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New prostate surgery methods address sex, urinary problems

Last Updated: Jan. 26, 2003

It’s a tough sell: an operation that leaves up to one in 13 men with urinary problems and far more of them unable to have sex.

But new techniques are changing prostate cancer surgery, and doctors hope more men may be willing to have the operation, which they consider the best option for beating cancer and not having it come back.

Some changes are subtle, such as new ways that surgeons reconnect the tube that holds urine, to help prevent incontinence.

Some are big, such as using nerve grafts to preserve sexual function, and doing the operation laparoscopically, through tiny portholes instead of a big incision.

All are aimed at improving a surgery that 60,000 to 80,000 men have each year in the United States to treat what is the most common cancer in men, other than skin cancer. About 220,900 new cases of prostate cancer will be diagnosed this year, most of them when the cancer is still confined to the gland and is therefore most treatable.

Surgery to remove the prostate is the gold standard in such cases if a man is young enough and otherwise healthy enough to withstand it. But it’s no picnic. Radical prostatectomy, as it’s called, usually involves a 5- to 8-inch abdominal incision, substantial blood loss and about four weeks of recovery.

It also often means lower quality of life. Studies show that it leaves 5% to 12% of men with urinary incontinence and 20% to as many as 60% unable to have an erection firm enough for sex. Rates vary greatly depending on the skill of the surgeon, the extent of the cancer and the man’s age.

To avoid these side effects, doctors in the late 1980s began doing nerve-sparing surgery, trying to leave intact the two cavernous nerves that control erections. These actually are a cluster of nerve fibers and blood vessels that form cordlike bundles on either side of the prostate and extend into the gland.

“The cancer likes to grow where those penetration points are,” so it’s often necessary to remove one or both of the bundles, said David Jarrard, chief of urologic cancer treatment at the University of Wisconsin-Madison.

If one nerve is removed, a man has a 50% chance of having sexual dysfunction, doctors say. When both are, it’s a near certainty.

“Even if you’ve spared the nerves, sometimes you may have traumatized them and they may or may not recover,” said Bruce Blank, a professor and urologist at Oregon Health and Science University who is on the American Cancer Society’s prostate advisory committee.
Tiny scope lights way

Performing the operation laparoscopically – using a thin, lighted telescope in the abdomen – may help.

“We work with a camera and have significant magnification. We actually see the nerve bundles better laparoscopically” than in traditional, open surgery, said Stephen Nakada, chairman of urology at the UW Medical School.

A couple dozen urologists around the country are doing laparoscopic prostatectomies. UW surgeon Timothy Moon did Madison’s first one this month. Peter Langenstroer and Frank Begun of the Medical College of Wisconsin tried it once at Froedtert Memorial Lutheran Hospital in Wauwatosa.

“We did one 18 months ago and after that we sort of backed away. We weren’t sure it was ready for prime time,” said William See, chairman of urology at the hospital and medical school. “The patient did fine, but it took a lot longer than we wanted.”

The operation is easier on patients, who lose a third of the blood they would with the traditional operation and recover twice as fast. But it’s tough on surgeons, taking twice as long – four to six hours – and demanding considerable skill and dexterity to operate microscopically through the tiny portholes.
Grafting nerves

Surgical skill and time also are crucial to another innovation in prostate surgery – nerve grafts to prevent impotence. UW is one of fewer than a dozen hospitals nationwide offering it. It must be done at the same time the prostate is removed and can’t be done afterward to try to restore lost function.

A plastic surgeon – at UW, it’s department chief Michael Bentz – takes out a section of the sural nerve that runs down the leg and along the side of the foot to the ankle. This leaves the patient with a little numbness but no other problems.

Jarrard, the cancer surgeon, stitches the nerve graft into the groin, trying to match where the cavernous nerve had been. He uses a device called the CaverMap that lets him see changes in the penis when the proper nerve ending is stimulated.

“We’ve done nine patients, and five of them are out over a year,” enough time to gauge results, Jarrard said.

Two of the five are having normal erections, two can when they also use Viagra, and one is impotent. Some had lost only one cavernous nerve, making their outcomes a little better than some national studies of nerve grafts for men who lost both nerves.

One study of 26 such men, published in Urology in 2001, found six regained normal erections, four had partial erections that became sufficient for sex when they took Viagra, two had partial erections that weren’t firm enough for sex, and 11 became impotent.

Evaluating dysfunction is tough because it may not happen all the time, and many men had trouble even before the surgery because of their age, the cancer itself, hormone changes or other conditions such as diabetes or high blood pressure.

“A good proportion of the men don’t have good erections to begin with,” Nakada said.

At UW, “we’re very selective in who we offer this to,” Jarrard said.

Most patients are in their 40s or 50s – the first was 40 and the oldest was 62. They must have no other health problems and normal sexual function before the operation.

Experts such as Blank say doctors should offer nerve grafts even if only one cavernous nerve is removed “to give your patient the best chance at having normal erections.”

Nerve grafting “is definitely something on the horizon” for more hospitals, said Jeffrey Derus, chief of urology at St. Luke’s Medical Center, where it’s not yet offered.

It has at least one critic – Patrick Walsh at Johns Hopkins University, the surgeon who pioneered nerve-sparing prostatectomy in the 1980s and has written a bestselling book on the disease for patients.

“It’s never necessary to excise both nerves,” and if it is, the patient shouldn’t be having a prostatectomy to begin with because the cancer’s spread already is too extensive to be cured by surgery, Walsh contends. “The most important thing they need isn’t a nerve graft but a surgeon who knows how to preserve nerve function on the other side.”
Guarding bladder function

Other changes to prostatectomy aren’t so controversial. Doctors are trying a number of new ways to reconnect the urethra, the tube that carries urine from the bladder through the penis, to prevent incontinence or urinary leakage. The middle section, which passes through the prostate, is removed at the same time as the gland, and most surgeons put the tube back together end to end, said the Medical College’s See.

He devised a way to place the smaller section of the urethra into the section at the bladder neck and to pull the bladder neck around the channel to provide increased resistance and prevent leakage. He gave a talk on the technique and its results at the American Urological Association meeting in 2000.

Derus is doing something similar at St. Luke’s to reinforce the bladder neck area.

Doctors also are operating more gingerly around the sphincter muscle, which controls the flow of urine.

With all three surgery refinements – laparoscopy, nerve grafts and incontinence-prevention tactics – it will take several years to get enough information to say they do or don’t work, or are equal to or better than standard operating procedure now.

A version of this story appeared in the Milwaukee Journal Sentinel on Jan. 27, 2003

For more information on:

Dr David Jarrard
Dr Timothy Moon
Dr Stephen Nakada
Dr Michael Bentz

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