Quality of life after brachytherapy or radical prostatectomy for localized prostate cancer: A prospective longitudinal study

ADULT UROLOGY

QUALITY OF LIFE AFTER BRACHYTHERAPY OR RADICAL PROSTATECTOMY FOR LOCALIZED PROSTATE CANCER: A PROSPECTIVE LONGITUDINAL STUDY SHUNICHI NAMIKI, TAKEFUMI SATOH, SHIRO BABA, HIROMICHI ISHIYAMA, KAZUSHIGE HAYAKAWA, SEIICHI SAITO, AND YOICHI ARAI

ABSTRACT Objectives. To investigate health-related quality of life (HRQOL) in Japanese men with localized prostate cancer who underwent prostate brachytherapy (BT) or retropubic radical prostatectomy (RRP). Methods. A total of 70 patients who underwent BT and 67 who underwent RRP were enrolled in our study. The Medical Outcomes Study 36-Item Short Form (SF-36), University of California, Los Angeles, Prostate Cancer Index, and the International Prostate Symptom Score were administered before and 1, 3, 6, and 12 months after treatment. No patients received neoadjuvant or adjuvant therapy. Results. The RRP group reported significantly lower scores in several domains of the SF-36 at 1 month (P ⬍0.05), but these domains returned to baseline within 6 months. The BT patients reported no significant changes in any of the general HRQOL domains throughout the follow-up period. The RRP group reported a lower posttreatment urinary function score, which reflected leakage, than the BT group. However, the BT patients experienced a significantly delayed recovery of the urinary bother score. The data from the International Prostate Symptom Score showed adverse effects from BT on voiding symptoms for the initial 6 months after treatment. No differences were found in bowel symptoms. RRP was associated with worse sexual function than BT, although nerve-sparing surgery minimized the difference. Conclusions. The results of this study have indicated that BT and RRP have meaningfully different profiles in the recovery of general QOL. The differences in the recovery of disease-specific HRQOL were pronounced during the first 12 months after treatment. UROLOGY 68: 1230–1236, 2006. © 2006 Elsevier Inc.

T

he traditional definition of success for prostate cancer therapy has focused primarily on overall and disease-free survival, as well as other disease-specific variables such as recurrence detected by the prostate-specific antigen level. Radical retropubic prostatectomy (RRP) is considered a safe and effective treatment for localized prostate cancer and has gained popularity among Japanese urologists during the past decade.1 In contrast,

This study was supported in part by a grant from the Ministry of Health and Welfare of Japan. From the Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan; and Departments of Urology, and Radiology, Kitasato University School of Medicine, Sagamihara, Japan Reprint requests: Shunichi Namiki, M.D., Department of Urology, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aoba-ku, Sendai 980-8574, Japan. E-mail: namikin@uro. med.tohoku.ac.jp Submitted: February 27, 2006, accepted (with revisions): August 22, 2006 © 2006 ELSEVIER INC. 1230

ALL RIGHTS RESERVED

prostate brachytherapy (BT) has been accepted as an option for the treatment of localized prostate cancer in selected patients and the 10-year survival data appear favorable.2 In Japan, the use of iodine125 seed source was legally approved in June 2003. Because prostate cancer is increasingly diagnosed at earlier stages and therefore has more favorable survival outcomes, the basis on which patients select primary therapy has shifted toward considerations of health-related quality of life (HRQOL).3 To our knowledge, this is the first report that documents the feasibility of longitudinal HRQOL with established validated instruments in Japanese men who underwent BT or RRP for localized prostate cancer. MATERIAL AND METHODS PATIENT POPULATION AND DATA COLLECTION From January 2004 to April 2005, 137 patients with newly diagnosed, early, localized prostate cancer (clinical Stage T2 0090-4295/06/$32.00 doi:10.1016/j.urology.2006.08.1093

or better) were treated with BT or RRP monotherapy at Tohoku University Hospital and Kitasato University Hospital, respectively.

TREATMENT TECHNIQUE RRP was performed at Tohoku University Hospital, using essentially the same technique as originally described by Walsh.4 Each surgeon had considerable experience before the beginning of the study. During RRP, neurovascular bundle preservation was assessed using a previously reported electrophysiologic test.5 The decision to perform a nerve-sparing procedure depended on the preoperative (number and Gleason score of the positive biopsy cores, prostate-specific antigen level, and patient preference) and intraoperative factors, prioritizing cancer control. BT, using iodine-125, was performed at Kitasato University Hospital. The details of the technique of seed implantation have been previously reported.6 All implant procedures were performed by a single radiation oncologist, accompanied by the referring urologist. The sources were placed transperineally. The maximal prostate volume allowed was 45 cm3, and the men had not previously undergone transurethral resection of the prostate. The delivered implant dose was assessed using a 1-month, computed tomography scan on the basis of the dosimetry after the implant procedure. The prescription dose was 145 Gy. The postimplantation radiation doses were determined by computed tomography at 1 month. Abutting 3-mm computed tomography scans were taken from the bladder base to just below the apex. None of the patients of either group had received neoadjuvant or adjuvant therapy. The overall median percentage of prostate volume receiving 100% of the prescribed dose was 93%, and the median minimal dose received by 90% of target volume was 162 Gy. The median rectal and urethral dose was 83.0 Gy and 156.3 Gy, respectively.

HRQOL METHOD All the patients were informed of their cancer diagnosis before being asked to answer the HRQOL questionnaires. Every patient who agreed to participate in this study received from their urologist a questionnaire, an informed consent form, and a prepaid envelope for returning the questionnaire. The questionnaires were administered at five points. The baseline interview was conducted within 1 month before surgery. Follow-up interviews were conducted in person at scheduled study visits 1, 3, 6, and 12 months after treatment. General HRQOL was measured with the Medical Outcomes Study 36Item Short Form (SF-36),7 which has eight domains targeting physical and emotional issues. Disease-specific HRQOL was assessed with the University of California, Los Angeles, Prostate Cancer Index (UCLA-PCI),8 which measures disease-specific HRQOL in six domains: urinary function, urinary bother, bowel function, bowel bother, sexual function, and sexual bother. The HRQOL scores are presented as the mean ⫾ standard deviation on 0 to 100 scales, with higher scores always representing better HRQOL. Voiding symptoms were evaluated with the International Prostate Symptom Score (IPSS) and IPSS-QOL score (score range 0 to 6).9 For the IPSS and IPSS-QOL scores, a higher score indicated worsening symptoms. All the questionnaires had been translated into Japanese and their validity and reliability previously tested.10,11

STATISTICAL ANALYSES The characteristics of the two treatment groups were evaluated using the chi-square test or Mann-Whitney U test. The analysis focused on comparing each HRQOL score of the postoperative groups with the respective baseline scores in the RRP and BT groups. The inspection value was shown by using the average ⫾ standard deviation, and statistical analysis was UROLOGY 68 (6), 2006

performed using repeated measure analyses of variance or Mann-Whitney U test. P values less than 0.05 were considered statistically significant.

RESULTS BACKGROUND CHARACTERISTICS The surveys were sent to 70 and 67 men who underwent BT and RRP, respectively. The demographic and clinical characteristics of the patient population are summarized in Table I. Significant differences were present in the mean patient age (P ⫽ 0.024) and Gleason score (P ⬍0.001). However, the two groups were comparable in the average pretreatment prostate-specific antigen values and disease stage. Of the 67 patients treated with RRP, 22 (33%) underwent a bilateral nerve-sparing procedure, 34 (51%) a unilateral nerve-sparing procedure, and 11 (16%) did not undergo a nervesparing procedure. HRQOL ASSESSMENT The total numbers of questionnaires returned were 137 (70 and 67, respectively), 117 (56 and 61, respectively), 130 (64 and 66, respectively), 119 (58 and 61, respectively), and 115 (56 and 59, respectively) at baseline and 1, 3, 6, and 12 months after treatment for the BT and RRP groups, respectively. The general and prostate-specific HRQOL scores and the changes in voiding symptoms are listed in Table II. No differences were found in the general HRQOL at baseline between the two groups. The RRP group reported significantly lower scores in several domains; role limitations due to physical problems, emotional problems, social function, bodily pain, mental health, and vitality significantly decreased during the first 3 months (P ⬍0.05), but these domains returned to the baseline level within 6 months. The BT patients reported no significant decreases in any of the general HRQOL domains throughout the follow-up period. The mental health of the RRP group had significantly improved at 6 months or later, although no such trend was found in the BT group. The UCLA-PCI scores showed that in the urinary function domain, leakage in the RRP group had decreased at 1 month and continued to recover over time, but remained substantially lower than the baseline level. In contrast, no differences were observed between the baseline and any posttreatment period in the BT group. In the RRP group, urinary bother at 1 and 3 months was significantly worse than at baseline but it had returned to the baseline level at 6 months. The recovery of the urinary bother score was significantly delayed in the BT group, although urinary function was minimally affected. The BT group reported lower urinary bother scores than the RRP group at 3 and 6 months (P ⬍0.05). In the domain of bowel func1231

TABLE I.

Demographic and clinical characteristics of study population

Characteristic

RRP

Patients (n) Age at survey (yr) Mean ⫾ SD Median Range PSA at diagnosis (ng/mL) Mean ⫾ SD Median Range Clinical tumor stage T1 T2 Gleason score ⱕ6 ⱖ7 Nerve sparing Bilateral Unilateral None

67

BT

P Value

70 0.024*

64.3 ⫾ 6.5 65 49–77

67.0 ⫾ 6.4 68 51–83

8.8 ⫾ 6.8 6.8 2.6–52

7.0 ⫾ 3.4 6.2 1.4–19.2

0.116*

0.834† 50 17

56 14

12 55

47 23

⬍0.001†

— 22 34 11

KEY: RRP ⫽ retropubic radical prostatectomy; BT ⫽ prostate brachytherapy; SD ⫽ standard deviation; PSA ⫽ prostatespecific antigen. * Mann-Whitney U test. † Chi-square test.

tion and bother, no differences were seen in the patterns of alteration between the two groups. The RRP patients reported statistically worse sexual function than did the BT patients throughout the postoperative period. Parallel to sexual function, the RRP patients also reported significantly lower sexual bother scores than did the BT patients throughout the postoperative period (P ⬍0.05). As shown in Figure 1, the bilateral nerve-sparing subgroup of the RRP group had significantly better improvement in sexual function than did the nonnerve-sparing group (P ⬍0.05). However, even the bilateral nerve-sparing subgroup reported lower sexual function score than did the BT group at 12 months after treatment (17.1 versus 31.8, P ⬍0.05). The data from the IPSS showed a substantially greater score just after RRP at 1 month (P ⬍0.01). However, the mean total IPSS and QOL score showed statistically significant improvement beyond 6 months after RRP. The BT group experienced significantly greater IPSSs during the first 6 months after treatment (P ⬍0.01). One year later, however, it had returned to the baseline, and no remarkable differences were observed between the RRP and BT groups. COMMENT Our study has demonstrated several important findings. First, the patients who underwent RRP or BT had different longitudinal profiles in the general HRQOL. As one might expect, some physical 1232

function domains were lower after treatment for patients who underwent RRP than for those treated with BT. However, these domains had recovered to the baseline 6 months after RRP, and no significant differences were evident between the treatment groups. This is consistent with the findings from other investigators, who have shown that men with localized prostatic disease treated with RRP report problems in some domains of general HRQOL, but these problems diminish over time.12,13 Eton et al.14 analyzed the immediate changes in general HRQOL in 256 men after treatment with BT, RRP, or external beam radiotherapy. HRQOL differences were noted in the physical function, role physical, social function, and bodily pain domains. In each domain, the patients who underwent BT had better HRQOL scores than did those treated with RRP. In contrast, mental health improved substantially and appeared to continue to improve for as long as 12 months after RRP, although the BT patients consistently remained stable. The present findings have confirmed the longitudinal trends observed by Litwin et al.,15 who noted that it would have been useful to have examined the surgical pathologic findings as a predictor of mental HRQOL, although this variable would not be available for radiotherapy or watchful waiting. Second, differences between the two groups were more pronounced in the disease-specific HRQOL than in the general HRQOL. A significant proportion of men complained of urinary incontinence UROLOGY 68 (6), 2006

TABLE II.

SF-36, UCLA-PCI, IPSS, and quality-of-life scores RRP

SF-36 Physical function Baseline 1 mo 3 mo 6 mo 12 mo Role limitation due to physical problems Baseline 1 mo 3 mo 6 mo 12 mo Bodily pain Baseline 1 mo 3 mo 6 mo 12 mo General health perception Baseline 1 mo 3 mo 6 mo 12 mo Mental health Baseline 1 mo 3 mo 6 mo 12 mo Role limitation due to emotional problems Baseline 1 mo 3 mo 6 mo 12 mo Social function Baseline 1 mo 3 mo 6 mo 12 mo Vitality Baseline 1 mo 3 mo 6 mo 12 mo UCLA-PCI Urinary function Baseline 1 mo 3 mo 6 mo 12 mo

UROLOGY 68 (6), 2006

BT

P Value (Repeated Measures ANOVA)

P Value (RRP vs. BT)

0.376 88.4 ⫾ 11.8 84.2 ⫾ 16.8 86.9 ⫾ 15.6 88.3 ⫾ 16.7 86.7 ⫾ 13.4

88.7 ⫾ 10.6 87.3 ⫾ 8.3 87.8 ⫾ 8.5 88.4 ⫾ 9.3 90.8 ⫾ 9.0

88.5 ⫾ 22.7 64.9 ⫾ 25.0* 81.6 ⫾ 23.6 85.0 ⫾ 21.8 81.4 ⫾ 20.3

86.0 ⫾ 16.1 80.7 ⫾ 25.3 87.1 ⫾ 22.6 89.3 ⫾ 19.6 88.5 ⫾ 24.4

86.0 ⫾ 20.1 67.4 ⫾ 23.0* 79.7 ⫾ 20.7† 86.9 ⫾ 19.1 79.1 ⫾ 18.1

82.4 ⫾ 16.5 78.9 ⫾ 22.3 80.5 ⫾ 15.2 80.8 ⫾ 16.6 85.1 ⫾ 21.8

60.8 ⫾ 16.3 58.1 ⫾ 16.5 60.9 ⫾ 16.2 61.8 ⫾ 16.3 58.6 ⫾ 17.0

58.5 ⫾ 14.7 60.9 ⫾ 14.5 61.0 ⫾ 16.4 60.8 ⫾ 14.6 61.5 ⫾ 14.5

73.0 ⫾ 20.4 67.7 ⫾ 18.7† 76.7 ⫾ 17.8 79.0 ⫾ 17.5† 79.3 ⫾ 15.7†

79.1 ⫾ 16.7 74.8 ⫾ 20.3 78.8 ⫾ 15.4 77.6 ⫾ 15.2 79.2 ⫾ 17.2

86.7 ⫾ 22.6 68.4 ⫾ 28.9* 80.4 ⫾ 24.3 84.4 ⫾ 23.1 81.0 ⫾ 21.4

85.0 ⫾ 16.9 81.3 ⫾ 20.8 86.1 ⫾ 23.2 89.4 ⫾ 19.0 86.8 ⫾ 27.1

90.1 ⫾ 19.1 69.5 ⫾ 26.9* 81.6 ⫾ 20.7† 88.1 ⫾ 19.0 84.2 ⫾ 18.1

90.4 ⫾ 16.0 79.3 ⫾ 33.1* 85.5 ⫾ 20.3 89.8 ⫾ 22.0 89.4 ⫾ 23.4

70.0 ⫾ 20.1 61.9 ⫾ 22.9† 69.2 ⫾ 19.3 71.0 ⫾ 18.2 67.1 ⫾ 21.5

71.6 ⫾ 16.7 71.3 ⫾ 21.7 72.0 ⫾ 15.9 71.6 ⫾ 14.6 71.8 ⫾ 19.7

92.9 ⫾ 18.1 52.1 ⫾ 26.7* 60.9 ⫾ 25.3* 74.4 ⫾ 21.8* 75.7 ⫾ 20.4*

88.8 ⫾ 14.6 89.3 ⫾ 18.8 81.9 ⫾ 29.5 86.3 ⫾ 27.5 92.4 ⫾ 19.2

NS NS NS NS NS ⬍0.001 NS ⬍0.001 NS NS NS ⬍0.001 NS 0.014 NS NS NS 0.412 NS NS NS NS NS ⬍0.001 NS 0.046 NS NS NS ⬍0.001 NS 0.032 NS NS NS ⬍0.001 NS 0.026 NS NS NS ⬍0.001 NS 0.019 NS NS NS ⬍0.001 NS ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 (Continued)

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TABLE II.

Urinary bother Baseline 1 mo 3 mo 6 mo 12 mo Bowel function Baseline 1 mo 3 mo 6 mo 12 mo Bowel bother Baseline 1 mo 3 mo 6 mo 12 mo Sexual function Baseline 1 mo 3 mo 6 mo 12 mo Sexual bother Baseline 1 mo 3 mo 6 mo 12 mo IPSS Total Baseline 1 mo 3 mo 6 mo 12 mo QOL question score Baseline 1 mo 3 mo 6 mo 12 mo

Continued P Value (Repeated Measures ANOVA)

RRP

BT

92.3 ⫾ 27.1 59.8 ⫾ 26.6* 72.3 ⫾ 28.0* 86.0 ⫾ 24.4 85.2 ⫾ 20.5

81.2 ⫾ 25.6 65.7 ⫾ 29.6* 57.8 ⫾ 33.5* 71.6 ⫾ 28.9* 88.9 ⫾ 24.2

87.9 ⫾ 15.1 82.9 ⫾ 20.1 84.0 ⫾ 18.3 85.6 ⫾ 13.4 86.1 ⫾ 13.7

87.7 ⫾ 13.9 82.3 ⫾ 18.1 84.0 ⫾ 20.1 87.8 ⫾ 13.8 88.8 ⫾ 10.6

93.1 ⫾ 20.9 84.8 ⫾ 24.5 88.6 ⫾ 17.7 90.0 ⫾ 13.3 87.5 ⫾ 15.9

88.3 ⫾ 17.8 82.1 ⫾ 25.1 83.2 ⫾ 25.3 89.2 ⫾ 14.7 86.1 ⫾ 21.5

37.9 ⫾ 24.7 5.8 ⫾ 15.6* 9.0 ⫾ 11.6* 9.1 ⫾ 13.9* 10.2 ⫾ 15.2*

34.4 ⫾ 23.3 27.5 ⫾ 8.0 26.1 ⫾ 9.5 27.8 ⫾ 8.5 32.0 ⫾ 12.6

71.8 ⫾ 27.4 54.5 ⫾ 34.1* 42.0 ⫾ 34.9* 49.2 ⫾ 36.4* 55.4 ⫾ 33.2*

72.2 ⫾ 21.4 72.9 ⫾ 34.9 65.4 ⫾ 32.3 68.3 ⫾ 33.6 69.1 ⫾ 34.8

9.4 ⫾ 6.1 12.3 ⫾ 26.7* 8.0 ⫾ 5.0 6.9 ⫾ 4.9* 6.6 ⫾ 5.6*

8.5 ⫾ 14.6 16.7 ⫾ 18.8* 17.8 ⫾ 29.5* 14.9 ⫾ 27.5* 7.9 ⫾ 19.2

3.8 ⫾ 1.6 4.8 ⫾ 1.3† 3.6 ⫾ 1.5 3.1 ⫾ 1.4* 2.9 ⫾ 1.4*

3.6 ⫾ 1.6 4.1 ⫾ 1.2* 4.4 ⫾ 1.5† 3.7 ⫾ 1.4 3.1 ⫾ 1.3

P Value (RRP vs. BT)

⬍0.001 NS NS 0.037 0.046 NS 0.717 NS NS NS NS NS 0.412 NS NS NS NS NS ⬍0.001

⬍0.001

NS ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 NS ⬍0.001 ⬍0.001 ⬍0.001 0.032

⬍0.001 NS NS ⬍0.001 ⬍0.001 NS ⬍0.001 NS 0.021 0.008 0.016 NS

KEY: ANOVA ⫽ analysis of variance; SF-36 ⫽ Medical Outcomes Study 36-Item Short Form; NS ⫽ not significant; UCLA-PCI ⫽ University of California, Los Angeles, Prostate Cancer Index; IPSS ⫽ International Prostate Symptom Score; QOL ⫽ quality of life; other abbreviations as in Table I. Data presented as mean ⫾ standard deviation. * P ⬍0.01, statistically significant change from baseline. † P ⬍0.05, statistically significant change from baseline.

after RRP. At 6 months after surgery, however, urinary bother had returned to baseline. Hoffman et al.16 showed that 75% of those who developed daily urinary incontinence still reported that the poor function was at most only a small problem. Although BT appeared to have a clear advantage over RRP in terns of urinary function, the UCLAPCI primarily emphasizes continence rather than irritative symptoms. Urinary function that reflects 1234

leakage is apparently minimally affected by BT. However, the bother curve showed more significant adverse treatment effects. These symptoms were relatively apparent in our analysis using IPSS. Previously, we reported that the mean total IPSS showed significant improvement after RRP.17 Nonetheless, the BT group experienced a significant increase in IPSS, and this trend continued for more than 6 months after treatment. Desai et al.18 UROLOGY 68 (6), 2006

FIGURE 1. Longitudinal changes in sexual function over time by prostate cancer treatment. BNS ⫽ bilateral nerve-sparing procedure; UNS ⫽ unilateral nerve-sparing procedure; NNS ⫽ non-nerve-sparing procedure.

demonstrated that the post-BT IPSS and acute urinary side effects peak at 1 month and gradually returned to baseline by 24 months. In our experience, the IPSS had more than doubled at 3 months after BT. This sharp increase in urinary symptoms within a short period is clinically significant. By 1 year, however, the IPSSs were indistinguishable from the baseline measures. Our study revealed that continence is not the sole determining factor in urinary bother, and BT patients may be “dry” but have urgency, frequency, and dysuria.19,20 To our knowledge, few well-constructed studies have assessed urinary function after RRP or BT using internationally validated methods, such as the UCLA-PCI and IPSS. We emphasize that multiple urinary evaluations should be objectively measured and discussed when counseling patients with localized prostate cancer. The bowel function and bother scores were equivalent between the RRP and BT groups. Our results are similar to those of other investigators.21,22 Snyder and colleagues23 found that rectal dose-volume histogram analysis was a practical method for assessing the risk of developing grade 2 proctitis after BT. The popular perception is that RRP results in greater impairment in the domains of sexual function and bother compared with BT throughout the postoperative periods. The return of potency after RRP is dependent on many factors, including preoperative sexual activity, cancer stage, patient age, and whether unilateral or bilateral neurovascular bundles have been spared. The potency rates after BT have been encouragingly as great as 90%, although a decrease occurs at 3 to 6 years.24,25 In contrast, those who underwent nerve-sparing RRP reported continuing improvement of sexual function even in the second year after surgery.26 Elderly Japanese men, unlike their American counterparts, do not report dissatisfaction with their sexual life, even when reporting erectile dysfunction and decreased libido.27 Additional long-term studies with UROLOGY 68 (6), 2006

larger numbers of patients are necessary to fully understand the impact of each treatment on the sexual HRQOL. This prospective observational study had several limitations. First, our total study population was relatively small. Second, the choice of treatment was not made in a randomized fashion but according to the preference of the patient after discussion with his urologist. Thus, we investigated using the multiinstitutional HRQOL survey. Third, our analysis covered only the first 12 months after treatment. We chose a 1-year assessment endpoint because most changes in HRQOL take place during this interval.28 Furthermore, because BT is a newer procedure in Japan, we had significantly fewer patients with more than 12 months of follow-up. We plan to report longer follow-up results in the future. Fifth, we did not control for the postoperative use of erectile aids. Finally, our study did not assess the relationship between the treatment choice and anxiety about the possibility of disease recurrence. For example, the prognostic pathologic information obtained from surgical specimens may confer some psychological advantage compared with the uncertainty that may follow BT. Despite these limitations, our study has provided important insights concerning the QOL for patients who are considering BT or RRP for localized prostate cancer. Treatment recommendations based on overall and disease-free survival endpoints, as well as HRQOL outcomes, allow patients to make better-informed decisions regarding prostate cancer treatment. REFERENCES 1. Arai Y, Egawa S, Tobisu K, et al: Radical retropubic prostatectomy: time trends, morbidity and mortality in Japan. BJU Int 85: 287–294, 2000. 2. Downs TM, Sadetsky N, Pasta DJ, et al: Health related quality of life patterns in patients treated with interstitial prostate brachytherapy for localized prostate cancer— data from CaPSURE. J Urol 170: 1822–1827, 2003. 3. Mettlin CJ, Murphy GP, Babaian RJ, et al: Observations on the early detection of prostate cancer from the American Cancer Society National Prostate Cancer Detection Project. Cancer 80: 1814 –1817, 1997. 4. Walsh PC: Anatomical radical retropubic prostatectomy, in Walsh PC, Retik AB, Vaughan ED Jr, et al (Eds): Campbell’s Urology, 7th ed. Philadelphia, WB Saunders, 1998, pp 2565–2588. 5. Namiki S, Terai A, Nakagawa H, et al: Intraoperative electrophysiological confirmation of neurovascular bundle preservation during radical prostatectomy: long-term assessment of urinary and sexual function. Jpn J Clin Oncol 35: 660 – 666, 2005. 6. Sylvester J, Blasko JC, Grimm P, et al: Interstitial implantation techniques in prostate cancer. J Surg Oncol 66: 65–75, 1997. 7. Hays RD, Sherbourne CD, and Mazel RM: The RAND 36-Item Health Survey 1.0. Health Econ 2: 217–227, 1993. 8. Litwin MS, Hays RD, Fink A, et al: The UCLA Prostate Cancer Index: development, reliability, and validity of 1235

a health-related quality of life measure. Med Care 36: 1002–1012, 1998. 9. Barry MJ, Fowler FJ, O’Leary MP, et al: The American Urological Association Symptom Index for benign prostatic hyperplasia. J Urol 148: 1549 –1577, 1992. 10. Fukuhara S, Ware J, and Koshinski M: Psychometric and clinical tests of validity of the Japanese SF-36 health survey. J Clin Epidemiol 51: 1045–1053, 1998. 11. Kakehi Y, Kamoto T, Ogawa O, et al: Development of Japanese version of the UCLA Prostate Cancer Index: a pilot validation study. Int J Clin Oncol 7: 306 –311, 2002. 12. Litwin MS, Melmed GY, and Nakazon T: Life after radical prostatectomy: a longitudinal study. J Urol 166: 587–592, 2001. 13. Talcott JA, Rieker P, Clark JA, et al: Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 16: 275–283, 1998. 14. Eton DT, Lepore SJ, and Helgeson VS: Early quality of life in patients with localized prostate carcinoma: an examination of treatment-related, demographic, and psychosocial factors. Cancer 92: 1451–1459, 2001. 15. Litwin MS, Lubeck DP, Spitalny GM, et al: Mental health in men treated for early stage prostate carcinoma: a posttreatment, longitudinal quality of life analysis from the Cancer of the Prostate Strategic Urologic Research Endeavor. Cancer 95: 54 – 60, 2002. 16. Hoffman RH, Hunt WC, and Stephenson RA: Patient satisfaction with treatment decisions for clinically localized prostate carcinoma: results from the Prostate Cancer Outcomes Study. Cancer 97: 1653–1662, 2003. 17. Namiki S, Saito S, Ishidoya S, et al: Adverse effect of radical prostatectomy on nocturia and voiding frequency symptoms. Urology 66: 147–151, 2005. 18. Desai J, Stock RG, Stone NN, et al: Acute urinary morbidity following I-125 interstitial implantation of the prostate gland. Radiat Oncol Invest 6: 135–141, 1998.

1236

19. Litwin MS, Pasta DJ, Yu J, et al: Urinary function and bother after radical prostatectomy or radiation for prostate cancer: a longitudinal, multivariate quality of life analysis from the Cancer of the Prostate Strategic Urologic Research Endeavor. J Urol l64: 1973–1977, 2000. 20. Wei JT, Dunn RL, Sandler HM, et al: Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol 20: 557– 566, 2002. 21. Han BH, Demel KC, Wallner K, et al: Patient reported complications after prostate brachytherapy. J Urol 166: 953– 957, 2001. 22. Soderdahl DW, Davis JW, Schellhammer PF, et al: Prospective longitudinal comparative study of health-related quality of life in patients undergoing invasive treatments for localized prostate cancer. J Endourol 19: 318 –326, 2005. 23. Snyder KM, Stock RG, Hong SM, et al: Defining the risk of developing grade 2 proctitis following 125I prostate brachytherapy using a rectal dose-volume histogram analysis. Int J Radiat Oncol Biol Phys 50: 335–341, 2001. 24. Merrick GS, Butler WM, Galbreath RW, et al: Erectile function after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 52: 893–902, 2002. 25. Stock RG, Kao J, and Stone NN: Penile erectile function after permanent radioactive seed implantation for treatment of prostate cancer. J Urol 165: 436 – 439, 2001. 26. Namiki S, Saito S, Satoh M, et al: Quality of life after radical prostatectomy in Japanese men: 2-year longitudinal study. Jpn J Clin Oncol 35: 551–558, 2005. 27. Masumori N, Tsukamoto T, Kumamoto Y, et al: Decline of sexual function with age in Japanese men compared with American men—results of two community-based studies. Urology 54: 335–345, 1999. 28. Downs TM, Sadetsky N, Pasta DJ, et al: Health related quality of life patterns in patients treated with interstitial prostate brachytherapy for localized prostate cancer— data from CaPSURE. J Urol 170: 1822–1827, 2003.

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