April 26, 1999
New techniques in prostate surgery improve quality of life
Recent developments in surgical techniques and technology are boosting the chances of regaining sexual function and continence for men who have undergone radical prostatectomies.
In the past decade, more men with localized prostate cancer have decided in favor of radical prostatectomy — total removal of the gland located at the base of the bladder — rather than radiation, despite the risk of permanent impotence and incontinence. “The advantage of radical prostatectomy is that you remove all the cancerous prostate,” says Dr. Paul Lange, professor and chair of the Department of Urology at the University of Washington School of Medicine. “You know better and sooner where you stand regarding cure and your prospects for survival might be better.”
Nerve-sparing surgery to save potency was developed in the early 1990s, but in the past 18 months the results at UW Medical Center, where Lange practices, have been improved with several new surgical techniques and instruments. “Until recently, doctors still felt some insecurity about saving nerves which are very close to the prostate gland because there was the risk of leaving some cancer behind,” explains Lange.
At the Annual International Conference on Prostate Care held last month at Whistler, B.C., Lange presented results using these newer approaches. In radical prostatectomies performed at UW Medical Center by Lange and Dr. William Ellis, associate professor of urology, the extremely meticulous procedure involves cutting from a different angle than in the past. Wearing microscopic loupes, surgeons get a better view of the extremely small nerve bundles so they can put them out of harm?s way before prostate removal begins.
The prostate is then frozen and examined under a microscope to determine the proximity of the cancer to the nerves. A decision might still be made not to save the nerve bundles if they are too close to the cancer. The frozen prostate is kept for genetic research into prostate cancer.
The microscopic loupe is used in conjunction with a recently developed device called the CaverMap Surgical Aid. This device, now being tested in sites across the nation, helps surgeons locate and stimulate the critical cavernosal nerves, which control erection. Electrodes on a probe detect nerve presence through penile tumescence changes.
“We have reason to believe that this approach will help us locate and, more importantly, validate the preservation of the nerves at surgery so we can advise and manage men better after they recover,” says Lange. “This device is the first big step toward developing even better technology to improve erectile nerve preservation.”
Nerve-sparing prostatectomy is limited to those with very early cancer. About 60 percent to 65 percent of patients have now regained potency after the nerve-sparing surgery, a significant increase over what was achieved previously both at UW Medical Center and many other hospitals, says Lange. Many men are able to have erections right away, while others may take up to a year.
Incontinence is another common side effect of prostate surgery that can be more effectively prevented with newer surgical techniques. Generally about 5 percent to 20 percent of prostatectomy patients are temporarily incontinent, but at some centers, including the UW Medical Center, this figure has dropped to 2 percent. Temporary incontinence can last several weeks to a few months. Those who remain incontinent may undergo minor procedures such as collagen injections or an implantable incontinence cuff.
“We are working on our next challenge — testing ways to get continence back earlier and to get the continence rate up to 100 percent,” says Lange.
