse in the RRP group.1  Hamada et al. evaluated 
QOL immediately before surgery and at several points during the 6-month period after 
retropubic radical prostatectomy (RRP). They reported that a radical prostatectomy 
aggravates the Social/Family well-being score and the FACT-P score.4  Other studies have 
also showed that prostatectomy and interstitial brachytherapy continuously decreased 
health-related QOL.5-8 Hanlon et al. showed that external beam radiotherapy for localized 
prostate cancer aggravates bowel function.9 Hubosky et al. reported that HRQOL showed 
patients undergoing cryoablation on average achieved urinary and bowel domain scores 
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comparable to baseline, but sexual domains remained well below baseline at 12 months 
follow-up and compared to brachytherapy, cryotherapy results in less irritative and 
obstructive voiding systems in the early post-treatment period, and may improve the 
urinary function for up to 24 months after treatment.10 
We reported QOL after HIFU for localized prostate cancer.11 In our report the total FACT 
score significantly improved at 24 months, and Physical well-being factor(at 6 and 12 
months after HIFU therapy) and Functionalwell-being factor (at 24 months after HIFU 
therapy) in FACT-G showed significant improvements. Further analysis of the elements of 
FACT-G showed such responses as “I am bothered by the side-effects of treatment” (at 12 
months after HIFU therapy), “I am able to enjoy life” (at 24 months afterHIFU therapy) and 
“I have accepted my illness” (at 24 months after HIFU therapy) to have all statistically 
improved. 
3. Urinary function after treatment for localized prostate cancer 
3.1 Urinary incontinence after radical prostatectomy 
Urinary incontinence is the most prominent side effect of radical prostatectomy. Urinary 
incontinence after treatment for localized prostate cancer is caused by sphincter 
malfunction. So, several technical modifications of open, laparoscopic and robot-assisted 
laparoscopic radical prostatectomy have been advocated to improve early and late urinary 
incontinence. 
Pardo et al. reported that urinary incontinence rates of patients treated with non-nerve 
sparing RRP and nerve sparing RRP were 69% and 54%.12 It has recently been demonstrated 
that reconstruction of the posterior aspects of the rhabdoshincter allows a rapid recovery of 
continence after retropubic radical prostatectomy and laparoscopic radical prostatectomy.13  
But, Joshi et al.reported that there was no significant difference in early urinary incontinence 
between the group for which the posterior aspects of the rhabdoshincter were reconstructed 
and the group for which they were not reconstructed in cases of RALP.14 They suggested the 
reason why there was no significant difference was a magnified stereoscopic view and/or 
the finer, more maneuverable instruments in robot system may allow better preservation of 
sphincter supporting musculature, hence improving continence, and may obviate the 
advantages of posterior reinforcing sutures. 
Di Pierro et al. compared continence rate between groups of patients treated with RRP and 
RALP, and reported that the continence rate of the RALP group was significantly higher 
than the RRP group at 3 and 12 months after RALP.15  Wang et al. reported that continence 
was achieved in 82%, 87%, and 91% of men at 3, 6, and 12 months after RALP.16 They also 
reported that the mean IPSS scores of these patients preoperatively and 3, 6, and 12 months 
after surgery were 14.1, 5.2, 3.0, and 2.9 and corresponding mean QOL scores were 3.4, 2.1, 
1.6, and 1.6.13 
3.2 Urinary function after radiation therapy, cryotherapy, and HIFU 
Sanda et al.reported that 18% of patients in the brachytherapy group, 11% of those in the 
radiotherapy group, and 7% of those in the prostatectomy group had moderate or worse 
distress from overall urinary symptoms at 1 year.17 Pardo et al. reported that compared to 
the brachytherapy group, the prostatectomy group showed a greater deterioration of 
urinary incontinence but better urinary irrigative-obstructive results.12 
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A Review of Quality of Life Following Treatments for Localized Prostate Cancer 
 
359 
Hubosky et al. reported that the urinary function was similar for the groups of patients 
treated with cryoablation and brachytherapy until 18 months, at which time cryoablation 
patients fared better and this was sustained up to 24 months.10 
We reported that the QOL index improved significantly at 6 months after HIFU therapy. 
Our data on uroflowmetry showed that maximum flow rate and residual urine volume were 
significantly impaired at 6 months after HIFU. However, the data on maximum flow rate 
and residual urine volume recovered to baseline at 12, 24 months after HIFU.11 
4. Erectile function 
It is important to preserve erectile function during treatment of prostate cancer. 
Postoperative potency depends on the preservation of neurovascular bundles (NVB), which 
are some times affected by tumor invasion.  
Hanlon et al. reported a normal potency rate at 1 year after treatment of 50% for patients in 
the RRP group, 65% for patients in the brachytherapy group, and 69% for patients in the 
radiotherapy group.17 
4.1 Erectile function after radical prostatectomy 
Generally, the potency rate is aggravated by injury to NVB after radical prostatectomy. Poel 
et al. reported a potency rate 53.3 %at 6 months after RALP, and 42% of patients had potency 
without using a PDE5 inhibitor. They concluded that prostatic fascia preservation resulted 
to good potency rates after RALP.18 Consequently, preservation of NVB and prostatic fascia 
is important to preserve erectile function. Di Pierro et al. compared potency rates between 
groups of patients treated with RRP and RALP. They performed RALP with a procedure 
using a transperitoneal approach and preserved the NVB through a tension- and energy- 
free technique19 as far as cancer localization allowed, and reported that the potency rate 
without PDE-5 inhibitors of the RALP group (68% and 55%) was significantly higher than 
that of the RRP group (25% and 26%) at 3 and 12 months after RALP.15 
4.2 Erectile function after radiation therapy, cryotherapy, and HIFU 
Pardo et al. reported that among patients with no relevant sexual problems at baseline, 
approximately 40% in the external and interstitial brachytherapy groups had preserved their 
pretreatment sexual status.12 
Merrick et al. reported that 39% of patients maintained potency after prostate brachytherapy 
with a plateau on the potency preservation curve at 6-year follow-up, and preservation of 
potency after brachytherapy correlated with preimplant erectile function, patients age, use 
of supplemental external beam radiation therapy, and diabetes, and was statistically 
significant.20 
Asterling et al. reported that 3.7% and 14.3% of patients had partial erections at 6 weeks and 
9 months after cryosurgical ablation. Besides, 21% and 24% of the patients had regained full 
potency at 18 and 24 months after cryosurgical ablation.21 
Hubosky et al. reported that cryotherapy patients experienced more negative impacts on 
sexual function steadily up to 12 months compared to brachytherapy patients.10 
We reported that potency rates were 52%, 63% and 78% for patients who did not undergo 
NADT at 6, 12and 24 months after HIFU therapy. Furthermore, potency rates were 39%, 
62% and 67% at 6, 12, and 24 months, respectively, after HIFUtherapy without the use of 
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Prostate Cancer – Diagnostic and Therapeutic Advances 
 
360 
PDE5 inhibitors.11  HIFU therapy can, therefore, preserve erectile function better than RRP 
and cryotherapy, and is similar to RALP. 
5. Conclusion 
5.1 QOL 
RRP and interstitial brachytherapy continuously decreased health-related QOL. External 
beam radiotherapy for localized prostate cancer aggravates the bowel function. Health-
related QOL was significantly improved in patients treated with HIFU therapy at 24 months 
after HIFU. 
5.2 Urinary function 
Urinary incontinence is the most prominent side effect of radical prostatectomy. But, 
RALP might improve incontinence rates of patients. The urinary function of patients after 
brachytherapy and cryotherapy were similar. In HIFU, however maximum flow rate and 
residual urine volume were significantly impaired at 6 months after treatment, and data 
on maximum flow rate and residual urine volume recovered to baseline at 12, 24 months 
after HIFU. 
5.3 Erectile function 
Generally, potency rate was aggravated by injury to NVB after radical prostatectomy. 
Consequently, using RALP to preserve the NVB and prostatic fascia is important for 
preserving erectile function. Approximately 40% of patients in the external and interstitial 
brachytherapy groups preserved their pretreatment sexual status. In cryoablation, 3.7% and 
14.3% of patients had partial erections at 6 weeks and 9 months after treatment. And, 21% 
and 24% of the patients had regained full potency at 18 and 24 months after cryosurgical 
ablation. After HIFU, 52%, 63% and 78% of patients who did not undergo NADT had 
regained full potency at 6, 12, and 24 months after treatment therapy. Furthermore, the 
potency rates were 39%, 62%, and 67% at 6, 12, and 24 months, respectively, without the use 
of PDE5 inhibitors. HIFU therapy can, therefore, preserve erectile function better than RRP, 
radiotherapy, or cryotherapy. 
6. References 
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[3] Brandeis JM, Litwin MS, Burnison CM, et al. Quality of life outcomes after 
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A Review of Quality of Life Following Treatments for Localized Prostate Cancer 
 
361 
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www.intechopen.com
Prostate Cancer - Diagnostic and Therapeutic Advances
Edited by Dr. Philippe E. Spiess
ISBN 978-953-307-319-4
Hard cover, 378 pages
Publisher InTech
Published online 25, November, 2011
Published in print edition November, 2011
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In this book entitled "Prostate Cancer - Diagnostic and Therapeutic Advances", we highlight many of the
significant advances made in our treatment armamentarium of prostate cancer. The book is subdivided into
four sections termed: 1) novel diagnostic approaches, 2) surgical treatments options, 3) radiation therapy and
its potential sequelae, and 4) medical management and its treatment complications. After reading the present
book , readers will be very familiar with the major clinical advances made in our multifaceted treatment
approach to prostate cancer over the past decade.This book is a tribute to our pioneering urologists and allied
healthcare professionals who have continually pushed forward our traditional therapeutic envelope.
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InTech, Available from: http://www.intechopen.com/books/prostate-cancer-diagnostic-and-therapeutic-
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A Review of Quality of Life Following Treatments for Localized Prostate Cancer

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A Review of Quality of Life Following Treatments for Localized Prostate Cancer

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