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Letter to the Editor

Reply to Paolo Capogrosso, Francesco Montorsi, and

Andrea Salonia’s Letter to the Editor re: Philipp Mandel,

Felix Preisser, Markus Graefen, et al.

[1_TD$DIFF]

High Chance of Late

Recovery of Urinary and Erectile Function Beyond

12 Months After Radical Prostatectomy. Eur Urol

2017;71:848–50. Late Recovery of Erectile Function After

Radical Prostatectomy: Should We Modify the Way of

Assessment?

We thank Capogrosso and colleagues for their interest in

our article

[1]

. For analyses of erectile dysfunction (ED)

recovery, we (and others

[2]

) relied on the short version of

the International Index of Erectile Function (IIEF-5) score. As

correctly pointed out by Capogrosso et al, we defined

<

18 as

the cutoff for definition of ED. Using this cutoff, we could

show rates of late recovery of 30.8% at 24 mo and 36.5% at

36 mo for patients who suffered from ED at 12 mo after

radical prostatectomy (RP). The authors of the letter

legitimately raised the point that an increase of only 1 or

2 points in IIEF-5 score could lead to achieving the 18-point

threshold defining erectile function (EF) recovery, and thus

does not necessarily translate into a ‘‘real clinical benefit

behind the reported EF improvement’’. In this context, the

authors cited Rosen et al

[3]

, who introduced the very

interesting approach of the ‘‘minimal clinically important

difference’’ (MCID), which defines the smallest amount of

change in the IIEF-EF domain score (range 0–30 points) that

patients may consider beneficial. According to Rosen and

colleagues, the MCID is 2, 5, or 7 points (average 4 points),

depending on the ED level of severity (mild, moderate, or

severe)

[3] .

When defining the MCID for our data, one also has to

keep in mind that we used the short version of the IIEF (IIEF-

5, range 0–25 points), which might lower the change in IIEF

score needed to fulfill the MCID. Taking ED severity into

account, MCID for the vast majority of our patients is most

likely to be ensured by a change of 4 or 5 points. Looking at

the increase in IIEF-5 score in our data for patients who

recovered from ED between 12 and 24 mo, 19.6% had an

increase of

<

4 and 29.8% an increase of

<

5 points (median

increase 7 points). For patients who recovered from ED at

36 mo, the respective rates were 15.5% and 24.4% (median

increase 7 points). Indeed, this calculation would lower the

reported rates of late EF recovery by up to 29.8% in patients

with an IIEF-5 score of 18. However, when using the

change in IIEF-5 score instead of a strict cutoff value, we

would also have to consider additional patients for the EF

recovery group who did not reach the cutoff over time, but

who did show a significant change in IIEF-5. For both time

points (24 and 36 mo) and different changes in IIEF score

(4 or 5 points) to ensure MCID, the number of these patients

exceeds the number lost from our analysis if using

MCID instead of a cutoff for patients who reached an IIEF

of at least 18.

Use of a measure to define the actual perceptible benefit

behind the reported EF recovery in addition to a cutoff value

represents a valuable and accurate approach, and both

confirms and strengthens our recently reported results

[1] .

Conflicts of interest:

The authors have nothing to disclose.

References

[1]

Mandel P, Preisser F, Graefen M, et al. High chance of late recovery of urinary and erectile function beyond 12 months after radical prostatectomy. Eur Urol 2017;71:848–50

.

[2]

Lee JK, Assel M, Thong AE, et al. Unexpected long-term improve- ments in urinary and erectile function in a large cohort of men with self-reported outcomes following radical prostatectomy. Eur Urol 2015;68:899–905.

[3]

Rosen RC, Allen KR, Ni X, Araujo AB. Minimal clinically important differences in the erectile function domain of the International Index of Erectile Function scale. Eur Urol 2011;60:1010–6

.

Philipp Mandel

a

Markus Graefen

a

Hartwig Huland

a

Derya Tilki

a,b,

*

a

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-

Eppendorf, Hamburg, Germany

b

Department of Urology, University Hospital Hamburg-Eppendorf,

Hamburg, Germany

*Corresponding author. Martini-Klinik Prostate Cancer Center,

University Hospital Hamburg-Eppendorf, Martinistrasse 52,

20246 Hamburg, Germany. Tel. +49 40 74100; Fax: +49 40 7410.

E-mail address:

d.tilki@uke.de

(D. Tilki).

July 1, 2017

E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) e 1 7 9

ava ilable at

www.sciencedirect.com

journal homepage:

www.eu ropeanurology.com

DOIs of original articles:

http://dx.doi.org/10.1016/j.eururo.2016.09.030

,

http://dx.doi.org/10.1016/j.eururo.2017.07.001

.

http://dx.doi.org/10.1016/j.eururo.2017.07.002

0302-2838/

#

2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.