New Surgical Techniques May Reduce Impotence, Incontinence

ORLANDO--Impotence and incontinence, the radical prostatectomycomplications that patients fear most, can be reduced throughsimple modifications in surgical technique without compromisingcancer control, according to two reports presented at the AmericanUrological Association's 91st annual meeting.

Previous anatomic refinements had brought the positive marginrate down to 8%, but had also resulted in a marked reduction inpotency, down to approximately 20%, said Peter T. Scardino, MD,professor and chair of the Scott Department of Urology, BaylorCollege of Medicine, Houston.

Thus, he developed a new technique, first used in November 1993."I felt it was very important, if patients were to continueto accept this kind of surgery, to go back and preserve some ofthe nerve tissue and allow more patients to recover potency whilemaintaining a low rate of positive margins," he said.

Dr. Scardino noted that the nerves controlling erection lie immediatelyadjacent to the prostate, near the posterior-lateral area of theprostate, where cancers tend to arise and extend. A major concern,he said, was "whether nerve-sparing to preserve potency couldbecome cancer-sparing," a problem borne out in some series.

His technique permits careful nerve dissection away from the prostatenear the apex of the urethra, while getting completely aroundthe cancer. In his analysis of the first 450 patients treatedwith the new technique, the positive margin rate has remainedlow overall, at 12%.

"We were able to increase the potency rate at 1 year in menunder age 65 to around 58%, rising to 65% at 2 years," hesaid. In men over age 65, one third were found to be potent aftersurgery. Age was the second most important determinant of postoperativepotency after technique in the multivariate analysis.

"Men need to understand that age is a powerful predictorof recovery of erections," Dr. Scardino said, adding thatyounger men can afford more compromise in potency because theirerections tend to be stronger before surgery. Indeed, preoperativeerectile function was the third most important factor linked topostoperative potency in this series.

Assuming good surgical technique, Dr. Scardino estimates that80% to 90% of men in their 40s are likely to recover potency,decreasing to 75% to 85% of those in their 50s, to 65% to 70%of men in their 60s, and to 20% to 30% of men in their 70s.

Although the enhanced potency rates are good news for prostatecancer patients, Dr. Scardino cautions that, "it is dangerousto embark on a course that emphasizes quality of life over cancercontrol. The worst quality of life is having a growing, spreadingcancer."

Urologists are also modifying radical prostatectomy to improveurinary continence. In his presentation, Charles B. Brendler,MD, professor and chief of urology, the University of Chicago,said that "our job as urologists is to do anatomic and physiologicstudies to better understand why men are or are not continent."

As a result of such studies, Dr. Brendler altered his techniqueso that the membranous urethra and its surrounding muscle arepreserved. "The bottom line is that these areas are criticalto the preservation of continence without compromising cancercontrol," he said.

He believes that physicians have underestimated the morbidityof this complication by asking patients up front if they are continent."They are either reluctant to answer or we don't hear thetruth," he said.

Instead of direct physician questioning, he advises using anonymouspatient questionnaires, where patients are free to raise uncomfortableissues openly. He did just that with his patients treated withthe modified technique--asking them in an anonymous questionnairewhether they wear any sort of pad.

Six months after surgery, 91% of men said they are either dryor wear at most one pad per day; 8% reported wearing two padsper day, and 1% claimed they need at least five pads.

Like Dr. Scardino, Dr. Brendler emphasized that prostate surgeryshould be performed with the utmost concern first for cancer control."If you don't do that, you might as well not have performedthe operation," he said.