MJA: Heathcote et al., Health-related quality of life in Australian men remaining disease-free after radical prostatectomy

mja.com.au | The Medical Journal of Australia

Health-related quality of life in Australian men remaining disease-free after radical prostatectomy

Peter S Heathcote, Peter N Mactaggart, Robyn J Boston, Anthony N James, Leslie C Thompson and David L Nicol

MJA 1998; 168: 483-486
For editorial comment, see Frydenberg

Abstract - Introduction - Methods - Results - Discussion - References - Authors' details
Make a comment - Register to be notified of new articles by e-mail - Current contents list - ©MJA1998

Abstract
Objective: To determine the health-related quality of life (HRQOL) of Australian men after radical prostatectomy.
Design: Cross-sectional study.
Setting: Private and public practices of three urologists in south-east Queensland, July 1989 to June 1995.
Participants: 140 men with no evidence of disease recurrence 1 to 6 years after radical prostatectomy.
Main outcome measures: Voiding and erectile potency and HRQOL. Recall of preoperative status and status at survey were established by an independently administered multi-item questionnaire.
Results: 112 men (80%) completed the study questionnaire. Difficulty with bladder control before the operation was reported by 25 (22%; 95% confidence interval [CI], 15%-31.2%), and the incontinence rate after treatment was 22/112 (20%; 95% CI, 12.7%-28.2%). Men with incontinence after operation were more likely to recall preoperative urinary symptoms. Eighty-four (75%) men were happy or coping with their sexual function after radical prostatectomy despite an erectile potency rate of only 12% (95% CI, 7%-20%). Twenty-eight (25%) had tried penile injections and three have had penile prostheses since their operation. Impotence was reported more frequently (40%) as the treatment-related problem most affecting life, followed by "concern about cancer" (12%) and incontinence (8%). Impotence was also the most common cause given for diminished HRQOL.
Conclusions: Loss of sexual function after radical prostatectomy is more commonly perceived as a major problem and is more likely than urinary incontinence to adversely affect HRQOL. Loss of sexual function and its effect on HRQOL needs to be given greater emphasis in counselling before radical prostatectomy.
MJA 1998; 168: 483-486
Introduction
Prostate cancer is the second most common cause of cancer-related death in Australian men, and in 1989 became the most common cancer in men in New South Wales.¹ This increase may be partly attributed to a more health-conscious, ageing population, as well as greater use of "routine" digital rectal examination (DRE) and prostate-specific antigen (PSA) tests.² PSA tests, together with DRE and transrectal ultrasound-guided prostatic biopsies, have enabled the diagnosis of potentially curable early-stage prostate cancer.³ In particular, increased efforts have been made to identify early-stage prostate cancer in men under 70 years of age, even though a significant survival advantage has yet to be demonstrated. Screening and case detection remain controversial. There is argument about whether the tests are sufficiently sensitive and specific for effective screening, and whether screening affects outcomes enough to be cost effective.^4,5
Opinions also differ regarding the optimal management of localised prostate cancer.⁶ In men over 70 years of age, or in those with appreciable co-morbidity, a conservative approach is generally accepted. Healthy younger men are more likely to live long enough to experience progression of their disease, so radical prostatectomy and radiotherapy, as well as "watchful waiting", are options in this group. Judging by current published studies, these options may provide similar outcomes in selected patients: up to 10 years after diagnosis, similar survival rates are seen in patients treated immediately with surgery or radiotherapy, and in patients initially watched and then treated with androgen ablation, transurethral resection or radiotherapy if the disease progresses.⁷ This has created a significant dilemma for both doctor and patient when selecting appropriate treatment.⁶
The lack of a clearly superior treatment option makes the impact of treatment on health-related quality of life (HRQOL) of greater importance. The difficulty in selecting appropriate treatment is compounded by a lack of Australasian data on the effect of treatment on HRQOL.
Radical prostatectomy has been increasingly used in treating patients with localised prostate cancer and is considered an appropriate option for men who have a life expectancy in excess of 15 years.⁸ Despite improved surgical technique, postoperative impotence and incontinence may still occur, although the reported incidence varies considerably.⁹
Our study was undertaken to record patients' perception of HRQOL after radical prostatectomy, to assist patients, families and doctors in their discussions about treatment expectations and outcomes.
Methods

Sample
Surgical audit data were collected prospectively on all patients having radical prostatectomy between July 1989 and June 1995. Three of us (P S H, A N J and L C T) performed the operations. We all receive referrals from other specialist urologists, and perform most of the radical prostatectomies in Queensland. We believe that the patients studied are likely to be representative of the Australian population, although there are no data currently available from other States or Territories.
We selected for review patients who had no evidence of recurrent or residual disease to avoid any effect treatment failure may have had on HRQOL. No evidence of disease was defined as a PSA level less than 0.1 µg/L and no abnormal signs and symptoms at the last clinic visit. Men operated on less than a year before the survey were excluded as complications may still resolve during this period.⁹ As complications are likely to remain stable after one year, we believe the cohort to be homogeneous for the purposes of studying the effects of radical prostatectomy on HRQOL. To minimise recall bias, we included only patients operated on less than six years earlier. Non-surgical factors, such as co-morbidity and ageing, were thought to be unlikely modifiers of HRQOL during this period, so that most of the changes seen could be attributed to the prostatectomy.
We decided that post-hoc subgroup analysis of a cross-sectional study with small numbers was of limited value so we included patients in the survey regardless of whether nerve sparing (which may affect postoperative potency) was contemplated or performed. Comparisons with non-surgical therapies may be facilitated by this approach.
Definitions
We defined urinary incontinence as the need to wear incontinence pads regularly, and defined erectile potency as the ability to achieve an erection firm enough for sex more than once a month.
Questionnaire
As higher complication rates are usually reported in studies in which patients are reviewed independently of their treating physician,¹⁰ our questionnaire was administered independently (by R J B). Each patient was telephoned before the questionnaire and a letter of explanation was mailed. They were assured of confidentiality, that the questionnaire was being administered independently of their treating doctor and that their answers would have no impact on management of their condition. Patients who had not replied within one month were sent one reminder.
As there is no current internationally validated HRQOL questionnaire for patients with prostate cancer,¹¹ two of us (D L N and R J B) developed the questionnaire. The initial questions collected demographic data; there were 16 items about bladder and sexual function, with similar questions to check for internal consistency; and another five items assessed postoperative therapies (such as penile injections and prostheses) and satisfaction with treatment. As our questionnaire is a new tool, only some sections have been validated.^10,12-14
The questionnaire assessed men's perceptions of their urinary, sexual and overall function during the month before receipt of the questionnaire. (This is a recognised method used in other validated scoring systems.^15,16) Urinary symptoms and erectile function, at the time of the survey and before surgery, were assessed on a five-point scale and included severity, effect and bothersomeness of symptoms. Satisfaction with treatment and willingness to have the same treatment again were also assessed on a five-point scale. An edited version of the Functional Assessment of Cancer Therapy Scale was used to assess health, social life and satisfaction with life.¹⁴
Statistical analysis
We calculated exact confidence intervals (CI) and Fisher's exact tests using the STATA statistics package.¹⁷
Results

Respondents
Of 185 men having radical prostatectomy, 140 had no evidence of disease at last review. One of these 140 died in a motor vehicle accident and three more were lost to follow-up. Completed questionnaires were received from 112 (80%) men whose ages at the time of survey were normally distributed around the mean of 64 years (range, 54-73).
Urinary incontinence
There were 22 (20%; 95% CI, 12.7%-28.2%) respondents with postoperative urinary incontinence (Box). Those with more severe incontinence were more likely to report urge incontinence or mixed stress and urge incontinence.

Twenty-five respondents (22%; 95% CI, 15%-31.2%) recalled "trouble with bladder control" before surgery, although none required pads. Seventeen of the 25 (68%; 95% CI, 46.5%-85%) were incontinent after the operation, compared with only 5 of the 87 (6%; 95% CI, 2%-13%) who did not recall having problems before surgery. That is, men with urinary incontinence after radical prostatectomy were much more likely to recall preoperative urinary symptoms.
There was no statistically significant association between age and postoperative continence, nor was there any association with level of education or area of residence (Fisher's exact test).
Urinary symptoms did not interfere with daily activities in 93 (83%; 95% CI, 75%-85%) respondents, and 89 (79%; 95% CI, 71%-86%) were either very happy or happy with their present bladder function.
Erectile potency
Of the 112 respondents, 99 (88%; 95% CI, 81%-94%) recalled preoperative erectile potency, but only 14 (12%; 95% CI, 7%-20%) described erectile potency at survey. Although only 14 were potent, 23 (20.5%; 95% CI, 13.5%-29%) were happy and 61 (54.5%; 95% CI, 45%-64%) were coping with their level of sexual function.
Since surgery, 28 of the respondents (25%) have tried penile injections and three (2.7%) now have a penile prosthesis. Of the 13 men who were impotent before surgery, two have tried penile injections and one has had a penile prosthesis.
There was no statistically significant association between postoperative impotence and age, level of education or place of residence (Fisher's exact test).
Health-related quality of life
Most respondents enjoyed a high HRQOL -- 104 (93%) were satisfied with their life and with their social life. Nearly all respondents reported good general health. The most common problem affecting their lives was impotence (44 men; 40%), followed by "concern about cancer" (13 men; 12%) and "bladder problems" (9 men; 8%). Despite the high prevalence of impotence, 104 (93%; 95% CI, 80.5%-97%) respondents were satisfied with their treatment and 98 (88%; 95% CI, 80%-93%) would opt for the same treatment again. Impotence was the most common reason given for treatment dissatisfaction (7/8) and reluctance to have the same treatment again (8/14).
A final section asked about "any other problems related to your surgery which affects your quality of life". One man had a problem with a lack of pad-disposal facilities in golf club toilets, and one, although potent, said that loss of ejaculation left him unsatisfied.
Discussion
Our questionnaire was designed to examine specific problems of incontinence, impotence and patients' perception and satisfaction with treatment and feeling of well-being after radical prostatectomy. We found impotence to be the most common cause of diminished HRQOL, followed by "concern about cancer" and then incontinence.
The preoperative urinary difficulty and impotence rates in our study are similar to those in other published prospective series,^18,19 and our postoperative results lie within the range of the results of other published studies,¹⁰ suggesting that our questionnaire and study design are valid.
Differences between our results and those of others may be explained by our case selection and independent data collection. In Australia, initial presentation of men with prostate problems during the study period was usually prompted by lower urinary tract symptoms. Men with troublesome urinary symptoms are more likely to have detrusor instability, a factor that commonly predisposes them to incontinence after radical prostatectomy.²⁰ Our respondents reported a 20% incontinence rate and 22% recalled preoperative urinary difficulties. In contrast, Steiner et al reported an 8% incontinence rate after radical prostatectomy,²¹ but the more widespread screening for prostate cancer in the United States^2-5 makes it likely that their patients were referred after screening and may not have had incontinence problems.
The methods by which data are collected may also affect reporting of incontinence. Other studies that also used independent data collection^15,22 have reported higher rates of incontinence (31% and 47%, respectively).
We found that men with postoperative incontinence were much more likely to recall preoperative symptoms. However, we advise caution in interpreting this apparent strong association because of the limitations of cross-sectional studies (such as only measuring subjects' status once and not taking account of variation in patients' condition, including only those with successful treatments, and not yielding true relative risks) and the potential effects of recall bias. Patients with incontinence after surgery may have thought more about their predicament and been more likely to recall preoperative urinary symptoms; and, conversely, those continent after the operation may have had urinary symptoms before the operation but did not recall being troubled by them.
Nevertheless, specific enquiry regarding urinary symptoms is advised when discussing treatment options with patients with localised prostate cancer, and those with urinary symptoms need to be informed of the association with urinary incontinence after radical prostatectomy. Lack of preoperative symptoms, however, does not guarantee postoperative continence as 6% of this group were incontinent after the operation.
The preoperative impotence rate in our patient group is similar to that reported by Jonler et al. Men in their study were of similar age, and data were collected prospectively in a community setting.¹⁹ After the operation 12% of our respondents were potent, which is similar to the rates Jonler et al²² and Fowler et al¹⁰ reported (16% and 11%, respectively), but lower than the 70% found by Quinlan et al.²³ Recall bias, case selection and independent data collection, as discussed for incontinence, are also plausible explanations for these differences.
Impotence was much more likely to be reported as a major quality-of-life problem than incontinence, which is consistent with other series.^12,24 Loss of potency as a cause of diminished HRQOL is not specific to radical prostatectomy, as Jonler et al concluded in their study of 1680 men attending a cancer screening program "impotent men have a lower QOL than potent men".¹⁹ Many men are prepared to trade off survival for sexual potency,²⁵ so some men may choose a treatment with possibly lower long-term survival to increase their chance of remaining potent. The impact of radical prostatectomy and other treatments on potency should be discussed in detail when counselling patients with localised prostate cancer before therapy. However, erectile potency and a happy sex life do not go hand-in-hand, as 75% of respondents were happy or coping with their sexual function but only 12% claimed postoperative potency. This may be because people who have made a treatment decision are likely to believe, and want others to believe, that they have made the right choice,²⁴ especially if they are disease free, as this group were.
References

Coates M, McCredie M, Armstrong BK. Cancer in New South Wales. Incidence and mortality, 1993. Sydney: NSW Cancer Council; 1996.
McCredie M, Coates M, Churches T, Rogers J. The rising incidence of prostate cancer in Australia -- a result of "screening"? J Epidemiol Biostat 1996; 1: 99-105.
McCaul KA, Luke CG, Roger DM. Trends in prostate cancer incidence and mortality rates in South Australia, 1977-1993. Med J Aust 1995; 162: 520-522.
Hirst GHL, Ward JE, Del Mar CB. Screening for prostate cancer: the case against. Med J Aust 1996; 164: 285-288.
Kaye KW. Prostate cancer: enthusiasm for screening. Med J Aust 1995; 162: 540-541.
Whitmore WF Jr. Management of clinically localized prostatic cancer -- an unresolved problem [editorial]. JAMA 1993; 269: 2676-2677.
Chodak GW, Thisted RA, Gerber GS, et al. Results of conservative management of clinically localized prostate cancer. N Engl J Med 1994; 330: 242-248.
Freedman G, Hanlon M, Lee W, Hanks G. Young patients with prostate cancer have an outcome justifying their treatment with external beam radiation. Int J Radiat Oncol Biol Phys 1996; 35: 243-250.
Madsen F, Bruskewitz R. Functional results of radical prostatectomy. Curr Opin Urol 1995; 5: 246-248.
Fowler JF Jr, Barry MJ, Lu-Yao G, et al. Patient-reported complications and follow-up treatment after radical prostatectomy. The National Medicare Experience: 1988-1990 (updated June 1993). Urology 1993; 42: 622-629.
Borghede G, Karlsson J, Sullivan M. Quality of life in patients with prostate cancer: results from a Swedish population study. J Urol 1997; 158: 1477-1486.
Brickman AL, Soloway MS. Quality of life 12 months after radical prostatectomy. Br J Urol 1995; 75: 48-53.
Herr HW. Quality of life of incontinent men after radical prostatectomy. J Urol 1994; 151: 652-654.
Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy Scale: development and validation of the general measure. J Clin Oncol 1993; 11: 570-589.
O'Leary MP, Barry MJ, Fowler FJ Jr. Hard measures of subjective outcomes: validating symptom indexes in urology. J Urol 1992; 148: 1546-1548.
Barry MJ, Fowler FJ Jr, O'Leary MP, et al. Correlation of the American Urological Association symptom index with self-administered versions of the Madsen-Iversen, Boyarsky and Maine medical assessment program symptom indexes. J Urol 1992; 148: 1558-1563.
STATA statistics package [computer program]. Version 5.0. Texas: Stata Corp; 1996.
Diokno A, Brock BM, Brown M, Herzog A. Prevalence of urinary incontinence and other urological symptoms in the non-institutionalised elderly. J Urol 1986; 136: 1022-1025.
Jonler M, Moon T, Brannan W, et al. The effect of age, ethnicity and geographical location on impotence and quality of life. Br J Urol 1995; 75: 651-655.
Goluboff E, Chang D, Olsson C, Kaplan S. Urodynamics and the etiology of post prostatectomy urinary incontinence: the initial Colombia experience. J Urol 1995; 153: 1034-1037.
Steiner MS, Morton RA, Walsh PC. Impact of radical prostatectomy on urinary continence. J Urol 1991; 145; 512-515.
Jonler M, Messing EM, Rhodes RR, Bruskewitz RC. Sequelae of radical prostatectomy. Br J Urol 1994; 74: 352-358.
Quinlan DM, Epstein JI, Carter BS, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol 1991; 145: 998-1002.
Litwin MS, Hays RD, Fink A, et al. Quality of life outcomes in men treated for localized prostate cancer. JAMA 1995; 273: 129-135.
Singer PA, Tasch E, Stocking C, et al. Sex or survival: trade-offs between quality and quantity of life. J Clin Oncol 1991; 9: 328-334.

(Received 7 Apr 1997, accepted 24 Feb 1998)

Authors' details

Princess Alexandra Hospital, Brisbane, QLD.
Peter S Heathcote, FRACS, Urologist;
Peter N Mactaggart, FRACS, Urologist;
Robyn J Boston, MB BS, Urology Registrar;
Leslie C Thompson, FRACS, Urologist;
David L Nicol, FRACS, Urologist.

Royal Brisbane Hospital, Brisbane, QLD.
Anthony N James, FRACS, Urologist.

Reprints will not be available from the authors.
Correspondence: Dr D L Nicol, Department of Urology, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD 4102.
E-mail: D.NicolATmailbox.uq.edu.au

mja.com.au | The Medical Journal of Australia

Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.
We appreciate your comments.


Abstract	*Objective:* To determine the health-related quality of life (HRQOL) of Australian men after radical prostatectomy. *Design:* Cross-sectional study. *Setting:* Private and public practices of three urologists in south-east Queensland, July 1989 to June 1995. *Participants:* 140 men with no evidence of disease recurrence 1 to 6 years after radical prostatectomy. *Main outcome measures:* Voiding and erectile potency and HRQOL. Recall of preoperative status and status at survey were established by an independently administered multi-item questionnaire. *Results:* 112 men (80%) completed the study questionnaire. Difficulty with bladder control before the operation was reported by 25 (22%; 95% confidence interval [CI], 15%-31.2%), and the incontinence rate after treatment was 22/112 (20%; 95% CI, 12.7%-28.2%). Men with incontinence after operation were more likely to recall preoperative urinary symptoms. Eighty-four (75%) men were happy or coping with their sexual function after radical prostatectomy despite an erectile potency rate of only 12% (95% CI, 7%-20%). Twenty-eight (25%) had tried penile injections and three have had penile prostheses since their operation. Impotence was reported more frequently (40%) as the treatment-related problem most affecting life, followed by "concern about cancer" (12%) and incontinence (8%). Impotence was also the most common cause given for diminished HRQOL. *Conclusions:* Loss of sexual function after radical prostatectomy is more commonly perceived as a major problem and is more likely than urinary incontinence to adversely affect HRQOL. Loss of sexual function and its effect on HRQOL needs to be given greater emphasis in counselling before radical prostatectomy. MJA 1998; 168: 483-486
Introduction	Prostate cancer is the second most common cause of cancer-related death in Australian men, and in 1989 became the most common cancer in men in New South Wales.¹ This increase may be partly attributed to a more health-conscious, ageing population, as well as greater use of "routine" digital rectal examination (DRE) and prostate-specific antigen (PSA) tests.² PSA tests, together with DRE and transrectal ultrasound-guided prostatic biopsies, have enabled the diagnosis of potentially curable early-stage prostate cancer.³ In particular, increased efforts have been made to identify early-stage prostate cancer in men under 70 years of age, even though a significant survival advantage has yet to be demonstrated. Screening and case detection remain controversial. There is argument about whether the tests are sufficiently sensitive and specific for effective screening, and whether screening affects outcomes enough to be cost effective.^4,5 Opinions also differ regarding the optimal management of localised prostate cancer.⁶ In men over 70 years of age, or in those with appreciable co-morbidity, a conservative approach is generally accepted. Healthy younger men are more likely to live long enough to experience progression of their disease, so radical prostatectomy and radiotherapy, as well as "watchful waiting", are options in this group. Judging by current published studies, these options may provide similar outcomes in selected patients: up to 10 years after diagnosis, similar survival rates are seen in patients treated immediately with surgery or radiotherapy, and in patients initially watched and then treated with androgen ablation, transurethral resection or radiotherapy if the disease progresses.⁷ This has created a significant dilemma for both doctor and patient when selecting appropriate treatment.⁶ The lack of a clearly superior treatment option makes the impact of treatment on health-related quality of life (HRQOL) of greater importance. The difficulty in selecting appropriate treatment is compounded by a lack of Australasian data on the effect of treatment on HRQOL. Radical prostatectomy has been increasingly used in treating patients with localised prostate cancer and is considered an appropriate option for men who have a life expectancy in excess of 15 years.⁸ Despite improved surgical technique, postoperative impotence and incontinence may still occur, although the reported incidence varies considerably.⁹ Our study was undertaken to record patients' perception of HRQOL after radical prostatectomy, to assist patients, families and doctors in their discussions about treatment expectations and outcomes.
Methods
Sample	Surgical audit data were collected prospectively on all patients having radical prostatectomy between July 1989 and June 1995. Three of us (P S H, A N J and L C T) performed the operations. We all receive referrals from other specialist urologists, and perform most of the radical prostatectomies in Queensland. We believe that the patients studied are likely to be representative of the Australian population, although there are no data currently available from other States or Territories. We selected for review patients who had no evidence of recurrent or residual disease to avoid any effect treatment failure may have had on HRQOL. No evidence of disease was defined as a PSA level less than 0.1 µg/L and no abnormal signs and symptoms at the last clinic visit. Men operated on less than a year before the survey were excluded as complications may still resolve during this period.⁹ As complications are likely to remain stable after one year, we believe the cohort to be homogeneous for the purposes of studying the effects of radical prostatectomy on HRQOL. To minimise recall bias, we included only patients operated on less than six years earlier. Non-surgical factors, such as co-morbidity and ageing, were thought to be unlikely modifiers of HRQOL during this period, so that most of the changes seen could be attributed to the prostatectomy. We decided that post-hoc subgroup analysis of a cross-sectional study with small numbers was of limited value so we included patients in the survey regardless of whether nerve sparing (which may affect postoperative potency) was contemplated or performed. Comparisons with non-surgical therapies may be facilitated by this approach.
Definitions	We defined urinary incontinence as the need to wear incontinence pads regularly, and defined erectile potency as the ability to achieve an erection firm enough for sex more than once a month.
Questionnaire	As higher complication rates are usually reported in studies in which patients are reviewed independently of their treating physician,¹⁰ our questionnaire was administered independently (by R J B). Each patient was telephoned before the questionnaire and a letter of explanation was mailed. They were assured of confidentiality, that the questionnaire was being administered independently of their treating doctor and that their answers would have no impact on management of their condition. Patients who had not replied within one month were sent one reminder. As there is no current internationally validated HRQOL questionnaire for patients with prostate cancer,¹¹ two of us (D L N and R J B) developed the questionnaire. The initial questions collected demographic data; there were 16 items about bladder and sexual function, with similar questions to check for internal consistency; and another five items assessed postoperative therapies (such as penile injections and prostheses) and satisfaction with treatment. As our questionnaire is a new tool, only some sections have been validated.^10,12-14 The questionnaire assessed men's perceptions of their urinary, sexual and overall function during the month before receipt of the questionnaire. (This is a recognised method used in other validated scoring systems.^15,16) Urinary symptoms and erectile function, at the time of the survey and before surgery, were assessed on a five-point scale and included severity, effect and bothersomeness of symptoms. Satisfaction with treatment and willingness to have the same treatment again were also assessed on a five-point scale. An edited version of the Functional Assessment of Cancer Therapy Scale was used to assess health, social life and satisfaction with life.¹⁴
Statistical analysis	We calculated exact confidence intervals (CI) and Fisher's exact tests using the STATA statistics package.¹⁷
Results
Respondents	Of 185 men having radical prostatectomy, 140 had no evidence of disease at last review. One of these 140 died in a motor vehicle accident and three more were lost to follow-up. Completed questionnaires were received from 112 (80%) men whose ages at the time of survey were normally distributed around the mean of 64 years (range, 54-73).
Urinary incontinence	There were 22 (20%; 95% CI, 12.7%-28.2%) respondents with postoperative urinary incontinence (Box). Those with more severe incontinence were more likely to report urge incontinence or mixed stress and urge incontinence.

	Twenty-five respondents (22%; 95% CI, 15%-31.2%) recalled "trouble with bladder control" before surgery, although none required pads. Seventeen of the 25 (68%; 95% CI, 46.5%-85%) were incontinent after the operation, compared with only 5 of the 87 (6%; 95% CI, 2%-13%) who did not recall having problems before surgery. That is, men with urinary incontinence after radical prostatectomy were much more likely to recall preoperative urinary symptoms. There was no statistically significant association between age and postoperative continence, nor was there any association with level of education or area of residence (Fisher's exact test). Urinary symptoms did not interfere with daily activities in 93 (83%; 95% CI, 75%-85%) respondents, and 89 (79%; 95% CI, 71%-86%) were either very happy or happy with their present bladder function.
Erectile potency	Of the 112 respondents, 99 (88%; 95% CI, 81%-94%) recalled preoperative erectile potency, but only 14 (12%; 95% CI, 7%-20%) described erectile potency at survey. Although only 14 were potent, 23 (20.5%; 95% CI, 13.5%-29%) were happy and 61 (54.5%; 95% CI, 45%-64%) were coping with their level of sexual function. Since surgery, 28 of the respondents (25%) have tried penile injections and three (2.7%) now have a penile prosthesis. Of the 13 men who were impotent before surgery, two have tried penile injections and one has had a penile prosthesis. There was no statistically significant association between postoperative impotence and age, level of education or place of residence (Fisher's exact test).
Health-related quality of life	Most respondents enjoyed a high HRQOL -- 104 (93%) were satisfied with their life and with their social life. Nearly all respondents reported good general health. The most common problem affecting their lives was impotence (44 men; 40%), followed by "concern about cancer" (13 men; 12%) and "bladder problems" (9 men; 8%). Despite the high prevalence of impotence, 104 (93%; 95% CI, 80.5%-97%) respondents were satisfied with their treatment and 98 (88%; 95% CI, 80%-93%) would opt for the same treatment again. Impotence was the most common reason given for treatment dissatisfaction (7/8) and reluctance to have the same treatment again (8/14). A final section asked about "any other problems related to your surgery which affects your quality of life". One man had a problem with a lack of pad-disposal facilities in golf club toilets, and one, although potent, said that loss of ejaculation left him unsatisfied.
Discussion	Our questionnaire was designed to examine specific problems of incontinence, impotence and patients' perception and satisfaction with treatment and feeling of well-being after radical prostatectomy. We found impotence to be the most common cause of diminished HRQOL, followed by "concern about cancer" and then incontinence. The preoperative urinary difficulty and impotence rates in our study are similar to those in other published prospective series,^18,19 and our postoperative results lie within the range of the results of other published studies,¹⁰ suggesting that our questionnaire and study design are valid. Differences between our results and those of others may be explained by our case selection and independent data collection. In Australia, initial presentation of men with prostate problems during the study period was usually prompted by lower urinary tract symptoms. Men with troublesome urinary symptoms are more likely to have detrusor instability, a factor that commonly predisposes them to incontinence after radical prostatectomy.²⁰ Our respondents reported a 20% incontinence rate and 22% recalled preoperative urinary difficulties. In contrast, Steiner et al reported an 8% incontinence rate after radical prostatectomy,²¹ but the more widespread screening for prostate cancer in the United States^2-5 makes it likely that their patients were referred after screening and may not have had incontinence problems. The methods by which data are collected may also affect reporting of incontinence. Other studies that also used independent data collection^15,22 have reported higher rates of incontinence (31% and 47%, respectively). We found that men with postoperative incontinence were much more likely to recall preoperative symptoms. However, we advise caution in interpreting this apparent strong association because of the limitations of cross-sectional studies (such as only measuring subjects' status once and not taking account of variation in patients' condition, including only those with successful treatments, and not yielding true relative risks) and the potential effects of recall bias. Patients with incontinence after surgery may have thought more about their predicament and been more likely to recall preoperative urinary symptoms; and, conversely, those continent after the operation may have had urinary symptoms before the operation but did not recall being troubled by them. Nevertheless, specific enquiry regarding urinary symptoms is advised when discussing treatment options with patients with localised prostate cancer, and those with urinary symptoms need to be informed of the association with urinary incontinence after radical prostatectomy. Lack of preoperative symptoms, however, does not guarantee postoperative continence as 6% of this group were incontinent after the operation. The preoperative impotence rate in our patient group is similar to that reported by Jonler et al. Men in their study were of similar age, and data were collected prospectively in a community setting.¹⁹ After the operation 12% of our respondents were potent, which is similar to the rates Jonler et al²² and Fowler et al¹⁰ reported (16% and 11%, respectively), but lower than the 70% found by Quinlan et al.²³ Recall bias, case selection and independent data collection, as discussed for incontinence, are also plausible explanations for these differences. Impotence was much more likely to be reported as a major quality-of-life problem than incontinence, which is consistent with other series.^12,24 Loss of potency as a cause of diminished HRQOL is not specific to radical prostatectomy, as Jonler et al concluded in their study of 1680 men attending a cancer screening program "impotent men have a lower QOL than potent men".¹⁹ Many men are prepared to trade off survival for sexual potency,²⁵ so some men may choose a treatment with possibly lower long-term survival to increase their chance of remaining potent. The impact of radical prostatectomy and other treatments on potency should be discussed in detail when counselling patients with localised prostate cancer before therapy. However, erectile potency and a happy sex life do not go hand-in-hand, as 75% of respondents were happy or coping with their sexual function but only 12% claimed postoperative potency. This may be because people who have made a treatment decision are likely to believe, and want others to believe, that they have made the right choice,²⁴ especially if they are disease free, as this group were.
References	Coates M, McCredie M, Armstrong BK. Cancer in New South Wales. Incidence and mortality, 1993. Sydney: NSW Cancer Council; 1996. McCredie M, Coates M, Churches T, Rogers J. The rising incidence of prostate cancer in Australia -- a result of "screening"? J Epidemiol Biostat 1996; 1: 99-105. McCaul KA, Luke CG, Roger DM. Trends in prostate cancer incidence and mortality rates in South Australia, 1977-1993. Med J Aust 1995; 162: 520-522. Hirst GHL, Ward JE, Del Mar CB. Screening for prostate cancer: the case against. Med J Aust 1996; 164: 285-288. Kaye KW. Prostate cancer: enthusiasm for screening. Med J Aust 1995; 162: 540-541. Whitmore WF Jr. Management of clinically localized prostatic cancer -- an unresolved problem [editorial]. JAMA 1993; 269: 2676-2677. Chodak GW, Thisted RA, Gerber GS, et al. Results of conservative management of clinically localized prostate cancer. N Engl J Med 1994; 330: 242-248. Freedman G, Hanlon M, Lee W, Hanks G. Young patients with prostate cancer have an outcome justifying their treatment with external beam radiation. Int J Radiat Oncol Biol Phys 1996; 35: 243-250. Madsen F, Bruskewitz R. Functional results of radical prostatectomy. Curr Opin Urol 1995; 5: 246-248. Fowler JF Jr, Barry MJ, Lu-Yao G, et al. Patient-reported complications and follow-up treatment after radical prostatectomy. The National Medicare Experience: 1988-1990 (updated June 1993). Urology 1993; 42: 622-629. Borghede G, Karlsson J, Sullivan M. Quality of life in patients with prostate cancer: results from a Swedish population study. J Urol 1997; 158: 1477-1486. Brickman AL, Soloway MS. Quality of life 12 months after radical prostatectomy. Br J Urol 1995; 75: 48-53. Herr HW. Quality of life of incontinent men after radical prostatectomy. J Urol 1994; 151: 652-654. Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy Scale: development and validation of the general measure. J Clin Oncol 1993; 11: 570-589. O'Leary MP, Barry MJ, Fowler FJ Jr. Hard measures of subjective outcomes: validating symptom indexes in urology. J Urol 1992; 148: 1546-1548. Barry MJ, Fowler FJ Jr, O'Leary MP, et al. Correlation of the American Urological Association symptom index with self-administered versions of the Madsen-Iversen, Boyarsky and Maine medical assessment program symptom indexes. J Urol 1992; 148: 1558-1563. STATA statistics package [computer program]. Version 5.0. Texas: Stata Corp; 1996. Diokno A, Brock BM, Brown M, Herzog A. Prevalence of urinary incontinence and other urological symptoms in the non-institutionalised elderly. J Urol 1986; 136: 1022-1025. Jonler M, Moon T, Brannan W, et al. The effect of age, ethnicity and geographical location on impotence and quality of life. Br J Urol 1995; 75: 651-655. Goluboff E, Chang D, Olsson C, Kaplan S. Urodynamics and the etiology of post prostatectomy urinary incontinence: the initial Colombia experience. J Urol 1995; 153: 1034-1037. Steiner MS, Morton RA, Walsh PC. Impact of radical prostatectomy on urinary continence. J Urol 1991; 145; 512-515. Jonler M, Messing EM, Rhodes RR, Bruskewitz RC. Sequelae of radical prostatectomy. Br J Urol 1994; 74: 352-358. Quinlan DM, Epstein JI, Carter BS, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol 1991; 145: 998-1002. Litwin MS, Hays RD, Fink A, et al. Quality of life outcomes in men treated for localized prostate cancer. JAMA 1995; 273: 129-135. Singer PA, Tasch E, Stocking C, et al. Sex or survival: trade-offs between quality and quantity of life. J Clin Oncol 1991; 9: 328-334. (Received 7 Apr 1997, accepted 24 Feb 1998)