The benefits of nerve-sparing prostatectomy

Mr Alan Doherty

When facing the diagnosis of prostate cancer, for most patients, the overwhelming focus is on eradicating the disease. However once the cancer has been successfully treated, the side-effects of treatment can have a major impact on quality of life.

I have seen many patients following a prostatectomy who are very distressed by their inability to resume normal sexual intercourse. Yet frequently, at the time of diagnosis, these patients did not view impotence as a major concern when they made their choice of treatment.

It would seem that we need to do more to understand patients and their preferences when they are choosing treatment for prostate cancer and offer them a wider range of options to meet their needs.

Radical prostatectomy, which involves the complete removal of the prostate, is the treatment of choice for 30–50 per cent of patients with organ-confined prostate cancer. Its appeal lies in the degree of certainty it offers in terms of removing the disease in one strike.

A traditional radical prostatectomy is undertaken using wide margins around the prostate, damaging the nerves which control the blood supply to the penis. This has been understood to be the safest way of eradicating cancer but causes impotency.

Specialised urological surgeons have been carrying out nerve-sparing prostatectomies for over 10 years. The task of safely removing all cancer cells without harming the hair-thin adjacent nerves demands a very high level of technical skill.

It is hard to measure outcomes in a very precise way – several different assessments of sexual function are used and the outcome for each patient will depend on a range of factors, not all related to the surgery itself.

Not surprisingly then, the reported outcomes from treatments vary widely. For example, following bracytherapy, rates of impotency are reported at between 14 and 61 per cent. Some of the widest variations occur in rates reported following prostatectomy. Impotency is reported in 26 to 100 per cent of patients and intact function from 9 to 86 per cent.

This makes it all the more important for each hospital unit to carefully measure and audit its own results.

Improvements in the techniques of specialist surgeons who undertake a large number of prostatectomies mean we are getting closer to obtaining the perfect result for patients – cure, continence and potency.

Although there are other factors which play their part in the recovery of erections (neurogenic, vascular and psychosexual), the results show patients do have better results following nerve-sparing surgery compared with non nerve-sparing.

The nerve-sparing techniques I have developed during the past six years, undertaking over 700 procedures, mean that 73 per cent of my patients who have had ‘high quality’ nerve-sparing prostatectomies have ‘good’ erectile recovery (defined as being able to have an erection sufficiently rigid for vaginal penetration).

Achieving this is dependant upon extremely good technique throughout the whole procedure. Key elements include control of the dorsal vein complex after apical dissection of the prostate, accurate dissection of Denonvillier’s fascia, a three stage dissection of the neurovascular bundle (NVB), avoidance of energy, avoidance of traction and careful placement of anastomotic sutures.

However, despite the progress which has been made in recent years in nerve-sparing surgery, studies suggest that up to 73 per cent did not continue their treatment.

In many cases, the effectiveness of the treatment was below the expectations of the patients. This was cited as one of the main reasons for giving up on the treatment along with loss of interest in sex.

By combining established erectile dysfunction treatments with the right specialist support, we see patients return to more effective erectile function over time as they recover from surgery.

Medication alone is not sufficient to overcome all potential problems. Men need to have individually-tailored care and support to ensure they keep up with their treatment and effectively address the psycho-sexual factors which they face as they recover from surgery and return to normal life.