An analysis of sexual health information on radical prostatectomy websites

Authors

  • John P. Mulhall,

    1. Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA and
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  • Cesar Rojaz-Cruz,

    1. Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA and
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  • Alexander Müller

    Corresponding author
    1. Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA and
    2. Department of Urology, University Hospital Zürich, Zürich, Switzerland
      Alexander Müller, Department of Urology, Sidney Kimmel Center for Prostate & Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 353 East 68th Street, New York, NY 10065, USA.
      e-mail: Alex.Mueller@usz.ch
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Alexander Müller, Department of Urology, Sidney Kimmel Center for Prostate & Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 353 East 68th Street, New York, NY 10065, USA.
e-mail: Alex.Mueller@usz.ch

Abstract

Study Type – Therapy (content analysis)

Level of Evidence 3

OBJECTIVE

To define the nature of information posted on websites related to radical prostatectomy (RP), specifically its accuracy and comprehensiveness, as RP is associated with erectile dysfunction (ED).

METHODS

We reviewed 70 robotic RP (RARP) and 20 open RP (ORP) medical centres. Their websites were reviewed for various factors, by two separate reviewers whose reviews were not seen by each other. Websites were graded based on accuracy and comprehensiveness of information by the senior investigator.

RESULTS

Of the academic and community-based RARP centres, 55% and 79% had specific websites (P < 0.05); 45% of RARP sites had generic information copied directly from the website of Intuitive Surgical (Sunnyvale, CA, USA; the manufacturer of the robotic system). ED was mentioned by only 54% of RARP sites and 45% of ORP sites; 17% of RARP sites were deemed accurate, compared with 30% of ORP sites (P < 0.05). Just over 1% of RARP sites were considered comprehensive, vs 10% of ORP sites (P < 0.05). A third of RARP sites had a direct link to the Intuitive Surgical website (16% academic vs 53% community, P < 0.05), compared to 10% of open sites (P < 0.05). Of most interest was that half of the RARP sites suggested that ED rates were lower for RARP than for ORP; this compared to ED rates being cited as lower for ORP on 5% of the ORP sites (P < 0.05).

CONCLUSIONS

Despite the stature of RP as a treatment option for men with prostate cancer, and the recent increase in the use of RARP, the accuracy of information pertaining to sexual health on RP websites is poor, with many making false statements about the long-term outcomes for erectile function. This inadequacy appears to be greater on RARP than on ORP websites.

Abbreviations
(L)(O)(RA)RP

(laparoscopic) (open) (robotic-assisted) radical prostatectomy

ED

erectile dysfunction

PCOS

Prostate Cancer Outcomes Study

EBM

evidence-based medicine.

INTRODUCTION

Each year in the USA alone, 200 000 men are diagnosed with prostate cancer and ≈25% will elect to undergo radical prostatectomy (RP) [1]. Erectile dysfunction (ED) is a well-recognized sequel of RP; the incidence of ED after RP is 20–90%[2–5]. With advances in laparoscopic surgery, RP has become feasible using a laparoscopic approach with or without robotic assistance. The advantages of laparoscopic and robot-assisted surgery have been delineated, and include improved visibility in the operative field, decreased blood loss, early ambulation and more rapid convalescence, without compromising cancer control [6,7].

Clinical experience shows that patients are often given unrealistic expectations, especially about the long-term outcomes for erectile function, as well as the time to recovery of erectile function. Indeed, rarely are sexual dysfunctions other than ED, e.g. orgasmic pain, reduced orgasmic intensity, orgasm-associated incontinence, penile volume changes with the development of Peyronie’s disease, mentioned to a patient before RP, or at least recalled by a patient after surgery.

There has been a rapid increase in the use of robotic technology for RP, and it has been estimated that the number of cases rose from ≈2500 in 2003 to >16 000 cases in 2005 and 35 000 in 2007. As of May 2008, a Google search using the search term ‘robotic prostatectomy’, found 50 000 sites. In a study by Hu et al.[8], men who had RP from 2003 to 2005 were analysed from a national sample of Medicare beneficiaries. During this interval the data showed a 30% increase in the use of what was termed laparoscopic radical prostatectomy (LRP) and a 12% decrease in the standard open technique (ORP), most probably due to the introduction of robotic-assisted RP (RARP). In 2007, the proportion of RPs performed with the da Vinci robot system (Intuitive Surgical, Sunnyvale, CA, USA) increased to ≈70% in the USA. Since the introduction of the da Vinci system, Intuitive Surgical has supplied more than 850 academic and community hospital sites with a robot system, while sustaining growth of >25% annually [9].

The purpose of this analysis was to survey websites for both ORP and RARP to evaluate the quality of the information found there as it pertains to the outcome for erectile function.

METHODS

Using the Intuitive Surgical website (http://www.intuitivesurgical.com; accessed May 2008), we identified 70 centres in the USA that were using RARP. If not overtly identified on the Intuitive Surgical website, an Internet search was conducted for the respective website URLs for each of the RP centres. To compare the information posted on RARP with that placed on ORP sites, 20 ORP centres in the USA were selected based on national reputation. Appendics 1 and 2 list the RARP and ORP websites included in this analysis. These websites were then reviewed for factors outlined in Appendix 3, by two separate reviewers whose reviews was not seen by each other. Websites were graded by the senior investigator based on the accuracy and comprehensiveness of information. Information was deemed accurate when the rates of ED cited were within those published, and when a range was given as opposed to a specific single value. Information was deemed comprehensive if it mentioned sexual dysfunctions other than ED and/or discussed available treatments for ED or other sexual dysfunctions.

For ED the websites were surveyed for the following information: Did the sites give realistic expectations about time to recovery and overall recovery? Are the ED rates cited within the published rates? Are the rates cited specific to the individual site or are they generic? For comprehensiveness: did the site mention the causes of ED? Did the site mention ED treatment options? Did the site mention sexual dysfunctions other than ED? Websites that were both accurate and comprehensive were graded as ‘A’, those sites that were either accurate or comprehensive but not both were graded as ‘B’, and those neither accurate nor comprehensive were graded ‘C’. Sites that were ungradeable because ED was not mentioned were graded ‘U’.

Descriptive statistics are reported for all variables. We used the Pearson chi-square test to evaluate associations between categorical variables, and the Mann–Whitney U- and Kruskal–Wallis tests to compare the distribution of continuous/ordinal variables between groups defined by categorical variables.

RESULTS

Of the 70 RARP websites reviewed, 36 (52%) were academic, while 34 (48%) were community-based. All ORP websites were from academic centres; 67% of RARP centres had a RARP-specific website, compared to 40% of ORP centres. Of academic and community-based RARP centres, 55% and 79%, respectively, had specific websites (P < 0.05). Overall, 45% of RARP sites had generic information copied directly form the Intuitive Surgical website. ED was mentioned by 54% of RARP and 45% of ORP websites (the difference was statistically insignificant); 17% of RARP and 30% of ORP websites were deemed accurate (P < 0.05). Just over 1% of RARP websites were considered comprehensive, compared to 10% of ORP sites (P < 0.05). There was no difference in accuracy or comprehensiveness between academic and community-based RARP websites.

RARP websites were more likely to be surgeon-specific than ORP websites (23% vs 0%, P < 0.05) and were more likely to cite the benefits to the surgeon of the procedure (11% vs 0%). Of RARP websites, 35% mentioned ORP, while 40% of ORP websites mentioned RARP. Strikingly, a third of RARP websites had a direct link to the Intuitive Surgical website (16% academic vs 53% community, P < 0.05), compared to 10% of ORP sites (P < 0.05). Half of the RARP sites suggested that ED rates were lower for RARP than for ORP; this compared to ED rates being cited as lower for ORP on 5% of the ORP sites (P < 0.05). Finally, only 7% of RARP sites, vs 20% of ORP sites, cited actual values for ED.

DISCUSSION

Prostate cancer is the most common non-skin form of cancer in American men. The American Cancer Society estimates that ≈185 000 new cases of prostate cancer will be diagnosed in 2008 in the USA, and almost 30 000 men will die from the disease in 2009 alone in the USA [1]. Prostate cancer is the second leading cause of cancer death in men after lung cancer. The use of PSA as a screening tool has resulted in a far more men being diagnosed with prostate cancer at the earliest stages. Thus, in the modern era, the vast majority of men live for a long time after diagnosis and treatment. This has translated into younger men being diagnosed with prostate cancer, and thus long-term sexual function is becoming an even greater issue, given these factors.

RP has undergone a series of refinements over the last 25 years, one of the most recent of which is the application of laparoscopic followed by robotic technologies to this surgery. With the aid of the dissemination of information, and marketing, currently most RPs in the USA are RARP [8]. Furthermore, the volume of information that exists on the Internet pertaining to this procedure is vast, with >50 000 hits for ‘robotic prostatectomy’ found using a Google search.

RP is associated with ED, irrespective of the approach used to extirpate the prostate. The introduction of the anatomic RP in 1982, while translating into a significant improvement in outcomes for erectile function, has failed to abolish ED as a complication of this procedure [10]. Anecdotal evidence and clinical experience shows that American patients presume that novel technologies result in fewer complications, whether it be laser prostatectomy, proton-beam radiotherapy or RARP. This factor has amplified the permeation of robotic technology in all surgery in which it is used. The advantages of laparoscopic and robot-assisted surgery were listed above [6,7].

The incidence of ED after RP varies dramatically, at 20–90%[3–5,7,11–13]. Walsh et al.[5] reported that 86% of patients were potent and 84% considered sexual bother as ‘none’ or ‘small’ at 18 months after a nerve-sparing RP. Kundu et al.[3] reported erectile function rates of 76% and 53% after bilateral and unilateral nerve-sparing RP, respectively. The Prostate Cancer Outcomes Study (PCOS) collected longitudinal quality-of-life outcomes data in men who had RP, using the Surveillance, Epidemiology, and End Results cancer registries of the National Cancer Institute. Data derived from the PCOS indicate an ability to achieve erections sufficient for intercourse in 20% of men undergoing RP [14].

To date, there is no well-designed study proving that outcomes for erectile or urinary function are different between ORP and LRP/RARP. Despite this, claims to the contrary have been made by centres using RARP [15]. Reports on erectile function after LRP or RARP appear to present results comparable to standard ORP, but erectile function data from the largest series are often limited to a small subset of the total patient population operated upon. Rozet et al.[7] presented a series of 600 extraperitoneal nerve-sparing LRPs and reported recovery of erections in 64% of men and an ability to accomplish sexual intercourse in 43% at the relatively short median follow-up of 6 months. Goeman et al.[16] reported potency rates of 64% overall and 79% among men aged <60 years, at 2 years after LRP. Menon et al.[6] reported 70% and 100% ability to have sexual intercourse at 12 and 48 months after RARP, respectively, in patients with no ED before RP. These results were significantly better than their results for standard nerve-sparing ORP, with 40% and 70% of patients capable of intercourse at 12 and 60 months, respectively. At present, small comparative, non-randomized studies of ORP, LRP and RARP have failed to show a significant difference in terms of sexual function outcome [17,18].

It has been suggested that patients with prostate cancer base their decision on which primary therapy to choose largely based on the outcomes for erectile function after treatment [19]. One of the tenets of good medical practice is the transmission of balanced and accurate information to patients, and the nature of this information affects medical decision making [19]. While historically this has occurred in face-to-face discussions or in written media, the Internet has increasingly become the primary source of medical information for patients [20–25]. Evidence-based medicine (EBM) is the concept that medical and surgical practice should be based on good evidence for the efficacy of any given treatment [26]. In the arena of RARP, EBM has unfortunately come to define ‘eminence-based medicine’, whereby known leaders make declarations that are accepted as truth in the absence of definitive evidence. Nowhere are there data, robust or not, that RARP provides better rates of recovery of erectile function than ORP. RARP websites routinely make statements such as ‘robotic prostatectomy offers numerous potential benefits over traditional prostatectomy including . . . retention of erectile function’, ‘for a month or so after surgery, most men are not able to get an erection’, or ‘the potential benefits of robotic prostatectomy include: minimal impact on quality of life including sexual function . . . ’.

The present study highlights how poor the sexual health information is on RP websites, and that these deficiencies are greater on RARP than ORP sites (Table 1). No RARP website obtained a grade A, with almost half being ungradeable because ED was never mentioned on the site. This latter deficiency was more prominent on community-based than academic sites. Only 10% of ORP sites recovered a grade A and a quarter were ungradable, again because of failure to mention ED as a complication. For both RARP and ORP sites, only about a half ever mentioned ED as a complication. With regard to the accuracy of information, particularly as it pertained to time to recovery of erections, only 17% of RARP and 30% of ORP sites were deemed accurate, and even more damning is that only one RARP and two ORP websites were deemed to be comprehensive. Sexual dysfunction after RP, e.g. penile shortening, orgasm-associated incontinence and dysorgasmia, are rarely mentioned on such websites.

Table 1.  Grading of information on erectile function
GradeRALPORP
TotalUniversityPrivate
  1. P < 0.05, *Private vs Academic RARP;†ORP vs RALP.

N70363420
%:
A 0 0 010
B19191820
C384432*45
U433650*25

Almost half (45%) of the RARP sites had generic information on RARP copied directly from the Intuitive Surgical website, and just as concerning was that almost a third of RARP sites had a direct link to the company’s website. In an era when the pharmaceutical industry is under close scrutiny for their relationship with academic medicine, should the same not be enforced for such device companies? For example, it is incomprehensible to think of an academic urology centre having a link on their website to http://www.viagra.com. Furthermore, only a third of the reviewed RARP sites even mentioned ORP as an alternative surgical option. Most bemusing in this analysis was that half of RARP sites stated that erectile function recovery rates were better with robot assistance than with ORP. Of course, this inference is based on no scientific data, as no direct comparative studies have been published. Finally, very few of ORP or RARP sites mentioned actual ED rates, generic or centre-specific.

This analysis is not without limitations, particularly that sites were graded on an arbitrary basis. However, this grading was done by a sexual medicine expert not involved in the performance of either ORP or RARP, thus minimizing bias. Furthermore, the data were collected by two reviewers, each of whom was unaware of each other’s review.

In conclusion, robotic technology has resulted in a rapid expansion in the use of RARP over the past 5 years. Despite this, the accuracy of information pertaining to sexual health on RP websites is poor, with many making false statements about the long-term outcomes for erectile function. This inadequacy appears to be greater on RARP than on ORP websites.

CONFLICT OF INTEREST

None declared.

Appendices

APPENDIX 1

RARP websites reviewed:

Alaska Urological Associates

Associates in Urology

Baylor College of Medicine

Beth Israel Medical Center

Bethesda North Good Samaritan

Boston medical Center

Brigham and Womens’s Hospital

Bryn Mawr Hospital

Cabell Huntington Hospital

Carolinas Health Care system

Cary Urology

Cedars Sinai

Centennial Nashville Robotic

Center Minimally Invasive Surgery

City of Hope

Cleveland Clinic

Clinic of Urology

Columbia Presbyterian Medical Center

Dr J Hendricks

George Washington University

Henry Ford Hospital

Johns Hopkins

Lancaster Regional

Loma Linda Medical Center

Long Island Jewish Medical Center

Maimonides Medical Center

Mayo Clinic

Medical College Wisconsin

Metropolitan Urological Specialties

Montefiore Medical Center

Morton Plant Mease

MSKCC

New York Presbyterian Hospital

Newark Beth Israel Medical Center

North Memorial

Ochsner Clinic Foundation

Ohio State University

Penn Presbyterian Medical Center

Physicians Urology

Presbyterian North Carolina

Robert Wood Johnson Hospital

Roswell Park Cancer Institute

Scottsdale Urologic Surgeons

Seattle Cancer Care Alliance

Sharp Memorial Hospital

St. Joseph Hospital

Swedish Medical Center

The Iowa Clinic

Thomas Jefferson

U. Washington

UC Davis Cancer Center

UCIrvine

UCSF

University of virginia

University Alabama Birmingham

University Michigan Health System

University of Illinois

University of Iowa

University of Maryland Medical Center

University Oklahoma

University Pittsburgh Medical centre

University Rochester Medical Center

Urology Associates DuPage

Urology Associates Manhasset

Urology Center of westchester

Urology of Indiana

Vanderbilt Medical Center

West Valley Hospital

Western New York Urologic Associates

APPENDIX 2

ORP websites reviewed:

For Peer Review

Baylor College of Medicine

Cleveland Clinic

Columbia Presbyterian Medical Center

Duke

Henry Ford Hospital

Johns Hopkins

Mayo Clinic

Montefiore Medical Center

Memorial Sloan Kettering Cancer Center

New York Presbyterian Hospital

North-western University Chicago

NYU

Ohio State University

UCLA

UCSF

University Michigan Health System

University of Miami

University of Virginia

USC

Vanderbilt Medical Center

APPENDIX 3

Factors explored on RP websites:

University vs community practice

Does the centre have a specific RARP site?

Is there a link from the institution’s main website to the RP site?

Has information between copied directly from the Intuitive Surgical website?

Is there a link to the Intuitive Surgical website?

Is ED mentioned as a complication of RP?

Is this information accurate?

Is this information comprehensive?

Is the site specific to a single surgeon?

Is ORP on the RARP site?

Is RARP mentioned on the ORP site?

Is it suggested that the RP approach is better than the other technique?

Have ED figures been explicitly mentioned?

Are there references to support the values mentioned?

Ancillary